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New Tr-rh i46C9 USA ■ '—' (?'6; 48^ - OJOC - Phone ^= (?'6) 288 • '198-' - fT t ')C'<j .1 TREATISE OS HSKASKSiiF rilK KVK. \(»SK, i<i\T \M> KAIi. Foil STIDENTS AND PKA( TITIONERS. BY VARIOUS AUTHORS. EDITED UY WILLIAM CAMPBELL POSEY, A.B., M.D. I KuKKS.'.llR IIP OPHTHALMOLOGY IN TH« PHILADCU'HIA TOLVCUNIC ; SIROEON TO TH« WIL1.« KV« HO'I'ITAL; OI'HTHALMIC SI'KQEON TO THP. HOWAKD AND KPM.EPTK HOSI'ITALS ; MEMBEK OP THE AMEKH AN' OPHTHALMOIXX.ICAL SOCIETY, AND JONATHAN WRIGHT, M.D., irrKSlllNU LARYSUOLOUl>r TO K1NU3 COUNTY HOSITTAL i LARYNGOI/XilST TO THE BROOKLYN EVE AM> EAR HO^I'ITAL ; SIRGEON TO Tl ' MANHATTAN EYE AND EAR HOSPITAL, THROAT 1>K1>AI;IMKNT: PATHiM.OUIST TO THE MANHATTAN EYE AND EAR HOSPITAL. ILLUSTRATED WITH 650 ENGRAVINGS AND 35 PLATES IN COLORS AND MONOCHROfylE. ('M«fiiCAL FACULTY ^\ M«QILL LEA BROTHERS «fe CO., PHILADELPHIA AND NEW YORK. ] 903. 1 Entered .ccording to the Aol of Congrew, in the year I»02, bv LEA BROTHERS ± CO., In the Office of the Librarian of Congre... All righU reserved. ,o'=\ D0RN4N, PRIJITEIl. PREFACE. Tin: practical convenience affor^lcd by cdinhiiiing the sui)jects of the Kve, I.'ar, Nose, and Tliioat within a single volume needs no demonstration. It rests upon obvious reasons. The anatomical and patholfigical relations of these organs .-ire so close that the speci.iiist in one subject shonhl have a thorough knowledge of the others: their aHections are so connnon anil widespread that they form ,1 large share of general jjractice, and their bearings upon inter nal medicine are ,so nianifold ,,iid direct tliat no i)hysician can igiuu. their influence or dispenx" with the light they cast upon morbid st.'ites elsewhere. The present volume has been arninged in view of the.se facts and in Older to give a comprehensive, authoritative, and practical expo- sition of these cognate de|)artment«!. The contril)iitors are men who h.Mve demonstrated their .s])i'cia! ability in connection with the subjects a.ssigned. It may be noted that the matter has fM-en distributed so that each author has been enabled to treat the subject committed to him in its entirety. KeiH>titioii, .so frequent a fault in systems, has thus been avoideil. Separate chapters on anatomy and physiology have been omitted, as such general knowledge is presuj)posed ; but enough information will be found in connection with each subject to exj)lain the pathology and symptomatology. The authors have aimed to adai)t the book particularly to the needs (,f general practitioners and students, though it is hoped that even specialists may find the latest expositions of these .subjects by their colleagues to jjo.s.sess much of interest and value. The arrangement of the Ophthalmological Section differs con.sider- ably from that usually employed: it has been adopted, however, for the puri)ose of bringing the reader into immediate clinical relation- .ship with the i)atient. without confusing him with the formuh-e of optics until the necessity of comprehending them arises in the fur- ther unfolding of the subject. The chapter on the Eye in its RelatUm ■■ VI I'liKFME. to General ^/.srrrsr. w vory (•(.inpri-hciisive. an,| it is lH.|>ed tliat it will r.r.)v<> .,f f.sp..,.iMl value t.> the Roneral practitioner ii, acquaint- inKlani with tho , .Hilar lesions of every jjeneral and I,,,.;,! a. ec-tion exhihitini; sudi manifestations. In the sertion on the Throat, Xose, an.! I-ar. the general chai)ters on Pathology, on Instruments, and or Routine Operations were introduced to secim- conciseness without curtailment of the matter necessary for the thorough elucidation of th.- subjects dealt with. LIST OF CONTRinUTORS. ALDKKTON, HEMIY AHXuLD, M.l)., thief of Aural flinic arj AsHi.«tanl M llir (hair ..f Otolojfv in the Long Island Modical CoUrn.-; Aural .Surgr.m to th.- Urooklvn Eye and Ear Hospital; Aural .Surgeon to the Kings County Hospital and to the Bushwick Hoh- pital; Attending Surgeon to the Ear, Xose, and Throat Department of the Nassau Couniy Hospital; Meniher of the American Otological Society; of the New York ((tologieal Society- of tiie American LarvngoloRical, Uhuiologieal, and Otological Society; of the Associated Physicians of Long Island; of the Medical Society of Gn-ater New York: of the Kings County Society atid Association, of the Long Island Medical Society; of the Brooklyn Medical Society; Chairman of the .Section on Laryngology, I{hinol.)gy, and Otology, Kings County .Me.lical ,Society; Attending I'hvs'i- cian for I)iseas<.s of the Ear, Xose. and Throat to the Home for friendless Women and Children. BIUKKTT, H. S.. Ml).. Professor of lihinolog> and Laryngology in the McGill T nnersity. Moi.ireai Khinologist and LaryngoloRi..*t to the l{oyal A'ictoria Hom-' ,1. Montrea;. F'ellow of the American Laryiigologi, al A-M.eiation. CASSELBEUHY, \V. E., M.l)., Profcsor of Laryngology and Pl.inology in the Northwestern Iniversitv Medical School; Laryngologist and Uhinologisi to the Si. I uke's and Wesley Hospiials, Chicago, 111.; FelUv of the .American Larvngologica I Association, etc. CHE.VTLE, AUTHITR h., F.R.C.S. Exo., Assistant .\ural Surgeon to the King's College Hospital. London; Surgeon to th<' lioyal Ear Ho.spital, London. CLARK. C. I., Mil, Professor of Ophthalmology and Otology in the Starling Medical College; Attending Eye and Ear Surgeon to the St. Francis Hospital, and Con- sulting Surgeon to the Children's Hospital, Colunihu.s, Ohio. COLLINS, E. T1{EACHE1{. F.H.C.S. Eve, Surgeon to the Royal London Ophthalmic Hospital (M.iorfields); Ophthalmic Surgeon to the Charing Cro.ss Ho.spital, and Lectun'r on Ophthalmology at the Medical School. (vii) VIII l.l\r iiF inSTIiinrrnHs (.IlnrKKI I. K. \.. MM, Vi»i»taiil 111 Ori.li.uy ill ill.' Hiii'Minl I iiiM-rsity MrWniil ^.Iiih.I, .\«.si»i;iiii SiirKcoii til thr Ma«wirlinwil« Kyc unit Kiir Intirin,. , ; \ iiitiii)f Aural ''iirisiuii til till' IiiluMl>' .iiiij Niniiiii Mnipiliil-, l»ii»tiiii, Mii!«>, DI \.\K, \I.i:.\ WhKlf Mil. IiiMiniilor ill (•iililliiiliiiiilui.'v iiikI Siirniiiii in ihi- Ilin|Hii»urv <>f ihf tnriii-ll Mfili. al Ci.ll.tfr. Nrw Vork: ^iukioh In ill. niilitlmliiiic ami Aural liij.ti- Hilc: < )|i|itliuliiiiil(i)fist to till- Saiii.iritaii lliiiiic: ^ iMitiiiK 0|)ht>iuliiiiilogii>t ti. the Italiilall's Maiiil Hospital. Niw \ciik. Kl I.KI 1, KDWAIfO ( ., Ml). Oplitliuliiiicainl Aural .Siiiifii HI i,i llir St. .lu-n'iili'^ Hospital, llie City Hospital, .iiiil till' Lratli (Irpliaii \<\liiiii, Mciiipliis, Trmi. GIKI(>I!1», H., M.I)., I'rofi'ssor of (»plitlial:iioloi;v ami O|olo(ty in the riiivcrsitv of Nfl ka. Oinalia. Ni'li. (JOOKALK. J. I,., M.n.. Assistant I'livsiiiaii lor hisiaws of ilir Nose ami Throat in tlic Massarlmst'tis • JentTal Hospital anil in tin' Huston Cliildren's Hospital, Hoston, Mass.; Miiiihcr of the Amcriiiin l.aiyiiKiilo)tiraI .Vssociation. HOI'KIN.s;, F. E., M.l).. I.arynKolonist ami Otologist to llir SpriiiKti.liI Hospital, Sprinnfield. Mass.: Fellow of tlir -New York .Vcadpmy of Mciliiiiir ami of tho Atiicrican l.aryti- polociial Assiiiiiiiion, rir. MAVKll, K.\in.. Ml). MiritiM.ii to till' Nrw 'I'ork Kyi' ami Far Inliiniary (Throat Department); Fellow of the AiiM liiaii I-aryiiKulojfiral A.ssoriatioii; I'hairnian of the Section on I.aiyii)j;iilo(jy of the New Vork Academy of Medicine; Kx- Pre.sidont of the Section on I.aryiiKoloay and t)tolo(fy of the American Medical .\ssociation, etc. NK\V( ')Mli, J. V... M.I).. Instructor in Laryn(rolo)ty in the Coniell Iniversity .Medical (^ollege. New Vork; .VttendiiiK I,aryn){"loKist to the I{oo..«'vell Hospital, Out-patient Department, and to the Deinilt Dispeii.sary, New Vork. Pt)SEV. WII.I.IAM CAMI'HKI.I, M.I)., Professor of Ophthalmology in lh, Philadelphia Polyclinic; .Surgeon to the Wills F;ye Hospital: Ophthalmic Siirceon to the Howard and Kpileptic Hospitals, Philadelphia: .Miiiilier of the .\merican Ophthalmological Society. HKKVK. I{. A., Ml).. I Professor of Ophthalmolo).", mil Otology in the I'niversity of Toronto; Ophthalmic and .\unil Siiiffeon to il .■ fjeneral Hospital and Hospital for Sick riiildr'n, Inroiilo, ( '.inada. IPIRl ItHHMIDSitN, ( M Mil.Ks \\ , M.i». SHI MV • KDW AIM) A , US , M |>.. Opi .liiiolojri^t lo ihi' l'ri'»l,\ ii'iiiiii He ■ .'I'liiisyh Hiiiii: \'(iliiiititrv As^mmm ■ il' (liiiiciil Mriliriiic, I'hiluilflphlH SIMI'soN. WILLIAM KKLLV, M I>. Siirgpon to thf Ni'iv Vmk Ey :,i„\ K.ir Iiil < hicf of ( linic iirul I for Wiilou. ,'iri(l >iii(flc Woiiicii William I'l-piHT L.iliiinitory f'liicf of (linic iiriil Iii..lni<toi- in Larvii^folon.v in Ihi' ( ollcjf.- of I'lu>iciHii anil Siirifr.iii.., Coliiinhia fiiivrrsiiy, \c-w ^ork : IVIlow of the Amtiri-ni I.aryiiKciloKical A-<soiialii)ii, ••ti-. SPICFIi. I. HOLM I I .Ii.(;..-«. Ia,, , -iirK<'oii to li,. Moorfiflds Kyi- Hospital; Opiithaliiiii- Siirnpor.' to the St M.irtholoin.'w's Hospitnl, Loniloii, Kii»tlaml. STAIil;. KLMKH (i , M.I>,. Cliiiii-al I'rofissor of l iphlliaiinoloKy in the Mcliral Drparln. nt of the v.T»ity of UiilTalo; Siiwoii to the Km' and Ear Dt-partiiifnt, Iniv. I)isp<.n«ary. Muffalo, N. V, ; Kye and Kar Siirjjeon . tlii> Erie founty Hosi.ital.CtMin.iii DfacoM.'-s' Hospital, and UtitTalo Hospital of Sis Ini- Tsitv itcru of f'liarity, Hi-ffalo. N. V. sr TEK, willia: ^HWooD, m d. I to the Kpivopal Eyi', Kar, and Throat Hospital, Wash' A«»i«tant Siir it r^f.n. T). » THOMSC' ,, .>■( LAIli, Mil.. K.K.C.S. Kno., As :, . I'hvsi.ian for Disi.nsf.s of the Throat in tho King's College Hospital ; Pi.v ician to the Ihro.it Hospital, (iolden Square; Lecturer on LarvnRoloRy .It the Pnlvclinir; lai.- Surgeon to the Royal Ear Hospital, London; (.or- respondinK' Kellow of the American Laryngological A"sociation; of the Acadenia .Medica of l'lr)rence. and of the ,Socirt# Francaise d'Otologie et de LarynRnlogic : Honorary Liliranan of the Larvngologioal Societv of London. VE.^SEV, CLAHENC K A., A.M.. Mi).. nemnnstrator of Diseases of the Eye in the .hfferson Medical College; A.ssist- ant Ophthalmic Surgeon in the JpfTerson Medical College Hospital; Oph- thalmic Surgeon in the Methodist Kpiscopal Hospital; Consulting Ophthal- mologist in the Philadelphia Lying-in Charity. WEEKS, JOHN E.. M.P., ^r .eon to the Ophthalmic Department of the \ew York Eye and Ear Infirmary; Professor of Clinical Ophthalmology in the University and Hellevue Hospital Medical CoUtg^; Fellow of the New York Academy of Medicine; Member of the American Medical A-isociat ion. x LIST iiF C/JMllllllTOUS. WOOD, CAUSEY A., M.I)., Proffssor iif OplithaliiKiloKy in the Cliicago I'dsl-graduate .Medical .■^choiil; l'rofes->(ir of Clinual (^plitlialiiioUigj- in the University of Illinois; Oph- thalmic SiifRi'iin to the I'assavant Memorial Hospital and to St. Luke's Hospital. Chicaeo; Consulting Ophthalmologist to St. Anthony's Hos- pital, Chicago, III. WHHDK.MA.N.N. H. V., M.I)., Prot'es.sor of Ophthalmology to the .Milwaukee .Medical College, and Chief of Eye Clinic, Ophthalmic and .Kural Surge<in to the Trinity Hospital; to the M iiikee Childri'ii's Hospital; to tlie .Milwaukee County Hospital; to the -Milwaukee County Hospital for llie Chronic Insane. CONTENTS. THE EYE, CHAPTER I. EXAMIXATIOX OF THE EVE Hy William Campbell Posev, M.D. CHAPTER 11. THE PHYSIOLOGY OF VISION Bv William No^iwooi) StTEii. M.D. CHAPTER III. liKFIiACTIVE KliliOliS IN GENEHAI Hy Alexandeh Diane, M.D. CHAPTER 1\-. THE MOTIONS OF THE EYEHALL AND THEII! DEIiANOEMENTS . liY Ca^^ey a. Wood. M.D. CHAPTER V. DISKASES OF IHK OUMIT, I.VCRYMAL AFPAHATCs, AND LIDS Hv I!. A. IJeeve. M.D PACE 19 .53 14.- 192 chapti:r \r. DISEASES (IF THE CON.IFNCTIVA, (OliXEA, .\N1) SCLEHA Hy .Iohn E, Wkkks, M.D. chapti:r \ir. F\IHi;VOLO(;V OF MIK EVE; .WOMALIES, DISEASES wn \.H lilES OF THE ims, (TLIAHY H(.DY, CHOROID, AND \ 11 ItEOF.S 2,5S Hv H. W Wi udemaw, .M.D. 3.'?1 (xi^ XII (t»Mi:.\rs. CHAl'TKR VIII. SVMI'AIHKTIC OI'HTHAI.MIA i?v H. (lienMii). M.D. CHAPTKR IX. 1)1SK.\SKS ol- THK 1>KT1NA. i )1>TI(' NKUVK. AND ITS CKliKKl! \l. I5i I'. Hoi.MKs Sri( Kii. !.!'.( .>. Km.. I'AGE OIUC.IN CHAPTKU X. DISKASKS Ol' THK (TtYSTAI.LlNK I.KNS . Hv Ki)« Mil) ('. Ki.i.Kii. Ml). (il.ArCOMA ('hai'ti:h XI. Hv K. rnKvriiKii ('(.i.i.i\~, 1 .l!.( '.>. Km;. CHAITKH Xil. DISIT KinNCKS OK VlSloN WllHOl I .M'l'AliKM I.KSloN H\ Kl.MKH (i. SlMill. M.l>. 417 474 .)24 Otis (MIAITKH XIII. THK KVK IN US liKI.AlToN I" CKNKIiAI. DlSKASKS Hv ('. 1'. Cl.MIK. M.l>. .>s:} ("IIAITKR XI\. (IKNKKAI. IMtKrAKAIToN l( H{ Ol'Kli.VIToNS lI'o.NTHKKVK UM Hi f'f.MiK- ' \. Vk.\>k.y. A.m., M.D. CIIAI'TKU XV. THK TKCHMql K oK IHK HA I Hol.O( IK Al. AND HA(TKI!loI.( •(;!- CAK KWMINVTIONS ol IHK KVK •">' Hv Ki)« Mill .\. SinMWAV. H.S,, M.D. COXTKXrs. xin NOSE AND THROAT. C'HAPTKH XM. THK nisToi.dcrcAr, i'athomkiy of diskasks or thk .\(isk AMJ THUOAT (1S9 MV .1. I,. (looDAI.K. M.l), CHAPTKH X\II. MKTHoDS (ir K.\AMI.\ATI(l\: INSTItlMKNTS AM) AITAUAIT AM) THKIH ISE Mv .1. !■:. Nk VMOMIi. M.I). CIIAPTKK XVIir. IM l..\MM.\T()l{V DISlvVSK-^OI'THK VVVVM AIU I'\SS\(iK-; H \V IKNKI!: I!HIN()HHH(1;A; .\STHM.V. I.MI.r:.:xz A Rv ClIAHLES W. UlCHMIDSON. .M.l). ("HAPTKR XIX. nil'HTHKIil.V Ol .NOSK .\M) THUO.U': I.NTIHATIO •iVl'Hir.b TrMKUCll.o.slS, HITS .VM) LKl>|{().sv OK .\( )SK AM THl!oAT;("HI(oMC l..\l{V\fiEAL STKXOSI.S; KoHKKi.V HOI)IK.> I.N \o.sK A.NI) THito.Vr; liHINol.ITHS . . . . ' IJv Wii.MAM Kki.1.. SnTi'sdx, M.l). 829 ("HAI'TKH XX. NKOIT.A.sMS ol' THK NosK AM) I.AliV.W: THK I.OC.M,. MKDI- Cl.WI.. A.NI) .slTUilCAI, ri!KATMK\T OK THK I..VI{V.\.\ . Mv W. K. Cassk I.IIKHHY. .M.l). (•iiapti:h XXI. l)l.<KA.SK.s (,i. rn|.; .U'CKSSOliV .sKMSK.s Hv StCi.aih Thomsdn, M.I).. K.IM'.S. K.\o. 022 ("HAITER XXII. DI.-iK.XSKS oK IHK oliol'H.Mn.NX AM) .\.\.S()I'H.U{YN.\ Hv H. ,S HiRht,rT, M.I). ()S.i XIV COSTEXTS. CHAPTER XXIII. NKUROSES OF THE NOSE AND THROAT . . . ■ Bt Emil Mayer, M.U. CHAPTER XXIV. EXTERNAL UEFORMITIES OF THE NOSE; CLEFr PALATE . By F. E. Hopkins, M.D. PAGE 103G 1053 THE EAR. CHAPTER XXV. FVVMINATION OF THE EAR; DISEASES OF THE EXTERNAL EAR; PHEXSES OF THE EXTERNAL AUDITORY MEATUS; OTOMY- COSIS; FOREIGN BODIES; WOUNDS OF THE MEMBRAXA TYMFANI Bv v. K. HopK.Ns, M.D. lOT.'i CHA1»TER XXVI. DISKASKS OF IHK INTKRNAI. EAR AND AUDITORY NERVE; DKAl MUTISM . . Bv K. A. (■llnCkKTT. M.I). 1097 CHAPTKR XXVII. PUHll.KM- INFLAMMATION OF THF, MIDDLE EAR li\ Hf.miv .\iin<ii,ii Ai.dkrton. M.D. IIOS ch.\pti:r XXVIII. (■HHt.NIC NON-SUIM'IHATIVK MIDDLE-EAK DISEASE By Autih u H. Ciieati.k. F.R.C.S. Eno. 1!76 THE EYE. CHAPTER I. EXAMINATION OF THE EYE. Bv WILLIAM CAMPHKLL POSEY, M.D. General Considerations. The studeiu of niediciiu" should ap- proach the study of tlic eye with a twofold purpose: tirst, to ohtain throufili it further iuforiiiatiou r;j-ardiiig the state of the geiiend system, and, secondly, to becon.e accjuainted witli the morbid |)roc- esses which attack one of th( most important orj^ans of the hody. There is no other orj;an in the body in which the ge'ieral systemic condition can l>e studieil to better advantage than the eye, for it presents in a compact form representation of nearly all the tissues of the l)ody. and by reason of the transparency of some of its coats the stude I is enabled actually to witness i)hysiolo(rical and patho- iofricai ])ioces,ses occurrinfi within it. A living nerve head, the optic papilla, and the retinal vessels are unfolded to the gaze of the oph- thalmologist, and an opportunity aHorded luiu of ob.serving the perfect cycle of the supply of an organ with arterial, and the escape of its venou-\ blood. For the proi)er study of this important organ it is e.s.>ieiitial that the stu<lent procee.l systematically and thoroughly, for while it often hapjx'ns that a trained clinician is enabled by the brief recital of .symptoms or by a rai)id glance at the eye to make a i)roper diagnosis, if is better that the student, who has yet to attain experience and skill, should tVjllow some settled order of investigation, and that for the purpo.se of future reference, as well as to ensure accuracy, he should accustom himself to record faithfully all his observations in an appropriat<^ case-book. Inspection of ths General Physical Condition. Before proce<iling to an inmiediat(> inspection of the eye itself, it is ailvantageous that the general physical condition of the i)atit-nt should be taken account of. For this purpose he should be seat"'" in a chair facing a win- dow, the student, with his back to the 'ight, seating himself several feet di.-itai.r ,' the patient. I'nder this .strong illuir.itiatioii i'-- entire person of the pati etit shou ld be raimlly inspected, and any de|)arture from the noriuaHff^liS^^^Lportions of the skin and of the glandu- GU^|G 20 riir: eye. lar sysiciii. ;is well ;is the cliMiMclcr 111' ;iiiy cniplion, iintcil. Iiiili- catioiis 111' arin'riiia nr ]il('llinia slupiihl he sraiclicd for, ami any t'vidciKM's (if jaiiiiilicc. I'itially. tlii' jrciicral ('\|ircssi((ii uf tlu- palii'iil aiiil tlic prcsciK r alisciicc nf pain, or of any iiitolcraiu-c to lijjlit. slirttilil III' laki'ii into ai'i'oiuit. Inspection of the Eyes and Their Adnexae. 1'liis p>ncral survey of tlic casi' l)i'in<; rotnpli'tcil. the atli'iition of tlic stmlcnt slioiiid he iliri'cti'il niori' rspci-ially lowani llic rrfiion of the eves, 'i'lic sliapi' am! jjcnrral nmlijiuralion of tin' head and the character of tlie wrinkles in tlie skin of the forehead and at the root of the nose should be studied. Any tendency toward laeial asyniinelry siiould Im' noted, ;ini| coinparison made whether l)oih orbits are on the same horizontal plane, and whether their cav- .es arc deep or shallow. Tile dejrree of prominence and the size of tlie eyeballs should be remarked, and the relationship which the eyes bear to one another. MsiM'cially should the |iresence or absence of iiiflarnination of tlio eve- balls be taken into accotmt : if but one eye is diseased, it.s condition should be compared with that of the sound eye, as comparative examinations of this kind are frei|uetitly of irreat value. The student should I'arefully scan the rejrion of the sinuses accessory to the eye, to detect swelling or si<;iis of inflammation in then.. Any sifjiis of jirevious injury about the eyes should be recorded. Tiio attention siiould then be directed particularly to the lids as to any inversion or ('Version of their edf^es, or thickening; or distortion or swelling of them: estimation should lie made of abnormal narrowness or width of the lialp<'bral fissures. The action of the orbicularis: in closinji the lids should be tested, and any twitchini,' of the lids and .-issociated muscles ol the face noted. The rejiion of the iimer canthus should be in- spected for evidences of swellinsr. or retained tears, or other sipis of faulty drainajce in the lacrymal apparatus. Havin-i ol).-;erved the <i;enei;il apitearance of the jiatient. and having obtained by the inspection of the region of the eves in a f;ener;il wav .some idea of the nature of the ocular complaint, before attemptinjr a cliser inspection of the eye the student should next obtain bv care- ful iinestioninjr ;i precise ;md complete history of the patient's family .-Hid person.'il history. Family and Personal History. The six. race, and afre of the patient should be recorded, and account tn.'ideof the n.'itureof the i>ccu|)ation, certain callings, !)y reason cf the accidents to which they expo.se the eyes. ;inil others, by the enforced strain which they pl.'ice upon them, bein-; particularly li.ible to produce ocular lesions. Inquiry should also be m;ide into the inarit.il relations: and if the patient be married, of the mimber .•md health of any ofl'spriiij;. Any hereditary ten- dency, particularly to ocular disease in the .•incest ry, should "be re- corded, also the temperament of the p:itient, w ' 'ther it be saiiftuine or the contrary, in order to ascertain the value a\u\ deirree of reliance to place upon the patient's statenients ri'<,';tiditi<r tiie sevcritv of the symptoms, iicr%-(ius sul).iects pxajifieratinn; and lymphatic ones sup- KXAMIXATIOX OF Till-: Fit:. 21 |iif>siii;; tlicir sensations. The lial>its slmulil he iii(|iiiro(l into, espe- .-ially rejianlin;; I lie use of alcoliol and tobacco. If .s\|)liilis lie suspected, (|iiestioii should !)(• made rej;ardin>: the primary sore, a.-^ as the tune ot appearand' i if anv s<'condarv manit'estatinn: .Ml previous illnesses should he taken account of, especially of the exist- ence ol j;()ut, rlieumatism, tuberculosis, malaria or other dyscrasia. The urine should he tested in ;dl douhtful cases, and its examiiuitioii made a part of the routine in all ca.ses rec|uirin}; important o|>erations upon the eyehall, such as cataract. If the jiatient he a female, she should he (|Ui'stiotied rejiardinj; menstrual disorders, and particularly as to the iiilluence of the menstrual epocli ujioii the ocular symptoms. I'inally. should the inspection of the patient have aroused suspicion as to invoh nient of the central nervous system, in(|uii>- should lie maile of all ,.ossihle .sensory and motor <listurhaiices. Ocular History. Ilaviiifi ol)taiiied hy direct and searching cross- ipiestioninji a i)recise kiio\vlcd<;e of the antecedents as well as of the personal history of the |)atieiit, the student is now prepared to direct his iiKjuiries to tiie ocular condjtion itself. Me will accordiiifily iiiiiuire as to the time and manner of on.set of the present attack: whether it was accom|)aiiied hy pain or inflammatory symptom;-, the de<;ree to whicli vi.sion was disturbed, and whether one eye or l)oth were affected, lie will inijuire into previous attacks of ocular in- flammation, and trace any relationshi]) with the present outbreak. Should tile case be one of refraction error, the previous wearinjt of ftlasses and their efficacy in relieving the ocular symptoms .should bo recorded, also regarding the location and character of any hea<l pain and the influence of the u.se of the eyes in reading upon it. If it he ai)parent that a palsy of one or more of the extra-oeular musc!"s be present, the nature of tiie double vision should he elicited. In fine, the student cannot be too searching nor too persistent in his((uestioning, and should exhaust every possible phase of tlie sub.ject before aji- proachiiig the <lirect and closer inspection of the eye antl its a])pen- il.lges. Direct Inspection of the Eye and Its Appendages. For ti.i^' ;nir- pose it is iieci'ssary that the student .should ajiproach tlie patient sufficiently dose to observe the finer structures of theeye and to permit of ;iiiy manipulation, either with the liand or with instruments, tli.-it may be recpiired: he should, moreover, refrain from handling the eye any more than is necessary, and eiuleavor to gain as niucli information iis is possible by insjiection with the naked eye, without the intervention of lenses or instruments, for .such aids -ire not always at hand, and, moreover, even the lightest touch is often sullicieiit to render sensitive eyes so irritable tliat furtlier ex- amination is impossible. In many young children, ami in iiidi- vi<luals who have an intense intolerance to light, however, ins])eo- tioii without haiKlliiig is fruitless, on account of the tightly closed lids, .so that the observer will be comix'lled to open them himself before he can obtain a view of the eye. This is best accomplished 22 77//-; Ai'/;. in yoimg fhildrcii l)V tin- "[M-nitor soaliiijr hinisclf in such a inanncr that thi' huht from a \viii<ln\v falls iipnii liis li^ht or Mt sidi', while Ihi- child's head is held tiniily hctwccii his knees, thi> hody Ix-iiiji supported ui>oii the lap of all atteiidaiil. who should also grasp the hands, the lefis heiiij: left free. The head heiiif; thus rendered iin- niobile, the surfteoii can inspect the iiei«hhorinK [larts delilx'rately, and cm examine the eye satisfactorily by drawinn the lids slowly apjirt, hy piessiii); on the inferior and suiM-rior orbital ridges, or by inserting a Desmarres lid elevator (Fig. 1) IxMieath them, always exer- 1 Flu. 1. 8= IXiiniarres' Ud retractor. cising the greatest care to avoid pressure u|)<)n the "veball itself, for fear of injuring the cornea. When there is marked intolerance to light, a 4 |M'r cent, solution of muriate of cocaine may often l)e success- fully employed to allay irritation, although in some ca.ses general atuesthetizatioii by chlorofonn may have to be resorted to before a satisfactory examination can be made. In adults it is possible to examine even the most .sensitive eyes by making gentle traction on the lids, by drawing them toward the inferior and sujK'rior orbital ridges, thereby avoiding pressure upon the eyeball itself. The Lids, the character of any changes which have been noted in the lids during the general inspection should now be studied more carefully, especial care being devoted to the condition of their mar- gins, as to misplaced cilia or the presence of i)edicuhe, and the char- acter of any incrustation or swellings. Lacrymai Apparatus. The region of the iimer canthus should be in.spected most rigorously, any locali.Tcd injectiim of the conjunctiva or collection of tears or mucus at that point exciting the suspicion of obstruction in 'he |)roi>ef canaliza'ion of tli<' secretion from the eye. The iiosition an 1 patulency of th(> lacrymai jnmcta sliould be a.scer- tained, and gen 1(> ])ressure made with the ti]) of the finger over the lacrymiil sac, with a view to expressing any retained contents. The Orbit and the Position of the Eyeball in It. I'neiiual |)rominence of the globes may be measureil by placing the straight edge of a card from the supra-orbital ridge to the cheek, and comparing the distance of the cornea from the card on the two sides. Palpation of the orbit should be practi.sed by passing the index finger along the bony margins of the orbit, the finger being allowed to dwell par- ticularly over the region of the lacrymai gland, to detect any enlarge- ment or uneveime.ss. Pressure ov(>r the foramina of exit of the rupra-orbita! air! infra-orbital nerves should not \n-- nmitted. The Conjunctiva and Its Cul-de-sacs. Before exploring the recesses of the cul-<le-sacs. the caruncle ■■md the semilunar fold in the angle of I.H w PL ATI" I Fli, 1 (.,1! Fi.| li Cih F,,l ^.^ (■..,! ■ii\mI ( ■.in,i.--li..ii 1)1 ( 'I I'l-ll 1 in . il llf;i! <;< Uli |f--1 itai- lun i.l AiittM lor Cih.tf^ Vcin-i, Er'i^elernl Venous Plexiii^. h:.\A.VI\MI'>.\ Of run EYK. %\ ntluis sliiililil Iw cXiitnilH'i llic IIIIH-r CM liiiilirs. The ciiiijillictivii I for sniiill growths or foroiRii if tlic lids, iMil/H'tinil ninjiiiirlini, slioulil tlii'ii !"• iiisiM'clfMl, Mini Miiy I'liMiiKi' ill its vasci ilaritv or in the fliariu'tcr of it- nittci timi. ami lln' prt'sciii-f of crai ulatiiuis or forcijtii liodics, I. T (Ml ) fxaiiiiiK- tlir coiijuiictiva <>f ll"' rvtrotarsal jnlds aiul the •ccssary to t'ViTt the liiis; tiiin Is n-Milily aci-oiii- f the lower ciii^ It-sac l)y tirawiiin the lower liil Inle-sacs, ll IS 111 IiII-IkmI ill till- i-ase ( . , , -, i mnllv.lowii with the index hiijier of the rinht hand, while the patient w told to direct his pi/.e upward. Ins|)<'ctioii of lh<" U|)|mt cul-de-sac w lesx simple, and is iwrfori 1 hy uraspiiijj the edRe ol th.e upjM'r lid .,nd H few cilia with the thuiiil. and index tinker oi the rijilit hand aiH 1 l.v deluessiiiK the ilp|M'r edge of the cartilajte o tiiip'i a i>ro f the lid with a ..f'tl'ie left hand, o'r'with .-".me convenient instrument, such as \U'. while the patient looks steailily downwar.l. IK n'(|U('stinK the i>atient to 'lirect his gazt till further downward the pal|M'hral iiortion o if the lacrvinal jrlaiid may he brought into view. The Uulhitr awiinirlirn is on liiiarilv invisible save for the few bloodvessels which are .list libut.'d throunii it. The color of the sublying sch-ra sliou i„. noteil, and any uiuliie vascularity ami prominences taKcr ''"iVfl'iii'proceedinjj further, it is desiral.i.' that the stmh-nt should have a clear idea of ''le vas(Milar supply of the exterior ot the eye, in <.rder that he niav ajipn-ciate the ditTerent forms ot congestion lH.(Miliar to the vessels of the several tissues, as no other synii)toiii .'ives -iuiir indication of the location of ocular lesions. " Bloodvessels of the Exterior of the Eye. The vascular supi.ly of the e\i(ii.>rof the eve mav b.' grouiK'd for convenienc- into three <v<leiii<- 1 The I'nslrrioi < 'uniiincliriil Vtsxeh, or the vessels proper ,;, the .■onjunctiva. 2. Th<- Ankrior Cilinrn Vessels. The.s«- consist of In) pcrl'or.Mtiiigarteri.'sa I veins, ami (/-) non-iK-rtorating arteries and veins. The p(>rforatii.^ arteries supply the sclerotic, ins aiul ciliarv bodv, th.'ir veins receiving the blood ironi the canal ot Schlemm and the ciliai •V bodv. Tl ies(> vess( ■Is are visible in health as .several iiiiparatively large tortuous vessc Is which perforate the globe about .) mill ve "tlie'corneal limbus. The non-iH-rforating or epi.sdtMal U which are branches from the anterior filiary vessels, are very lil th heir )f closely set ves-els around the cornea. ,, ;i. The Aiiterinr Coiijiiuctirnl Vessels /."»/;. -p/cj/'/'v on" tile' Corneal Border. The.se are the ves.sels ml immediatelv adjacent zone iiiimeious Mild lorm a zone o Thi'V are invisible in health proper to the margin of the cornea a if coniunctiva. and it is by means ( f these numerous minute branches w hicl 1 iire o itTshoots of the anterior ciliary vess( •Is tliat svstoms 1 and J Mllastomo.se (Plate I.. Fig. 1.) Conjunct" 1 congestion is the nan given to indicate that f' :i ■ s cohgestioll \\ lich is caused bv .an injection of the j.ostorii •tiv; ' vessels. The inie( junc its imiii.'i tioii is most markeil at the for: \ .'in iiat e liel 'hboih d. where these vessels are iiu; and is less noticeable aroum id the cornea. The vessels being ? 24 TIIK EYE. tl 111 till' con arc e ijunct iva, iiiav 1)0 made to slide readily over the filohe, and iisily emptied hy pressiiiji on the lid with llie tiiifjer. I:i thi form oieoiifiestioii the eoiijunetiva assiimi a v< 'llow or hriek-red hue specially in the re^rioii ot the inner eai thus, and there is more or le lUicopurulent dischaifii Coniunetival eoiij;estioii is diajjiiostie of eonjui tivitis. (IMatel.. Fif^. -'.) CUary or circumcomeal congestion is the name given to an in.i<-( ^ •' ... 1 : ,.l,..t<Jt' •if<\iitiil t hi* ('111 tion which IS iiio <t markeil in the zoik iminediatelv around the cornea. iid firadually fad t thi' periiihery of the filohe. It i causei hy injection o As these are sitiia f the anterior ciliary am i anterior conjunctival vessels. place* 1 or niad( ipaiiyiiifr ihschaip ted beneath the conjunctiva to disappear by pres.sur thev cannot he dis the lid. There is no In this form of coiifiestion the circiimeor cs either a pinkish or a .sea rlet hue, while in otlier ac<'oin ileal re>;ion assumes cim.-i n ,.....x..-,. ... .. • - rsi; ,r,- cases drHM.-s..at.'d patches of a lilac or violaceous color ai^i-ear ( iharv i„j,,,,i„„'i„.lica.cs disea.s.. in the cornea, ins, or cihary '"'Iv- ^vlie.i ,1,. p,.,.,.liar liia.-colore.l patclies are present, disease ot the dcper Ivini: tissues, the s.^lera, and ciliary body is indicated; and when observe.! in connecti..n with enlarpMuent of the episcleral veins, a chronic hicrease of intra-ocular teiision-filiuicoma— may be sus- pected. (Plate I., l-ifi. :].) . , f , . ;. Mixed Forms of Congestion. On account ot the free anastomosis „f the three f;roU!)s of ves.sels, it frequ.M.tly hapiH'iis that tiiere is in.-nrinfi „f the different types of congestion into one anot i.'r It shouMbe borne in mind, how, .T, that while a prolonged cihary ,..,n.r,.,tion -raduallv producs more or less conjunct iv.d congestion, th,."converse is not 'true, for a conjunctivitis will not excit." a ciliary injection unless the cornea or iris also is aflected. The Cornea. Tlie shap.", tlu- -eneral curvature of th<. cornea, and the .position, extent, and d..nsity of all invfiularities and opacities in it sli.H.M be stu.lied on account of the imp.)rtant bearing which tiiey have upon the vision and n.fraction of the eye. lor tins purjiose two UM'thods are available: examination of the corneal ivll-'x and direct inspection. , ,• , f Examination of the Corneal Reflex. Wlien the lifihl from a win- dow i~ pennitted to fall .lirectly uix.n the cornea and the eyes are „,.„!,. ,,, follow th<' hnger of the surgeon while it is tnoved ni various directions, it will !.<• noticed, if there be any irrefiulanty „,„,„ ,1„. .utiace of the c<,rnea, that the imafje ol the vyindow Ini- wluch is thrown upon it, inst<'ad of beiiifi reflected clear and well defined, will be broken and ill defined at these ponits. The same principle is made us.' of in th.' api.li.-ati.m .)f the I lacido disk iV\» 2) This con.sists of a tarjiet nu which are coii- .vntri.' allernat,' lilack an.l whit.' circl.'s. with a cntral p.'rlor:iti..ii In its emplovm.'nt. the pati.-nl should b.' place.l with Ins back :,. ,!.,. li.ri.t "tlie ^utw'on viewimr the ivflectum .)! the inuiiie ot •1„. einles np..n th.' corn.'a through th.' op.'niiifi in the c.'iitre ot the ,>'sk. .\nv irr.'}:ularitv .)r .'xcssive ditlereiicL' in the curvature -••ir.^-'T^-'" L i:xAMry.iri(>y of the eye. 25 n.TicHans ..f the conica will ho inaiiif.'ste.l hy a break ..r .li^- „,,,,„„ i„ tiw cirdes. Th.> cor,m,l rejkx should always ho studio.l 111 till' ini PlacMo's disk, or keratoscope. .,. pail of tho loutii.o ..phthalinoscoinc oxaniinatioii, the ohscrvcr M.linnin!: hiinsolf for this purpose hehiu.l a...l to one •'^•'li; <''<"; p:,ti..nrs hea.l. so as to have the patient s face ni shadow. The light Fio. 3. Corneal Utuiie. IS then thrown upon the eve hv a i-laiie mirror, and llu- shadows care- fnllv studied through a hole in the mirror. iVuie lietmoscopy.) 5 I ^ Tllh: EYE. ■n„. ,„„, n.c;,.,o .,.1 ,..].».«- ;i::j;;',i,:':ri>™,;:;;;:!'X „f th.' vnvnrix l)v iitilizms: tlu" ivilrx tli.tl it (ax. opi.thaiMx.uiotcr. ( r*wr pafi'- n^) , ^^-.^^ „„, „;,u..,l Jackson's liiiuiiular inannitler. ;i;'r:::a;'r:;::*n;i:i::«:.;;»y i. us,.,u,„,.i, ,.,i«.n spt'cially coi.j^truct.Ml for tliis purpose. Fio. J. OMiiiiie or focal illumination. tnra! }!l<l>n>.>i'il>IH>: iscul 10 cucnural. llic light upon llio cunu'u. ^^h^\v the (.tlu.r .. t used lo couci i KXAMiyATIOX OF THE EYE. (>iii]ilt>yf( [IS a i»:i cnifii'i thiDudi which tlic ilhiiiiinatfd surface ma\ lie -liichi't with t 1. iKifl. 5.) riic iwticut slioiild l)c seated in a lark rooiii lie lijrlit on t^.e teiiii.-)nil side and siifjlitly in front of tlie phUK Tliis method is extremely vahiahle, for l)y vary i| tiie patient's tac'i lis: the distance! 1 (•iian':<-s in illal i tlie lens from tiieeye it is possi ilile tosti.dvnotonly tlie cornea, Imt also tliose in the anterior chamWer, iris, and an( I if tlie pupil l)edila ted and the lifjlit thrown almost peri)onilic Iv into tiie eye, chaiifies ii 1 the anterior layers of tlie vitreous iiiav be niai le out as \v( ■11. I.IIS.< llj SllhsldlICi in the viirnvdi vpitlivliiDti ma V be demonstrated by instillinfi a drop of tluorescin in cent.: carbonate of sodium, ;}.5 per c( to the eve ((iruebler's tluorescin, 2 per ■lit.), the surface frosn which thf rpithelimn \vliil<^ the n is removed being stainei 1 pre* •111 isli vellow bv the drug. St of the membrane remains cU The iitiir)if--f of the cornea \ tested best by gently touching it with a wis]) of cotton if sensation be unimpaired, the eye will wink ri •Hexlv: but if the lids remain iinmt ibile, further investigation of the sensibihtv o ,f the skin of the surroundnig tissue should Ik> tnade with an a he.siometer, to determine the extent of tlie aiuesthesia The anterior chamber Should be examined in respect to its depth and contents: among iiig the latter w hicli the chamber may contain being ,|„„d, or hjiphnnw: pus, or huropijon. and foreign In bodie; The Iris. In the exaii nil iition of the iris the attention should be lirected chiefly to its color, to the appearance ( if its stroma, and espe- cia iris llv to the size, position an< 1 behavior of the pupil. The color of the du( to tl le auK )uiit and distribution of the pigment in it: m ;ilblllisni. w here there is an absence ( )f pigi lien t. the iris is translucent, 'I'***'*/ p^^ ton* Tlieirisi. (Kiths.i Miwi ill iiewlv born children it is almost invariably of a ligiit grayish _ blue The "irides iiiav ditTer hi color in the two eyes, chmmalic asiiw- m m>'lr>r or iiarts of tli'e same iris may be colored ditTerently, piebnld m u;>. Discolorati.m of th<> iris .sliould always .-xcite suspiciui. <,t inllalliliiatioll of melilbriilie. :sw«HK-'£ ■'^if^syfi-mss^-^t^mmmmtsmjnijmDs-j, IP 28 THE EYE. Wlicii vicwcil ilirniijili a iiiaiiiiityiii;: ass. witli tlic aid of ()l)li(iuo illiuiiinatioii, llic iiis is seen to I ic (Miinposci )l' a sciics ot elevations (Fiji. t>) ;""' ilepressioii vessels, wliicli run rat while the deijicssions cor s, the foiiner ix'infi occasioned by the hlood- liaily Irom the base of the iris to the pupil: res"|iond to cryiits in the stroma of the iris. and are found chietlv near the pn|)iilary luargni. Although these elevations and depressions are sharj) and distuict in the normal eye. they become blended in intlannnation, which constitutes an important sijin of iritis. Ciianfies in the i)iane of tiie iris, tears in its i)upillary edge and base, and any wavedike movements on its .surface, /r/V/<«/('/(c.s/.v, should be .searclH'd for carefully. Thickening; and vascularity of the membrane .should be remarked ami the character of any nodulation noted. ThePupU. The chief characteristics of the healthy pupil are it.s circular outline and its mobility. The size of the i)ui)il varies fjreatly in health, ranging from 2.44 to .').,S-_' millimetres, \m\\^ intlueiiced by age a: ! refraction, and is directly dependen, upon the stimulation of the lighi. acconunodation and coii- verfient imp\ilses which it receives. \Voir',!\v places the average at 4.14 millimetres. As a rule, age causes the pupil to grow smaller, and it is also more likely to be smaller in hypermetropia than in myopia. Its width mav be 'a.scertaine<i by means of the i)upilloineter, which consists of a scale, pr(>ferably of glass, graduatcnl in circles ranging from 1 to S millimetres. (Fig. 7.) This is held close to the eye, and wliile 1 Fir,. 7. nirschbvrn's piiplllometer. the patient fixes his gaze upon some distant object, the circle should Ix' found which corresjionds with the diameter of the pupil. I'ntil the student has ac(iuired suflicieiit skill to enable him to obtain tin accurate measurement of the pupil by simple inspection, some such scale slxiuld be employed in ail {'ases. The pupil should be" nnnxl, but this is usually prevented bv astig- matism, which gives it an oval a|ipear;mce: it should also be situated sliirhtlv to the nasal sid(> of the centre of the cornea. The sejiaration of the jnipils from each other varies with ag(> and sex ;iiid with the form of the face: i" .adults it has an nvi ol 58 mm., although Nagel places it at i\.\ nun. fXAMISATIoy or THE EYE. 29 Till' pupil is rarely dear hhu-k, the antorii)r surface of the lens re- lli(tiii<; some lifjht; iiuieed, tins reflex is often so marked in elderly siilijcct.s that the grayish film due to sclerosis of the lens is often mis- taken for cataract l)y the inex()erienee<l observer. If ol)li(iue illumi- nation he employed, however, the true nature of the opacity in the lens becomes maiiifeat. Fir.. ». Ganglion trunci vaiji- Suj). cervical yanglion- \^Cilio-3pinal' rt-gion Vagits ,iud BympatheticX' ntt'ves S- 2nf, cervical ganglion^ Aminlii.f of VicHs^cna- SttUcite ynr.ijlion~ Card''fc nerves Illustrating the paths of Innervation of the iris. Constrictors from the corpora (luartri- i,-.iiiinii hy the thirrt ner\'e. ciliary (faiiRlion and nerves to the circular musoles of the iris, nilatoir I; the hulbanrt coni by anterior roots of the first three thoracic nerves, especially the second ■■iiiTii romniunicanles. cervical »yni]«ithetii' ami nantjlla, (iasserian ganglion, ophthalmic branch ol 111.' lilih nerve, ciliary gangliun and nerves radiating to muscles of iris. (Waller.) Til.' iris is the diai)hrafrm of the eye, and by its action in intercepting iii:ii-^Niial rays it prevents an excessive amount of lipht from entering the ry. In order that this may be accoiiii)li.shed with great rap'dity mihI tlie size of the pupil instantly changed, the iris is provided with a de!ii':itc met 1);!!!!^!)! Wonderfully adapted to the function which it has topeifdini. This consists of two antagonistic factors: one, a constrict- ing mechanism, to contract the pupil ; the other, a dik.ting one, to dilate :«) 77/7; EVi:. the iHipil. Tiic toiiricr is accoiiiplisliiMl hy st'mnilatiiui of the oculo- iiiotor nerve and (•(.nscimeni cDniiacti-n of tlie sphinclor pupilhe, a circular niiiscle SUIT. .nil. lin^' the pupil; tin- latter, l.y tiie absence i.f this stimulation aii.l l)V the coiilractinji effect of the cervical syinpa- thetic, which sujiplie-^ th. .lilalor pupiihe, the ineri.lianal muscular lihres'of the iris an.! ai.'.> the hloo.lvessels of the iris, < traction of these vessels causinfi narrowiiifi .if the iris aiul dilatation of the pujiil. The reaction of the pupil is eith.'; irjlcv action, in which event the impulse passes al.irifi the o|)tic nerve, the afferent nerve, to the oculo- mot.ir centre, ami aloiifi th 'uLimotor nerve, the afferent nerve to the eye. throuf;h the me.lium of tihres which connect the cor]»ora <|Ua.l- ri"eniina with the nuclei i>f the oculomotor nerve; or it may l)e ((.-«>- n7iliil, in whii-h case the imjiulses arc set into action sinuiltaneously with etlorts at accomin.i.lati.m an.l converfience. The .lejiree of the puiiillarv contraction in associateil action is always less thasi that ohserveil in the reflex reaction. TiiK iii:i-i.i:x 1{KACTI()\ of the juipil may he either dinrl or nmscn- siKil. The ih'ircl Hijlil n'jh-x is the extraction of tiie juipil which is ohserveil in the eve when it is exi).ise.l to increa.se.l illumination, the (■Diisfiisiiiil or itiilircrl liiilit rcjlrx beinji that which occurs in the pupil of the other eye, foll.iwiii}; e\i)osure of one ey(! to lifjht. The direct ' li'ilit rvjler is hxtcd hy alternately shadinji an.l un- c.)verinfi the eye in daylif;ht with the iiand, or hy concentratiiifr artificial li};ht upon it, either hy means of ..hli.pie illumiiiati.m or t\v the mirror of an ophthalmoscope, the fjaxe of tlie patient iieinj; iixed on a .li>tant .ihic-t. to avoiil any associated stinuilus from < ither accommodation or converjience stimuli. It sometimes haiipens that after the cover is removed from the eye the hrst contract i.m of the jMipil to light is followed hy dihitation. and often an interval of extreme contraction, heing succee.led l)y mo.h'fate dilatations and contractions until the iMi)il hec.imes stationary. This condition is terme.l liippm^. an.l is cxplaine.l hy Swanzy .'is follows; V.wh con- traction .if the pu|>il, hy .liminishiiif; the sujiply of light to the retina, contains in itself the cause .if the succee.ling .lilatati.m ; an.l for the c.inverse rea.son, each dilatati.in sots ag.>ing the succeeiling coii- triu'tion, imtil at last e.|uilihrium is attaine.l. llip)ius is seen in cerehro-spinal sclerosis, ilisseminated scler.isis, neur.isthenia. hysteria, psychical .listurhanc.'s. ejiilep.sy. an.l acute meningitis in its e;irly stages. The conscnspdl or indinrl jiiqiillar;/ nadion i." Ii'slcd hy .iliserv- ing the motions of tiio pupil in the other eye while the eye under examination is heing alternately covere.l and unc.ivere.l. This test is ilepen.ient anat.iiiiically u|)on the fact that fihres pass from the retina .if each ev(> thr.iugh tiie chiasm partly int.i the right .an.l partly int. I the lelt optic tract, an.l th.'it t'r.im these the stimulus is trans- mitte.l ilirectly to h.ith right an.l left ocul.imotor nuclei, each micleus setting up a contraction .if the pupil of its own si.le. t:xAMiyATwy of the eye. :J1 Tlic (lircM-t light reflex is tested for tlie purjjose of detectiiiii the cxisleiice of adhesions of the iris to the capsule of the lens (posterior synechia), and to deteiinine the sensitiveness of the retina and of the visual apparatus ftenerally to lifiht. The reaction is an exceedingly delicate one, and indicates the presence or ahsence of (|uatititative perception to lijiht. It will presently he e.\])iain(>d, however, that the iailer function may he wantitif; in certain diseased states, and yet the pu|iil reflex take place; or the pupil reflex may he wanting, and [xt- ccplion of lifiht still be present. Tlif (issocifitt'd rciidion aj the pupil, or the (i(r<iniminkitii>n and ruiinr- iltiicf irjh.r. is tested hy ro(|uestin}i the ]>atient to look fixedly at an nlijcci iield in t.ie median line about 10 cm. in front of the face. The ccntraction of the pupil which follows is due to the intimate associa- tion of the central innervation of tite sphiticter nuiscle of the iris, the ciliary i)ody, and th>' internal rectus muscles. While accommodation unassiiciited with converfience will not cause contraction of the pupil, reaction follows converfience stimuli alone. In contradistinction to the contraction of the pupil when acted upon by lii;ht or accommodation or conver<;ence stiir '" the pupd inmri- tililif ilildtes irlien itrted iipi>n lii/ seuyori/ ytinndi. 'l.hs the ])U[)il which is contracted diu'inK sleep and deej) narcosis dilates at the moment of \vakin<r. The pupil dilates also under nervous excitement, such as fear and siu'pri.se, and also witli deep ins|)irations and expirations: it is dilated also during Imnger and in aiuemia. Irritatinp; or i)inchinji the skin of the neck is followed also by pupillary dilatation (pain reaction). Moth |)upils should be e(|uai in size, unc(|ual pupils (nnis- cco/vV/ 1, although freciuently of no import, lu'ing often a grave sym])tom. In testing the reflexes, it is essential to observe whether contraction aM<l dilatation of the pupil occur simultaneously and to tiie same degree in both eyes. As a rule, it may be stated that the least niov- :il)le pupil belongs to the atTected eye. .\s ileepjy seated disease of the bniin and spinal cord freciuently manifest themselves in some disturbance of the pui)il, it is most essential for the student to understand fully its nervous connections. The Behavior of the Pupil in Disease. Pathological processes which affect the iris inanifest them.selves either in a contraction of the pu|)il (miidsis), or in a dilatation of it iwiidrinsis). |{oth of these differences in the diametiT of the pupil may be the expression of litlicr s|ia,sin or i)aralysis of the nmsculature of the iris, or they may be the result of some inflanunatory condition of the iris or within the eyeball, as. tor example, the myosis which .■iccom|)anies iritis, or the Miydriasis which is seen in glaucomji. Myosis (contraction of the pupil). Myosis may be due either to spasm of the sphincter puf)ilhe or to au irritation of the contracting centre 111- nerve fibres, .s/w/.v/Zr mi/osis: or it may be the result of par- aly>is (i| the dil.iting hbres of the jnipil or of the pupil-dilating centre <ir nerxc hbres. pawhjtic nujosis. Kitlier cause operating alone oc- casion> a moderate contraction of the pupil; if both are active, the 32 TIIJ-: i:yi:. I'lipil IS (•(iiitiactcd to a |)iiii)<)iiil. ('out raft ii.n df tlic pupil follows :""»i''':'^' i'"* Klimulution of both dilatiiij; aiM coin met iiij; mccliaii- isiiis. The most comiiion cause of coiitractcii pupil in disease of the eye is aillierence of the iris to the lens capsule. Sjuislic „ni„si.y is syinptoinatic of intlanunatorv alTections of the i)rauiand its ineniii>,'es: it is present in the earlv st:i«i-s of intracranial tumors which involve the third nerve; it is se'en at the bcfiimiiiiji ,,f hysterical and epileptic seizures. I're.ssure upon the pons cau.ses myosis. It results from stimulation of the pupillary contracting centre, and occurs in those who sutler from tobacco amblyoiiia and In those who follow trades which demand lon<; maintained" efforts of accmimodation (wat( hmakers, jewelers, etc.). If, in the course of a case of cerebral .li.sea.se, myosis jjives wav ti> sudden dilatation, the im.RiK.sis becomes uravo, the stapc of depression with paralysis of the third nerve beiiifr indicated. .Myosis may be a rcHe.x action in ciliary neurosis: it accoinpaiiii's m;mv disea.sed conditions of the por- tion ot the eye supplied by the fifth nerve. The pupil in irritation myosis IS but htlle affected by reflex stimuli; it is verv su.sceptible however, to drufts. mydriatics dilatin^r it widelv.and mvotics c(.ntrac- tiiifi It ml mnximum. In contradistinction to" this, the pupil in par- alytic niyo.sis reacts actively to the ditTerent reflex stimuli, ami is but little afiected by mydriatics, althoiifjh myotics contract it greatly. Pariilnlir mi/osis occurs in spin.al lesions above th(> dorsal vertelme and IS especially sif;nificant of tabes dorsalis. In the earlv stages of this di.sease, in which the cilio-spinal centre or the hijiher n'-gion of the cord alone have been atfected. the pupil is but moderatelv contracted, and reacts to both lijjht and on convergence: later on, th" pupi! I>reseiits the phei leiia which have ben characterizeil as inii/ll- Rohnlson i„ipU or /-cy/cr iri(lo,,la,i„~i. v., the pupil responds verv .-liKhtly or not at all to lifzht, but is .active in accommodation and conversreiice. The lesi„n which produces the .Vrfjvll-Hobertson pupil has been variously situated in the fibres which pa.ss from the proxi- mal en<l of the optic nerve to the oculomotor n;.,'lei. and to a nuclear Ic.si.in pure and simple. Another pupillary sijrn which is seen in tabes dorsalis is known as iniiUiUrnl rvjh:r iridnpliqla. In this con- dition one pui)il react-; to accommodation, but not to li<;ht, while the pupil in the fellow eye resi)oiids normally. It is probablv the result ot a lesion in the nucleus of the sphincter of the iris. Paralytic myosis is seen in jrcneral paralysis of the insane, in mye- litis ot the cervical portion of the cord, in i)aralv.sis of the cervi'cal sympathetic from pressure, in bulbar palsy in association with jiro- jrressive muscular atrophy, in .sclerosis of the brain and spinal cord, and in some forms of multiple lu u."itis. Mydriasis (dilatalioii of the inipil). This mav be the result of either irritation or paralysis of the -entre or fibres jrovi'minf: i)ui)illarv .u-tivity. Sjm^lic mi/drinsis occurs in hy])eraiiii.a .and irritation of the ccMvical portion of the .sympathetic, in tumors of the cord ami brain (although :v: \ KXAMiyATtoy OF Tilt: evi:. 33 r.iii'lvi: in tabes ilm-salis: in '■'Ttain fdriiis r)f intestinal irritation, t-|jc(ially intestinal tinnms: in anu-niia; in psycliieal excitement, for e\:ini]i|e, fear, sinprise, acute mania, melanchoiia, ami profiressive |iaialy>is of the insane. In this latter disease the myilriasis is fre- i|iiriilly unilateral ami is assoeiateil with inyosis in tiie other eye. In spastic mydriasis the pupil is motlerately dilated, contracts >lii:liliy to li;;ht and converjience, and does not dilate to sensory -liiiiuli. .Mydriatics dilate the pupil <ui niiuinirini, hut myotics exert 1ml little action upon it. I'lintlijlic Hinilriiisi.y, or, as it is sometimes called, iridojilfiiin, is c.iu-i'd hy [laralysis of the fibres of the oculomotor nerve, the liranches w liicli iiniervate both the intrinsic muscles of the eye — /. e., f lie sphinc- Irr pupilhe anil the ciliary muscle — beiiifj usually affected. It may be ilir result of paralysis '>f the nucleus of tiiis nerve in the pons, or truin failure of the stin Jus to be conducted from tlie retina to that ciiitre. The pupil is n derately dilated, reacting to sensory stiiuuli and to li<;ht and on converg'-nce, accordiiiR to the seat of the lesion. Thus if the lesion be between the iris and the pupil-contracting centre, tlirrc is no reaction, eitlier direct or consensual: but if the lesion lie Ik I ween the retina and the pupil-contracting centre, the pupil will ncit contract directly to light, although it will consensujilly and on convergence. Mydriatics dilate the pupil ad timxinnim, but myotics <'ontiact it but moderately. I'aralytic mydriasis occurs in diseased |)roces,ses at tiie l)aso of the br.ain, involving the centre of the third nerve: in affections of the orbit which exert ])ressure on the ciliary nerves: in cerebral processes attended with mark(>d increase in the i)re.ssure within the skull, such a> tumors, hemorrhages, and absces.ses, and in the advanced stages of thrombosis of the cavernous sinus; in i)rogressive paralysis: the later stages of meningo-<'ncephali1is, and acute dementia. .Macewen i- authority for the statement that hemorrhage into the centrinn o\ale and cerebral ])eduncles also produces mydriasis. (llililli(thii<>iil('(/i(t intcriiii is the name given to tlie dilatation or |iaiti,il dilatation of the pupil associated with a failure to contract iHKlcr stimulus: loss of accommodation accompanies it. The condi- liiiii indicates a nuclear lesion. Transicnl mudn'asis affecting first iiiic eye and then the other, is generally regarded as prodromal of iii-:inity. It may be stateil as a general rule, that dilatation of the pu])il wliin observed in connection with a cerebral lesion indicates an ex- irii>ive lesion of th(> brain; ind, when it is of spinal origin, irrita- tion lit the part affected. Mydriasis is conunonly observed in glau- I'liiiKi. When mydriasis is due to a failure in transmi.ssion of the liirli! -linmlus to the pupil-contracting centre ami nerves, |)upillary aiii\iiy occurs only on convergence. The mydriasis which accom- panies ijptic .'(trophy is the type of this class. Till' dilatation of the pu])il which is observed in complete blindness "iiiiinirosis) should not be considered as a disorder in tlie mobility of 3 mmmim 34 THE EYE. tlio iris, hut should rather 1m' n-pmlod as a physioloKicitl inhibition of th(> impillary n-flcx .liic to th«' witlidrawal of tiic iM-nrption ot heht. The Iwitii'iinoiiic piiiiilliirn innctiim sit/n (Wtrnirkr's). Hv a of tl.ix sipi it is somctiiiK's possible to di-tcriniiH' ii' (vrtaiii cast's of half-bliiidiicss whctluT tin- s.-at of the lesion is situ:;ted anterior or posterior to the (•oii«>ra .|im.lriKeiniim. (Fiji. 0.) This t»^t de|K>iids upon the fact ihat the visual fibn-s in the optic nerve join the hbr^s of the third nerve, which contro' th:- sphincter pupilhe at the corpora (luadrineniina. If the lesion Ix- iM)sterior to this point of junction— i. e., ■ back of the coriM'ra, in tlu' oc"ii)ital rortex-there will !«> no inter- ference with the i)upillarv n-Hex. Should, however, the lesion Im» situated anterior to the eorpora, the reflex arc of pupillary activity will he broken, and an irregularity in the pupillary contraction wil manifest itself. The hemianopic pupillary inaction test is jH-rforined Ix-st bv placing the patient in a <lark room, with a suiRle source of Iim«tmtinK (he twt for hemianopic pu,.lllary Inaction ; the lii.w represent n horljonul plane llm.ngh the left eye an.l Us visu«l tli-l.l F O. fun.lii, .Kull. H M.unl,i lutea. A Naaal Imlf of the lleUi. which is Hnwihetlc in tenii-.m! hemiunopsla. T. Temi"™! Imll ol retina. T F. Temporal tiel.l P. Pupillary H,wrti.re. iMj" to u°. the equatorial arc or sein.cirilc. IIU^. vertical ,K>1.U and line [«».inK through centre of eye t,. M. 70° and iifi. rays of light striking the iaseciUve nasal half of the retina, proriucing no pupilUry retlex. (Skuuin.I illumination back of him, *he eye not under examination being closely baiiilaged and the patient being directed to l<H)k uito the distance. An assistant sht.ulil then moderately illumine the eye by directing light 'ui>on it bv a plane mirror, while the examiner turns a narrow beam of light, reflecteil from the concave mirror of his oiihthalmo.seope, upon the different parts of the retina, and closely observes the effect upon the movements of the iris. The cerebral cortex rejhx of the pupil, or Hmth's rejlex, is the con- traction of the pupils in both eves which occurs without change of aeoomiuodatioti or rt.iivergf nee when the sv ieet, seated in a dark room directs his attention to some Imght object within his fielil of mF^m. wm wf^m. KXAMfy.lTlnS OF THE EYE. .•»6 vision, the amount of fontructioii Ikmiir proiM)rtionat(' to tlic luiiilit- riCSS of till" ot)j<'ct. Tlif (irhinihtris piipiUarij mirtiini, wliich is used to lietcriiiiiic a |i..ssiiiic paralysis of tlic sphincter of the pupil, is a coiitractioii of tiic pupil wliirh occurs u|)on forcci I closure of the lids. Clifford, the discdViTir of this reaction, Wieves this contraction to he an over- He iw stiiiuilus which is excited in the nuclei of the orbicularis hhres of the facial nerve, anil conv yed thence to the pupil-coiitractinjj centre. It is Ix-lieved that when trigeminal anasthesia is associated with rellex i)upillaiy innnolnlity it may 1m' a.scrilM'd to a lesion of the spinal root of the fifth nerve. I'lirtuliixivnl piipillnni reovtion refers to the condition said to he observed at times in meningitis, when the pupil dilates U!K)n exposure to lifrht, and contracts upon its withdrawal. The Light Sense. In order to test the power jK)S.ses.sp(l by the retina and the visual centre of appreciating variations in the int«'n- sitv of the source of illumination, an instrument is em|>loyed which Phciiometer of Kiireter. (FucHSi is known as a photometer. (Fip. 10.) This consists of a square box in whii'li are placed black lines ecjual to certain standard letters when seen at one-third of a me' -• from the eye. These lines are illuniinated by a standard candle, tl; degree of light l)eing regulated by a window, the size of which may be varied. The patient is first made to look into the apparatus with the window closed. The window is then slowly opened and the lines illuminated. As socm as the lines are recog- nized the size of the opening re(iuisite for this jnirpose is noted, anil if it !«■ found that -m oiM-ning more than 2 mm. sciuare has been re<iuired, a subnormal light sense is jjre.sent. Before making this te.st, it is neces- sary that the subject under examination should remain in a dark room forat least ten minutes, in order to adapt the retina to the absence of light. The study of the dimiiiutiim of the light sense is of great value in certain diseases of the retina, when lowering of its acuteness out of proportion to the visual acuity is of great significance. The light sense of the periphery of the retina may be tested by passing a candle flame affixed to the are of a perimeter through the fi 3tf THE t. YH. (lilTlTfllt IIHTlillMIlS III liluycdiisa poiiil nf ll\:itii'ii. fli.Ilt nf tlic <■>•(•, Willi"' :i ^"•••"li'l <•;> UK III' is J'lWi rifMnf\isi..ll.i Ilnldrn'stl'st for tins ,„„.,,ns....-uiisi.tTin':;Mvrtaiimif: tli.- ,H,ii,ts uii tli. I«'«i"";'<''; •>' wllirli Wl.ini :i >.'Vi..s nf t. st >^rr^. i~ |K.nvlV... . Vn drU.-l .IptUll-all. I . ntrnu,.,liMt.. an.l .-iiliiil /uii..s ..f ti..- h.'l.l. Ii. .Miiplnys a ran , " „„, ,,,,..U ,„.i,i, -11 ....... A.U' a.ul a 15 iiini. ;,ua,lia.i ut M.t ) . li.vin,' luui-litths nf tlii.int.-nsity ..f tlu; wlut... on tlu- o lu • \\ iii ■rim,..,.r ul' :;() .■in. ra-lius tli. Mark point and «ray ,>^. .•!. a.o .; .. , l.v .1... noniial ..y.: oiilwanl »:. .I.%mv- upward .« d.-j:n-.- , ■ rd r. d<■"••'•<•^ downwanl :;:. d.^-nvs. To drt-'t jM-npluTal di- Jid'; lid a' dark..,- «.ay pa..!, having ">'--"' "-.""• "":i";;;,;i^ vvliit- on ,1,.. otliiT. i:a.-li >l.oi.ld i... s..,.n on tl„. I7-'"'''''''^ ' /'l: l.nvin^r pnints: ,.„tward 70 d.-n-.-s, upward l.> d.rn-.'s. mwa.d ■>.. ilc.Mvis, and ilowiiward .V)dcs;nMS. ; . i:.,hl.. uf tension or intra-onilar rcsistam-c i> liaiiic Tension. As tiii'dc^ivi 111 vary in many discascil taiiH'd ill every case. eonditions. it is es.sential tiiat tins he ascer- Cliiiieallv it is not jioss sihie to a.s('ertain direetly the intra-oeiilar Uiiiieaiiv II 1^ I"" i".^.-..- - f . , „vs>u,v 1 lit a sulliei.nllv aecurate estimate may he made of it l.> '"i. n^' t!ie tension of the eyes as felt with the liii«ers through he ,,. H.riid. To .lo this, it is hest to employ th.- two index hn^eis ,, „ I ,.,• tinjiers heiii« spread out on the temple and hrow to atlonl , h s support. The' patient is direete.l to look down, ai.l slight J- e is made on th.- plot..- alternately with tlu- two tin^.Ts. 1 lie ..ree of tension d..i.ends not only upon th.- mtra-oeiilar pressure, ;i;;: "iKn:;.;;:;;;:. si,;.;;d o.. o.. .h.. lempie an,i u... t.. affo,., ti pre: llrio't:: '"r^ilMit ':V;;;a ■:;.; th^-elastleity ..f tl. selen-tie, wlneh vi.:' with. :;e,an.l also v.:ih the in.iiwd..il^ „. hiipovtaiit, there- fore, in esthnatin^r whether the tension ot the eye ^^ t^'f'^^ - t,„„ „„,,„al. always to eoinpare it with that ol the tellow eve, pn- siimin« th.'it it is unaltered. The (litTerellt dejlives of tension aiv noted as tollows: T \ Normal tension. T full Sli<'htlv more than the aveia,'.;e normal tension t' i \"-li"iit hut decided inerease ahove the normal tension. t'. -2. More'marked iiu-rease of tension, hut where the fiiifiers eau still sli'ditlv impress the jilohe. . , T. :{. ■increase of t.Misioii so marke<l tint no impivss can he niade ;'n the jrlohe. Diminished tension in the same way is recople.l as ^ Several dilivrent' instruments have Ixm-,, invented for recordin- Hie U'.isi.m of the eye, call.'d hmnmetcr.-^. None ol them is ot .sulticient practical u.se to need description hen if three dejirees: the KXAMtXATlOX OF TlIK EYE. a? THE 0PHTHALM08C0PB. llir ^tiiiicht haviiiK ai'.iuaiiitcd himself with the appfaraiici- of the 1 as iinicli nf the interior as may In- Icarnci! l)y Atclllil' <' if thi' eve am |;,i,i:il ilhimiiialinii is iniw prcpami l.> (•cimplclc liic I'xamiiiatii III. ,\ v\\ iliiriii;; miiiutfiy tiir inicrior nf tlu' v\ Dm ai'iiiiiiit i)f cciiam optical lesion ich an examination rannot I,. l,y the nakeil eve, and the student will have to eall to his ,1 -I deviee whieli will .ivereome these and remove the hiiideraneew ppose his view hito the eye. Aithoiij;!: liie prineiples of siieh ulilcll o :; dr\ici su^Ijtesteil and near v attained l)v a mimher of early >iii'iitisis. the honor of perfeetm): an irii'iit lielollils to 1 elalHUatiii'' them into an instni- ,////,.// IIIIISCIIJM' 111 llelmholl/,. This distinfinished physicist invented th» 1S.")1, and l)V this instrument solved the prohlem of -.miiiltaiieoii .■illhoii v ilhiminaliii"' and viewinc the interior i.f the eve ^h the iiistriimeiit employed by him was crude and inetlicieiit iny wavs. it comprised allOf the optical principles of the later- iplithalmosco|M'. his instrument immediately opi'iied a new held The discoverv ot t Mill on Iv ii the studv of ophthalmolofiy hut in that of clinical medi- well. Conditions w iT the names of amaurosis aiu hich were ilescrihed by the older writers 1 l)lack cataract, terms used to li'-iLrnM te all forms of blindness the cause of which was not apparent ,f the aiterior segment of the eye, wore an examination o veil into vari( )Us diseases of the opt ic nerve retina, am", choroid. Ii WM- fniiutl, furthermore that svstemic disorders <|uite remote from Ihr v\v sue as a tTections of th<" kidney iieart, and brain, often pre- I tl'"ir !ir>t 'uamies •ount no routine examiii nil- :hm lie lim iKir i< a ciinician ju itations in the hidden tunics of the eye. I'pon ation of the i^\i^ can k' considered to iiiilil ii'iiii'ni IICIAI perlv performe.1 until the ophthalmoscoiM' has Im'cii emi)loye(l (•linician justified in rendering a diajinosis in many ca.ses is aware of the intra-ocular condition. It should be br'i-.'d that bv no other means is it iiossib'e U> sec a living ■ad and to study the complete vas( ular cycle in an orpaii, of llie elitl'ance o if its arterial and the exit of its venous blood. I.ike most instruments of a similar nature, its use presupposes :, rrtain ainoimt of prai'tice, and the student will succeed m anpur- inu' :iliililv to us(> the ophthalmoscope only after the exercise of I Mn-i.|rnil')le patience ami emleavor. One api)roachinL' its study should iiHi . ;imIv b(> discourajied, nor should he expect to become expert in IN M-.' ill a few weeks' time: he should sedulou.sly cultivate every '|i]i'itiii!iit y that jireseiits itself to e\;imin( tli(> interiors of healthy ir It IS only by a il ri.ndiliiilis mav be recoirnized kiiowleil<;e of the phvsiolojiical that patholo;ri .\rtilicial eve: .ire iif drciiled Value when it is imiiossible to obtain na such as 1 tural 'ernn s. eves for 1 J |.-i,iil |,rni.'i|ilosiiiV(ilveil In .jplnhrtlmoM-ni.y, thf llu'i.ry of ihe ophthnlmnwoiif. mid the • let. rin:^ iiiun nf ihf ri'fmotiun of the eye by it will bt coiisiik-iv.l in tliu I'hapter on Kelraclion. •M Tin: EYi:. stiiily, «>r a r:il)l>il's eve may l)c utilizi'.l. In on' t tliat tlic stuilciit niay'lM' lau'ilil accunicv, and Miay ai>|>ivciatc fully the iiaimv of tiic ciia'iijli's whicli the o|>liilialinosco|M' reveals In liiiii. it is a(lvisal)le li>r liiii '^..sketcii what ill' sees; for while but few persons possess sntli- cient skill to make an artistic .Irawinu' of the tindin-is of tlic oplithal- nioseope. nearlv everyone may proihiee a schematic rei)resentation (if I hem. especially it" lie employs a sketch-liook sudi as has been (levisecl i)V Haali. The writer knows of no nhjectioii to the student's inakinj; his tirst trials with the oi)hlhahnoscope upon eyes the pupils of which iiave heeii arliliciallvdilate,!. The employment of the instrument isfjivatly facilitated thereby, and the fact that he has once seen the fundus will enable the beLdiiiier to proceed with more conlideiice upon eyes the pii|iil--of which are undilated than he wiio has never experienced tile sensation of aetuallv viewin-i the head of the optic nerve and the retinal ve-^sels. To avoid any possible accident resulting' from the emplovmriit of nivdriaiics, individuals under forty years of ap' slK.ul.i be i-hoseii, and eyes which are free from external sifiiis ot ilise;i-e llomatropiiie in weak solution if irrs. ad. f.-.j i is a con- venient druf; to employ for this purpose, as it proiluces a dilatation of the pupil in thirty nVmutes. and its effects are very evanescent, and may be rendered -till more so by the instillation of a_i'ew ilrops of a solution of eserine loerine suljili.. ^M•. >s; a^i. <lest.. f ."ij ) at the com- pletion of the examination. .Mtliouirh not es-eiilial. unless tile student have markedly ilefective eves, it i- di'-irable, to avoid errors in the estimation of the refraction ami to nbiain the clearest imaiie of the fundus possil)le_. that he have the refi.-ictioii of his (iwii eye< estimated and <'orrected. if neeils be, by <rlasses before attemptin<z ophthalmoscopic work. ^ Method of Ophthalmoscopic Examination. |.\ote. Since the prin- ciple- which irovein ophih.aliiioscupy .are not described until the next ch.-ipter. it will be supposed, to avoid ambiL'uity, that both the eye- of thi' -urireoii and those of the patient are oi normal refraction.] The Instniment, The most i— lailial pari of .an ophthalmoscoix' is ;i mirror with a centra! perforation, as it is necess.ary that tiie lijiiit dmuld lie rellected into the eye ;m.l an opportunity afforded the .ili-ei-ver to ^r.iin a view of it< interior .it the same time. There should he iwii miiini- on every instrument: a plane one to detect opacities ill the media and sliLdit' chamrcs in the I'olor of the eye--rroun'' and a r. me.aveoiiedf ;il)out :|l»(Mn. focal di-tance. for ofdin.ary exaie ion. In addition iu the mirrors, everv ophthalniosi'ope -honld be ji. vided uiih ;i series of lenses to neiitrali/e the refraction of the eye. in order to (li)taiii a -harp and distinct view of the det.iils of the back,irro\i:iil of e\-e- of .almormal refraction. W bile there are a host of ophthalmoscopes employed throughout till' wc'iiii, liie most |iopiiiar in llie i'niled Sl.iie- and the I nited Kimrdoin are the l.firini: .and the Morton o|ihtlialmoscopes. resp<'c- tivelv, Uoth of these instruments exhibit to a m.ar' cil defrfce the W" npmnsMiil j:.\.iMis.iri(>y of nit: eye. 39 ni,,st I'ssciitial t'ciituivs in :in ophlhaliiioscopc. viz.: larficiicss of field ,,l view. iini|)cr iliuiniiiatioii. and the aliility to hriiis a variety of IriiH's licforc tin- sijtiitdiolc in tlic miiTor, witlioiit tlic necessity of iviHdvin; the instriiitient from tlie eye. When propi-iiy nianufac- i,,,...,i m, ,■ wl" these instnnneiils should la.-^t the averaj;e ophthal- II, u, ...i-; a lifeii.;," , , ■ ' , : „-lii'i iij,l,n , Iniosropc. As shown in Imj;. 11. the Loiinj; ,,.,! I.;, ,|,,sc.i|..' i: providetl with a coneave mirror, parallelojiram ill . , .with ,1 .-entral perforation from ;{\ to I mm. in diain- ,1,1 The mim.. is so hinif; upon the frame that it may he tilted ■_'() ,|ei;rees to the rigiit or to the left. For the purpose of focusing i,,»ring's ctphtlialnioscnpe. !;,■ r ■ !,■ 1- I'l |M| nhirl !,'ll-i I'aiii; C.I :: Tl ivs upon ihe fundus in the i-vent tliat the format ion (>f the ~ almiiinial, and secomlarily to oi)tain the dejiree of refraction ..1 the eve. the instrumenf is provided with a series of lenses V \»' rotated hehind tiie sijiht-hole in the mirror. These I i!ia\ ^ iiv .'ontained uiion a full disk and a (|uadrant of a disk, and iiniii the weakest convex and concave spiierical lenses to those -Mviiirili suflicieiit to iieutrali/e the lii^hest ocular defects. . \ln,i,„i Ophtltnhiioscoiif. (Fifi. !■-'.) In this in.struiuent the - !v —t in a <-v!i!!d,.r in the form of ail en-lless chain, and are pro- li'll'i i.v M siroiifi'drivinfi-wheel. The instrument is jirovided with tluv, miners— one plane and two concave, one of 10 inches focus and pflf m 40 a sniMllrr mw n\ ., Tin: i.Yi:. illl'lli'^ |(ICU~ Tlir t wo lust, wliu'ii ar '(• si't hack to ick ill Hill' iiKiunliim an I arc fcvcrsihlc, ar niil iviiiioscoiiv: tlic siiiallci- concave on( htliali (' for iiiilircct examination is for the direct iiietliod. has been introduced by Oiiite receiillv a stationary o, . , i i • •nionirnFi-.'i:ii.\vliicli.altlion};li too larp' to i.e .iianipuiate.l l.ytnc iiaiid and roii-.r>|uenllv valueless in ordinary rout,,w work, altords an un(M|ualled opportunil v of viewing the fundus williout annoyiiif,' Till' Miirl.iii ■.iilillinlniMSCopc. reflexes un<li'rl)rilliant illuminalion and iiiudi nia'Jinilicalion. ami wjth- ,,ui the necessitv of relaxation of the observer's a<-conniiodatioii. \\\ an arranjieiiMMit of pri-ins it is possible for tlie teacher to a.ljust tile instrument lor the student, and to ilemonstrale the clianires in (!,(, I'.n.Jij- bv viewinir them simultaneously witii hiiii. Examination by Transmitted Light. Before proceediiu: to the ex- amination of the det.ails of the backiriound of the eye by either tiie.liivct or the indirect metiioil.the student should hrsl acciuaint mmii /.'.Y.i.u/.\.i7/o.v or rill-: i:yi-: 41 iM'ir with as niucli as may lio loanicil l)y simply thrnwinj; llic ii of tlic oplitlialiiinscopip miiror iiiti) tiip oyo at a distance iidiii ;}() t(i 40 cm. l'(ir the |iriiiicr pcilDrmaiicc of tliis test, as Fl(i. in The ThonuT (*i.hthKliiH>sr<>iH\ i :i~ I'll' ilic mi'llidiis of oplillialmiiscopic cNaminatioii to lie prcs- ^'\ ii;i iiiiniicl. tiip |iati('iit sliodld 1)(' scalcii in a darkened rodin, ' I liiilit pliiccd a little l)eliind tlir head and to the side of the eye 1 \:iiiiinalion and njion a line with the ear. .\n .\rgand limner IhciiHiociMlt cuil lor i'iihIhntiiH»i'"l'.v, ■•:i;|t!<tyri|, or a <-!nsely woveii i!u-aiidf.--i-('nt ("oil (l-'i-r. 14) ": ;i lirackel which should lie lapatile of heiii}! moved in ail direc- \ii old-fM<hioiied oil lamp wilh a broad llame jrives an excellent wnc ;. ..' v^*.'a *« -.^ji fwrnSSATJ-viTir TS>i...-.-J^.<.'^?iL''; :•'-.- -^ 42 /■///•; K17v. li.rht and (lavliRht mav Iv (■ihi.1...vc(1 hv p.Minitting the rays to f;am rulraiur into" tlic room tliroufjli a narrow slit ni a l)lnul or stmttcr. Sui.li<'lit i< to l>c prclVrrcl when it is .Icsiral)!." to study clianpcs n. tlic tundus as ncariv as possil.lr in their natural color, as m ana^nna. If the patient he l)odri.l.l<Mi. it is lr('.|ucntly necessary to resort to a cmdle as a source of illumination, and the ..l.server may he compell.'.l to make the examination in a constrained posture. Such ('xannna- li„„s an- ai)t to he uns -tory. l)ut the student should never desi.t nor allow himse'' - --me discourajred until he has satished himself that he has ace. .., .i>he.l all that was possible uiu ler the cir- cumstances, la the ])erformance of all onlinary tests \yith the oi. h- thalmoscoix', the observer should b." on a slifilitly higher level than the P'lti.'nt and both he and the jiatient should be comfortably seated: the cu.s'tom which prevails in ;oine Jilaces of the surgeon standmfl and bendinji over the patient's ey is ,leprecated as timdinf; to favor hurried an.l sup.Tticial examinations. In exaimmns chihh'en s eves the p.ilience and iiifrenuity ..f the observer will often lie taxed l„.f,,re a -atisfactorv view of the fundus can be obtained, aii.l a third ...rsnii is often ne("essary to attract the tiaz(> of the child trom the liirror towanl some distant object. ., , , In examination with transmitted lif;ht,the student, with the larfje eoncave mirror of the ophthalmoscope held clo.se to his eye, throws the li^rhl upon the eye under .ibservation. the patient bein.sj; instructed to direct his <:a/.e in front of him. , , , , ,■ \ faint pinkisli-re.1 glow will be seen to replace tlu- blackness ol ,1„. pupil. This is know, as the iimJns rvjUx, and is occ.-isioned by the reileciion of liuht from some i)art of the illuimnated interior ot th,. eve With the 'iuht from the mirror still concentrated u|)on the pupil' the student should now tilt the mirn.r in difTerent directions 'md WW the .•hanicter an<l the direction of the movements of the shadow which will be seen to travel ovr the eye, thus obtammj; an idea of the refraction. The jiatient may then be re,|ueste<l to rotate his eve through the different meridians, and follownifi this the student .houid move his own head fn.m side to side an<l back and torti, the better to obtain the ivllex from all parts of the eye. The mobility o ihe iris <liouldbe tested bv throwhifi the li^'ht upon the pupil, and the perceptive power of the entire retina ascertame.l by redectmj; the li'dit from different angles upon all l>arts of that membrane. \\\\\\' use of the mirror it is also jx.ssible to determine ///<■ jixntion noiul This is done bv observin.-; the coriK'al retlex. This method, ;,tt..nlion to which was called by I'riestley Smith, is practise.l ni the lollowin- wav the patient is told to look at the mirror; the hfiht is tlu'n thrown"ui)ononeof the i)atienfs eyes, am! the exact position of the lifjht reflex upon the surface of the cornea noted; the student then quicklv turns the lisiht to tlii' other eye and compares the .osi- tioii of the'corneai li^dit re(1e\ in the two eyes, 'ilir corneal < Hex L',-nerallv api.ears a little nearer the inner than the outer clue ot the piijiil as the visual axis usually lies to the i...ier side of the axis ot T^rssr. - sc-"S^'?=^iij«aB*-' ■ i:x.iMiyAriox of the kye. 43 ihc ciinica. If hdtli cyos ho properly iliroctod, tlio position of the (■(MIii'mI rcH(>x will he syiiinictriciil in the two eyes; but if one eye ilrviatcs, tlic reflex will he ilisplaced. I.i this way imperfect fixation ill >trahisnuis w'"' he readily detected. H\- transmitted li^lit alone, the presence of npncUies in the mediu may lie diagnosed; these appearing like dark shadows in the red iKickjirouiiil, because the rays of lifi;ht as they return from the oye- ^'nuuid are arrested by the ojjaiiue spots in the media, just as all (iliiicts which do not transmit light api)ear dark when seen in front (if a luminous surface. .\s th(>y often are seen best with feeble illniiiinatioM, it is well to substitute the |)lane mirror for the concave ill searching for them. With a view to examining the media more closely, and to ascertain more definitely the character and position of any opacities, the student should now rotate a high convex spheri al liiis berorc the sight-hole in the o|)hthalmoscope and approach the . \r until he is witliin the focal distance of the lens. For this purpo.se, Flo. 15. l>iaj;iiosis of the site of iiti (»|iurity from [laratlactU' ilisplticenipnt. iFl'CHs.^ iIm' Moiidu ophthalmoscope i< priividc<| with a lens of ,") cm. focal Iriiirtii ! -jn D.I, the I.oring with one of ().2.') cm. (- Ki D.). I'nder ihi- high niagnihcation any foreign body or opacity which may have iidii (ivcrlookcd usui'lly becomes visible. To determine the exact '■H-Miiiin of opacities is often diflicult, and careful observation is re- . ;iirii to state iletinitely whether they be in the cornea, in the anterior I "iii'iii (if the lens, in the posterior portion of the lens, or in tlie an- I liiii- pdrliiii of tin vitreous. It may, however, be stated as a ■.'1 ' ' Till rule, that stationary opacities are in the cornea and lens, and i!i.!i nj.acities in the vitreous, although ;it times fixed, are usually ll'.-.'iiiL'. It is fretiuently possible al.so to determine tlu' location of an w]iiiii\ by comi)aring its i)osition with other structures in the eye in i!i<' - iiic iil.'iiie, as, for example, the conjunctiva and the limbusin cases 'if iijiK iiy of the cornea, and the iris with the anterior part of the lens. \ \. I \ ■icr-iirate. and at the same time a very simj>le mode of loca- tiiii: till position of an o|)acity is by mean.s of the jHiralloctic displace- im III iif the of -ty with reference to the margin of the pupil. Iri 44 77/ A.' KiK I'lfT. I.), 1, 2. .i. 4 n'prcsciit I'diir n|i;ii|iic [loints in tlic (.|ilic;il ;i\i^ "I the vvi; sitimtcil in the .•<,nic;i. u|),,i, i!,,. aiitcridr (•.•i|.sul(. nf the let's, at tlic |)(,>trn,,r p,,!,. ,,f il„. l,.|,s, and in the anterior part of tlie vitreous, resp,Tlively. W lien tiie ol.server is stationed at U all • •ur ponits will I,,, nierfred, and he will see l,i,t one. Should, h.nve'ver '"' '.'"'^'W* '*• "'•'" ""• l"'^iti<>ii nf these p„ints in relation to the I>iipil will he ch.uijred. Thus. 2 will remain fi\e,|. while 1 a|)proaches tlie upper. an<l ;{ and 4 the low.'r part of the pupil. 4 the more so In the appheation of this test, tin- observer notes the position , f the oi):ieity hy lookiii}; direetly into the eve aloiij; its optieal axis He now slowly moves his h.-ad to one side. If the .sp(,t remains inunol.ile It IS situated m the plane of the pupil. If it moves in a direetion' "i'Posed to that of th.' observers eve, the opaeitv is .situated anterK.r to the pupillary plane. If the motion is in tiie .same direc- I'on then the opacity is situated in the deeper part of the lens or ni tile .anterior portion of the vitreous. Havinjr e(.mpleted this |mliiniiiarv .studv of the media wMh the mirror and by tlie u.se of the liijih inafinifviiif; lens, the student should now rotate the disk upon the ophthalmoscope until the si^^ht-hole of the instrument is onee iiiotv unob.structed bv a lens, and should tli<-n proceed to ;m examination of the eye-frround itself. For this purpose he has the choice of two metliod.s. the direct and the indirect • tlioudi •he befimiier will do well to familiarize himself with both in all e-ises Indirect Method. In the ai)i)lication of this method, the studimt stations huns..|t m a po.sition corresponding exactiv to that assumed III the test by transmitted li;;ht, at a distance of about :i() cm and throws the HRht into the eye under examiiiati,)n bv the concave !iurr.,r of th(> ophth.almoscope. A.s has just lieen de.s'cribed, the red reflex <•! the lundus will at once become visible; but unless the eve bo iijlhly nearsiKlit.'d, nothiii}: more will be ob,s,>rved unless ji nmvex lens of about o cm. locus l)e iiiterpos(>(l before the eve and held at Its focal distance. If |h,s be done, an inverte.l imajre' of the eve- jiround IS obtained, which will be seen between the lens and the slu.lent s eye. Some difficulty is usually found bv the bejiiimer in .■H-eomphshmfr this, on account of reHectior.s from the surface of the lens and the cornea, and his tendeticv to accommodate either for the ey.' or the auxiliary lens. The refl.Ttions mav be overcome bv -entiv tiltins the lens from side to side, by bearinjr in mind al.so'that the nnajie o| the fundus is ,an aerial .me, au.l bv inakinjr an attempt to ad,iust the eyes, both bemjr kept (.pen, upon a point between his own e.ve and the lens; the latter dilhculty may be dispelled also and he will avoid the natural tendency to accommodation. In •■xaminin-' the eye. the student should apply his rijtht eve to the si<:htd.ole in the niMTor. the msfrum.Mit b..inf; -nisped bv the ri;;ht han.l while the auxiliary lens ,s hel.l in the left. It is advi.sabl.. t<. steadv the hand which holds the MUMh.irv lens by resfn- the tij. of the little or rinj: tinirerui.on the patient's brow, and to utilize one of these finders to rai.se the upper lid wh.'ii it is desirai)le to examine the lower pan ^ff hXAMf.XATIOy OF THE EYE. 46 ..1 ihr (vc, or if tlic lid is covcfinj; tiic pupil, ;is is frctiuciitly the r;i-c ill iiill;iiii(Ml eyes. If ihc ri<;lit eve is iiiKJcr cxaininatioii, in order to hriiij; tiic iicad ,.| the optic nerve into view the patient siiould he toltl to diri'ct iiis ;;:i/.c at the raised little finj;er of the observer^ ri>;ht hand as it grasps ihf lip of the handle of the ophthalmoscope. When tiie left eve is l.( iiiii exaiiiiiied, he should look at thi observer's left ear. riie indirect inetho<l is to be [)referrod wlion it is desirable to obtain a irnieral view of the fundus ami in eys with hazv media or in hifih myopia, as the image obtained by it is more luminous than that froni Fill. 10. The inilireot methmlnf o|ihibaluicwo|>ic cxiimination. 'I"; 'linTi niethoil. By this method the image of the fumlus is mag- "iii''l about five diameters, ten diameters le.'is than bv the direct "" iliod, but greater magnifieatioi, mav be obtained o"^f the aerial iin:.-r hy rotating a -r S 4 I), lens before the sight-hole of the ophthal- i!iii-r(i|-iic mirror. It .-liuuid i„. remembered that the image in the indirect method is ■ tn inverted ,,n(>, mid that, t.-erefore. the u])i)er part of the image cor- |'-p"ndstothe lower part of the eye-ground, ami the right .side of the '•'■'■"■■ '" t':,- left uf the eye-ground. It is e.vlremelv useful in 'A-niiinmg patients in a reeuml t posture, ami is very Valuable in '■\:iiMiiiiiig the eyes of children, as it is often impossible to obtain a 46 THE EYE. view (if the fundiis in this class of ciiscs l)y tho direct method, on account of tiic iiiipossihility of i<cc|>in>; thcin iiiiict. On account of its fircalcr niapiifyinj; power, tlie direct nietho<i is to he preferred for the recognition of tine 'etails in tlie fun(his, and it possesses the fnrtlier advantafre ovi-r the indirect in tiiat it i^ pos- sihle to estimate tlie refraction of the eye by it. The Direot Method. In the application of this method tlie student approaches as closely to the face of the patient as is possible until the ophthalmoscoix- is broufiht within one inch of the patient's eye. The instrument .should l)e gnus|H'd with the ri^ht hand when the ripht Fio. 17. The direct method of ophtbalmoBCopic examination . eye is Ix'ing examined; but when the left eye is under examination, tiie hand as well as the position of the light should be ehanjied. The student should aim to keep the pupil steadily illuminated, and should endeavor to keep the .Miiall circular shadow which occupies the ('(Mitre of the jjlare thrown by the mirror, and which represents the sifiht-hole of the ophthalmoscope, directly in the centre of the piijiil. This he will timl greatly facilitated by the practice he has aci|uired in the observation of the eye by transmitted light and in \\\v indin-i't nu-thoi!. The red refi'X of the fundus ^'-r-uld at once become plainly visible; but, as a rule, nothing more, the details of the fundus being still hidden from view. This may be due to on 1 is mil cut the I'hc gilt ion, and pies fnts the has and ! at tails f to PLATE II. Nor'mal Eye-gr'ound (Aver'age Tint). Normal Eye-ground (Br-unetle). m^mmmm^mmm^mmmmmmit^m^^ EXAMlSATloy OF THE EYE. 47 ictlrciiiins I'ldiii the ciPiiica aiul lens, which ',i- osiHrially ili.sturhiiig ill iliiisc witli ilfi<|ily iii^inctitiMl iriilrs ami siii::ll pupils, or to an ;iiiivc accomriKHlatioii in cither the surncon's or the patient's eye. Tci ilccreasc these rcHcctions. the niirmr shmilil lie nidved aiiiiost iin- |,rr iilii)ly friiiii side to side until a spot is t'oiiiid where the rellcctions -dill to disapi)car. i'or optical reasons which will he e\plainc<l in the next cliapter, it is necessary, iti ordi-r to see the details of the HKidiis clearly, that the acconnnodation in hoth the observed and the (ii-civind eye should Im- relaxed. This is accomplished in the patient's v\r liv liaviii": hitn look into the distance in a (iarkene<l room. I'rac- lice alone, however, will enahle the student to lose the desire to iii'coMiiiHidale. which has heeii iiatural to him in re<;:)rdin<; all near iilijects hitherto, and to view the interior of the eye situated hut an inch or so from him as thoupii it were a far-away object. He will tiiiil that relaxation of the accommodation will be facilitateil greatly hv keeping both eyes ojK'n, and this should be practised durinfi the (■utile test, for while the imaftes formed upon the miemployed eye will at liist be confusinji. he will soon accustom him.self to ipnore tlit'in. Tiie student should now searcli for the head of the o|)tic nerve, as ihi- is the most prominent feature in the fundu,«. To bring tliis into \ir\v. he should request the patient to din'ct his gaze sliglitly toward tlir Icit when the ripht eye is being examined, and virr virsn for the Irit eye. If he now looks closely, he will observe that the glare from ihc fundus is not imiformly red, bu* that it contains a disk of color wliiili is yellowish white. This whitish reflex shouhl be kept stoatlily ill \ir\v,and as his accommodation relaxes he will Hnd that the whitish ili-k resolves itself into an oval body yellowish white in color, forming a tiv.Mg contrast to the reddish color of its surr>)iindings. This is the head I'f tile optic nerve. If the nerve does not come into view, one 111' the retinal vessels frecjueiitly will, and this should bo followed up until the nerve is reached, the avenue of entrance and exit of the I' 'iiril circulation. l.il no one fancy, however, that the interior of the eye reveals '-r!l at the first attempt of the beginner, nor let him be discouraged 'hat account, for usually much [HTsistence and no little pains will i' luaiided of him bcfcre he accomplishes his purpose. It is not lilc at first for the student to try to discover tlu^ lens in the I iliiioscope with which he .sees the details of the fundus best, for 'Illy possible after much practice and after he has learned to lii- accommodation thoroughly. For determination of the i ill by the dir'M't method, ritir page 118. "".:■ Normal Eye-ground. (I'late II.) On account of the many ! h- iii the normal eye-ground, the beginner is urged to famil- ' iiiiself with the appearance of many fundi which are known • althy, to prevent confounding f)hy.siological chafigcs with i . ' iiical ones. He will find the study of children's eyes especially ' |iled for this purpose, as their pupils are likely to be larger 4H 77//. A'KK .„„1 ,1,,. rHi-Tli!.}; t.MMliM rlranT il.ai. in ..M.t im-.i-I.-. nnd. ;i< m mlr . . s:;!:,;;';n;:Aiiiin.iy ... .i... 1,^..,... .....in.. ... ••--;,-";;";, Ilic .vli.i;!! vi's^cU talMM-ili^' i.o.n |l. ;i;:;,-y^--;r';;;-;ttj;;;':;.:;:t''i:;;:H '';;: ,1„. .AT iFis:. IS.) Tl.is ,-..1. is ..s..ally .......ri-sLai..-!. I'Ut x...... l'h)»ioliiKi.'..l .■xiuniiiHticiii. (S/.M.i.) ,.,,a.lv i.. si..> a...l l...si.i,.„ :,< w-ll as i„ (.nnlm..mt..m. If ...a> ; r,- small .l.-nJi.... .na.ki.,j: .I..' 'uU-anrr ... .In- l.lno.lv..s.<..l> ., ;:;;!,; s,u.i,i...i ui.i. „ayisi.-bhu.k s,....s, .i... p......s ..1 .■.■.,..„.•.. "M;i;::nJ;';hr,iisi< is i,> .van-v i,... i.:^ ....... i.. .na..,......- 1. m^^. .,ui, ■ la,,r; l.v .lu> ai.vH „.Hh...l.a...l as . .s tl... .-..Iv p..r.... .. , lus Nri.i.-li has a fix.Ml for.,., it is ..sr.l :.s a la...l...:..k t., ...... rhv ".....• 1-si.io.. of ..l.a..j..s i.. .!,.■ h..wl..s as ....• ..xamp •'. .' , „. 1 a,., is' ..0....1 as l,..i.„' !.. .1..' .Hi.K. two ,l.sk .l.a.......-s al.u.. ll...Mlisk ,i:;):!rt-- n..ss: .!... i.,...M-.,.ost. a wl.i.isi, nvv\. Ihr .cicrninn,,. ='" ' " " - „p„„ .hi. a ,)ifr....M.t.Ml .-i..;:, (/"■ <-l">r'>"l"l '""'• ^'^ ^'■•'" '" "" AAM.W/Xir/O.V iiF THE KYK. 49 ,.,.,ial.:mviii>: illuslr.'ition (FiR. l!t), which w taken fr.mi Fiichs. The (Irial rinn i' the rt'suli of a larger (iiH-iiiiin in tiie liiuroid tliaii txa. 13. ?M '''"> ' a Ha H sf '' ^*^ t' "' ll™.| c.f !(»■ nplic nerve. A. Ophlhalni<»o<.|.ic view. S..me« hut to Ihe inner sirte of the centr.^ of !l,. i«|.ill»ilie mitral urlery risen frDin tielnw. and to the temi.iral »l.le ..I it risen tlie cemnil vem. 1., ilie leiiii-.rttl side of tlie latter Ilex the Miiall i.liyslolosii.il Meavation with t-ray sti|.|)lini! of the UiHiiia inhro^. The i«pilla is eiielrcleil by the llKht Mleral rln« (lietween r and it) and the dark . I,i.r..i.|ui riiiK at '/ ;(. I.ongitu.linal section through the head of the o|.i.e nerve. MuKiiitied U x 1. I ',.• 'ruiik of Ihe ni rve np to the lamina orlbr<iBa of medtillated nerve fibres, n. The tlear Inter- „r, - ,., wi.iratinK iliein eorresi<,nd to the sepu eoiiii«i!.ed of connective li.sue. The nerve trunk .•lu.U.i.il liv the sliealh of pla mater, p. the nrachnnid sheath, ar. and the sheath of dura inaler. .'.. Tliere H a free iniersi«ce remaininK Iwtneeii the sheaths, consisting of the subdural siwre. nt. ,.,l Ihe suhurai-hnoid s|«ce, m. Iloth si«ceii have a blind endini? in the sclera ai e. The sheath of • liri, 1. later |«.«ses into the eitemal layers, m. of the sclera, the sheath of pia mater into the internal . rv. *,, which latter extend as the lamina cribiwa transversely across the course of the optic ■ .-. The nerve is represiMiled iu front of the lamina as of liRht color, bi-cause here it consists of tiiedullatcd and lience transparent nerve fibres. The optic nerve spreads not in«in the retina, r, .^. li a «i,v that at its centre there is pniduce.1 a funnel-Bhapc<l depres.«ion. the vascular lunuel, - :i .iliose I'liuer wall the central artery, a. and the centml vein, r, ascend. The choroid, ch. shows » ir„-ver«e section of its numerous bloodvess.>ls, and toward the retina a dark line, the pigment , i ! Inliiim : ne-; the margin of Ihe foramen for the optic nerve and corresponding to the situation • i.e thornldal ring the ch..r.)id Is im.r.- darkly plgmente.1. ri isa |-»terior short cihary artery : i n-M h, s the .■horold lliroiigh the sclera. The i,»terior portion of the scleral .anal forms a .. .lin , t.^l backwar.1. Ihe anterior i«rtion a funnel dirvite<l forward. The wall ot the anterlo: . 1 wh.Mi seen in front ap^ars to have Ihe extent. c(i, and corrc«iK)nds to the scleral ring vis'ule "I {illmhnoscoiie. (FtCHs ) •riera.to iM-riiiit of the entrance of the ojitic nerve into ihe (-yo, ■i'iise(|uence of which u portion uf the aclera is exposcil. The 4 50 THE EYK. choroidal rinp is formod by tiic iicapiiifi iij) uf pifjiuciit where the clioroid adjoins tiie optic nerve. Thv rcssel.s of the retina (Fip. 20) consist of a main arterial and a venous stem, the central artery and vein of tlie retina, which divide, directly after they have emerged from the misal side of the excavation upon the head of the nerve, into two main branches, the superior and iid'erior. These further subdivide s(>veral disk diameters distant from the disk into the sujM'rior and inferior temjjoral and the nasal l;ranches, respectively, Mid still further subdivide into smaller branches: these branches nevei anastomose. (Vide page 41c8.) The macular region is sui)plie(l bj small twigs from the superior anil hiferior temporal branches, anil often by two small twigs directly off the parent stem Flo. .». IMstrihnllon of retinal vnwclii. (Jirhkr.) on the disk, the su[X'rior anil inferior macular arteries; larger vas- cular stems never invade its territory. The arteries are .smaller and straighter than the veins, and are yellowish red. while the veins are purjjlish. Moth have a light streak along the centre of each, which is fainter upon the veins, the rejles streak. The veins usually accom- pany the arteries, ;iiid have tlie s;tme distribution and name. It is usu.il for a distinct pulse to occur in the veins upon the '>ead of the nerve. Puls.ation in the arteries, however, is always pathological. The retinal vessels fre(|iiently present great variations, botli in distribu- tion and characteristics, and the observer will often be jiuzzled to decide whether such variations fall within physiological limits. The two most striking variations are an arterv, which is occasionallv .seen. KXAMISATIoy (>!•' THE EYE. 61 iind wliicli iiriscs in tin- clidroid iuitl runs iiiwanl toward the disk, tlicii i:ikiiij: a jii'iicral direction toward tlio niaciilii, and a cilio-ntinal rrsxcl. il'ii;. L'l.l Oiitiai-iiliiinj rvssd is tiic iiaiiio ftivcu to a I)rancli of tin- ciiitral vein or artery which disapjjears at tiie edfje of the (hsiv. '{"lie student should ac(iuire tiie hal)it of ohserving tiie retinal I ill Mid vessels with {jreat care, for their condition is fre(|uentiy indic- :iiive of tlie condition of the bloodvessels elsewhere throughout till' system: and on account of the ability actually to view the blood cnluMin itself, an exceptional ojjportunity is afflmled him of diag- iiiisini; patholoijical conditions of the blood. The reddi^li a])pearanee of the fundus surrounding the optic nerve is due chieliy to the blood in the choroidal capillaries, although the ictiiial circulaticm is also a slight factor. (>f more influence in affeet- iiiij the general coloration of the fundus is the pigment hi the retina, Mccording as it is present in greater or lesser (luantity. Thus in liruiiettes, in whom there i.s an abuiulance of pigment, the "general tone Fio. 21. ' ihiHriiinnl artery. From the outer nnd Icmer margin of the [wpilln rims a cilio-retinal artery, <i. iiii.kuiK u hooli-llke iCTii, In this case it Is larger than nsiinl. because it is desUned to replace ilK^ iiiiiii, Mifero-exlenial (inferior temporal branch) of the central artery, which branch is wantlnit ll-'lcHs.l •' i- deep red or evil slate color in pronounced cases. In blondes it 1- "ticii a delicate pink, and, owing to the absence of pigment in the I'lin.i ;ind choroid, the entire circulation of the choroid, whic!) is 'I'lile obsciire in brunette eyes, is laid bare to the gaze. Alohn'.wt I'li-eiils this to an extreme degree, the red choroithil vess«>ls Ix-iiig -I in to course over the white background that is formed by ;he sclera. I 1^'. -'-'.I .Vlthough the retina in health is transparent attimes, e.spe- ' i:illy ,11 ciiilih-en, it is so rich in connective tissue that a striated, i:i...vish .ippi-aiance is given to the fundus, especiallv in the neigh- '"■'■ i""d ol the disk. These irjlrxcs fr(M|uentlv accompanv the ves.s<>ls, ^'lid :'ie sii i.roininent that they give the retina a watered-silk apiM-ar- •'I"' liiey are usually more marked around the vellow spot and '"■'M-inii the h;il() which surrounds that area. A number of small shining bright dots are sometimes seen in the renn.M .•nitenur to the retinal vess. !s: thev were calle ! bv Marru-Cunn who lust descrilM-d them, '-crvrk dots." They are only visible bv the w go THE EYE. «liroct niptliod, aiul aro not oasily socii. Thoir nature is not known; they may occur in si'vcra! nieiulK-rs of a family, ami are often hereditary. r , • i The macula, the region of greatest imp«irtance of the retma, reveals itself only after some difficulty upon the part of the oi)htha!mologist, as it has no characteristic suliicicntly striking to delineate it. It is an oval area, with the long axis horizontal, is more ileeply pigmented than the surrounding fundus, and is avascular. From its centre a bright reflex is emitted, tkc lorea centralis. Fio. 22. ^^M' Ophthalmoiicopir reprosonliition of the eye-grouiiil of an albino. (Jaeo«b.) To examine this region when the i)upil is undilated, the ophthal- moscope siiould l)e slowly luovetl upward and inward, while the observer brings his line i)fvi.sion to a i)ointalK)ut two to two-and-a- When the pupil is dilated, 'ient gaze directly into the The iH-riplnri/ of the eyc^ and in order that no part of lo follow each l)ranch of the half ilisk diameters outward froiii the i the macula may be seen by havin sight-hole of the oplithalmoscojiii ground should also be carefully st it may escajie, it is well for the st central arterv of the retina as far iorward as is po.ssi ble. CHAPTER II. THE PHYSIOLOGY OF VISION. By WILLIAM NORWOOD SUTER, M.D. Vision is the mental interpretation of an impulse conducted from the rods and cones of the retina through the optic nerves and tracis to the visiml (ireax of the brain. These areius are situated in the cuneal and occipital lobes at the internal and posterior region of each hemi- si)here. As to the manner in which the physical impulse is trans- fi.rnieci into vision, we have no knowledge, as we have not of any other kind of ixTception. The visual impulse normally results from the action of light on the rods and cone;:,. This action "is, in part at least, chemical, the visual jmrplc of the retina being changeil into a colorless substance. Artificial (electrical) stinmlation of the optic nerve or of the visual ureas cau.ses only the sensation of light (illumination) as distinguisheil tioiii darkness. For the distinction of objects by the vi.sual sense, it is icmisite that the object l)e reproduced in an image on the retina, tliu> stimulating only such rods and cones as are covered by the image. Ill tliis wav a mental picture is realized corresponding to the image dcliiieiitedOn the retina. Thus the (juestion of the physiology of vision resolves itself largely into an investigation of the laws of light, ill adaptation to which the eye is constructed. OPTICS. Light is a form of energy capable of giving rise to vision, but . ripablc, also, under suitable conditions, of being transformed into it her kind of energy. iliat branch of science which treats of the laws of light is called • '/■/((. Optics deals not only with light in its relation to the organ t I vision: it investigates the laws which govern light-<>iurgy, irre- i . iiixc of the eye— the organ by which alone the jjhenoinena of light :ii" liKiiiit'csteil to our consciousness. It behooves us to consider here, In, Ai \ri', only so iiiucli of the sul)j('ct of (i|)tics as will afford a correct MU'li !-taiiding of the formation of the retinal image. A l.iidy whose constitution is such as to produce light-energy — to • iiiit r.izlit— is said to l)e self-luminous. Such a Ixuly emits light in :ill diivciions ;ind in rhythmical impulses or waves. Siiur we cannot conceive that light or any other form of energy iiia\ tiiiveise space without the intervention of a medium, it is neces- (53) ^1! 54 THE EYE. sarv to assume tlic cxistoncc ..f an all-porvading substance, called cthvr, l)V means of which lifiht-vibnitions are transnntted The velocity of liflht thioufih si)ace is, as demonstrated by astro- nomical observations, about :i(M),(KK).(MH) metres (1,S(),(X)0 miles) per "'" A'luminous bodv does not ordinarily emit a single wave, but a num- ber of waves of different lenfjth and rapidity of vi' -♦ion. ( )» y those wives within certain limits of periodicity (from :V.H million milli.ms to 7(W million millions of vibrations [.er second) affect the eye as vismii. Color deiiends upon the wave-lenj;th and rapidity of vit)ration Uie wave of greatest ieiifith and least rapidity fjives rise to the sensation „f red; that of least length and greatest rapidity pves tiie sensation of violet. Between these limits are comprised all light-waves, which produce the colors of the rainl)ow or .v/>« ■rum. ( )rdinary white liglit is conipose.1 of all these wav.-s actin"; upon th<- retina m unison. It is not definitelv known how color-sensations are i)ro.luced: Ini acconliiif,' to the Yoiinjt-Helmholtz theory (th' .ommonly accepted i it » I one) there are three sets of rods and cones, ejicli set benift affected by waves of certain Imgths only. The.se jtroups of waves (■orrespond t<) th<. three prima,. col..rs, red, green, and blue. Hy the combmed effect in varying proportion upon the retina of these three elements all color-sensations are produced. A substanc.- whi<-h p.-rmits the pa.ssage of iipht is calle.l a mednm or a transparent body. ( )ne which does not permit the pa.s.safte of light is said to be fipnf/Kc. ._ ^ , ,i i • , .!>„ \Vh..n light meets an opa.iue bo.ly. it is either rfjlvclvd back into he me,lium from whi.'h it <ame, or it is «/..ser^<'./-converted into other form of energv. . . , If the medium surrounding a lummous point is homogeneous, th. light emitted from this point will travel equally in all .lirecti.nis and the wave-front will be si)herical. (Fig. 2.3.) \ small portion of this wav:- Hi O B), such as might enter an eye, is called a ;»<>/(r(7, \n inimitesimal pencil is call.-,! a rnij. \Um. mathemati.ally. a ray is a straight line {B O) iH'rpendicular to tlu; wave-front. ■HTfcrr THE I'll Y.SIO LOGY OF VISION. 55 li! the study of optics it is often convoiiipnt to ropml light as com- imixmI of rays" ])ro('c('( ling in cvory direction from a luminous i)oint; and we may with propriety make this assumption, provided we do so with the understanding that it d<x>s not represent the tiue mode of kvery |".int of a luminous l)ody emits light, hence there proceeds ln.nial)("lv of api)recial)le size a great numher of waves whose i)aths (loss each "other in various directions. We must a.ssume, tlierefore, that many waves may traverse the same medium at the same time, each wave-disturhance being sujM'rpo.sed upon that of the other, a i.rinciplc with which we are familiar in the su])eri)osition of motions. Formation of Images. In order that an ohject may be reproduced ill an image, it is essential that light from any point of the ohject shall n ach a corresponding point on the intercepting screen, and that light iiuiii all other parts of the ohject shall \n' excluded from this pomt. 'I'lic simplest way in which this can be accomjjlished is illustrateil in lilt. 24. .S .S n-prestMits an opa(iue diaphragm in which there is a iiiimitc opening, O. Light from .4 parses through the opening and tails ii|.oii the screen at .1,. Light from other parts of .1 B cannot ivacii .1,. Hence at A, the luminous pohit .1 is reproduced: so for ryrry other point of A U, and .1, «, is an inverted image oi A li. i'lic 'objection to this device is that the opening nuist be so nunute - to allow the passage of a single ray, or at least of a very small ! .11,11 from each point of the object; onseciuently the image is very !rrl)iv illuminated. Refraction. In the eye and in other optical apparatus greater ' uiiiinatioii is secured and the apparatus made more sensitive by rc- M M tion of the per-cils. Hy this means, larger pencils are concentrated ' • :i |ioiiit ill the image. i' i- louiid that the velocity of light is less in dense than in rare Ml'. I iiices. The effect which this retardation lias upon rays is illus- !i:.i.>l III Fig. 25. in which BOB represents a section of a spherical \\a\i' iiii'ctinir a denser medium in the plaiu S S. That part of the \v:ivr uliich travels along O A meets the surface sooner than that \\ liii li t ravels along B; hence when the former traverses the distance 56 THE EYE. \ H in tUr .lonse Miediu.n, th.- latter travprs(>9 the Rreatpr distance )i S .:> tt.j r..i luciiu.u. In this way the wav(>- n.nt is flatteno.l so that the centre of the wave is now situated at /.' * H S being the wave-front, the ravs are represented by lines drawn pen)endicular to the -irc .S // .s- as / .S and / //. The .lirection of all the rays is chanp 1 except that of A, which is ,K.riH.ndicular to the surface. \il other ravs are said to l)e refracted. The degree of refraction de- l,ends upon "the obliquity with which the rays meet the surface and FIO. 25. the relative retardation of light by the second medium. The latter is called the relative refractive index for the two sul)stances. W hen the first medium is a vacuum (ether) the relative inilex becomes the abso- lute index The velocitv o.' light in vacuo being reg.-rded as unity, the absolute index of 'water is 1.33, that of spectac e gla.ss is about 1.52, and that of air is 1.0003, and, being so nearly identical with that of ether, it is regarded as unity. FIG. 26. J__- Refraction at Curved Surfaces. What has bwn illustrated as occur- ring 'It a plane surface occurs similarly at a curved surface, rig. -ib illustrates the passage of a wave from a rarer to a denser medium at ■i convex surface. In this ca,se the flattening of the wave is greater than it would l>e as afl"ecte<l by a i)lane surface; but, as with the plane surface, the pencil is still .livergent after the refraction. \\ ith grc-ater convexitv or refra.-tive index tlx' flattening may Iw such that the wave is plane after refraction, as illustrated in Fig. 27: tlie refracted rays are p.'irallel. I we assume f.r .be p.-esent that the refracted wavelront 1. spherical, anrt that ">e refracte.! rejf all ,,roce.Hl from the »me loint, /.• we shall learn later that tbla a«umptlon 1- ,..rm.,«lble only wbtn a Miiall i.irlliin or iwncil of the wave Is eoniildered. T^BT^f^^f THE PHYSIOLOGY OF VISIoy. 57 Tliiidly, ns illustratod in Fig. 2S, the retardation may U' so groat tliMi after n'trartion the rays converge to a jK)int, /, which is tlie jocus (if the rt'fractctl pencil. This focus is ilhnninated by all the rp.ys of the pencil SOS; it is consequently a bright point corres|]on(ling to tiie l.rifiht i)oint O, from which the jiencil procmls. / is the image of i). and the two points are called amjwjdle foci with respect to each "tlier. In Fig. 2() light from O api^-ars after refraction to cf)me from / ; I) and / are, as in Fig. 28, conjugate foci, but in this ca.se / is not an Flo. 27. illuminated point. It is calle<l an imaginary or rirhial focus, in contra- distinction to the real focus / in Fig. 28. The distances A and / .4 are called conjugate focal diManees ; the line O /, on which the distances are measured, is called the axix. In I'ig. 27 the rays are parallel to the axis after refraction, that is, niMtlieniaticallv they intersect the a.xis at infinity. The point F, so situated that the rays are parallel after refraction, is called the prin- rljuil focus. Relative Positions of Conjugate Foci. If we examine mathemati- cally the relation between ct)njugate foci, we find that when is O' :rr-i^ -ii'Kii.d nearer the refracting surface than the principal focus the I'liijusate focus / is virtual; it lies on the same side of the surface as ". ' Fit;. 2f>.) W ill n O is more remot(> from the surface than the principal focus, III. I juiiate / lies on the opposite side of the .surface, and is real. ' 1- isr. '-'s. ) .\- t!;.- jiuitit O ifccdc^ from the rurfare the conjugate on the oppo- >iii' -Idi apiiroaches the surface, and whr-i the distance O .1 liecomes inliniu , that is, when the incident wave iM-onu.s planv (the rays ! 1! tft' ' ■ i ^ V. 5M THE EYE- F J 2S.. V .-l/is .!u. ../lr/,-r ,;nn..i,.al focus U^t^s p.'".'.-.!..., ..vn. h "; nt.T or ,„i.H-i,.al torus an- lurall.^l «//.. ,vtra,-t.on. an,l rays x rh a'v i-aralk-l Ijore rcfrac-ti.... convrfi.. to tl.. ,.ost.-nor prnH..i.al locus. Fli.. J'J- O- Fourtlily, the wavi' is In this case till' surface. the point O inav lie to tl.e ripht <.f the surface, that is. alrea'lv converfrinji to this virtual focus hi'tore retraction. / lies on the same side of the surface as (> an.l nearer to (Fitl.;5<t.) Flu. 30. CoUective Refraction. lu the con.htion illustrate.! m l-i^-. 2b he ,liv..rg.>nce of the i>encil is .li.nini.sh.M by the retraction; in that i us- Xru^\ in Fip.27the .livrgeiur is neutralized; m the con.lition illus- r M in Fis 2S the .livergence is ...on- than neutrah.e.l. the wave is ren lerea couverpent, an.l in th,- fourth cn.liti.m tlu- c.-nvrpence of . nlrea.iv convorgiuK ,K-ncil is increas...!. H.-mr the n;fracti on Ihi.'!. ..ccurs when light passes from a rarer to a .lenser me.hum at a convex -surface is n)//cdn'c.)rr(»/(rm/p«/. , .. , . , •„ is evi.le.U that we may n-verse the course of hpht in these illus- trati..ns that is. wo mav rcKanl / as th." focus before ivtraction, an.l O a. th." conjugate after refra.-tioii. H<-nc." th.'s,> .hapams serve e.,ually w,.ll t.. illustrate refraction which takes pla.'.; when ifiht passes from a ,l.'ns,.r to a rarer medium at a c.ncave surface. Such refraction is therefore c.illective. . Dispersive Refraction. It w..ul.l be superfluous t.. illustrate h.Tc the r.-fracti..n which occurs wh.-n lifjht pa.s.ses fr..m a rarer t.i a denser m.'.lium at a concave surfac.'. ..r. its e<iuivalent, that at a con- 1 An e.«.,..i..u u, thb .n..e>ir. . il ^ whci the in,i,k-n. .v*v. 1. .Ifre.tP.-l towarrt the centre of ,h...r. f«ce all the r»y« iheti bems pcr,«nmcular to the surfc™ there «1U be no refm.tion ; and (i) « hen [he wave , conve,KM.^ to a ,H,lnt .. the le.l ... C. that Is to a ,«int nearer the snrfaee than the centre, In Jhioh cl"he mvergen ce of the pencil will be' i„crea.^-eou<lltions which do not art* la ocular refrRctlon. TIIK rilYSKtLOOYOF VlSl'iS. v,.x <urfaco whon liplit passos fro... a .lo.i.or to a rarer n.rd.u... It i< •n.i.aivi.t that tl.c ctTcH of such r.-f.a<'tio.. is opposite to that \vh.H. 1,;; „.,.,. illustrat.Ml, that is, the .liverpM.ee ot the pe..e,l w.l l.e i„..rease.l l.v s„ei. refn.ctio,,. This .s ea ile.l ,/,../>.r>Mr ref,-aet.o. \ ,„.|,.'il of'licht .liv...-«inK from a poii.t. I.e...^ re...l.Te.l st.ll ...or. ;iiv,..-e..t l.y .Uspersive .vfraetio... ea.. ..ever 1«' .....ted l.y s.ieh ... a ''''rdmation of Images by CoUective Refraction. The i,;.n,a.io„ of i,„;,...s l.v .vfra-'tio.. is ilh.st.ate.l i.. F.^ M. All .'ays ot the pe„e.l .livn-siii.K f.oi.. O, a.v eo..ee..trate.l at the eo.ij.istate foei.s ,. No H„ ?.-om other pa.ts ..f the ..l.jeet O O, ea.. .vaeh /hut eae h po.u lyiMfi iH-twe.'.. (> and O, has a eor.-espo..<lmt: eo.ijufiate ly...j: l.etwee.. / iunfl,: heiiee / /, is the ii.iafre of <> <h- . , We have lea.-..e.l that i.. eulleetive .vl.-aet.o.. the.e xv.ll he a real ,„,.us .-ouiu^ate to a..y poiut (O,) ^vhe., this p.n..t .s lurther Iron, . he MMfaee tha.. the iirst p.-i..eipal foeus: .e„ee ihe.v w. he a rea an. ,„ i„ve.-te.l i.nage of O O, xvhe,..-ver the .hsta..ee .1 O (or 1, O , h (, <\ a.i.l / /, are .-eally ir.'s of eireles whose ra.lii are C O au.l C /) is fireater thai, the principal focal .listai.ce -I F. Flu. 81. Cardinal Points. It is appanM.t that any ray, as O, /„ wh..-h passes llnou-h the centre of curvature of th.- refraetinn s.irlace u...lerpo.'S no ref.a.^ion. Fro... this p.-ope.-ty the point T is ealle. the mulnl ,m„it: an.l a.iv .-av (O, /,) J.assinn th.-ounh this point is called a «'<-;'»<l';p- axis, in" c.mt.-adisti.ictio.i to the pi-i...ary or pn>ict,>nl axis () I I le point ,1. where the surface h.tersects the pri.icii.a' axis, is called He nrlm-iixil mint. These two-the nodal and pri..cipal iM.n.is-t..getlier with the two prh.cipal foci constitute the carduml imints of the re- '"'ir. as has h(.en done in the fipure. the diagra... Ih> so drawn that the incid.M.t rav O, '% ;in<l th.> refracted ray N /„ are each parallel to the axis O"/, it is evident that in so doi..K we have a ineai.s ol deteniiiniii!; the i.osition of the pri..cipal foci F a..d /• . I onversely, if we know the positio.i of these foci a..d of the other two cardinal points, we may hv the same geometrical construction ascertain the l.ositinn and the size of the in.age (/ I,) of an ohject. O O,. The Aphakic Eye. Since it is requisite ior vision that a real ....age of t!..' "l.jeet viewed he funned on the retina, it is apparent that the eve must he .so c.nstiucted as to co.istitute a coUect.ye refractive apparatus The si..iplest .levice of this kind is that of a single surlace. 60 TiiK f:yK ,1„. con»-a. tl... aMn.'"Us humor, aiul th r ' » '^ _' ',' ^, : -.^ „,^ SU.-U au oy.. I.rovi.10,1 |t has ^;'' "■'»'' «*';•,; „, „( a.la .tin« luents of .mtun- .•xcpt "i cue n-s,M.ct has o in. a the ..pposi <• sule of '''"^ ^ [ •; ' ;^,^ ' ,,,. ,„r,„,v ,hat .listant ol, eets surfaces, both centre<l on the same axis. \' I...sarec,asslHMaooorain.t..th^j7-foun^^^ ,„,l..s to the ax,s of the [>' '";^^' ^^^.,"1^., "[, a o -linarical lenses, that !;:tSar:i;s::S:^^::t;':nhet.on.^ .0 the fornea the lo« er Index of the .queou.. THU J'llYSlOLOHY OF VISIOX. (U ,tho principal mcridiam), but tlio curvature is Rroater in ono than in tlic othrr meridian.' , » „ ,.„,. L,-i.^-s are rlassitied also in res|)ert of curvature, a«: 1, /j/amw-""' ••r.. •2. (.(-coHrfj; 3 and 4, c««mr/>-tv»irej; 5, plmw-concare; an.l «>, Oi- '"TrtifiiiufieS's are made usually of Rla-ss and are surn.un.led by .,ir and since the refractne index of glass is greater than that ot air, i, i". apparen- that plano-...nvex and bi-e..nvex lenses ar." c<.llective „ .H-ti 'n that plano-concave and i.i-concave lenses are disinrsive, and ..a .. cavo-convex lens..s an- collective (.% Fip. 32> or d.s,K.rs.ve ! I- .:}•.') acconlinK as th,- convex or the concave refraction .s ..n-iter ■= In the former case the concavo-convex lens is called a con- 'rniinumfnisrus, and in the latter a divcrrjin,! meniscus. Meni..ci are (••lilcd also /xri>(»/)/c lens«'s. . -n . . i •„ • T,,,. funnation of a re.al image by a collective lens ,s illustrate.l in l-i,r ;« As in collective refraction by a single surlace, a real image i<?:.,M.i-d when the hrst conjugal., focal distance is greater than .e ;„.incii.al focal distance. As the .listance ot the object mcreas<.s the conjugate focus moves nearer to the lens and when the object is !inmted so far that the rays may 1h^ regan led as parallel, the image w n \,c formed at the posterior focus, F'. When the rays are a rea.ly V .« before ent'ering the lens, the image will lie between the lens ! nltl e posterior prin.-ip.al f.-cus. \Vh,>n the object is situated at he , ,. r'focus I'X- rays will be parallel after passing through he .„., and no inu.ge will be formed. When the object is wi hm he .„„crior principal focus, the rays after passing through the lens suW a,,,«.ar to come from a virtual focus-the image mil Ik- virtual. ' Sine., a .lis,K>rsive l.'ns increases the ,li^, rgenc.- ..f ixmcil.s ,t is ap- pan.ntthat a real imasre can be forme.l after ref,act...n by such . .',.„< „Mlv when the rays have n-ceivd, by previ,.us .,r -"l)s(..iu .a ,.„!l....tiv.. n.fraction. a convergenc.> greater than the .hv<;rgent act <^ of th.. .lis,H-rsiv.. lens. The a.-tion of a .li<l)ersive lens is >""« ;•''•" 1-i.r :u Havs pr..<v...ling from a point (K app.ar aft<-r n'fract on by ,he lens to come from /. When the distance C may be r..garded as the case of concave lenses w rrl ■nit: KYF :x I |)»'l.iri' !• iractii'ii. Tlii'MMtHinr prinripal fm-iis is /■' ,Ih iiin.l th.> I- f-r .:->- "licl. ar.. ,|inct(Ml tuwanl Orn poiui l-f-rr r.-fr!i(!i..i. at raraii. i a.f. >• rclrar iiiiiiiiif, / cuiiicMi-' with / '. \vlii>li i- thf sinr-il is tl... virtual ; ..us fur ray- «l.i.h arc p^" MMnnT. ira.-ti.-i, tloll. n- at. Cardinal i aiuts ;n Lens-refraction !'i rrlr,, i. i. i sih,K iffac ravs passi!.;; (hmut-'li ;l.o cciurc nf rvaturr ii,.;. i-z.) noivti no. •m'.l, as \\v .ivt! l.v :.mI the ccnli \ .urvaiun." i^ >n this .. .)U:. calhMl till- I 'xlal p<u. t II ihc n]\uu\ > iitrc itu' tlicri' arc tvo rcfrtctious. the t>pti(;ai f< -m- luu ' 1'- asrcpinlsa. vray p>--iui; ihroufihit tli' "fn. " n nuist I) I'xai :ly couutrractctl hy that at O, r /, (l!'_' ;>:!), pussiuy; throu^ih thi' <>p -•liaii^c ill (i ivctinii, l)Ut a latiTal dispiaci ' .ar. ■■ III-- i>f t!M" Ictis. I'll. Tf arc two no.!'.! pi lilt-- 111 lirst > '\) ni. i^^ prim i il axi> lowar .vliicii ' • iin ! rays an .iir^'tt-.: Ih'! ti, III the scci.li., one ' V) is I I'oiiit 1 u wii ll appra, tl. proceed alter pMactinii. Aiiv iri.iai ray, as ", / . is a seroi-iary ,: . ami as il of tlielciis l)oc()ii"ics iusijinil I -it in coniparLsti 'tii tlie th Moilalravapproxiiuatt I -irai^l hi •. l- 'i'\> '" points arc nier^ed in :-. shiii v nodal -oil emncidii ceiitl-e. Hence wlieil the nklicss ,.f \'w lelis is . artificial lcnsc> u-d in o] lalinol :y), the r«n///e in numl.-r: the I' ! pnii. or tii-- optica ntre) .uu .. ci])al fi'i'. Tile principal f whicii in iliis n-' tlie two prinei|)a: ness of the leii wlietliiT one nl ray- Numeration of enses. 1 a^ t is .li a|. ■ ■ ■ -■iin llier ol iiice 111 Ici ■ii;.'|.il -.. Iirsi -ii'fae iiidei : ilh th' i llie ic- -r ays I icl<r.es.s ' »nces, 111 lal „p. \ ivA (: -t :ire th 'C ,,• l\v.> |ir i- iiieasu!' roll! ' nodal point 1 th . and, :.- so measured, I, fi, lisreirardini: tlie thick- ,,. .i^,, fraeti.Hi must 'le tiie same, • t sii'iaces In vIhi-. to incident iicipal focid •: r the local /,7»/?r^^f "a'lciis, 1 isuresit-ii. u'tiM' jiower, ,u,i- heinc; in- versely proportion .. tlie lueal leii-iii. Tlie ui ..■ nieasurcinent in iiphthahuoloirv i- ue </-e/, Tliis rciircsents il,e p-wer of a Cns havi!;tr ., fdca! !e!!ff!L: of nnc n -e. A ieiis haviii;: a focal length ot .ill. lalf metre i- 'tv ice - -tr^ as tiie nnit-lens. and conse.|ueiit!y has , p„\vcr I •• t\^ .pt' : a i''"^ liavin-; a focal h^iifrth of two Titf: "/ir"«/".'."''' >' "/■■ visius. w.\ „„ , n- \\xx^ a powor O.:. 1 • . .'t. (V.Hoctiv.- l.-nsrs ar*- .|riu.|fMl l,y ,,,.. ,.lus ( ) -ijIM, a., hiisi -IMV. ....- In tl..- nimus (-) s.^'n. The Crystalline Lens. Hi- is .. In "nv.'X 1oiisc..iii|)<)hm1 ,, hl.nll.i. Mni.tui.. in-nM> in l.M„.ly t.,war.l tin- .•.•ntn- or nu.-U-u., t ..■ v|,nlc l-iii" .'iirliw. : ill :• tr;iiis|.aiviit caiwil.' niul Misi«'ii.lc.! »).v I i<' ,„.,..„-. .rv'lidanx'ir '..•tw.'c tl.c a.|U-.iu. l.m.i..r aimTiurly ai.l tl- vitrcm 1h«Iv |-<-' .-••ly . I..- n-frartiv.- in-l.-x ut '"■ •■';>>i='' " „.,i-<:i- 1 whoii' -ll,.t;,>in..!nit nfrocln. ,m/.u -is alMmt 1 »..> wl ,1,.,, ,, tl„. ;,.|U.-n.w an.! vitrcHis is al.oiit 1 .:!;!7. Siiicr tli.^ ui.l.'N ,1,;. I, ivx cr' tail:.' !.-ns is j:r-;,'.T lliaii that of the sun..im.lin!i • ,„.;■, tliis , MIS i; list .fl a (•(.licet ivc action IIIM.M tlir ray- • t'-rht pass tim.ujrli i. al' r iitiviiift uii<lcr<;..iic rdiaction ,' the 1'. 'X c cornea 1 r. I ractioii he anterior Incus is al>nnt 2:? mm. from ' tha Ireu' •iicr tl and since ol)ji n 'his, it I'lillow- viewi ,1 liv the eve lUv at a yrcaler .lis tlie rav~ from :'ii\- point .1 th (ject •onverfimK t" ^talline lens, i of tlie lei. ,11.. |e lieliin.l the coritca leV won! Jiiy;:' converjieno , that the ray.- ihout the lens. IS mere; when they hv the col are 1. ijlht Compou Optical Systems Several rifrnctii l" SU! ,ice: focn cenlieil :i coninii xis, and separated l)y intervals, tl' I' eve, institute a conitHiunc I optieal system. I' was tlie v:',riolls ,surl:iccs 1 Krst deiuon- slrated hv the inallicniat itin ('tan- that <tem IS e\ ;icth ana lop )!i-^ to a simp SVs M, e\ce| I that the an', t'lur and posterior iical (hstanres are iik-m-^ Irom a sm iniici I tlucl jHtl jxiiiil" Sep: lints, haviii (Fi«. IW) I interva ^igniti trl' it. but from tirn >\\\i\ laiiy tlie noi •re are hni ts of a loin lens n the eve, the final 'dium differ in index from the first tl;e [iriiicipa! ]>oint>^, roii'paraltle to a sinjrle The Schematic Eye. refract i points do not eoiii<'id( in position with in a Ion: 111 th •t tl le eve is aturi'<. indice: ve media of the ht ind positions tel\ tlie ■ve hrive heen very accurately iiivcs- tlL':itei 1. The following tahle presen tstl le average values w hi.'h 1 lave ■11 determinei I for tlie normal adult eye. CURV.vn-KES. .Anterior siirfiifc 111 'he ciirneH 1 isttrinrsurfHi'col the cornea '.•ilerior si.rfHC! of the !>-■"« ilurini; r. Uxntion ..r the cMnry nmwle Posterior ."UffAceol' the lens ... , . ■ Cornea, 1.377 ■ . . . ■ .\iiiieoiiH, l.'.vyi ■ ' ■ ' l.onn. l,l;V< ' • • ■ Vitreous, 1.337 lo.O Thirkiirn*. 4.0 t In the old .v.len, of cnnu-ration the ,n,l,-tr,„ ^^:» taken as the no.t ..f me«.urement. A. let.-e, ... .,.„..; .....^, ..f ..., „ ,„<.!, ..... «.!.i.>ni o.^.,l ,„ o.,l,ihalinol..Ky. e.c weaker lenses in roni- nn'" ..Jh«"r«lUoteex,,r,.-*.linrraelio„H. Thnsalensoll L having' « l.*all.n^lf.,ll.,rtyE..K,,.i. „,,-,cM«oul,i l.eclcnot.-l . ■. the frH.,-H>,. > . a let.so". I., won'.! l«cxprcs*.l by thefract...u ' »„cic. g^ THE EYE. Bv apnlvinp the formula ..f fiauss t- those .lata the followi„ff are ,le«hHr.l as the eanUnal p-ints cf the average normal eye: F>„tprind^l point (U) i.g m™. behind anterior ...rf.ce of c,m,». Second prliicl|i«l piiint (H'l -]•■ First ni)dal point (N I - i ■■ Second nodal point (N') '■ ., ,„,„„„ „f, he cornea Anterior principal foe. «(r|. • • ' ' . ,,ehlnd anterior surface of cornea. Pi«teriorprinci|>Hl focus (F) . . . -' \ .liaprainniatie eye e..nstruete.l in aeeor.l.mee %vith the.^ ■ ueas- ureiuents is ealle.l a sclieinatif eye. (!ig. 3o.j Fio. 8'.. fi The Reduced Eye. It two pniiciii am I Ix'l wee 'II efllect this iiitevv „ ,ti('e(l that the interval between the tlie two noda". i>nhits is only 0.:^ • mi. . if we 1,,. 1,.-,. iiriiwiiiMl .-Hid th.' !«■() nodal will lie no il anil nieifre the two principal and th lOlll ts into a siiifile priiieip 1 and a silisie nodal point, the refraetivt HVct of the eye is in all ivspei'l siiita noin i)le cnrvatiiie. the surface in tsare merged, and the indices being . .. ilar to that of a single surface of tersecthig the axis where the princi])! smi tl >f the first (air) anil final medium (vitreous), respet the ri'ihind cm Th .,,,„>tivelv. Suchasul)stituti.in is called lucc.leve is useful for the stu.ly of refraction, esp ally for experimental demon tration. The index of water is very arlv tlii> same as that of the vitreous heiie ■ we inav make an arti- ficial eve for demon ^tration hv filling a suit :ihl(> receptacle with water. the cornea being npresentei I i)v a verv thin spherical segment of gla,s.s aiK 1 the posterior face of the receptat ■le having a ground-glass face on which images are projectei represen itation of the retina am Tl ic curv tancesarea the refractive mei ature of the artiticiai cornea s pproximately iMjual to those ( I; or, for the study of the fundus, a painted \ bloodvessels may b' substituted. liiould be such that the focal tlis- if the normal eye. If water is liu'm the radius of curvature should be about .") nmi. The'i.<.sterior focal distance of the schematic eye w Emmetropia. The posterior local ti.. ...... . M.mroximatelv) 21 mm., and the second principal point, from which SSu'ei; measured: lies about 2 mm. behind %■ anterior suriace of th CM r le-i- hence the posterior f.ieiis of the eye lies 2:5 mm, iM-himl thet ealsuliit: thai is, parallel rays will be brought to a f^.cus at this distance from the cornea. If the retina coincides in position with this focus, the <-ye is a.lapted to receive a clear impression of a is lint ohiert. When tlii^ n!,.!ion exists, the condition is ea le<l cm- ; ;: L. S'his is the itleal or normal state of ivfraction; but as ins relation depends upon the curvatuit' of the vuri(.u.s surfaces as well aa ri/A' I'liYsioiou y OF risioy. 65 „ tlu. .i7(> of the evcliall, it is not to »k' cxi^cctcd tlial it uniformly :;::';" i l ' l hv ..-.;. m fact, stn,.tly .p-akin,, ..n.n.Kropm . . „; .X . l.ut it is only wh<-n thr variation fron, tii<; stan-lard is i . .^^ in 1 in« disturLance (visual or n..rvov.s, that the con- ;,■!•;;,„ is to L n-anUM as ahnonual; any deviation lion, emmctropia " AbrnZrChave. for the sake of simplicity, implied tluU all the rMvs of •! refracte.1 pencil meet the axis in a common point- the focus To fulfil this con.Ution, there must l.e a suitahl.> diminution of curya- uith increase of distan.r from the axis, for m si.hencal refraction ;, ii lend ravs are proportionally too strongly deviat.., so that ,1;;.^ iZs.-ct th'e axis'nearer the surface than .lo the central rays. This is called xitluriad abirratwn. 'Hu- rVfractiiR surfacs of the eye, while more nearly resembling ir, id, surfac(-s differ at the axial portions only sliphtly froin :!l;iX!l li£^^. and are regarded a« silch in all calculations in the ''tn^^r^^'li i^ necessaiT, i" .-Ut to pronire a sKajp ■u'^hs- splu-rical refraction, that all but the more cen ral rays be X ch de. from the refracting media. This is accomphshe.l in art.hcial y V means of an opaque diaphragm having a circular ope^mng oVth.' .leslred size, through which the central rays are -"'"""ed to the n-fr ict ing nu-dia. In th<> .-ye peripheral rays are .-xcluded by the m. e ce ral ravs being admitted through its central aperture- fee ,,,7- vich varies in size acc<.rding Xn necessity. In bright lUu- ,i„ le pu,.il b<-comes very small, thus ad.ling to the sharpness I 'n.„nal image and preventing the .lazzhng of the retina which w. 11 occur from The excess of light. In feeble illumination he pupil dilates, so that, if possible, sufficient light may be aflorded for the iirniMT stimulation of the retina. ... • i 'oLomltic Aberration. Hesi.les spherical abermtmn there is abo ,l,n,ma;ic or color alM-rrati-.n, which is .lue to the fact that tl""! 'P ^e I 1, iMtion ..f light vari<-s with the wave-U-ngth or color violet Ik> ng ,i ; e s efracte.1. It may Ix- experimentally demonstrated ,1," t ;lr alH.rrati..n occurs in refraction by the eye, but it is too slight 1(1 lie noticeable in onUnarv vision. ncrea e of Aberration with Increase of Sixe of Object. Aberration i. °"ter according as th.- secondary axes an- tlu- m.>r.- ren.o e n,n the i.rincii.al axis Hence it is evi.lent that there is a linut , Iv t t i ' of aportun. (the pupiH. but also to the size of the „.,. vhich will affont a dear image: the ohj.rl ,„u.t nhcay. he .,ml Zl,.rison vilh the }orol .listances. It is thn.ugh the peculiar co- structilm of the n-tina that we are enabled ..see large objects ^^lth ,.l,,,„ess It is onlv the central porti.m ot tins organ, he macula La Ivinc near the prin.'ipal axis, that is sufficiently sensitive to con- vev a wISl detined iinpn'ss'on to the brain. The macula lutea covers .„.,-„vtd nn'M about 2 .nm. in th.. h..rizontal and 1 nmi. m the^ertlPa di..meter. but not even all <.r the gn-afr i-art of tliis area is concerned f 6tf rilK EVE. in .liroot virion; tho form centralis, upon which must fall tho inuiKc of " .rH ,j^. • -U tin.-th- s....... is . .ninut.. .lopn.ssiou n..:.r tl- -"tro o 1„ n.J.la "'lu.s .mlv that part ..f tho n-twial unap- whu-h is nu.s u rSus,>.l is utili...! iu\/-r.d vision. Tho less oloarly fonno. ^; Ion of tho in>a.o .lopioto.i upon ti.o loss — ^x ij-y';;/^,;; , J rotina is howovor, of f^roat s.tv.co hi oniarfiuiR tho ho d ot iwlncl vi im \nv ol.joH ..r part of an ol.joot lyinf; in this ho .1 of .n.l.stn.ct vls!!!n' if h Jxoiis attention, is brought ahnost i..stantly l,y the nms- cular apDaratus of tho v\i' into tho Ihio of dnoot visimi F^i ion of the Choroidal and Retinal Pigment Tho -' --; ^^f „hoto..raphio oa.nora islino.l with l.lack sul.stanoo.l.y >'f "^'f ^^'"^ ,ht .vHoot<..l fron, tho piato is al.sorl>o.l; othorw.so >>•;";--«-; ,r.ns fron. tho interior of tho oaniora tho plato would h "octod b^ this unfoouso,! hfjht. and tho in.ago would bo n.arro.l. tl^ ovc this function is p..rfornH.d bv tho pipnont of tho cW. .1 and ^''♦l"'\, =, Mental Projection and Rectification of the Retinal Image. It is apluZt tbat tho in.ase as fonned on tho retina is an rnverted nuago. Fio. 3fi. u..vortholoss, objects app.>ar in their true relations as porce.ved In ho visual .o„se. The roctitication ..f tlu- i.nase .s porlonnod by the nnnd, possiblv as tho result of ox,HMionce, in that -i- rotn.al nnafio Use .s !„ „uuufost...l to consciousness, but the ox aal pro.,..ct.on of this i,nage-lhat is, u-e do not see the irmuie on the retina: we seetheot>jed. Srdinj: the two nodal i.oints as u.erp..l in a sn.jile pon.t the ray r s raifilU lino passing through the nodal pou.t and connoctnig any point .Fan object with tho corresponding pon.t of ho unago n.arks h din.ction of tho external point. (Fig. 3(1,) H .s because tlus hue ,„,! onlv this lino, represents, in nonnal v.sum. the true .Un-'.on o :,nobj.."ct that the n.in.l has learned (through assoc.ati.m n the visual sons.- with otlu r senses) to i>roject images along the nodal Imos. and this even when, thn.ugh artificial or pathological conditions, those lines do not indicate the true direction. Tho estimation of th.- p..silion-the .listance-..f an object is, like- wise not th.- result of anv distinctive ch.arac*<> . ; of the image, but is a inontal product <-ftecte,l by the associatio ■ .: .-r senses and by the working of tho two eyes in unison. THE PHYSWhOUY Of VlUloS. 67 ACCOMMODATION. u-.. Invo •illudo.l to tho fact that the eyo possos^-s the moans of ''''Z}^':^^^^^^^ -ti„u; tho rays hoh^^ int.r- •'" M hv to retina bol< re reaching thoir focu., th(- inmgo as .lo|ncto.l '■'''• r!tinM uml.1 bo bhirro.1 In or.lor to aff.ml a clear un.iR.- .„,„,„ ho retina n^^ou l.o ^'";[; , , ,^„ i„,rease of convexity '■'''"'. eofn V ueinm mh.pt the eye for .Ustinctnoss of nnapo. nnpulso iM-caiiso ol the nieniai <u i transmitted al)l.' of unih'ruoinp; change of shape. -(irv ligament, (rig. .»<.) .«i,„«r>jtnr irriilur nortion tl„. nUnni '""-/'• '■o'-i^'^ "f *-? i:::;:! tin? 1 l. m' 'u face of „,av 1.0 aos.Tibo,l as a r.ng-sha,Mvl "'"^ ^^ j,' f. \\'V s,.con.l orlongi- ,1.0-solora just behind tho -fr.^rn.^X^-^^;;^l^^^^_^^ Jr^^^ n,dn>al portion '^.'-''-I'-f'' 7^"'' ;";.^,;;' ' XrhVwv the o.,uatonal the circular portion, and which exton.l poMeno.ix GS nm EYE. it rcfiinn of the cyoball, whoro they an- insortod into tlio ohoroidal coat. In the normal cy' t'"' fiiTular filircs prcdoininatc over tlu- lonRitudinal ones in tiic proportion of about ten to one. .Vs-vuininf; tiic sclcro-form-iil attai'iiincnt to 1)0 tlio fixed jxiint in tlie !nu.><eular action, it is ai)parent that contraction of tlie nion^ powerful circular fibres iiuist diminish the diameter of the ciliary rinp, while contraction of the less potent ineridianal portion of the muscle will, at mast, produce a slight tension upon the choroid. When the ciliary muscle is uncontracted, the anterior suspensory ligament is held tightly stretched, the posterior jjortion beuig much less so. (Fig. M, 1 .) The stn-tching of the anterior ligament causes a flattening of this surface of the lens; but when, by contraction of the muscle, the anterior ligament is relaxed, the anterior portion of the Flo. 37. lens is allowed to bulge forward (Fig. 37, 2), so that the convexity of this surface is increase<l. In maxhnum relaxation of the ligament the form of the two lens-.surfaces is practically the same, the radius of curvature being about 5.5 mm. in the young adult: for the posterior ligament also undergoes a slight n-laxation, the radius of curvature of this surface iM-ing reduceil from 6 to 5.5 mm. Tscheming's Theory. Certain physiologi.-its, most prominent of whom is Tscherning, believe that the theory advanced by llelmholtz does not afford the true explanation of accommodation. They believe that contraction of the ciliary nuiscle produces, by means of the longi- tudinal filires, an incn-asc of tctisioii of tin- ^usirtnisory ligament, and that by this ten.sion the curvature of the ajiices of the lens-surfaces is incrt'ascd with a dimimition of ourvatun" at the j)eripheral jxjrtions. TIIJ-: rnY.si')LO(i r of visiox. G!) ■ 1 ..V,nn,r,> i^ nhv«ic.illy possible culy in the event of the nuclens T' ii :/ i^ -.1^1 -I -^il' tlu' cortex is fluid or gelatinous Th.s .. :; flu/ n.l i of tl.e hunuin lens in ehiUl'uooa an.l early a. ult 1. f e " 1 ' , . tvhich aeeon.nuHlation is nu.st active: henee U wouM t i is "xplauation is less plausible than that o H(-hnholtz Meiiemen^o Acco^^ Acconnn.Hlation ,s n.easuml by ,1 l^n TSvvhen placed in fn.nt ..f a.ul as near ius po^s.l, e t.. the V.'. u ul. li V > san.e focusing power as the acconnnodat.on cN-r- 1,;„ tlir >.mK «''■>- ' I I J ,,„ „.|,|,.l, a„ eye can ' '"'"■ " , :'■ ' u,,» . M a nl l„. a ......,n,.l,.liv,- |«.vv,.r-th,. acconinioilate, tne iins t^ ""'^•"' , ,f , /) :^ n.)-, metre in ,„ ,ll„„k. „l acco„wmlation-oi the eye. If L i. O..o l,.ngth, the acconnuoaative power is 4 I)., etc. Variation of Accommodation with Ai;e. Since acconnnodative hardened wjth ;"7«;- "^f j^,^/^ ^i^l^ In enunetropic eye can ,s;;;;;;^;ow;^a.;;^i;ou;l-r of Seventy or™ ha. Iu...n reached acconnnodation is n.. h.nger P'^'-'We- The following table (Don.lers) gives the acconnnodatne pow. r at intcA-als of live years; 11 10 14 -.0 lU ;io X> 41) 5.'> 4.0 4r> X5 8..'. 175 l'4l 1 (,:, 70 uVj O.i'. 75 00 Presbyopia. In ordinary near work .ich as rvjuhnj. theobjoct of vision is usually at a distance of about f ; /""^Pf ^^ ,„„., fi„e the eve, or even nean>r in the case ofNcrv small prim . work: In order to adjust the eye for tins /l'^/'^"'';,;/^ .'^j//^-'^ 'his ;;i::;;:;iE";:;Sz,z:i^™rgS^ TIIK KYE. ;il)out two-thirds of the total iimphtiido is available, and with ud- vaiieiiiR years a still smaller proiM.rtioiican he utilized. If one attempts to engage in iHvir work without this reserve arcommodat ion, the eyes six-edily tire, vision l)eeomes blurred, and pain in the eves, sometiiiies aecomi)anied by headaclie, develops, so that the work 'must l)e aban- doned. After a short [MTiod of rest work may a^ain be resumed, with more or less ])romi)t return f)f the aforenientioned symptoms. If near work l)e jH'rsist(>d in under such eireumstanees, "the .«ynii)toms will in time become very distressing, and to those already noted may be added extreme hy[)ersensitivenes.s to light, and conjunctival con- gestion and inflannnati(m, which fre(|uently ensue. In order that one may be able to use continuou.siy '.\ I), of accom- modation he must have a total amplitude of 4.5 D." When from in- crease of age the crystalline lens has become so hardened that the amplitude falls below this amount (corresjjonding to vision at 22 cm., or !) inch(>s), the condition is called imshijopia (old sight). Reference to the table above given shows that the presbyopic state is reached when the fortieth year of life is passed; practically the condition is usually manifested between the ages of forty-three and forty-five years. It is <)ft(>n nearer the latter age when relief is sought, though the exact time varies according to the physical condition, to the char- acter of work pursued, and es(>ecially to th(> refractive Lstateof the eye. The jihysiological condition of presbyopia should not be confouiuled with hyiK'ropia, which may give ri.se to similar symptnm.s. A person having ;} D. of hyi)<To|)ia will re(]uire (as W(> shall learn in Chapter III.) this amount of accommodation for distant visicm; at thirtv-five years of age the amplitude is 5.5 D., and if .'j D. of this must be" used to focus parallel rays on the retina, only 2.5 D. will be available for the additional focusing re(iuired in near work. This amount being insuffi- cient, near work becomes burdensome, hut this is not presl»/oim; the inconvenience arises not becau.se the accommodation ' is weak, but becau.<e an abnormally high amount is re<iuired. With the aid of a convex lens correcting the hy[)eropia the svmptoms dis- appear, to reappear, however, about the age of fortv-five, when an .iilditional convex lens will be re(iuired to take the place of the failing accommodation, that is, to overcome the pmsbyopia. On the other hand, a person who has .'5 I), of myopia will never develop presbyopic symptoms, because he can focus rays coining from an object i)laced at the reading distance without any accommodation. Such a iK'rs(m will, liowever, become i)resbvopic (his accommodation will fall below 4.5 D.) at the usual age, and if he wears glasses correcting the myopia, he will have to remove these in order to read fine i)rint. Alth.High presbyopia is a i)hysiological condition, in that all eyes are sui)ject to it, it would nevertheless entail most serious conseciuences among civiiixed race^i if if .,vcn> nc-t that artificial condition.^ of life hav(> brought al.-^o artificial means of relief in the substitution of a gla.s.s lens for the lo.ss of accommodative action of the crystalline lens of the eve. TirK PHYSIOLOGY OF VIS/S 71 I'lu. following table give? the probable strength oi l.ii.v ner. ssary in ■,l,.r In enable the {)resby()i)e to engage coniforlably in i.'. c »vork: r* I 2.75 60 3 2:> 70 3.3 So Tor reading a glass of 3 D., or, at most, 3.5 D., is suffirient, even V h.n the acconiinodative power =. entirely lost ; hence the rule u<uallv given that 1 1). siiouh! .e.l for every live years is not ,p„li.-able after tiftv-five years. vidental.^. that the strength of i,'n^ must vary acroVding to th.- c ,a. - r of the work , it may be neces- .uv in eertain handierafts to use u lens of 4 I)., but a lens of this .'tn'iigth and even one of 3.5 I), would cause objects situated at a distance (^f one-half metre or more to be blurred, and for work which ,„u^t U' performed at such distance a lens of 2 1). would bt> reciuired when all acconunodative power is lost. It is al.so ar)parent that in ametropia the pn'sbyopic lens nmst be :„1,|.mI to or subtracted from that correcting the ametropia according lis tills is hyjwropia or myopia. VISUAL ACOTTT. The size of the image as formed on the retina varies according to th.- distance of the object. Thus if O (Fig. 3!t) represents the no. 39. li,„,ir dimension of an object, the image of this dimension will be nM.ivsented bv / /. or /, /„ according to the situation of the object. Conversely, an object, 0, 0„ Kig. 40, will form on the retina an image ni tlic same size as that of the object, O. no. 40. The Visual Angle. The angle X (e<iual to / .V /) is cM i;r visiud angle The >=!na!!est .angle which two points (as i) and O) M,MV subten.l at the nodal point of the eye, while they a^e distin- L'uished as separate, is called the minimum visual angle " - mini visual angle measures The mini- the ristw/ acuteveKs of the eye. It has ^^ . (^ ! 72 Tin: EYE. Ik'oii found by cxixriinnit that un.lcrsuitahloilhitnitiationtho smallest iUiRk. under which two white lines separited hv a black interval am H> distinjruished as .separate is for the n(.nnal human eve .sliKhtlv less than imc iiiiiiiilc. ' Test-letters for Measuring Visual Acuity. Making use of the foreRonifi cxiK-rnneMlal determination, Snellen constructed u series of test-letters so arran-ied that when placed at the proiH-r distance each stroke of each letter would subtend an angle of one minute at the no,ial pomt of the eye. This is illustrated in Kijr. 41 When placed at a distanc of :H) metres from the eye, each side of the.s(,uare rta. 41. would subtend an angle of five minutes at the iiod.il jioint and each stroke of the letter v-uld subtend an angle of on<> mituite. In testing visual acuteness, U • onvenient to have letters of various sizes the distance at wliK^h ti. subtend the one-minute angle In-ing noted on the card. (Fig. 42.) Method of Conducting the Test. The test is usuallv conducted with the letters placed at a distance of fi metres. If at ihis distance :hi eye ran dislingui.4, tho.>e t<-tleis which subtend the one-minute angle, the visual acuity is normal. It is expresse.l bv the .-(luation V = (i() or V = 1. Jiut if at this distance the eve can distinguish no smaller letters than those which subtend the one-miimte angle at ^m TIIK PllYSIOLOIiY OF VISlOX 73 r> iiii'tivs tlic visual iicuitv is only ono-half as gn'at as it should 1m>: il' i< i\|)ri'ssoa 1)V till" ciiiatiou \' = «) 12. In nencml. the visual Miiitv is cxpirssfil by a fraction, the iniiiicrator of which is the dis- tiiKv at which tho test is coutlurtoil, and the denominator is tin- ,iistancc at which tho smallest distinRuishahle letters subtend the oiii'- iiiimiteanple. Via. 4J. Tlioriiigton bracket with test letters. Visual Acuity Exceeding the Standard. Partly Ucause of th laniiliaritv with the al|)halK>tiral characters and partly because t he ^i.indnnl adopted bv Snellen (one minute) is slijrhtly lar-er than the ini.muum visual anple in young persons, it fre<iuently ha|)pens that Miialier letters can be read than those indicated for normal vision. ri,„< \- = (14 or V = 6 3 mav lie recorded. In old persons vision cNc-edhip (iti is not connnon, because of diminution of transparency Estimation of the Refractive Condition and of the Accommodative Power by Means of Test-letters. Since an eye must have its maxi- nial seeinji power when the imap" is properly focused on the retma we have in the t.>st-letters a means of determining whether or not tl„. ..mmetropie condition is present. If the visual power is incn-as«'d l,v placing a convex lens before tho eye, we know th; ' without this Irns the focus falls behind the retina (hyporopi: if tlie visual |M,wer is increased by a concave lens, the focus without the lens M,ust fall in front of the retina, either from excess of curvature or of i,„glh of eveball (mvopiai. or from undue actmn (spasm) of the a<Tommodation: finally, if the maximal visual pow.-r is obtaine. with il... aid of a cvlindrieai lens, tho eye is, without the lens, adjusted to the object in the meridian of the axis of the cylinder, and hyix-roi-ic 74 Tin: KYh:. or myopic (iistipuatic) in the moridian at rijilit unglw to this, accor.l- iiiK as a convex or concave evlinder is re<iuireil. Havinn .leteniiine.! wili» tli.- distant test-letters liie refraetiv.- con- dition and tiie visual acuity of an eye. it is ix.ssil.le, l)y means of small letters constructed upon the same i)lan, to measun- the accoimntxla- tive power. I'lacing Ix't'ore the eye the lens which affords the con- dition of emmetn.pia, and noting the visual acuity, the same acuity should l.e obtained in near vision so long as the acconun. .dative i)ower is sullicient to adjust the eye for the distance at which the tyiH's are held. DURATION OP THE VISUAL SENSATION. The leiipth of time required for light to produce stimulation of the retina is jjracticallv instantaneous; the shortest flash of light that can he produced exjK'rimentallv is seen by the eye as iH-rfcctly as a nuich longer Hash. Moreover, linwever brief the in-riod of stimulation, the visual impression always jx-rsists for an apjireciable interval (about one-eighth of a second') after withdrawal of the .stimulus. Thus a .series of rapid stimulations apjiears as a continuous stimulation -the s)>okes of a rapi.lly revolving wheel api)ear to cover every part of tlie area of the circle. BINOCULAR VISION. This .subject will be considered in another chapter. It -.uflic <'s to sav here that in normal vision the muscular movements of the eyes ari' so associated as alwavs to bring the image of an object (in direct vision) upon the fovea centralis of each eye. When this is aceom- plished a single mental impression is received— slightly more mten.so and with better appreciation of form and perspective than is obtained from one eye acting alone. ■S^ ■wwwwrtP CIlAriKR III. UEFRACTIVK KUUOUS IN OENKH.Vl. Hy ALKXANDKH DIANK, M.D. EMMETROPIA AND THE VAEIETIB8 OF AMETROPIA U„KN ravs con.inR fn.in a .listant objert-rays. that is. vsluoh are '" -n" ';' ,'il',.i nm'lio just at tho iH.st.-ru.r f..c-us ,.f the eye. The eye :;::,'.;,;; ol-ieets, fomnn. a shur,, i>nape u^m t^u. - -;^^ •. ^ .^ S.S t:::::z::si':: =ri^;^^^. ^^ ^ays .,.. its retina, is railed em m€<ro/»2a (L.). (t»g- •*•»•) Fio. «. ,f ,„« ,.,int f.'» the fundus i, illuminated*, that it .end. <^ujra>,^^^^^ ^^^^, ^^_ ,.^ < y .. Hia-p ,««lng back .gain thn.i«h Up ryrt.l.ine leu. and cornea. opposed to ommetropia is the couaition i^'»X ej^" amX'e^^e whi 'll the retina is not at tlu- ,>ostenor ocus of the >^' ^J'\;' f -, ..„se,uently is not adjus,.<l - t«u^ X>nt'.^'^SXd^tive ikf a caiiu-ia OUT of lofU.s, an<l canmu, i.-il., .. . ..hierts ,.,Ton or l.y the aid of a .lass, fonn ^^\^:^:;l:^'^^!Sn. up„n its retina. Ametropia comprises the \ armas errors «/ / wlii.li arc myopia, hyiK-ropia antl astigmatism. ^^^ ^ 70 Tin: f.Yh:. Myopia iMv.), or iitnrsiiihUihuss, \> \\v.\\ ctuiilili m ill wliicli tlic n-liiia lic^ lit'liiml the iHistninr Incus ..i \\v eye I'lic eye tlicii if* likr a caiiH-ni wiiicli is nit of Incus Imhwiusc its rcciviiif? plalc is tiH. far hack dl' its lens. (I'ijj. J4.» /> u Tli>;inyn|.io.vi' cr, l."i« rfpresenting the mrni>« hihI rry«t«lliiii' leu- n( the eve r.>llwtivi-ly, >; Ihe |.rimi|«l f.K'U" i.f (' C, .ir of Ihu lye, lyltiu In frolllof Ihe retiim V .V. Ki>« tin..natliiK fn.m »dl»l«i!t cbjict, <> aiKl hiTioe |«™IUI LxiDuaiioth.-r (l»kiig Itwomr-' l> C. P I'l wh.ii Ihtj- rwiih Ibci'^o. iiif Mm- i«.1 by (Tnt f In iMiit of the PctinR. The lye l». tl.er.r..re. ii..t «.tiii»t.-.l f..r " Tln-(.m."int by which It In out nf l,xii»-/ ( . the ilUwnce botwwii /■«n-, V -me«i.urt>^, Iboainaiiiil oriiiyo|.lrt. Hyperopia, or// ///M^rwWr»i/</Vj (H.),aisi> callcii jursiijlilalm ■< xvlonij- siiihlt tl fii.^s. is that coiuiitioii in wliicii tiic retina lies in front of the |x)sterior focus of llie eye. The eye tlieri is hke a camera vvhicli^is out of focus JH-caus*' its receiving >late is too close to its lens. ili^. I.).i Fig. 45. Thf uypeniplc eye CC. lem repn-sentitiif the; cornea and orystalline lens ccilli'ctivily. F. the I.nii<-ii«il l"<-ii- iif r f, or of llie eye, ti.hiri(l the retina .V .V. Ray? emanalliiK from a ■liMaiit object. O. an'l hence iwmlU-l looiic auoUier heloreftrikinif the eye (tukiiiit. Ihenlore. the course /) C, D Ci. ,vill, after refraction throUKh V C, )»■ converised t.)»arO >'. They will hence slrilie Ihe relina U'fore they come to a f.M'Us. The eye i», therefore, not ailjusted for (). Tlie aiuonnl by which it is ont of l,«.aji_i f., the amoiinl of Its hyperopla-l" nicaBured by the distance between .V .V ami F. Astigmatism (As.) is that condition in which tin several meridians of till- e\c ilitTer from each other in refraction, so that larh will focus parallel rays at a different jioint. Instead, thei . of there being one principal fociiH for all meridians alike, as in myopia or hyiK'ropia, there are a numlier of foci, ono for each meridian, ami tin ~e foci lie one liehind the other. If the focu.-^ for any on." meridian I,, j^peiis iu lie upon the retina, that meridian will he emmetropic, while all the other meridians will he myopic or hyperopic, Wecause their foci are in front of the retina or iM'hind it. If the retina lies hi fron! of all %m iih:n!.i<Tiyi: i-:i:iioi!s i.\ uiskum. n mi, iill ili«- iiH-ridiiUis will !i,rs ; :mil if the ri'iinii li••^ I' ,^[\\ \h- MlVLpic. I»lt W'll"' """■'• ' Accommodation. A* we lui\ uh,. wishes to f"'<'i>'* f<"" '» """"■ that is. I'V iiirn'usiiiK thi' c.iivfN liyiMTopli-, l>llt solllf :!inrc lllOIl ml all th<! fori, ull Wv mcri.lian.s 11 DtluTs. (FiR. 52.! M'*n\ in ('hii|)tt'r H., an eiiuiiftrojjn lijt-rt iliK's s(i l>y acfoiii'iKHliitiMR, V (.f his crvstalliiu- U'ms, ami thim r:i;;;i,':;s .-J... i...., .i. .. (n^. 4,.) -nns ..... a --. j^-. n^. „, ,, i,,, fru.n /' such a .lirecti.... that the .-y ( can forus them , T, ti. •! V V If th.- cvr (' i< onii.ictn.in.- .'« lias hc-n iiia.le '?:";;;■!-/ ; : i i^ i^ a.lju-.M f..r ,.arall..l rays .1 nu«t ;:;.K; ;;';:';hat .liv,-r.e fr,..i /• ,;ar.U.;. to o-. ^uiother. Hut ..^^o this. .1 must have ,Ui. I must nave a f..cal length.. .1 I'. Hh.o the a,mh.,n,l<^ ,;./; r. 7,rr..,«/.< the ,vr„mm,.Uitire effort that the ei,e makes „ r.iu>4- , VJn on. near ,^nnt must have a joa,! length e,,oot to the ZZo !hot «</./ Iro. the eye. This amounts .,,su>-.nK „.at when a patient a,l,asts fora pomt ^'^^^]'';;if;^^^''^^;Z „l,ls to his ,.ve l)V aeeoiimio'lative effort a 10" ( D.) l«n>. wno ;:;itl ■ f!!r half that .listanee. he a.Ms a U-ns twice as strong:. e,e. Flu if, r > .V , ....,, .,,«r..U.l r.y,. m.y be ..IJu^e.. for ^^« " "' ' i;',.^, ^^ °C ] Thl, len. mu.t have •i.Kth ,1 R fiirlbmoiiiy will a n)»li<! » .lai uiv^rig^ ■ r" :, air''.lon .ha. .he len, C wlU >- w e ,o ru. • = hem u,«n .he re,l..a > .N. .. f .. „ ,„,,, ,, wi.itive nrocoss i.^ verv helpful in This comriition of the vo- iixiatn. pro... iiUif^eil ,.nn-i.l...iiiK the eorn-ction ot relractnv errors. It is so f-^r ™ ;' „:\;l, J„.ay, if we wish, actually repla^.e <'>'• ;;-<-;-; f^^^ ,,,.•,.!= ..f iu-t such an v.uxiliary lens, an.l thus a-ljust the o>. t. r i y : ■• IZ point. Thus, suppose we paraly^e the a-onunoj^anon , . .l-telv in an e.nnietrope with atropn'-c, so that h.s cvc un.u lo; ,. :,i 'see aistinetlv at .listanee only. Tli.-n by placnip a . D (8 ) l,.„s l„.rorr his eye, wo at once a.ljust las **'«'^^ f;^,".f^'J,., r,„„, l,i,M, .•ui.l enable him torea.l at that -hstance, just a. if h. ^^<n. ;-in<'aii. , ivaletit amount of ac.oinnuxlation Vrsin u. Ametropia. Difl^Bion Images. An '"f 7''^^;' J. """ ^ nle alwavs .s in .Hffusion images. To un.lersta ml ^^» '* 'lu. Llu^Jh...- only to con«i.ler what happens when tb.> ray^ema- KUins from a distant point, .1 (Fi^-. 47), strike an eye ^^>' ' f"; ^J ..ea. amount of astig.liatisni. These ray., unpmgmg u,H.n the cor 7H TIIK KYE. II Ilea, arc coiivcrgod, tlicn pass tliroufrli the jmpil and, striking tlic lens, an* coiivcrjicil still niorc. so as finally to unite protty shari)ly in a l)oint. li, sitiiiitcd at the posterior focus of the ;'ve. They thus form a conical or pyramidal bundle whose base is formed by the jjupii r. and whose ap(>x l)V the ])oint li. The cross-section of this ))undie will have tlie sain(> siia|H' as the pu])il, iM'inn;, therefore, usually cir- cular, hut, in cases of irregular pupil, heing oval or any other shape, I). In cnunetropia the retina is situated at the posterior focus of the eye, iind will intersect th(^ bundle (' li at K, where all the rays of the bundle unite in a single point. Conseciuently, the retinal inuiRC of the point .1, which image is formed by the union of the rays com- ing from .1 and forming the bundle (' li, is a single sharply defined I)oinf of light. A distant object, Ix-ing made up of a s<'rie.s of lM)ints, such as ,1, will then form upon the retina '. series of sharply defined points like li, each one of which resembles its original in arrangement and distinctness. Henc the retinal image will Ix" a true and clear representative of the extenml object. Flii 47. -a ' Ditl'usion imaK^-s. The ray« enittlmtiiit; from n tlisUnt |K(itit. A. pnws thnuiKh tho triangular pupil C C C, and are convermHl to form h pyramidal bumlle of rays, CH, V li. C II, unitiDt; in a nharp iKiint At H If Ihi' rctiim is at .' it'iunu'ln>|>ia). liii" itnaKU of tlie iH)int A Is the |>iilit /) If the retina is at 1 ihyfieniplal. the itnuKe ot A is the IriaiiKle J), which Ik larger hihI more hazy in pro|x>rtion a« P lii in Irontuf H. If the retina is at ,)( myopia j, the Image of .4 i* the Inverted triangle A". XJand /,'arv ilill'nHion linagi^. II It will be odierwise in irnetropia. Hen- the retina is either in front of li (in liy|)e!ii|)ia) or behiml it (in m -•pia). In hyperojjia the retina, intercepting the rays before they come together, will have formed upon it, as the re|)resentative of the point .1, a figure, I), of the same sha])e as the pupil. It is evident that the further off 1) is from li — /. c, the greater tlie hyiH-ropia— the larger l> will be, and therefore th(> fainter, too, since all the light that in emmetropia is concentnited in the one point li, is now .scattered over a compara- tively large area. ."similarly in myopia the retina, being behind li, will have formed upon it a figure, A', of the .same sluipe as the pujiil inverted, ami biggei and fainter in proportion to the degree of the myopia. The faint, enlarged images I) and A', formed on the retina ii: REFRACTIVE ERRORS /.V GEyERAL. :,iiicli()i)ia, and rcprrsoiiting ii single point of light, arc callod (Inlii- siipii images.' .,111 III astigmatism tlio shajK* of the tliffusion nnagos will (l(>]Hni(l upon the amount of ametropia in the different meridians and the shajM- i,i the diffusion images upon the direction in which the least ame- tropic meridian lies. The six-eial varieties that occur will he discussed later on. In ametropia the retinal image of the distant object will tje made up of t. series of overlapping diffusion images, which will more or less <(infus(' one another. Hence such an image will Ik- blurred, and the more so the greater the size of the diffusion iinagrs. The size of the diffusion images is de[X'n(lent not only on the degree .,f the ametroi)ia, but also on the ,vue of the pupil. For it is evident that the smaller the latter— i. e., the smaller the ba.se of the cone (■ /i_tlie smaller will l)e the sections D and E. This sho\ys us why ill aiiietropes. and likewise in presbyojH's, who for objects within their near point also see in diffusion images, vision with contracted pupils is much A\iiT\yoT than when the pupils are dilated. Indeed, an ame- trope of even high degree, provided his visual [)erception is intact, will see iiearlv as well ivs an etnmetroj)e, if only his pupil is contracted ail vKiximiini or is made artificially small by the use of a pinhole isteiioixeic aiM-rture).^ This fact is utilized when in t"sting a patient we wish to asce.tain whether he s<>es jioorly l)ecause we have not yet given him the proper glass, or because, owing to some imperfection of the media, n-tina, or nerve, the seehig power itself is impaired. Ill the former ca.s<< the pinhole will imt)rove the sight, in the latter cnse it will not.' It is for this rea.son, also, that inyoi)es try to improve their sight by s(iueeziiig their lids together. This in effect narrows their natu- rally wide put;ils and gives them smaller liffusion images. Hyj)eropes, wiio JKive n.iturally small pupils, and who besides can get around their .li!liculty oy using their accommodation, generally do not need to riiii)l(iv this device. I"()i this r<>ason, also, the vision in ametropia is usually worse m a iim light, whe:i the juiihIs dilate. And many ametroiu's and pres- livopes secure good vision by • nng a strong light which falls directly ii'lioii the eves, and s<i contracts the pupils to pinpoint**. Hcsuining, we mav say: hi (imctmpin the retinal immje of a distant IKinil irill he a (liffu.voi, (maqe whose .v/iri/x- viU he the shafie of the pujril. n„<l irh,,.:' si:e will he (iireithj jn-nimrtiomil to the deifree of ametropia on Ihc one hand and to the size of the pupil on the other. The resultinn hlurrimj of sight will be directly irrojiortimuil to the sue iij tin diffusion images. > ! .uHlly c«llu<l .UffuMm eirrlet: but, lui pointod nut. v hllc Ke.iemlly circul.r. Ihey m.y hav« «nv -h.i|v. ilcjionililiit upon the i.hH|io i.f the pupil. ^ s..ni.. of the ilrst si«M lacles were nolhli.K hut pinhole »iHTtuiv« In raeul plates. W "h the-e -i : .\..|«. cnilil a-e ilWltielly at a (ligtanoe. ami a pii'Hbyope could rea<l. ' TheuretieHlly : h»t. an a raatler of fact, the pinhole eiH. off so much Mght that the tfit If not a wry ^. rvitsjHlile <>iie. 80 THE EYE. '} ; . i K. Correction of Ametropia. To obviate this hlurriiig and onabl(> the ainctn.pc to s«'(- jx-rfcctlv :it a distance, \v(> must in some way abolish his aim'troi)ia. This is effected sometimes by the aecommoibtion, som.'tinu's 1)V tlic use of glasses. However etiecte.l, tlie eorn-etioii pra( liealiy eoiiverts the ametrojK' into an einmetroiM-, and he sliould .see Hke one i)oth for distance and near. Myopia. Far Point in Myopia. Tlie inyojx', as we have just re- marived. sees a distant ol)ject in <liffusion images. Such objects, therefore, apiH'ar blurred to him, and the more so the iiiglier his mvopia. Hut while tiie mvoix- .sws poorly for distance, he s<'es well tor near. For if the eve is such that parallel rays enti-rngit focus at F in tront of the retiiia (Fig. 44), rays that <liverge from some comparatively near point, R, will focus back of F, and, if F is sutficiently near the eve, will focus right upon .V .V. Tl " : ye, in fact, is like a cainera w-hich is adjust«l not for distance-, "nit tor tlu> luarer object R. It is practically in the same condition as the acconmiodatingeye (hig. 46), and like the latter, mav be regarded as ecjuivalent to an emmetropic eye to wiiich a convex lens has been added. (Fig. 48.) Such a con- no. 4H. The myopic eye conridered as an f!mmetr.>pic eye. with n convex lena K.l.le.! The myopic e>e „my be regarded w an emmetropic eye, E. with a onve. lens, M. representiuK the myop.a added Suit. H lens win collect ray. coming fn.m its f.Kus, K. and render them p.irallel. when h. the emmetropic portion ol the eye. will fiKos them ui.m the retina. .V .V, The eye is thus, by it. exj^ew of refraction (r,>pn«.nte,i bv the lens ill. nalnrally adjnst.-.! for a point. R, which is. therefore. Us far |,.lnt The focal length of .If - -If K-i ' . the amount of extra refraction pro.lnccd by the myopia -i. e,|ulvalent to a convex lens whose liKial length equals the distance of the Idr point from the eye. ception of mvopia, while not absolutely accurate, is yet essentially mi and is so 'far justified in that we can imitate ([mte i)reci.-<ely the conditions of .1 mvopic ev 1)V acHially placing an apiiropnatc convex glas> before an emmetropic eve. Thus if an emnielniiH' wish .-> to hav(> an idea of how a mvo|)e of S D. sees, let him |)iace an S 1) conv.'X glass before his own eve. Distant obj.-cts will at once apijeai altogetlicr blurred and indistinguisliMble, being s(>(ii ,<iin|)ly in outline or only as a unifonn blotch of bhiek and while ' while objects jusi within' ."/will ai)i)ear not only disthict, Init iilsu magiiitied. and fiirtheniinrc will be «een without accoiiiincMlative strain. Ill fart, so far as vision is . oiiceriied. it makes little difference wlirtlicroiieiseuntiiiuoiislvusing2n.ofhi-:Mromm.nl;tti.iii(Fig. 4()V (,r i,.i< .•! + ■-' 1). glass before his eye and u.ses ii<i accoiniiiodation, oi HEFHAVriVE ERRORS IX GESERAL. 81 is myopic 1) ( Fig 4S ) In each instaiico he will ho adjust^'d for ., ,lisfuicc of 20"; at this distaiioe ho will sco clearly, aiul iM'yond it will'seo indistinctly, In-cause lu- sc.-s in diffusion ""»««';:• 'rhi< surplus of refractive power, or extra lens, M (Imr. 4S), thai , ,nvo„,- possesses ..ver and above an e.ninetro).e, is the nu.us.ire of ii p a. It also gives us .lirectly the point for which his eye is I IjusUM without th.. exercise of any .-ffort ol f '•<''";""' •f"'"7V,;;; ; V. s us hisA,r ,m„t. For if R is the far point, the. -^^ and A together will focus upon -V .V ravs that emanate^ fron. It. Hut to do this, ; n make these ray^ parallel, for then K, the emmetropic qu<.ta ;! r.^-e which is adjiilted for parallel rays, will f-- ^^^ l-;j;;^- If howVver }i is a lens that ren.lers rays coming from It parallel, 'n ust he is principal (anterior) focus. That is, the mm>trp,e may ,,^,L'ute.n,. e,uirale^>t to an .^wetropic e„e to vinch ha. hen Ma rourrs ,,laJ harin,, such a strength that U. imncipal focus wM lie prmsdij at the far jmni of the eye. Flu. 49. . >c Ktt>8 II (,, A (. M.Mrm K .n' • '' iiluminaled b.hI sei.^ls oul ni>». A t, ,.. principle of .n„J,.i.-«le fm-l u„.l w.M •"'." here .. n«l '"^^'^f'-'.^ ";,,,, ;, ,.., ^ „„| g,ve pKrailel my,, /' /.. /' /.. k ,liv,.,^-,.n« as if.h.y .-nine r.™ f;" ' ' ,7^'', „ '! ."J^, ,„,„ « ,„ i,e , :,., p,H.*. A- U hence th. pri„ci,«, f.H-n, of f-^;-J-«';X ;--;■*•• «'" •'"- '" '- "' * correction of Myopia The foregoing r"'""^;';;;^. ';;!;'';':;:;.i!:;\ t ,„„,,. ^„ ,„„luce the way to correct myopia. ' ';' " " . , .^le, s ,„ excess „f refractive power, such as is represei te. h> a <onx( x u lis, ; " vill h;.nnec,ed'hy a glass that will I-'-f'^ ''- -J=^" ^T ;::r;rti-l;;- it M,n<t •idiust the eve for t.andlel nivs. .\s, ho«e\tr, ' '( i .y • , ; ;' iiUtl'l for rays Ih.t are already -ii-'-'^'-^'^Vmu ? 1^ for r,vs- I{ r, R ('. divrging fn.n> R, the e..r.rct.ng gias^. /•• '""^ J sueh t \o nmke parallel rays diverge as if they came from R. Su.h 83 TIIK EYE. a glass must Ix' a concave lens, and its focus must be at R. We see, tliercfore, that the i/lfi.-<s which rtirrerts the mijojiia aj an ajc miiM be a conanc Icn.s whose focus is at the far point of that eije. .Myopia is usually measured hy the strength of the j;lass that cor- rects it. Thus we speak of a myopia of 4 1)., meaning an eye whose correcting lens is a — 4 D., ai. I hose far point conswiuentiv is about !()" in front of the eye.' ^ The efficiency of a glass in correcting mvopia will vary somewhat acconhng to tho distance of the gla.^^s from the eve. For, no matter where the corivcting (;la.ss L is situated, it must have its focus at /(■, the far point of the eye, in order to give parallel ravs the proper direction for the eye to focus them. If, then, /. is pushed away from the eye, say to L', its focal length, instead of being R L, it will'ln' the shorter distance R L'—i. e., it will hav<> to be a lens of shorter focus, that i.s, of greater power, in order to do the same work. For instance, if a givii) myopia is corrected by a glass of— 10 D. ( - 4" focal length) place<l J" from the cornea, it will need a glass of SJ" focal length (= 11..') J).) to correct the myopia when the glass i.s" placed r trom the coriien. That is, what would be a projier correcting glass if^ placed \" from the r-ye, luis ijccome l..')0 D. too weak when shoved V' further away. \\'(! sw, then, that the strength of a concave y!ass~t. e., its ahili/;/ to omrt uinojnn—is lessened if the i/lass is carried away from the ei/c, and is increased if the (/lass is hrouqht neanr the e?yc. This is true whether the concave glass is used f(')r distance or for near. As will be seen from the above example, the differe ice produced in this way with strong glasses is considerable. It IS for this reason ihat we see personswho.se gla.s.se' do not fully correct their iiiynpja pushing the gla.s.ses close in against their eve- h.ls 111 order to .>('.' .listiiietly at a distance. They thus in cfTl'ct increase the effect of their glas.ses. Accommodation in Myopia. Near Point. The nivope can, without using .•my ;i.ci.iniii.idali.iii mI all, see distiiictlv an object situated comp;iiatively near him, namely, at his far point. He can still, tliirelore. see c|uite iie;ir obje.'t.v sharjjly, even if his accommodation IS paraly/e.l witli atrnpine. |f, |„.wever. he uses his accommodation, he can focus down upon |M.iiits still nearer. When he uses all lii.s .icc<iiiiiiiMdati(m his eye is adjiist.Ml for his near jmint. Obviously this will i)e nearer to his eye thai, is the near point of an emmetrope having an ei|iijd amount of accomiiioilatioii. Thus an emmetrope having t I). ,,f accommodation can, i)v using the utmost accommo- dalive eftoil. see an object situated 10" from his evi'. A myope of } 1). uill be able to see in object at this di.stance 'without lisiiif any ;i(e,.iii,no,iation at all: and if he does use 4 D. of accc.mmo'^ 'ImIioii 111 addition, he will be able to see an object at .V from the eye. I'or. as cnnipared with the einnielroi)e, who in using all his ' TiK- «tH(einciu i» iM,t ,|iiili. ur.unik' i(, «i. Mi.iiil.l proiiTl.v l». .i,,,,,.. thcdiMano-of tl». fur |«,iiit i-n.ck.,,,...!, „ni .„„,. ihf i-Hiit where the glau 1» ,„„«|iy placed, but In.in ihe n.Ki.l ,«int oC the t'ye. wliifh iHHii iTu'h firnht-r hark. HEFRAt'TlVE EllRORS /.V llEyEHAL. «3 iccoiiirnodatioii lias in offoct placed a +4 1). glass before his eye. he is like a person who has a +4 1). jjlass ( represent inji (lie surplus of icfiactioii ilue to his myopia) eoiuhiued with another +4 1). glass icprcsciitinp his aeconunodation)— (. f., lie is in eti'ect an eninie- troi«' with a +S I), glass before his eye, or an eiiinietroi)e who is nAuii S I), of aeeoniinodation. A^'niyoiM's rannc nf distinct ri.siou is obviously very limited, even when the nearsightedness is of low degree. Thus a myope of 2 I). wiio has () 1). of aeeommodation, and has. therefore, a far jxiint at '()" and a near point at 5", can see distinctly tiirough a range of only 15". The higher the myopia the more this range diminishes, and in fairlv high degrees it tecomes jjractically ?til. Thus a myope i,l 10 1). with an accommodation of 6 D. would have a range of only 1..")" (from his far jioint at 4" down to his near point at 2.5"). Some conii)ensation for this limited range is found in the fact that a myope in doing near work is partly or wholly indi']>enfhnt of his iicconnmiliilion. Thus a myoj)e of 4 D., as he sees distinctly at a disiance of 10" without using any accommodation, will never need to have a gla.ss for reading, no matter how old he becomes. A myope of even 2 I), will not nee<l to use glasses for reading nearly so soon as an enimetroiM' will. For, while tlie latter usually has to get glasses when his accommodation is reduced to 4 D., or when he is about torty-three years old. the myope of 2 D. will not have to get a glass until his accommodaticm is reduced to about 1.5 l).—/.c., at the age of tifty-fivc years. For the same rea.son we can u.^e atropine or h<miatroi)ine in ihvojk-s with considerable freedom, as we can assure Ihcin that the instillation, even though it does abolish the acconi- tiKHJation, will cans*' them little or no interference with near work. \s nivoiH>s, and particularly nivoin-s of fairly high degree, need to u-e dieir acconimo<lation so little, they have not the same facility ill this regard as enmietrojies and hyiK>rmet ropes. When, however uc correct a nivoiM" we convert him suddenly into an emnietrope, and i„. has to accommodate like one. Naturally this sudden .•issumi)tion ni an almost disused facultv is not easy for many, and. indeed, most invuiM's fin.l dillicultyat first in using their glas.ses for near work. Thr older the j.atient, the more pronounced this difhculty is. It is a^iunisiiiiig. however, with what ease most myopes reac(iuire this aliility to use their accommodation, many doing so at once, and nrarlv all <loing so in a verv short time. When, however, the near- M-^lit' exceeds 12 D.. we fre(iuentlv hnd that the myoiM-. especially ,1 he is of .adult age and has not used suitable correcting glasses, :i!!!i.>t even ;!fter persistent etfort. learn to use as strong a glass for ■I. ar as for distance. In these cases the accommodative faculty is Hinally lacking, and this is due. as anatomical researches have -hnwii." to Mtrophv of the ciliarv muscle. Ill itivopia of low degree the accommodation is usually «iuite .ictive. ,11.! ina'v often, indeed, act rj-ccssiirhi. producing an apiiarent exag- . latinil of tiie ne:irsight. The accommodative etTort. in olher wonls. 84 THE EYE. will cause an cxrossivo liuijiiiig of the crystalline ions, and tlius add just s<) much to the rcl"iacliv(' power of the eye. already too Ki't'at. Tills factitious or accoininodative myopia, pniduccd i)y spasm of accommodation, will he considered later. (See under "N'arietie.s of Myopia.") One effect < ' .■■ iii.s •> of accommodation in myo|iia is to produce an nrcomnio..., i. runrvnjvnrf-insiijfirH'urii, or exoj)horia, wliicli may develop into a n ;ular ■' .-erRent .scpiint, which at first is periodic I marked onlv for -i ' ' Its mcipiency ;i (U\ l)y the u.se of cone, accommodation, ani Varieties and Cat< eVP as an emmet . ifterward constant. An e.\()|;lioria, and in .sipiint, having this origin may he corrected .lasses, which com|)el the patient to use his nee also to converf^e. >n of Myopia. We have regarded the myopic ; <'ye with a surplus of refractive |M)wer added to it. Tliis is true of many ca.sf>s. Tliat is, in these ca.ses the eye is of normal lenjitli, hut the cornea or lens has its refractive pow'er increased, so that the two together focus too strongly or hring the rays together too soon. This overplus of refracti%-e power may he due to excessive hulging of tlie surfaces of tlie ct)rnea or lens (curvature myopia), or to changes in the density of the lens, cornea, or a(|ueous, altering their index of refraction (index myopia). In mi)st cases of myopia, however, the cornea and lens are of nearlv normal curvature and density, the eye heing myopic simply 1«>- cause it is too long, .so that the rays, although normally focused, come together in front of the retina (axial myo|)iu). .\ transient ciirraturc mj/opia is produced in what we call .'ipa.sm of accommodation: when the patient, hy excessive use of his accom- modation, temporarily increases the curvature of his crystalline lens ahove the proper amount. This (ircommitihiliiT ini/ojiia mav happen ( I) as the result of excessive near work : or (2) from the ert'ort Of trving to see hy a poor light; or (;^ of trying to, see when the sight is ohsciired hy an opacity of the cornea or lens. It may also (4) result from the effort to see more distinctly in astigmati.sm, and ('>) it freipiently is pro(luced hy the elTort of accommodation exjiended in overcoming a concave glass. .\n emmetrope or a hypermetrope with good accom- modation can see as well with a — 1 I). gla.ss as without it, hecause he almost immediately contracts his cili;iry mu.scle, hulges out his crystalline lens. ;ind thus gives his eye an jidditional refractive [Miwer <if 1 I)., which, acting like a convex lens of that strength, neutralizes the concave glass. My a similar |)rocess a man who i.s actually mvopic 1 1). will .see MS well with a 2 I), as with .a -1 I), glass." The <p.'isinodic coiitr.iclion of the ciliary muscle hy which ;i man may tlius appju-enlly increase his myopia if he is really myopic, or simulate .a myopia wIh'M he is .ictually emmetropic or hyperopic, is callecl sj)ii!<tii ()/ nirtDintidddtiiiii. It may he transient or last for a considerahle period — years even —according as the cau.ses which ' And evou If nl several yt'tirs' stumlliig. UEFHAVllVE KHRORS IN (lESERAL. 85 In,... ii ire transitorv or iM-niiiimMit. Hoinatropinc, or, in tht- cius*. 'r p.'r'UH.t sp!;>!m,atn,inn.., n-p.-afMlly inslill.-.l will abolish th.- . ,.;.,n,Hli<- .■..ntractioi. of tlH> muscle a.i..l with it the TactiMous myopia. 'Y\{^< m.nt.s of .lianiiosis should always be e.uployeil when there is a .,i<i,lci..n of <pasin of a.>eoniino.lation, au.l, as ex|K-rience shows us ,l,.,t ii, people below fortv-Hve years of age a spanii of this sort very ,;„,urntlv exists, it is itniK.rtant to use hoinatropiue or atropin<> , L-.T we ean in our .•xaniinati..n of the refraction. ( )th.Twise we Inll ofl.'i. .-stiniate the myopia too liiRh or the hy|K'ropia too low. S.e remarks upon "The Tso of Cydoplegics." later on.) ■ rcnnnmHl nm-nlurc m!io,m is usually .lepen.lont upon structural ,,,„„„.. in the cornea or lens, due to .lis.-ase. I'.xamples are the ..n-oiTia of .■onical cornea and that associated with many opac.tM"^ ! nllc corn..a. and tlu. nivopia produced by a crystahne lens which 1. dislocuted an.l, beiiiR thus freed from the tension of its suspensory li-nmeni bulges out l.ecaus.M,f its own elasticity. Permanent curva- ,uv myopia is a.ssociated almost always with astigmatism, olten of till' irre"ular variety. . ... ■ , \M ..Campl.^ of in,lc.c mnopin is that often occurring m the .levelop- ,„;.,;, „,■ ,,uaract, wh.-n the lens, owing to alterations in .ts.len.sity, and . ridlv to sclerosis of its nucleus, l,ecomes m..re r.'tractive. This „ vopia.'which may aniomit to several dioptres, is olton also asso- I'i'u.'d with astiRinatism, as the increas,- in .lens.ty d.M^s not take ,,|.„r in all parts of the lens to the same dejiree ' ' . a, Jient myopia often .leyelopin|, in iritis' is held by s.,nH^ „. . an example "f in<l<'X "'vopia the increas,- in refract, ve-.^r l„.i„. attribut.'l to increased density of the a.|ue,.us. Tt is doubtful, however, whether this explanation is v.did. [rial ,w,"pin is by far the most common variety. It is due < ti,c -^radind elon,ati;,n of the eye which "I""- "';';; '7'' ,?^ „, vmith and which causes a jira.lual recession of tu- letu.a. us . , '^s c curri.m^ normally in all eyes, occurs excess,v..ly m le.vo .e.-j, as it y 's on. tends I make them more and more nearsi.hte.L I'v'.;;' millimetre of such n-cession corresponds to an increase of about ' TluM-lIln-'a^olfi; myopia affects almost oxclusively .he ba.k part ,,, Ve y "v cli 10S.-S- its gh.bular form and bulges out m the fj.rm . V2 ' Tl e". ' of this egg-shaiH".l fiR^re lies about at the yellow ; -u;:! the parts in the vicinity of the latter consequen ly suffer ,!;;;';.::;;' fnlm'the stretching produced by the ••'"XluU clnng " ■Il„. ■,.>rt^ in front of the lens, on the contrary, suffer little ( hange, ' !;: ..!:;„:; n',ai;:in;;ts curvature, and the anterior chamber its normal ''VL.,.,„ l,.r tins erresxive elongation of the back I^'-J^f^'-lj^! ,1... reason, that is, for the development and P'-^^^;'' ' ' ^use h,.s no. been .satisfactorily determined. There must bo some cause. AmouDling wmellme* to 2 D. or more. 86 TllK EYE. I'itluT cxtcriiiil force or internal pressure, actinj; to ilisten.l the haek of tlie eyehall. This eaiise lias been variously eonsidered to lie the pressure of the external iniiseles, es|M'eiaily the ol)li(|Ues, uiuhie aeeoiniModative action, the traction of the optic nerve, etc Whatever the cause, it is held usually to he one that is particu- larly active when the i //c.v arc iisvd Jiir t«iir irnrk. Statistics are forth- coininj; in aliiindatice which seem to show that myopia increases /«;/•( /w/.v.si( with the amount and c((niplexity of the work to which the eyes are suhjecteil. Thus it has Iwen made (|uite certain that mvopia is of lowir de>iri'e ami also less prevalent in the lower schools'than it is in the higher s<'ho()ls and in the collejr,.s: aiid the inf'Tence lias heen drawn that the myopia results in the lirst instance from the moderate apjilication of the eyes in the lower sciioois, and is then eiihaiici'il l.y the further and jireaier strain imposed upon the eyes hy the more complex work (,f the higher schools. This inference, althoufrh i)erhaps, in part, corrcM. i.s not really warrante.l hy the statistics, for myopia, heinn a profjressive alTection. ,ind itu reasing naliually with ajje, would of necessity he more frequeiil and of hijrher gnide in the older pupils, wiiether they use.l their eyes for near work or not. .Moreover, it is <|uite fre(|uently tlie ca.se that mvopia, e.s|M'- cially myopia of hijih degree and rapid progress, develops in tiiosewho do not use their eyes for near work at all. Thus it is fairlv coimnon in peasants who lead an (,ut-of-door life and who camuif read nor write. The influence, then, of near work in pro(hiciiig myopia, although undoubtedly markecl, has probably been considerably "overrated. In any case, the use of the eyes for near work is not the sole cau.sp of myopia. It is :it most tlie vxcitiiuj cause. For of two childn'n of the same age, and both subjected to the .same kind of work in the same school, one will become nearsighted, and the other will remain hyperopic or become simply emmetropic. Their .-mst be some /w- ilisjm.'^iHii aiHsr acting in the former ca.se to pniduc the myo|)ia. .\ssuch jiredisposinir c.-iuse^^ l-.r,. |,,.,.ii alleged t}u- shape (..' the orbit (a low. broad o.bit being s'lpposed to favor the development of myopia i. ;ibii..nnai i isertion of the external mu.scles, especially of the obli(|Ues, insullliieiHy of the iiiterni, etc. .\ more importaiit cau.s(> piobably than any of these is a n.alural distensibility of iho back of the eye. allowing it to recede under the influence of even a normal pressure. Whatever the predisjiosing causes .-ire, tliev .seem lo be nilirrilrd. for myopi.a. .and p.irticul.arly the raphlly progressive form of It. tends to run in families, ("oiisanguinity in the jKireiiis also seems to have -omi' t Itecl in producing it. Complications of Myop;a. Myojii;! is associated (|uit.' frefjueiitly with ••oinplic.ations of the fundus. The chief of these are the so-callei| crescent or coiiiis; rarefaction and other degenenitive changes of the '•lioioid, gronpeil under tiie name of sdero-choroiilitis posteririr: actual central choroiditis: lieinnrriia,!r( s ii <!.• choroid or retina: the formation of a black .spot, probably due to piument proliferation in the macul.a liitea: and detachment of tlie relit, ,i. REFllAtriVK ERRORS l.\ (iEXERAL. 87 f)f till- <•(»/(.'/.• I'iisl, tliir i; pap tlli'l.t (IKHI-flnSllK ilirt'i' v;iri('tirs may Im- (listiiifiuislicd : tln' .■oiijicriilal form, skirling the lnwcr bf)r(lt'r<)f the tributcd Ui an ain'^t of dovclop- Tlii-i viirit'iv, wliicli is at 1 OCIM iiiav tliru _ the fipial fissuri-), is usually associated with I'tc'dcuri"' i«l' iiivopia and aslinniatisiii, altliouuli it "ft<'» :»!'«' irs ill hyi cropic eves, 'llic myopia ioiiiid with a conncnital (•oml^ )(• pvo^rcssi^c, ailhoutjh in many cas.'s it remains stationary iifiii (I the (-onus inferior as sui h lias no .-iKTial sinniti- caiiee in in(h(alm(; an ai Ivaiiee of tiie myiii)ia The second i'onii of coiius occurs as a ino< hni ,„•>.•,.„■ lerately hirp', sharply de- 1 white crescent, skirting the temporal, or, more rarely, the nasal, ■if the disk It mav Ik- coiiilmied with the inferior conus, or it the iii.iv ehcroac ■h on the u'p|M'r border of the disk. This form is ■iTular C'^ncomi taut of myopia of !U(Mlerate dcKree, that Is up to 10 I). Vet it is aliseiit in not a few cases of myopia, even in tho.se (il con or wi adjacent cho nivopia, mu siderahle amount, and frei|uen tiv is found with ( inmetropia th hyperoi'ia. In itself, if imassi iated with rarefaction of th' roK 1, it does not ar>jue an active progres.sion oi tiie 1 is not to l>e regarded as pathological The third form of conus i wiiile 1 coiiceii >iile o laimu sometime! ,,,, .. the \iiVff' triangular or irn-Rular'y oval i,.'itch of" atrophy with illnlefined borders, or with a s< fi -i of trie bonh-rs (terraced conus). This may occupy the t..;.' „,i.. (f the papilla or spread so a- liar C( 'iivolop the latter on ail f I'estations o ,..^,. It is found n'guhu'ly witii myopia oi 10 D. or more, Iso with myopia of less amount. It always indicates to be reftarded as one of the mani- osterior, other evi('"nces of which inus) |)nij:ression of the myopia, and is to 1 if a sdero-ciioroiditis j are a iiomenon. Jmost invariably presen It. It is, therefore, a pathological phe- .<(lrni-rli<iroi(iitiK po'itrrior, un ler wliich term may Ih' included all f, ,nn. of rarefaction and atrophv of the choroi.l, with or without the .U OM<ition of pifimeiit, occurs regularly with myopia of more than 10 1)., 1 sometimes also with mvopia of only f, or D. Whenever present, it t,d shows that we are dealing with ites ailvaiice of the myopia, a II ai)n(irma ,!■. N'ei' Uv distensible or, ;it all even ts, an abiioriuailv distending irelv indeed a myopia i mis and without evidence; The other luiidii.-< rhnttijet III tlaiiH na torv alterations in the ye .f more than 10 I>. is found without f rarefaction of tiie choroid. -viz., hemorrhages, degenerative ami pot, and detachment of the iitiiia — occur w 111 -how that inui-h more common m luyopi:; of .') or ,ith moderate freiiuency in myopia, statistics .nirarv to the usual opinion, tln-se accidents are not the verv high degrees of myopia than in (i !). But inferences drawn from statistics aie not ilirelv tru.-tworiliv. The: ceidents are more likely to oci iifier the ordiiiarv ( ■hai IJIv'S o liaxe la>te<l a Ions; time Progress of Myopia. Myopia is a>es associated with an inferior conus, no f myoi)ia (sdero-choroiditis posterior, eto rarely congenital. Some nf the loubt, date from bir'i.. m THE KYE. Mini sdtiH' (itlicr coiijiciiital rases am probably liiu* tn iliscasc of till- eve occiiriiin in utcro. Hut in llic ovciwIiclmiiiR iiiajoritv of « ' the airi'; tin^uislicil. as<'s iiiy(i|iia i- an aniuircd atTcctinii which dcvolitps iK'twccii if five an went v. Three <'lasses of cases may Ix' <lis- jn the fiM cl(i.'<f of ca.M .- tlic niyo|iia never exceeils 2 |). Such a iiivojiia may develop in laie cliililliood or in yontli, in whicli c:use lis ad\ance, if not airested s(M)ner, ceuses at the age of twenty-one i.r twenty-two, when the patient attains full (rrowth. A myopia lif tlii- sort may als;> start in adult life, anil is then generally the result I'f excessive use of the eyes for near work. This low myopia is usually associated witli astifrniatism. It is probable that this association is not fortuitous, but that tlie astigmatism is tiie cuus<' of the myopia : that is, a patient starting with hyperopir astigma- tism, converts this in his efTorts to .s«h' distinctly first into a mixed then into a myopic astifimatism. Myopia of this amount ami not u~uallv assciciii led will) a (-onus In the .•^criind r'<i.-:s itj rnsix the maximum pitch to which the myopia attains is about to '2 to II) I). Such myopia develops in childhood, especially durinp the school a>;e, ami tends to increase up to the lino of twenty-one or twenty-two, when, with rare exceptions, it conies to a st'>|). It> .idvance «|)|M'ars to be directly |)roportional to the demands ma<le upon the eyes in sch )rk. Hence myo| iia )f this kind is often called " .-chool myopia." Vet, as before remarked, there is jiidbably no actual intimate relation in most cases between school-work and the pro};ress of myoi>ia. I-^xcessive near work may initiate a myojiia, but is not probably the main factor in causing its a<lvaiice after it has started. Myopia of this kind is often accoin])anie(l witii astigmatism. It is fienerally associated witli a simi)le temporal or na.sal conus, and not with the |)iojjres>ive (lai j;e. teriacod, or annular) conas, nor with true sclero-i'lmididitis ))osterior. In the IliinI rla.^s of rases the myopia l)e<;ins in early childhood, increases rapidly duiin'.; the growing jM-riod (often reaching 10 or V2 1). at the .age of t<'n). and so far from coming to a staiKl-still at twenty-one, ke( p^ on increasing in adult life, so as ultimately to attain b") to 21), or even L'o to .'{() I). This kind of myopia besiu-aks an unusually yieldinir ami distensible eye. It is almost invariably associate(l with a large conus and marked sclero-choroiditis jMisterior, wlii( h may develop loiig iM'fore the myo|)ia has reacluMl a high grade. In contradistinction to the other kind, thi.s form of iny()|)ia is denoted as imiiirrssirc or jxrnirioiis. This form is distinctly pathological. It does not develop particu- larly a.'^ the result of excessive near work, and, indeed, occurs com- paralively o'len in tho.se who u.se their eyes but little. It occurs more oftcr in tli foreign born than in native .\mericaiis, and more often in di-|)en<;iry patient.'^ tli.aii in the well-to-do. It is. in fact, a vice of development. Hlltn.UTlVK EIIHOHS l.\ (lESEHAL. H\) „„ •, „.t.. ,.la.v .liscnnlinnnnsh,, so that tlu- n.-HrsiKl. ....u-ss w. 1 ',;•;, th-i-nn.- ,H,int for-,>.Tl.aps s..v,Tal y.ars a... tl..-n su.l- i , .k.- n.. a.lvan.-... Tl.is is show,, in .nany .•as.-s i,y th.- pn-s.....-,- ;!l ', JnMc.i .•rrs.M.nt a.ljoii.ii.K the i.apilla. oa.h tt-rrac.' n-pn-.s^-nlinK ., nriio.! of rriH'\v<-'l progress. . . U .hoi.l.l Im- not4Ml that notall.-as.>sof pro^n-smvc iny..|.ia an-, ue ,„ ',,„., „i.,„ .,f the h:u-k of the eyeball. The a.lvance .nay Ik- .Ine ,. , ,1 increase in tlu- corneal curvature, as m true lenticonus an.l J; c tain other cas.. not strictly classifia l.le un.ler tins hea.L -huul.l also U- ren.en.lH.rul that .nixe.l cas<-s ol curvature and ax.al Mvupia .lu.- t.. changes in the curvature n. the cornea an.l lens eon.- |„„,. I with elonpiti..n ..f tlu- eyel.all. are n..t unconunon. Vi ion in Myope.. Myoin-s hav.- very hazy sight for .hstance. iJ. r..pe of i 1). rarely has n.or,. than 2 KK) v.s,.jn. one jv.th 4 1) „;:;•. .!.un. im^ers acr..ss the ro...n: an.l ,n tin- '^ ^ ; ;^--; ,„..„.i.rht tlu- l.lurrinR is still nu,r<- pr.mounce.l. lhi> l.lun.ng is ; , ,; l,v the .r.latation of the pupils which is usually present in h .-ases/an-l whi.-h acts by enlarging the .UtTus.on '>'I='«;- 1„. ,„.„; ,.,i„ts n.yoiK-s have very poo. 1 vision ... t;""'- -'^"I " vii, . than en.nu-t.-opes. since .u-ar ..bje.ts a,.iH-ar to th.-n, lar^. r , 1 . V .1.. to einmetr-MH-s. Mon-over, as n.yo,K-s .lo .u.t hav.- t., 1 ,• acco,....u..la.ion. eve., wl.e.. the object .s .,u.te ,u-ar, th.^; . . .• an ..bj.-ct without accon„,u..lative stra..,. As an ..ITs.-t .. is i . ',, h.p,K-ns that they hav.- to hoUl an obj.-ct s.. dose to i, i ,. tlv tat tlu-v cannot keep both eyes convc-ge.l up..n .t. 11.' «ei i.,to the wav of looking with ..„ y o.u- eye at a tinu- ;;ll, •,•„; tlu- ..ther c-ye to .liv.-rge. They thus have only n.onocular "'7uh ,ln..cs. the- visio., in .uyopia of low an.l nu-.Uum aepn-es is „. .'illv ..early or quite norn.al.. I., n.yop- ^^l;^^^^^, ;^:^ i ,.i,i„„, better than 20 40, a.ul m n.yopia of 20 I). « r '>^< r ^^' '-'" '> :,. t e. Im . 20 70 ..r even 20 200. Yet if marke.l fu.u us changes -;.;. !:lll;;t ,1;;- sight ,nay be .nud. better than th.s: an.l I have s.-e.. ' Z7:::::^^.::^^rt'::t .. visi.. is uk^y .. b.. -j ,:,.n:.l, althouglf if the refractt..n be «-rrecn-;l c-.;^u^ - vHi.m nriy, n. .:.any c!us<-s, be brought up to nearly or qu.t. tiie '",'"'' '"","i"!"!vith ...•irk.^.l sdero-chomi.litis posteri.)r the vision is ,.:;..:;;:: ^ . 1 - 'nl^re are he,T...rrl.agos, degc.en.t.ve or :;,,;;;,;!j,:"; dia;;;.;. or a pig,.,ent spot m th- ...acma, the .ght -iJ;:„^"Slr^S to^'ifiL- is — 3f iS:^: ;,„, or ...ore pn.bably of the conv.-rgence, for l^r^^^''" ;.„;.,„ a..(l co..vergence are rdaxed the pupil regularly diUtts. MICIIOCOPY RESCHUTION TEST CHART (ANSI and ISO TEST CHART No 2) 1.0 I.I 1.25 1.4 2.5 2.2 1.8 1.6 ^ APPLIED Its/MGE Inc ar^ Rochester. New vorh '4609 uSA '-aa (716) 482 - 0500 - Phone !M) THE KYE. Jr MyofM's also s(iiiint the eyelids in order to diminish the size ()f the piiltil, and fliiis to lessen the size of the (hfTusion iinafjes. For the same rea>on myoix-s incline the head forward, us by so <loiiiK they partiallv eover the |>iii)il. :ind so look through a narrower ehink. The most strikiiif!; feature, and one that the laity take as a sIrii of nearsi^lhtedness. is the manner in which the myo|>e holds objects close uj) to his eves in order to see tlien>. thus hrinjiinj: the object within his far i)oint. lliis, however, is not an absolute evidence of nearsiphteclness, beinj; sometimes due merely to habit, some- times, also, as we .shall .see later, beinfi found in hyixTopia of a high dcfiree. Hyperopia. Far Point in Hyperopia. \ \)A\m\X with uiicorrcHted hvpero])ia sees in difTusion imap-s. Conseiiueiitly his sifjht is blurred, aiul the more so the hifiher the hypero]>ia. His natural distant vision then is pool ; l)ut, contrary to what takes place in myopia, his \ision __:nr---fi K:ir jxiint ill hv|«roi.lrt and P""r«! nf iniorgeiit rays, correction of liyperopia by accommoda- tion or by a miivc.i gla.ss. U. the fur i»iii.i "f the hyiieropic eye. Kays Midi as D C K. D C R, oon- vcrKing tntturd R. will hv the lens C C (represciUinK the iMrnca ami crystalline lens colleclivel;) be Kiven the a.liiilional conversenee C S. C .V, so us to tie focnseii upon the retina .V. So, also, if S I9 illnminiitert and sends out ravs .V C, .V r, hacli through the eye, these rays, after pas.slng through (•(■andemerKinRfrnnitheeye. will take the direction r D. CD. as if they divergeii from B (prin- ( i|.le of conjugiile foci), and' will form an erect virtual inmi;e of .V. which will appear to be at R. II supplementary lens correcting tiie hypi^ropia. // may be cither an actual glass lens (artlllcial cor- rei-tion) or mav represent tlic extra bulKing of the crystalline lena, produced by the acconiraodailon (natural corrw'lion). In the former case, i/must be of such a strength that it will make the parallel rays II II II II. lake the direction /> r A', /) C I!, and converge to R. for if they are Kiven this con- vc'rKcnce tlic lens C Ccan then focus them. R must then be the princiiial focus of the lens //, and () R its r.H'al length If the lens // is moved out to //', ils focus must still lie at A" for it to give par- allel rays the pn>i*r convergence, so that its local length will now be o' K— i.e.. If will be a lens of longer I'.HUs— i r., a weaker lens than //—and yet do the same work. for near oi)jects is poorer still, for if his eye i^ naturally so weakly refractiiif; that it cannot focus even parallel rays upon the retina, still less will it focus rays which, comiii;,' from a near object. ;iie already diver<jent, and lience are just so much the more ditlicull to converjie. The far point of the liyperopic eye, therefore, that is, the point for which it is natundly adjusted without any effort of accommo- dation, is neither at far distance, as in emmet ropia, nor at any neiirer point, .-is in nivopia. W here. then, is thefar |>oint in hypero[)ia? < )r to put the ipiestion in another way, If the eye is neither adjusted for parallel rays, as in RKFUACTIVK ERRORS I.\ OESERM.. 91 I'liuiK'tnii m nor for divorgont rays, jis in myopia, for wliat kind of is it adiiii ;t(>d? rii.' answer to tliisciiu tion is sitnij'.c. The liypcropic eye 'I'lR. 50) uili not 1)1' al)lc to focus ttii' ))aralU'l rays li li upon the rctnia A, |„c ,u<c it cannot give tiicni .piitc the amount of coiiverf;ence reiiuired ,.'.ii,i,„t ^'v mav sav, bend tiiem (juite stnmgly enough. Hut it „ ill U'ni< ravs lik,"' I) (\ D (\ tliat are already <'<.nverj;ent to a certaii. ,,n.mnt an.l which will, therefore, re<iuire a les> anumnt of additional ',.,,„ v.iMvnce or l)."ndinp to brinp; them together at A . Hays like I) ( I) ( ■ if not intercei)ted bv the eve, would meet at some point, as li. back ,,f tl„. Idtci- We sav," then, that the hyperopic eye is adjusted tor ,„• will without acconunodative effort, focu.s rays that are conversing iMuani the point li, lying back of the .'ye. The {mint li is Ihvn the jar noiiit of the hy])eropic eye. . ■ , , , ,u- i Ihe less th( refractive power of the eye, that is, the less a<lditional ,.,iMven'ence it is able to impart to the rays impinging upon it, the .Mv.ternmst be the initial convergence of the rays C t which can F,e Incused bv it upon the retina. But the more C C converge the ,.l„s,.r will li be to the eye. Hence we see, the higher the liyperopia ilic closer the far pohit. Correction of Hyperopia. The hyperonic eye is like a camera which is out of focus because the sensitis.' plate is too close to the l,.ns Such a camera may be put in focus .nther by carrying the plate ba.'k to its proper place, or by leaving the plate when' it is and ...Min..' to the strength of the camera lens. In the eve both methods of comix-nsation are possible. I He c;/e „„„/ hwilhni, and tiuis shift the retina back to a pomt wh.T.- parallel , , V. will l)e focused ujion it. Such an elongation ot the eye actually ,.,kes place .luring th." growing p.>ri..d, and thus the hyperopia origin- :,||y present in nu.st eyes is gradually lessened or even entirely neu- " This process, however, is one that goes on very gradually, and, v.n if it took plac<> very much fasfr than it d.H-s, it could not Ik- i,ili/.ed f..r the rapid correction of hyiK-ropia. This mu.st be effect, d Inn, by ad.ling in some way to the deficient retractive power of "lilVhe natural eve this is accomplished by nccommodalmi. The :l,..nv mus..le. acting in .,uite the san.e way as it does ^^^^'^n ^'^^ ,„„;.tro..ic eve focuses .h.wn from a distant t.. a near object, causes stalline lens to bulge, and thereby incn ases its refractive jMiwer riv th n'i|uisite amo hown in rig imit 'The con.lit'ions, in other words, are \m Fig. .')(), where the lens (', representing ' th !h bv tl le acc( own 111 1 If;. •"'. -. .' ■ , . , I,, stalline lens of the hvix-ropic eye, is sui)plemee.te.l b\ the "additional refractive power [lut The conditions that will be observed a and cry ins //, which repr(>sents t jinmodation. alogous to those shown in i'ig. 40 d)ilitv of the eye IV neutralize its hyi)eropiM, wi to put forth this accommodative effort, an< il obviou^iv diminish as the elas 92 TUE EYE. I ■I i ticityof the crystalline Ions diininishos. It will, tluMctdn". docrcasc steadily with ajie. It will also he reduced hy anytliinji that irnjjairs the power of the ciliary muscle, and will he entirely ahrojjatc<l by a cyclo|)le<ric like atroi)iii( \\( may then neutrali>-e hyperopia by a cert un accommcM etTort. produciii}; an increase of refraction represented by the l( iativ( (Fig. ")()) // ^\ e niav also produci su< 1 an increase in refraction by a (jlnxx Iriis placed directly before the eye. Theoretically, at least, it makes no dilference whether // is actually a lens of jjlass or sitn|)ly th< represents extra huljiinj; of the cry-talline lens produced by' the cili iry muscle. The hypermetrope focu.sed for distance is, in fact, in the same po.>;ition as the emmetrope focused for near. In either case, it makes no ditTerence, so far .as vi.-;ion is concerned, whether the focusinj; is done by accommodative" power, or by a filass lens, or {)artlv by cine me.ins and jiartly by the other. Xaturally, then, hy; -.'ropia is corrected by acconmiodation and arlilicially by a convex lens which either neutralizes all the hvDer- opia or .>io nuicli of it as the accommodation fails to correct. Tl le amount of liypero|)ia is usually measurecl iti terms of the gla.ss that comjiletely corrects it. Wlial^ then, will be the stremrth of this filass'.' If we revert 'o Fi-;. .")(), we see that the refractiiiR media of the eve rei)resen)ed by the sinfjie lens C will, unaided. ))ring to a fi the retina rays haviiifr the direction I) R, 1) 1{~^ "w^ upon ('. ('., rays which ar ilready conver<;iii.u toward the eye's far point, /(". The fens //, ther(>- fore, which will aijjust the eves for i)arallel rays, must he ju.s't suffi- ciently stiotift to make the parallel rays take this same direction, /> /^ and converfre toward R. If it does this much of the work, C will do the rest and will focus the rav; parallel rays converge to R \~ ,i h s upoi, the retina. Hut a lens which mak(>s ns will ise principal focus is .at R: li<>nc(> the iilfiss irhich nnniili'tcli/ cnrmis thr hiip,ri>piit is a convex lidrinti ils jiriiifipdl l'(icii.''(il Ihcfar I the st.itemeni made in re<raril to tl lens 7 lis priiwipal joni." at the jar point itj the fii/peropie ei/c. fCompar ■■•■■meni made in re<raril to the correction of myo|)ia, pajje S2.) IS in the ca.-<e of myopia, the strength of the correcting lens n hyi)eropia will rari/ oeeitrdiiKj to its tlistonee from the ei/e. R heinj; the principal focus of the correctinft jrla.^s //, // R is its focal dis- tance. If // is moved away from the eye to //', it will st parallel rays the proper converjience : that is, will still corr .lust 1 ni give le rrect tl hyi)er(>pia, |)rovided its i)rincipal focus is at R. Its f now. however, is //' R. which is greater than // R. Since the strengtl .f 1 enses diminishes as their focal distance //' will not neecl to I increase tl ocal distance ngth le lens placed at )e as strong to do the same work as if placed at //. Or, to put the ca.se in another way. the effect of n convex ;il, Ih n eorreelin<i hi/peropiii is I, iijhtened if the (jlii e eije. ;in 1 is ili shed IS carried aivai/ froi. I IS enrrii'l tmriird the eije. In ca.se of a high hyperopia the difference jiroduced in th(> correct ijig <r];,ss in this w.ay may i>e coiLsiderable. Thus a patient who h.is harFa cataract IlFA-llMTlVh: ERIKiR^ IX (iKyiCIlAL- 'J^J }r a +11 I), will iiltcr its stn-iiRth by a wliolt Airactcil and is wcariii 1" lie sliifts its positidi liol .trc 1 sinn oiic-thinl inch fonvar 1 or l)acl\. ill] l)c can fullv noted tliat in gcncri d this increase in strenj;tli |l|o(|l iced ni a convex "ftiass by shiftiiit; it away from the eye ap]) lien the glass is used for distant vision Whei les 1 a convex !.■-< is '/.-■<'( / jiir midiiui. ils xtrmijth ix dim hid 1 )V carrvmn i t otT iViiiii tlie < ye, |)rovided the l he patient is eiiiinetroi)ic or hut little hypei- pic if, however, his hyperopia is nion than 4 I)., and in soin . <.l: w 1).. hi lien he holds'a hook far off), if his hyperoina is no niori ould tiie effect of his glass by carrying it off hall .1 I'., ne >miuhi Uicrea ""iTie tnu- 'reason whv inanv presbyopes, even though emmetropic. ,,ii<h their rea. ling-glass away fn.m t!ie eyes when it is too weak, i. that thev thereby increase the size of tlwir retinal images, although ■It the same time they make them less distinct. .,,•,, -n,,. far i.oint of the hyperopic eye can be determined directly frotn the strength of the c.rrectimr lens. Thus in hypen.pia of 4 I). „, .„„. ,.orrect<-d l.v a 10-inch len- the far point is 10" behm.t the eye. Accommodation in Hyperopia. Near Point. The uncorrect.-d hyper- opic eve. as we have seen, has used up a certain amount of its ac- ,:,n„nodatioii in or.ler to neutraliz.' its hyperoi-ia aii.l to s.-e distinctly ,t H .lisfince It has. conse(|uontlv, only a resi.lue ot acco.nmodation l,,i; for focusing down ui.on a near point. As compared with an „„„„„,ropic eve, theirfore, having the same accominodativ.- power, i, ,,„J..,.,. ,]hi,rts „> close. Thus a hyperope of 2 I), who iias f. I). „f ac<M,mmo.lation will, after nee.trali/.ing his hyperopia, have only 1 1) left to use in focusing upon near objects. His near p. .m, there- lure' will be at about 10", and he can see an objec that far „n onlv bv using the whole of his acconimo.latioir while the emme- ,,„pe with the .san... accommodative power will still hav(> 2 DJ It ulu'i, vi.-wing an object at this distance, and by using all of ins ,,,„„,„„„ iat ion can f<.cus down to 7". As a hyperoi.e aiul an ,,,mietrope of the same age have about the me amount ol accom- „,„datioi', it follows that the hyperope will become presbyopic, ihit is renuiiv glass(.s for reading, considerably sooner than the ...nmetrop.- will. For, as is .-vident from Fig, ofi. his -'ear point 1,:,. ivceded further than the emmetropes-m fact, is as tar ott ,< is that of an emmetrope who is a number ot years older. \s an offset to this, it should !>e noted that the hyperope s accom- n.ndation, while not grc.ter h. amount than that ot the (.nmu'trope ,„• inv.me of the same :■:.; is in constant exerci.se and is more iradilj ,„aintained. In coiison.ince with this, we find that in hypero] '■« 111,, ciliarv muscle is particularly well developed. The excels of accommo<latioii which the hyjM'rope has to put foitli n-id- fre(|uentlv to nrconimodatire roinrruoin'-c-vrrss, which mM> ,, ni.-iin as an esophoria. or may lead to a convergent s.|uint that is ,1 iii-( marke-i onlv fur near points, but afterward be<-omes pro- 4I.11I1CIM both for distance and near. 94 THE EYE. In .so„„> oasos ut hyporoph. the acco.Min.Klatioi, ,„av bo callo.i in p ay s.. ,-x..,.ss,voly as t., ..vor-c.rr.rt th,...rr.,r. ,.v.-., f..r,lista..<-.. a 1 thus r,.,H ,;r th,- pat.ont apparently ,n,,o,nr. This is ..sp,.,.iali; ho oaso if astigmatism is pros..i.t or if tiio patioi.t 1ms uso,| i,,;. P .por Klassos. I,, as soi.u-tiin,.s happens, a concave f,lass is p e- s ..... or tins apparent n.y.pia. the patient may, l.v contim in,. i..> constant accom.no.laf.vo otlort, l,ecom,> truiv mv.pic I he hy,H.n.pe may corivct his hyperopia entirely with his accommo- 1.1 tio ,„• ...ay relax his accommo.lation altogether an.l allow us to 1 ouexe , he al ows „s f. correct a portion of his hvporopia with a I T' . ; t" • ""' ''"■7''"^^ ^''" '■•"■•^' "•'*•' '"^ "'•'•"".mu.lation (4 ( IS, ... fact soaccustomo,! to usms his accommo.lation continuously t at generally he <.annot no matter how we nv^, him. jtivo i p t h^ "t ort at once when we place a convex jrlass l„.fore his eve 1 ut h e retains at least .some of his accommodation-/, c. .1-at w.'.rk If ... such a ca,se. w.- }iive a Rla.ss .stron-.T than // by O.oO I).', the amount that U crriTied ,.ll the time I, ■ tla- nccommoliM T,' /„:, ^til . «'""»ni.Klttt.,m. The be c.rreclt.l hy the mcomcKlati.,,,. i, eallcl h. nLuW^il'Lrli^^,^^^ pati.M, will a once begin to see lo...s .jistinctlv, for he will t .„ i,, .■licet, have belore his eye besi.les the len.ses .1 an.l //. which thor <'';.-n|ct Ins hyperopia ...n.l make him emm..tropic. a lens of ^ OSOD which will make him practically a myope <.f .50 I) A patient as shown in Fig. 'A w.niM be apparently hvporonic ;;. r,::"TT'/;" "y'''^?;^^ •- actual total \i-pero,^a w-luM^b .M-cropia. The ..nnj,.; l,y,„ro,,i„, in other worWs. is the am i '.«''' t'"' i'""<;-'t will .•.■veal by the utmost voluntary relax his accommo-lation. an.l is represent,., I by th,. hi,::e.;t cnvex Jhs with .hu.h he ,.an still s,;,. ,lis,inc.ly. th,- latr., /.j/J^^l^^Z cMiainmg hyp,.ro,.ia. which he will not ivveal in this way because le k.rps It .■orivtcl by his accommo.lation. Th,. tol„l hn.a;,,uo is the sum of tne latent aii.l manitVst hyperopia ' The patient's vision will be p.aclically the same whether he cor- the hyperopia entiivly by accoinm.xlati. >.». or entire >.V a •lEFliAV'nVh: KHHOllS IS (lIlSKltM.. 95 ,,,iiv.'x plus?:, or i)!irtlv by tlic glass and partly l)y accDminodatiDii. I j.r .-,1.1 In cases, tiu'ivforc. whciv the patient's vision is already ,r,,n7|. l)eeause although I'e has hyperopia his aceoniinodation eorreets 'ill ol it. we eannot demand of a eonvex glass that it shall iinjji-ove \n< A"hX, hut onlv that it shall still keep the vision as good as it was ImImiv We sav," then, that he iuri'i>h that glass. If he accepts a vun\i'\ glass, it is proof tiiat he nas liyperopia of at least that amount. li r,,r instance, he s<'es as well with a + l.oO I), as without it, lie ,:iun..t have hvperopia of simply 1 D.. for in that case the addition „{ 1 .")() !)., by over-corre:'ti.ig the hyperopia, would render Inni Mi.iciicallv invl)pic, O.oO !>., and would blur his vision. We cannot "sav that a iiatient accepts a concave glass, for, as we Ikivc seen, any Verson witii good accommodation will evercome a 1:,\\ concave glass and sei- at least as well with as without it. To MKive ihat the patient rcallv re(iuires a concave glass, we .should show iliMt he sees milhj hvUvr witli it than without it. If he sees simply ,. well with it, or ai)parently sees somewhat more sharply, but cannot •iituallv disthiguish any nmre, he is not myopic to that amount. Varieties of Hyperopia. In hvperopia the point at which the eye Incudes i)arallel ravs lies behind the retina. This may be either because ihe retina is too far forward, or because the retina, being in its proper niace the cornea or lens has too little refractive power. Hence the Iivuen.i)ia may be due either to changes in curvature (flattenmg) of tlie cornea, or lens (curvature hyperopia), or to changes in theden.sity nl ihese iiK'dia (index hyperopia), or to an undue shortness oi the ivcball (axial hvperopia). Cirvatiirc hinnTKpUi is fouml as a result of opacities f)r cicatrices ,.t ilic cornea associated with flattening. This form is generally coin- liiiied with astigmatism. The peculiar sort of curvature hyperojiia in A Inch one of the refractive surfaces is not simply flattened, but alto- u. iher abolished, is that produced by absence of the lens (aphakia). This in eyes ])i-eviously emmetropic produces a hyperopia of 10 M I'D.' \u example of index hiiprropiit is that which develops m old age i^ a result of sclerosis of the lens, rendering the latter more homo- ,'i neous, and hence less refractive. AslaUnipvropia is by far the most common kind. It is also appar- 11, ly the Original conilition subsisting in the vast ma.ior:ty of eyes, 1 examination of newborn infants has shown a very great pre- .iiuleiance of hyperopia, and particularly hyperopia due to a com- ■ni alive shortening of the eye. Dining the growing jM-riod of childhood and youth the eye I^econies !( a.lilvhngcr, so that the hijprropia uroir.'^ /p.v.s- nnd less. It may thus . transfonned intoemnietroi»ia, or jwissibly go over hito myopia. r!ii> process of (>longation regularly ceases at tlu age of twenty-two rars, so that if any hyperojiia is left then, it nnnains stationary iii nal'iT. I tiie iuillimetre of shortening of the eyeball corresponds to about THE EYE. i). of (xiiil liypcrojiiii, so tliat. lor iiistaiicc. an cvi' wliici 1 IS nun. slioitcr than noiinal will he liypcroiiic (i I). In axial liypciopia tlic shoitcni'"- allccis cliicliy tliat |>ortion of the eye hack of the lens, altlimmli . -p 'i.illy in liijili hyperopia the cornea may he flat and the anterior cliainher shallow. A patholojfical form of axial hyperojjia is produced hy exudates pressinj; the retina forward, hy detachment nf the retina, and hy the presence of tumors hehind tin- eyehall, which in<leiit the latter. Amount of Hyperopia Two classes of cases may he reco);nized. In one the hyperoi)ia does not exceed o I)., and hoth I'Xterior and fundus present no ahnormalities. Such hyperoi)ia may he called nor- mal. !I^- ropia of over "> I), may also he iiorinal, i)ut very frequently in hype of this amount we find evidences of arrested develop- ment, as alhinism, microphthalmus, a small cornea, an imper- fectly .-veloped fundus, etc. Such hyperopia is ahiiormal. Vision in Hyperopia. The si^lit in hyiwropia de|H'nds u])on the patient's ahility to correct his error hy means of his accommodation. .\ youuR person who has an ahundance m accoimnodative power and no inordinate amount of hyperopia will see distinctly and without .•my fireat dilhcuity hotii for distance ;ind near. .\s he grows older and his accommodation diminishes, he will he ahle to see distinctly only hy the expenditure of more and more etTort. Finally, a point is reached where near vision is efTecteil with dilhcuity an<l strain, althoujth distant vision is still easy. Later, distant vision hecomes dillicult and near vision impossihie, and, last of all, liis accommodation fails him even for distance, and he sees poorly at jdl ranjjes. The hyperopia that the patient can fully correct hv his accommo- dation is caih'd jdciiltnliir: one which he can correct oi;ly hy calling into exercise an amount of accoimnod.ative jxiwer which induces a converi;ent s(|uint is called rcliilirr: and one whicl' rect at all hy his accoimnodation is called ohsdlulf. The [leriod at which this failure of ;iccominodat" • for liyjieropia occurs — i.e., at which the latter hec(, varies a good deal, according to the general huild •iiio c.)nstitution of the patient, the kind of work to which his eyes are suhjected. etc. In general, persons with less than 2 I), hyperopia, whose eyes are not excessively tax(>d in near work, will not suffer serious inconvenience mitil past twenty-hve or thirty years, when they will generally require a glass for re;iding, hut will not .-ihsolutely require one for distance for perhaj)s ten or twelve years later. .\ liyperope of 2 to o I), will prol)al)ly experience some amioyance in youth if he uses his eyes much for studying, and aft(>r the age of twenty will usually n^piire a glass for near and prohahly, also, for disl.-mce. Hyperopes of ;i to 4 I), u.-^ually recpiire glasses in childliooil. jioih for distance and near. as. while they still can see distinctly, they do So at the e\penM- of considerjihle etVort. and hence develop eitiier an ;isthenopia or a convergent s(|iiint. •:o clot cor- i/ensafe .ii'-nlute— UEFH.UTIVh: ERkoRS IS i:ESKHAL. 5)7 llviMiciw- i.r more than ."i I), rarely cmii ovcrcoinc tlicir dcl.Tl l)y „,,,n,i,i,Mlativc (.tTort.aiiil .in not (.ftcn make -iii allcinpt to do so. -.mil uaticiils siiiii.lv iiavc poor vision and do not have asllicnoi.ia. Ihrirsifilit, fv.ii with the l.rst corn •(• lion, is olt.-n suhiiorniai (2(140 I,, _'()'J(KtorU"ss). External Evidences of Hyperopia. HypcroiM's often iiave small ,„M„7.v This is l)elieved to be oceasioiied l>y tiie exeessive accomnio- l-ilive etVort, or rather the excessive conv.-rfjent et!<.rt, tiiat such |,;,iii.ins make, as the acts of accommodatioii and convergence are il-^o(iate«l alwavs witli contraction of the pupils. ■[-he front <.f"tiie eyehall in well-marked hyperopia olten ai)l)ears l|.iii. 11,.,! and the anterior chamber may he .shallow. M.,..t hviMTopes tend to hold their hooks rather far away on account ,,l t|„. recession of their near i)oint. Now and then, however, a inti.'iit will be found with hy])eroi.ia, particularly when the hyper- ImiM i^ of hi'di degree, who holds his book very dose to him, and on tir.'t accum? is thought to be myopic. This mistake is the more intmal as such a patient often has poor sight for distance, because 1,'i. hviieroi.ia is t..o great to be n<-utralized by the accommodation. . »| ,nur,se, his vision for near is s.iU poorer, and the more .so the closer |„. l.iings ..bjects to his eves. Hence he is not rea ly like a n<-ar- H"liled l-erson. who bv bringing objects closer makes them more ,liMin<-t The hvper.iiM- brings the object i.rarer to make it appear larger, and hence more readily distinguishable, even if it is more Astigmatism. Varieties of Astigmatism. Disposition of the Meridians in Astigmatism. In astigmatism the .lifferent meridians of the .T'j have diir.Mvnt refractive powers, so that each focus.'s the rays... light dilferentlv from the merl.lian adjoining. If the change in retractive power takes place uniformlv aii.l by regular degrees from one merid- ian to .another, so that each m.-ridi.-.n in s-iccession retracts a little more St ron.rlv than the one belVre it ; and if, furthermore, the refraction i„ „,■ meridian shows no great or sudd(-n changes trom its cent.r to its periphery, the astigmatism is called rcjnUir: and in the contrary Thit kind of astigmatism produced by .lifference m refraction iMtween the nmtral aiui peripheral j.art of any one meridian of the I vr is called mrriditnial (ihvrraiion. ... r * In most cas.'s of regular astigmatism the meridian that retracts hr most highlv, that is, focuses the rays of light most .,i>iekly. is vertical or within ■.W° of the vertical, ami such astigmatism is sai. ■,, 1„. u-ith Ihr r„k or lUrvct. Tlu- next most frefpicnt van.'ty, called ,^tigmatism ,u„unsl the rule, or inverse astigmatism, i^. that m w_hich '„. most highlv refracting meridian is horizontal, or withm .50 <.t t he ..rizontal i-ess often met with is oW«/»c astigmatism, m which the Mrriiii-m of greatest refraction lies at from litf to ()()° from the vertical. in regular astigmatism the meri.lians of gnate-t eurvature (prime .Tidians) are usually si/mmclricall!) dw/w.sW in the two ey?s: that J)« Tin: i:yi:. . iMith Mil' cither jii it vertical nr iusi li(iriz(iiit:il, ur Ixitli are incliiieil Ipv ail c(iual aiuuuiit to tlie teiiipnial nr hotli to llie nasal side ot the vi-rtical. Much more rarely the mcriiliaiis are /«im//i7 in tlu' two eves. It also unconinioii to tiiul them /wn 'tlM. \'erv rarely the I irime inerilians in itlnr siiiiniiftncdl nor liie two eyes are at riijlit «/(///«'•••■ to eacli other In regular astigmatism the meriiliau which refracts the most stronjily almost always lies at rijiht angles to the meriilian which refracts the least. These two are calle<l the iirlnc'iuil mcridtons. The amount of astijrmatisni then is m-asurcil by the ditTercncc in refraction cxistinj; between these two. Etiology and Development of Asticmfttism With regard to the etiolofiy, we should distinguish i)etvvccn idinjMilhic or jtri'iinrn astig- matism, whic', I- not, and sirondnrij or iHitluiltitiUiil astigmatism, which is due to disea.se of the eye. .\ certain amount (0.25" to ().*)() D.) of primary astig.natisiu may be n-gardcd as jihusidlof/irdl in that at least that amount is found nea rlv every eve i'hysiologicai astigmatism is regularly i)res( Ml botli in the cornea and in the lens, ami in both situations is partly n miliar and partly irregular. The hifihcr ilfiiru of itrimanj (ixliijmnlium (over 1 D.t arc mainly of th(> regular variety. .Vstigmati.sm of 1 to 2M D. is very fre(|uent, although not .so nmch so as to he regarded as iioruial. .\stigmatism of 2 to 4 I), is fairly common, while prhnary astigmatism of more than .") I), is raie. This non-i)liysiological prim...y astigmatism, like the physiological, is usually pre.sen' Ixith in the cornea and lens, although the cornea is apt to play a much larger part in its production. I'"r<'i|ui'ntlv orneal astigmatism with the rule is )mi)ine(l with lenticular -tigmatism against the rul<', so ti>at the resulting total astig- a matism is less Mian the conic 111 astigmat'sm. In other cases, but less often, the lenticular astigmatism adds to instead of correcting thit of tlie cornea: the astigmatism of both lens and cornea being then usually inverse, .\gain, the combined corneal and lenticular astigmatism v the eve as often such that the meiidian of greatest refraction of whole d(M's not coinciile with the meriilian of the greatest curvature of the cornea. These variations are imiiovtant in esti- mating the value to be ascribed to the findings obtained by tlic o]ihthalmonieter. In the cornea primary astigmatism is <lue to une(|ual curvature. In the lens prim.uy astigmatism may also be due to unequal curva- ture, but more usually to the fact that tlr lens is tilted somewhat, and, furtliermore. that it is built up of sei)arate tibrilia- of difl'erent densities. These tibrilla' are grouiXM" .so as to form star-like tigures on the front and back surfaces of t.ic lens. Hays of light pa.;.sing from one fibrilla to aiiotlu'r are refracted somewh.'it irregularly, and thus a certain amount of irregular as well as of regular astigmatism is proiluced. HEfliACTIVi: lAilions IS l.ESr.UM.. n ,.n„nrv •.-ticnuitisn. is .■itluT .•..np'i.ital, ..r prnl.al.ly n.u.-l. n.nrr i^iz^ :S!;:=i r;;;:;":5;:ii:i:' ;="V: tlii^ is the ivfiular inverse astismatwii ol - i<> ■-* "•' M^"' ;;::;;;irin; "::"i.«^:-o., .,r l,. aU..n„i..ns ,„ ■ 1™.,,- ,„a,.l,.a, 1.. .;. ,.r ..tliT chanires due to advanml ape). '" "■'■ '"■"»)■"" i1,v':r..'.r;;r, ::;; s :h»w ,1;.;;;™..; .lunn'. It ,\'m. .121 «;C l>»v.' ^7» ,,;r"T'" t r.u..l, tl„. v,.rlir,l '"•;";'"■; ^;;; A"i™-3 S: ■t:";l:,ai ™™i,i,a,, » » «,« iictween III tl ic "\ am) vei! case we wi *^1 ill suii|i()s<' this to measure mm. IW rut: i:yi: If now, llic rctin:i ii !it I. 1 in ffnl of .1, all llu' incriilian^ of llicfvi' will I"' iiyiMinpic, and llic liori/.oiiial nicriili.in most so. In I'ai't, llii' vertical mnidiaii will 'n- liyiMro|iic ;! D.. Iifcaiisf, so far as this meridian is coiieeriied, the eye is 1 mm. loo short, while the horizontal meridian will Im- hy|HToiiie '.» D., Iwcausc so far as it i- (•oiicerMe.| the eye is I? m. .. t<Mt short. Th.- dilTereiice in niraction l>elwc<'ii the two meridians— /. c, the astifrmatism— is therefore*) D.. or tlie eye has a hviMTopia of ;{ D. eomhine.l with an astinmatism of (i I). if now, the retina recedes to II. rays passing through the %-erticai meridian have conif to a focus, and, so far as this meridian is concoriifMl, The abwilule refraction in astigmatism. Form of rtimiiilon images. A. focus of rays pBMtnK ihroiiKJi • rtical meridian II'. B, focus of nij!, iirtsslng throuuh horizontal meriilian ////. A IS fcK-al lnler\-al. I, compound hyi»Topic a-stlgnmlism ; II, simrle hyperopic astigmatism ; III, mixed astigmatism; IV. simple myopic ttstmmatism V. compound myopic astigmBtisra E, F. G. J. K lormsot diffiision images at I, II. Ill, IV, V. res[«ctivcly. the eye is einmetroi)io. In fact, if by usinjc a vertical slit wo shut ofi' all rays hut these, the eye would he adjusted acciirately for dis- tance: hut for rays pa,ssiiij: throujih all other meridians the eye is Iiy|M"roi)ic, uiul, in fact, for the hori>, mtal meridian is hyix-ropic () U, We have, therefore, still a ditf'erence hotween the meridians, or anustifimatism, oftil)., althou^rh now one meridian is nninetropic. This condition is called simple luijwropir astijtmatism, while the condition obtainiiifi while the retin:i is at I is called niDijiduiui hypcr- ofiic astigmatism. It is evident l! it ihe compound dill'ers from thi' in:yn\fTivK i.nitnhs is nEsr-iiM^ lol i ,.. aMipua.isn. .u-.r.-iy in .u l^n. thr .„...■ Mnount of hy,«.rn,u. i,/,l,i^ ,..,,. :t D.I to all iiii-ri.li.-.hs aliK ii.iw, till' n-tiiiu ri-cfdcs ti- 'U|'|«l '1 two-thinls .>!' iiiilliiintrf ill 1„ ,|„- vertical i.irri.liai. tlir .•>(■ will n-w !«■ inynpic 1 D., ;H.i:..,i."-'" ; - ' ; „';,„, „:,k,. »ii ti..- „„.,i.ib„s..i .ho |"'"'";r ' : t> i ■ v ■ -n,.. vif.™ run,,, wi,i,-i, »,,, I tliiir> I) have now Ix'cnmc myopic. I' ni.n.ua. , I' -~ ii'-i" - ' • "'' . , ., V 1- 1- ■vi . . V. re liVDcropic 1 it., II M .111.1 /' /' on citlicr side ol I \ . \\\ ri ii>|« > i "''»';;;;. t;;;".:;K'."?:'r;:;:™..M n,,i™ . „.« .,,,,„-. i. ,iiyo|uci. 1). 11" -I -'l-'",.,,, It i>; cvi.lciitlv evolve, from -T'T ''''t\ 'tile ,vS;i-'Tv:' one millimetn. hehin 1 H, all the 1 mally. when the ■'^'•\ _;'.,.,, ,„„. ., 1).. an.l the horizontal rr'^:^:^:.^^":^^. '-1-. ii.i.-..i^^> ■• '-W::;;'';h.7^(;:;rS;;:s;:;in«with a ..crt^iin amount of Hype. Jn n m V ■ Kra.luallv elonsatinp his eve, or by eqimlly ' ;■ .-..t tl/H conversion ..f on.- vari.'ty ol asti-n.at s.n ~ ' ; . .He^.l <•.- verv fr..,u..ntlv eitlu-r th-oujrh ^ra.lnal ^^r^; vr';;;;H,:^;lu.,r.linn..•ri".l....•.l^••-f.l-.t<•- ., F ,.,. n-fvM.'tiv.- ,..Aver pn»h..'e.l by acconm.o. lation. t .,v :;JIJ ;:r,m.h. .l-ul U- an artificial incr...se or .lecvase of V 1,1 !mv.. : <ti,matisn>, .•>|H.cially wh... pres,..t m the cry^. ,:l,' ,...,. luce c.;si.leraW.; .l..fonnity ..t ••7;!;;; j; ^ -,, . ,1„. iva'on whv stars l....k lik.> stars inst.-a< of like i"" " * ^"''^' :,;, .riiilht as thev should -lo. is hcause ot ""^ l^^yl; , f ^- ,;L, 1,?^ lens .hu> t.. the star-lik.. 'l'"P"f;": .f'^:.,^ " trin« ;,. ,,„M,lar a>r.j;mati»ni the amount of aist.)rt,on an.l b.urnng )„ ..a' ixnuls upon the dOfu.um image.. lu«,K.-ct.on of 1 -g. 5- 102 77/y-; i:yk. will show that at I tho difl'iisinn imago of a point will he a liorizoiital olli|)sc, E; at II a horizontal line, /«'; at III a horizontal oval, (! fwhirli as the n-tina recedes will be converte.l first into a eirele, then into a vertieal oval): at I\' a vertical line. ./; and at V a V('rtical oval, K. At II the iniape of a point is a fine horizontal line, and the image of a horizontal line, which is nothing Imt a series of jx.ints stnuig along horizontally, will he a series of faint horizontal "lines. These by successive overlapping will reinforce e.-icli other and form a broad <listinct horizontal line a little thickened an( I hazv at its ends. (Fig. 5.1) «)n the other hand, a vertical line, being comi)osed of a row of points oil.' above the other, w!" („,•„, .an image made up of a .set of faint horizontal lines one alx,., the other, and will thus form a dim hazv more <.r les.s broadened band. Hence it is .seen that, although the r\u. :a. B I) B I,m.«i^ -r a I,,,,. r..r„u.,i i„ uMiLMn.ui.,,,. .1. a v.Tli.-al lino co.isl.tinK „r a viTlioU r.n» .,1 ,.„„l. /( .t.s ,„«,.■ »lK.n. a. in ri„. r.j. n, ,h, voriln.l ,„iri,lian „f th.. .ye is un„noir„,,i. : r its hnaee ' '"■""' "f ''/""■ '" I-""-^ -''^' •>>■ ^"1^- ' it' l>n''S.'.' «h..i, ,l,e virtual m.ri.lia,, ,.f ,1 '"'ve « I'mniriri.,,,.-; /, i,. n„aBi' »Irmi Ihc l„.ri/nnial meri.liaii „i;he t-.w In cTOinttroiiK-. vcrticid nieiidi.ui is emmetropic, the image of the \Miic;ii line is very indistinct and th.' im.age of a horizontal line is (|ui' sluirp All object- will appe;ir dr;iwii out into horizontal iJKs. At i\ all objects will appear drawn out into veitic;d lines and c(mse,|ueiitly, althopgh it is imw th,- horizontal m.'ridian that is eniiiielropic, the horizontal lines aiv seen most imlistinctlv and ver- tical lines most cle.irh-. Ill other w.ads. in >imple ;isti^r,„Mtism. nivopic or hvpen.pic fhosr lu„s,,r, >,,/, m....' ,/,.-/n,r/h, nhirh nn, al rn/lil am/Irs lo'lhr rmmrtn.nir Inir/iliilii . ' It will also br readily >eeii th.it when the IVtilia is ;it H a s.iu.'ire WuiiM |,„,1, IJI,,. ;,,, ,i|,|oim; drawn on.t hiterally. with i!ie (.•...- ,|i-i:i-.,.{ ^iii'l llie -ide< blurred: .a circle like a horizontal ov;d etc ' |f"the leiin.a were al W . the re else elTecl Would be pro.luced. In fact, as iii:riiACTrvi-: khrors ix hesehm.. 103 . i„ ,.,i.r„u.lisn, .■h:.n<ros from hypon.pu' to nnxo.l, an.l llu>n to n.>..l) , ,,;„.„.,• of th.. .listortion will .-han^.., so tl.at sun.etim.-s ...e .1 . , 'tin,... anotluT s,.t of liiu'S will appoar .l.stHU-t, un.l objects ....,„ to 1... -Irawn out now in one, now «. anotn.-r -I'rcH't.on. H..ia.-s tlu-s.. distortions of shape, asti^nuitisn. pro. uc-s ^"'nu'CulaT ,,,„ , nhj.rts smuinK to have close to them a la.nt sha.low of ;i,!:,Xlves The position <.f this .l<.ul.i.« inuvRe will vary aeconhng ■,, 111,, direction of the i)rincipal meridians. A oii^odation and Astigmatism. As we have n.,ted ^^^T^^ ,•„;: frmiientlv alters the character of the astijin.atism changing !'" , ; vp,.n.pi<' to mixed, and then to myopic, to smt th,. need . pSenf vision, but it rarely changes its amount, at least i,.iiilhulnr to till' iixt:' Hri> I'lniviMUi'i! 1" •"■ , ,,,„i.,llv We do however, fin.l in a certain mimber of cases that : ' :;ln;2;. i Vn.a,er under atropine than without it U-. m. „ ., .ui)pns.. that the acconnno.lati..n had coi ceale.1 y- ; „„„„t ,1 it An.l occasionally the astigmatism becomes le>s, an, :;i.. „.■„■< when ••itropine is instilled. fro>n which w. should inlei V a-JSnatisn. to be a ipurious one. produced by une,,ual accom- "clrlrctiofof' Astigmatism Astigmatism -nay then "'i;;^ '•';';;; ,,v ,o a vnv slight extent, be corrected by ''--'^''-f ';'"^„,.; , ,;,, ,,,,„„;„..datinM. while leavn>g th.. ''"7" ,;;^ r; '^f f 1,., 1. ..,tT..,.ts the visi.m fav..rablv by a.l.iustmg the .'><> - ;,„;.,..,■; ..ts .-f lin..s. a,. ..y... t.-r instaiHv, wh.-h ^. 'I' - ■•"'^' j .„.,t<tl by Fig. 52, U. will s.... h..nzoiital lin(.s .listincth. but m 1(14 77/ A' i:yj-:. roadinp: and manv othor visual acts it is iiuportaiit Id sco vertical lines distinctly. This the i)atient may do by exeitinfj his acconunn- dation so that his condition is changed to that of I\'. He will then see vertical lines distinctly, and, if it is also important to see horizontal lines distinctly, he may do this by narrowing the tissm-e of the lids a litth- so that he may look through a horizontal chink. We may also correct astijimatism by means of ci/linders. (\vlin(h-ical fila.sses are either convex (positive) or concave (uoga- *ive). The nmirx cylindrical e;lass siiown in Fip. ")4 is a slice, A li (' 1), taken from a cylinder. The line I'J F, parallel to the axi.'. of the orifiinal cvlinder, is called the axis of the glass. Rays .such as / / ent<M-ing the cylinder along its axis K F, pass through it in tiie i)lan(> F F (I 11, and will undergo no refraction, because tlii' lines they cncounterare notcurved but .straight. Rays, on the other hand, IS A' A', entering the cyUnd"r in the ])lane ]M'rpendicular to its axis, will be refracted just as in a spherical lens, for they will strike a lino, /. L. whose curva- ture is a circle, and they will therefore come U Jp r. "iimvi" cvlinder. to a focus at a j)oint, M, behind the glass. Rays passing tiirough the glass ol)lii|uely to the axis will also be refracted, but not so nuich as A' A', because they strike a line which is less curved than L L, and they will hence be focused at a point behind .1/. The more inclined the rays are to the axis F F, the more they will be refracted. Hence a convex cylinder is a glass which along its axis produces no refraction, that is, acts like a plane glass. .\t right angles to its axis it produces its maximum effect, and in intermediate meridians pidchices an effect .vhich increases with the inclination of the meridian to the .axis. .1 cnanr cylindrical gla.ss, .1 li (' I) E F (i'ig. .V)). rejjresents the cast of a convex cylinder. Its axis would be / //. It behaves precisely like a convex cylinder, except that it acts like .i negative (<lispersingi iH>tead of a jiositive (converging) lens. In tiaiiiirig cylinders, it is necessary -nvo thi'ir sign, strength, and direction of their axes. Their slrcn\,,' is that of their meridian of greatest refraction ( ■ nr— ), that is, the meridian a' right angles 1(1 their axis. The ilinrllnti of the axis is denoted in a number of ways, of which thn^e are indicated in I'igs. .">(), ">7 .")N. Whatever method is i..-ed, it is always best to have on prescrii)tion blanks a diagram like one of the alxive, and to indicate by a stroke on the diagram the precise direction of the axis. This acts as ,i useful check and guards against mistake a.> to the intent of the pre- scribfl. .\ glass which is comiiotindeil of a spherical glass and a cylinder is called a sjiIk ni-riilindcr. REFRMTIVi: KRRons IS <!KyER.\L. 105 In to^tinR refraction, it is iniportant to bo al.lo to a.l. and subtract ..V lor with facility. How' this is .lono is shown bc-st ,ha,ra,n- .natically. A +2 cylinder axis (K)°, for ihstance. is denoted b> +2 .-+2 in which the glass is .npposed to be seen face on. n„.ndian r.Mxis) is D., the horizontal niendian has The vertical the effect of n {right «»«) Flo. 67. L<hn i; {riijht '■lie) . ., llK. cyli.uier is dcn..tea by llu- angle il makes w. h the y rfca^l «-;""'*•> ; __ i„i-.il or on the tcn.i-.ral side, and Is written as follows : ;li>iii/untali. Fm. .T». . .-."n. .'t -.'i"l. etc. down to ;f -■■«P one eve, and fn,n, left to right in the other. ''-'7!'* '' f •"•'^;' ^^'J^J,^^^^ ,M,n.«rlnK. for the ri«ht eye I. the »ame in the symmetne.l and the i^ralltl mctho. 1 .r the left eye the nunil).'r" niii jnst oinxisite. jiK. .T*i). while 106 a t- ////; /'.lA-. I'. si)li., ami till' iniiTV i'liiiii; nil ridians have pffc.'ts raiipiu};; In.ni I), to — •_' 1). cvliiuUM- 1S()° would bo dcuoteil by -2 — anil a L' SI) li. hv —2 -+2 +2- +2 I'siiii: thosr diagrams '.111 +2 1 iiotiii}: the r(>su Its obtained by siipor- nnp' sin<' one sucli diafiram upon inotlirr, it IS easy to prove grapli Iv the following |iroi)osition: 1 ■ 1. A cvlinder and a splicnca il ill )f tlic same strenjjth and of o])posito sijrn \c oiijinia ru tl :l.t 1. lso° ■_'. '\\y s added tn^et 1 cvlindev. but of oppoi her make a eylinder of the same sireiifltb :ite si<£n am 1 with its axis at anjile: to It. Thus 1.00 sph. _ <i eviiniler ;.(H) sph. _ s of tin •J.OO evi. ( 0° 1.00 evl. !tO° -2.(M) evl. 1(U)° + 1.00 lame siijii am 1 same axis added tofjetlier niakra evliiidci-e(|iial to ' . ;i.(M)evl.<.tO° =- ' .VOO' - -A.m evi. Hf. the sum of the tw( Th 2.(M) evl !K)° (■\ lind cvlinili'is oi em I iinl to the ditTcivnee between !M)0; -l.(M)eyl.-_'0° ~ -2.(K» eyl. 20° = the same axis added together make a the two and having tiie sign if I III' -iron,i:rr eylimler. riuis • -.MM) eyl.7.-)° Z ^ l.(H)eyi. ,.)" 1.0(1 evl. V.r :!.()0 I'vl. 'Mf ■J.OO I'vl (i(P !M) ; vl. (10° }.0(t evl. 00° 0. 1. CviiiidiT- of the same slgl 1 ami < if I'lrual streiii —2.00 evl. (iO° '\h erossed at riijht an>.'lrs ma ■10° ' (■ a ^|llu'ln•al >riass < if the same streii nth. Thus • 2.00 evl- U(V 2.00 eyi 1.00 "sph. 1S0° 2,00 sph .(M) evl. :)0° l.(H)evl ."). Ci.nverselv. any s] alcnt to two eylu iheiieal filass may be rei>re.seiited as equiv- <tren<;th and same si<;ii erossed dci's of the same at n rht anirle; <l at \nv two evlinders, « and h. of the same sijiii, when erossea rjoht angles make a spherieal filass e.|i.al in strenfith to the weaker (.^Ihioer a eombined with a eylind.'r equal m stren-th to tlie dilTer- ,,„,.,. h,'twren e ami />. and havh.fi t!,.' same axis as the stronger e>j- i,;,l„, /, Thus +1.'.<M. .-yl. 00° Z -i -tM) <'yl. 1S0° =- +2.(M) sph. „ + 1.00 evl. 1N0°. . , 7 \ Z cvlinder of stienjith n crossed at niiht ansiles ui)on a - .-vlinder ',-f -tr.',.;rth h makes a ghi- whieh may be repn-iMited a so iiva -'- si.h.'riealof,.trenKtlMM-onibhM'dwitha--eylindeio strenjith ,;, . M and havin- the axis of /-; or else by „ - spheriea ot streuK h / nibined with a , eviinder of strenfith ia + h) ami havn.},' the REFKAVTIVK ERRORS IS (lESlUtM^- lt»7 fvliiKlcr at rif^lit iiiidlt cal I'ffcct. Ill sli()i"il<l work <<ut tlicso |)r<i[)i)sitioiis by ■Z V. V.' ,..on..s.ti..ns sluAV that wIu^m t.. a - .•yl.n.l.T w. a.l.l Vv i H -r it. iH- sa,H.. axis or a - .■ylin.l.-r at r.ftht ansles wc :,/,/ n mud. to tlH. evlHulrical .tT..rt; a.ul wh.-n w.- a.M to .t a '''''.Ji. in tl... san... axis or . . c-ylitj^.-r .. n.l.t and.s. w. „/,/;,„■/ iust so nmch from tlic cyimarical .'ftfct. ';';■ ::'"J;;;! llLp'^s aho^;; l..ili.-at.-a. an.l l.y ♦•.. sa,..,. means "Cm ..Iv al kh t^ of prol,l..ms .•onnect^-l witl. c;yjinaru-al c.un- , ,r mt li. .".n .lo sucl. problems at onee without stoppn.g :;; r." ' al; mtU helan.loth^- hewillbeeonsi.le,.. y i;.;„:ii",ppe.l i.. an phases ..f his refraction .,.rk, an.! will seareelj be ,1,1,, tu.lo it with either rapi.hty or preeision V ...<i.,nallv preseriptions are se... in whieh two ey nul.'rs an- or- „, ;.; ;.l„.;'e.'to eaeh otlier. - 'h a eon.lnnatum c-an alw.^ I , V, v..-nt Ml bv me eviie.ler eombined w,th a spluTiea glass, lo „ , ,: , tren.nh of th.. axis .,f the eylin.ier an.l the s reufith : "nl e;i<.nWr ^s in these cases requires a trifion..n,etneal e., eu- . , .Iv when .•vlind.-rs are con,bine.l with then- axes e.th.. : ';,:;„,!;, ,t ri.h. anjrle; that the .-.uivalent jrlass ,>,hero-eyhn,le,, ■ viin.lrr or s|>here) can b.- f.mn.l by the above snnpe rules. A 'I'hVrieal lens .nay be n.a-le to have the e/M .,1 . ajluukr b> iiiiio; ii iMiiicr sideways or wy an' 'A^Ucation of CyUnders to Correct Astigmatism It is ex ..^ff!.r,n,. lo IM,. :.l. that uv n.nv '-''^H.^e eo..,:it.o.. 1 o ■ down. It is evident, .iditio.i I |,v ..,.r- .•tn.jlThe Ii D. of hyperopia with a ^ ■[ D. sphe.-.n.h^la---. ,. will ,vn,le7 the verti..al n,e.-i.i;,M e.n..',et.-op,e. a.';! ;;'ll ''"I" ' «• ^,y:n.pinof,h.-ho,-izo.,tal..u.,i,H;u.fn..,Ul>..ob . N.^^^^^^ ,„ „>• V -il er cMiJition V into eon.ht.on 1\ by n.r is .1 a -.} H. „: Vi s. Jhien will .li.nh.i^h the n^l.-a.-tion ol all the .ner.d.ans 'v . nno.n.t a...l will ...ake th.' ho.-i.outal n.e.-.u.a.. enn..et.opu , I . x" vt " d n.e,-i.lia.. n.vopie .1 1). Lastly, w.. ...ay elunjje eo,,- i, 11, ,o CO, h.i..n iri.v ad.linff a -2 l)..an.l .nt.. eo..ud,on ' V I 1 a -. » 1). spl...ri;.al glass. Thus at.y lor... of ast.gtna- 'i;. ■;' be':.o,.ve,.ed nito si...pie i.y.-op->: -t;.;:;^r Sif^ bvn,ca..sot a sph.'.ieal glass. It ivmains. inav con-eet si...ple astiginatis... )\vn i.i Kig. ")- at ,laci' the inactive al meridian of the lallslM T..\'o.i.'et the si...ple hyperopie astig..iatisn il we.houldusea f f. D. eyl. ax. 00°. Ihis' .i-,,! Iheevlhideroi.positetheenm.etropicv( ., , ,p,,„.i„. ,lu. h:..i:'.o.,tal ..uM-idia... which is iKvpenjp.c , ,,„„ „i , „,,io.. ..f ...... glass which a-ts like a +<> sph. ( ppos t ■:,„';' ..leriaians of the eye which g.'adually .e.-.-ease .n rel ,c^ne ,,„, ,■,.„„ ..uunetropia to a hyperop.a ot (. D.. we ,.!ace a glass iiirii ir.ailuailv nil iiie.-idia... therefore, ... •perop.a oi n w. »< i""^> •• i~_ ^ fractivc (lower from I) to f() v turn has its deticieiK y in .cf .active poNV.-r •etei I, anil thus is n.ade e..unet.()i )1C, 108 N>, (i cvl >;. lS(t°. t the Till-: j:yi:. l-i)ll(lltlnll slKIWIl 111 IV slimilil use :i lis w null I ciirrcc t tlic iiiyopia nt tlic vcrticiil 111(1 iif t'iicli siKTcctliii}: .iicriiliaii, aii< 1 leave the lidiizii'.tal lueiuli; 111 eiiiiiieli't)l>i('. A little eoiisuleratidii w asti<j;iiialisiii we may prnceei luav place hefore the eve a mnrc.r v\ ill slii.w that to oiiieet any ease nl regular •'••l ill either one of two ways. Hither we v.i.r.M- i-vlinder of a strength equal to the anioiiiil ol asliy;iiia tisni. with its axis ui the "liiliaii of {ireatesl fraetiiin, and then coin ret rat correet the refraction cyliniler of the sanu refraction, am of this iiK bine tliis with a spherical f^lass that will -f that nieri(li;'n; or we may use a cnnntrr treiifith. with it. axis in the meridian of least 1 add a s|)liencal flla.ss that will correct the refraction ridi; () cv Thus ditioii I iiiav he corrected either hy +'.i > , 1., ax. 1)0°. or ^ !• spli. Z — ^' •'>■'• ='^- 1^"° -'• <-'■' ^^'•' '"^'V ,,.^., li'tinn I as heiiiR condition II. in which the retina has been brought forward 1 inni.. or in which all of the meridians ol tl refjaru com eye have a as condition that all I like been made -i D. more hyperojiic; or we may rejiar. 1 it I\', ill which the retina has been advaneeil .i mm., so diaiis alike have been iiiad(> more hyiieropic by !) I). Ni com litioii 11 may be corrected either by ^(> cyl., ax 00° or I IV () sph. r — •> '".V'-. "X- 1'*^'^^ conditioi III. either by —1' sph. _ () cvl. 00° or by +4 .sph. _ cvl l.SO° by — (> s])h. cyl. 1S0°: condition IV. by — tl () cvl. '!K)°; and condition \'. by — :'. 1. -^ +()cvl. 00° sph, r — (1 cyl. 1S0° or by —0 cy In jieiie' 1, when possible, we ])refer to combine a sphei wit I .-liiider or a — sphere witl — cvliiider. rather than combine spheres and cylinders of opposite sifjiis Nome pr ■(>fer to correct a ca <e of mixed astimiiatisin liv rnissri. •:lliii(lcr>'. prescribiiifi. for instance, iii c; 1S0° Tl lere is no s| leciji ISC advantasic m e(|uivalent prescription, i sjih. r HI. thi; A\ cvl 4 cvl + 1) cvl otr aiKl th atter iisiiallv are onlerei 1S0° I. 00° fripti( or - _•) cvl i'r the sph. Anisometropia, .\ir oiii(>trop liffers m not imcoiiiiiion. difference mav b i;i is a condition in whi''li one evi its 'refract ion from its fellow. Sli<;ht decrees of it are are rare. In some c;i~:(>s the ascribed to pathological influences wliich have silt \>'h degree; ITecti liiferelitlv the two eye: but more often no cause can ascertained. Th^ more ametropic c ve often has very jxior sight, and fre<iiieiitly qll int^ ivergeiit strabisliius iKing particulriiiy common. .\parl from true s(|Uiiit, liyperplioria :i ind other anomalies are more IrequenI in aiiisoinetropK thai I in other eves. SYMPTOMS OF REFRACTIVE ERRORS. Varieties of Symptoms Common to all Errors. The main direct -symptoms that refractive errors produce are imiiairnient of sight ami REfiiMTivi: j:ju;<irs is gkshiul. 10!» ,l'll<l in llic (■yi'>. 1 ipia. \\\ ii>^llit napiit is meant a sense of f:iti,:iue ami (li-coiiilort rodiiced 1)V u Tlien :iv l)e tatijiue alone Ui^licniipm lit .r I . I li- the fatiKiic may l)e aceonipanieil l)y pain in tlie <'y ,,,.ll.i iii'ptd tigui iliilois), pain in >iiinii( ,.-il.< ■lival irritatiDn inai the liead [nMln'iittim irjihaldliiiiv), or lifested bv hicrymation and eonftestion "/' ■(( irrllniis) Phis hist niav h'ad to actual conjunctivitis id liiepliariti A iieculiar t'onn of asthenopia (/«(/«»r((W'» astlimoiiiin is that in which -(■use (I ii' vertijio, contusion, am 1 uncei-taintv is induced l)y lookinji at ninvm .■ilTecle( <s. and esi)ecially at hiillian tlv illuminated ohjects. Person? -Iio watclnii'; 1 with this symptom often suffer considerable distress from tore, or walking in a crowded street, or from ppini; m a cmwdei Astl pnieessions, hall n/iV'hes, or play leiini'ia may o led this is done as soon ill niaiiv case ten be r(>lieved by ceasing to use the eyes, pro- the syiiii)toms manifest themselves : but it iM-rsists for iiours, or ev en until the following day. Ill SOIIK cases, again, tisthenopic symptoms ( 1(1 not appear until the inlldwing dav. , , Tl„. .ause- of aslhenoi)ia from refractive .rrors are partly undue .„-,.,iuini."lative effort inrrommoddtivr <,slli,',„>ina): purtW Xhoprv^i^un- ,,„ the eve ami the congestion of the lids pioduced when the latter are „iu.M./e(i together in order to narro v the palpebral fissure, and thus ,.,' able the patient to see more distinctly {tarsal (islhe>u>i,ia): partly ., Itiain imposed ui.on the external muscles of the eye {muscHlnr „,/,,,,„): and partly over-sensitiveness of the retina {rc/<«« „sil,rJi,ia). it is enhanced by anything (bright lighting, etc.) that ,!iake> unusual demands upon the eyes. , , , li .hould .e noted that asthenopia is by no mcflH.s alirmjx diiv <> ,, rorhn' .nor.v It is often due to muscular anomalies, particularly ...Mivrrgence-insufficiencv and hyperphoria, an.l. in not a few instances, .,, nasal atTections, such as jtressure in the region of the middle tur- !„., ites Someof themo,st severe and obstinat.' ca.ses I have seen have :,,.„„ ,iue t.i this latter cause. Such ca.ses are apt to be as.socia ed ,,v,th marked eveache and occipital pain. Again, a.sthenopia is oiten In, I urasthenia an<l other conditions marke.l by enteeblement .1 I lie mavous svstem. , . i i^esides th." headache, .'veache, etc., that, .is noted abcjve, may , , uiimanv asthenoiiia. or inav also occur imlei)en.lently ot it m con- ,,,i„i' with refnictive errors. w.> find occasionally oilur .viniptomx. ail a< naus..a. interterence with mitriti.m, various parasthesue, etc !';.,! Ti.aver reflex manifestations (epilepsy, chorea) ever are caused ., nira.tive errors, is doubtful, although there is no question as ,h,. pnipri(>tv of correcting such errors in iM.rsons afflicted with .. n'ain,ses,'and thus ivlieving them of at least one sour.-, of Symptoms in Myopia. '1^. W( „,. tind that in myopia, wiieii m.t of inordinate aiamint, the nni.tom >.- .lie inifwirment oj rish>, for distance, which is -r.-ater It ' I It 110 Tllh: EYE. ti) tlic ilccico of lu'iusifilit. Tlic sijilit t'lir near, i>n thf tlicr liaiiil, is very disl'mct, objects appfaiiii^ not only clearer cut in |iro|)ortion :o ina Init al: isewinii, einhroK )rk ^nilietl, so tliat tiie iiatienls are ai)le to »lo very fine W( lerv). Al the same time. oi)jtH;ts are lield very close aixi if l)inociilar vision is inaintameil, tlie excessive convernenct [•ITort nay produce asthenopia The l)lurrin.i; in distant vision nsyal.y causes no discomfort in ordinary myopia, but in low myopia, wheiv the hlurringissliniit and the patient makes constant fruitless etVorts to see distinctly, a ili.sa)ireeal)le asthenopia may develop, which is re- lieved by a concave gla.ss. Ill hiph myopia, particularly when there is advanced sclero-choroi- ditis posterior, there may be aching {xiin in tlie back of the eyeball '■ ' ' has tla.siies of r ,. it, asthenopia and symiJtoins of retinal irrildlioii.aw from hviiera'sthesia of the retina, etc. lyjx In myopia tnu scfc rolildiilcs are fre<iuent. This may 1m' no mop than a noriiiai phenome non, wliich is accentuateil here simply because the myope sees in a sort of haze or cloud upon which lie readily pn jects tile floating black sjiecks. In high myopia the floating bodies an larger, and are (>vidences of ii(|uefaction of the vitreous itself <hi( to disease of tiie fundus. Symptoms in Hyperopia. In liypero])ia of moderate degree tin sight is 1 for distance and near; and if the accommodation effective, is performed without stt.iiii, am hence without asthenopia. When the accommodative power is low as comi>arcd totlie amount of liyperoi»ia, nstliiiiopld develops for near work, and later for ilisiance 111 high degrees of hyperuiiia \\\v ."itiht h(()ins to he hliirml for nd, as accoininodation diminishes, for distance too. At first the blur itself is momentary only, the sight clearing u]) as soon as the patient rests the eyes; but later on, tlie interference with sight becomes m<ire and more constant. In very high hyiiempia the also, near, a jiatient never set distinctiv either for distance or near tism tlie sislit is blurre^ As soon as the vision iK'comes indistinct the astlieiiojiic symptoms generally cea.se, because the patient no longer tries to accommodate HciKlficlics, fjicnrhcs. etc., are not very common in hyperopia uncomplicat'-d by astigmatism S3rmptoms in Astigmatism. In astigina by the characteristic diffusion images. There is niorc or less ills/(,rti(»i of oiijects looked at, and there may be wotiociildr diplopin. Moreover if the patient be using his accommodation to adjust liis vision for different lines in succession, he will see first upright, then horizontal lines distinctly. This produces in him the i>tTect of an (ipinirenl iim >l of I bject> that wlieel-liki> figures ajipear to revolve and check patterns to dance. The re ■suit is often a sensation of (rr//*/o and /('»''■-<'«. For the sa me reason panorama asihrnapia is common in astigmatism. < 'r•■!in;^■^■ "^-ihrDiipiti cki bineil with hcadachv and eiivurlu '< frei|uent. particularly when the eyes are u.sed for near work, lik. reading or sewing, which re(|uires accurate definition of the outlines of objects. In low astigmatism, cunjunrtival irritation and blvplutritit; are not in- lih. Ill KFH.UTIVE EintoRS IS CEM.KMj. mM|iiciit. These mio doubtless due to the fro(|Ueiitly re|.c:ite,l sln.iin n.iitnictiiin of tlie li'ls iiia.le in order t.. narrow the i.:il|.el)r:il aperture ;ind thus eiihanee the eleani<-ss of sijilit. Tliis euulraelioii leads to a mere nr less pertiuuietit venous congestion. QENESAL £EMABKS ON METHODS OF EXAMININO FOR REFRACTIVE ERRORS. Varieties of Tests. Routine of Examination. We have various means for examining tiie eye for refraetive errors. In some ot the lest- used, such as the tests of visual acuity, trial case tests, and astiR- mitic charts, we are depen<lent upon the patient's stati'inents of what he .sees. Tiiey are Ik'Hcc called si,l>j,rtirf h:sls. In others, such •H "those made with the oplithahnometer, the ophthalinoscopo, and, >kiascopy, we are inde|K'ndent of the patients statements. These are the ohjcclire lesh. , , , , i • i Isually both subjective and objective tests should be combined ill iii'dviiif; an examination. Sometimes the sul)jective tests are uiap- piicible, as in children and illit.Tates; but whenever they can be 'luplie.l thev should, in Reneral, constitute our court of last resort, aiul 1 lie evidence derived from them should outweijih that of the obj<"ctive methods. In other wonls, the correct inn-glass determined on is that wiiich gives the patient the best vision, an<l not that winch is api)ar- ,.-,itlv shown bv the ophthalnioscolK- and shadow test. I'ractitioneis differ a great deal in their estimates of the relative vihie of the tests and the wav in which they .should be applied in orictice It prol)abiv makes little .lifference what routine we adopt, provi.led it be svstematicaliv jmrsued and contains a sufhcieiit number „f te<ts to act ks checks upon each other, and tlms ensure certainty ,,r re-ult I shall give bri<'i1v vnj oin, widinv. premising that I do not ,v.nr,l it as essentially superior to any other that may l)e adoiited. ^rt.Ttakhig the history and getthig at the symptoms I make an rxternal and an internal ,:xaminatio„ of th." eye, using in su.'cession ..MiMueilhuninali.m, direct illumination by transmitted light with ..>e „,,l,thalm..scoiK> at ten inches, examination with the ophtha n.oscop.- 1, ■ the in.lirect method, and lastly examination with the ophthalmo- -;■„,.,> bv the direct method. From this I gather, whetluT the eye is i„,,ltliv'or not, the probable amount of vision, the pr.'seiice o opaci- ue. or other .lefects infrfering with sight, and ai-proximatebj the -late of the refraction. F<.r the latter puri)Ose I often ad<l an oHIiand -timate with the shadow test. , ,,, , . ;„ , rimse who use the ophthalmometer should here make an (■xamin..- i,m with this instrument, and thus .letermine the amount ot corneal -ligmatism. The same thing may be roughly d..no with the I laculo 'tthen take the patient s vision, and iH-gin tlie test with the trial ,M.. proceeding in the way hereafter descril)ed to determine rapidly m 112 Tin: t:Yh:. tlir Kla.--' tliiit (■itriccl- llir niaiii tlif |);iliciil's vision Inr in':ir. iiiu rcadiiiy:. If, ill llll'Sl lll>t!llHM'S ill-til IhiiiiMtnipiiif. ami. iiiiiiuM i'csl crrnr. I at tin' >aiiir lime ti'-t I tiiid llic tflass that suits iiim lor 1 wisli tn use a cyclnpli'nic, 1 tlll'll liatclv. licfniv tlic linin lias time li> I't, make the iiuiscic tcsl>. i-atcr. w li>'ii till' (•vcliii.lc>:ic a<li<>ii I >( th hitiiiatrnpiiic is (■oini ili>l( , or iiraiiv so I (li'tciiniiii' tlic iciractioii w itii ski ISCdpV, 'riu'ii 1 ciiiiliriii nr iinHlit'v this result with the trial case and tiiiallv rUt rk (ilT these last results afiaiii l>y skiaseojA 111 certain cases, as in chiiilreii am I ill verv nervous penple, it save time am 1 is less tiresome to the patient to cut the subjective exaniiiia- tioii short, and to proci' the shallow test, iiiakinsi ■d at once to the oi)jective examination with thi> elullv as possible. Isinj; the cor- rection tliiis found as a basis, I ajcain ma ami now }:<'ii<'i"i>lly •'""' ''"'^ ''"''"'' ''^ ^'' ke the test with the trial case little left to do in order to helinarresiilt,so that now I do not have to tax the pjitient arrive at t attentioii unduly nor mtike miu h ilemaml upon his patience or judjimeiit. The Use of Cycloplegics untarilv exai;};erate .\s we have seen, the myolH' inay invol his myopia, ami the hyperope wholly or partlx ■onceal liis hyi)eroi)ia by usmj; his accoiniiioi lation. Patients whom ill we examine for out the precise to alxilisii the accomnio( are so ai)t to do this Jiat. if we wish to find refractive state of the eye, it often becomes necessary lative etTort altogether. This we do with a rilv used is homatropine, a 2 per cent. cvcloplejiie. The one ordina solution of which instilled every five or ten minutes for five times pro( lu( ■es 111 El neral complete paralysis of the accoini iiodation in from I a half froiii the time of the first instillation fr< X hours. In instillii.>r the homatroinne it is to have the patient throw the head back mil an hour to an hour aiu . , . ^ The effect soon befriiis to wi-ar off. and di>;ipiM'ars entirely m Iroiii twenty-four to thirty-si best.as.Iackson su-ifiest: . . look down, so that we iiiav drop the solution .lirectly on the upjMT part of the cornea. The eye in which the instillation is made should be held open until the I'latieiit vohuitariiy opens the other eye. This ])reveiits his s(|uee7,ii <i the dro]) out of his eye Homatroi)iiie is an ,rrit;int producing a moderat:' coiifiestion of the eye, which, however, i:'. transitory, and has no ill -ffects whatever. ■ Sometimes .-cpolniinnc in 0.1 l)er cent, solution is used, but m my experience it has no advantafjt' ovor honiatidpine. In cases where we wish to produce a very thorough and lastiiig (.fTect — /. c, in spasm of accommodiition— atropine may be useil in 1 per cent.', or in i)articularly obstinate cases 1.") jht cent, solution. This is instilli'd ni^dit ami morniii}: for one or two d.ays before the ex- amination. The patient should be examined three hours after the last instillation. The j.aralysis of the accommodation in these ca.ses lasts fullv :i week. \\ilh the cvclojilefric ncdr rision for the hypermetrope and cmm.'irope is rend.'red impossible. ( Vcloplejlies, besides abohshnifr accommodation, dilate the iHipil. They hence render tlu' vision BEHlAVTlVi: KlilHtliii ••>' iiKXKIlAL. iia ,„ ,n..-tr..,.i!i wurs.', n..t ..nly l.y pn-v.-i.tiiiK acr..mn.o.lativc effort. ;,;„ Mso l.v inm.asin« th- si.,.- ..f tl,. .lilTusmn mu.p..; an. it ,- mnrrallv fcviixl tlial .'V.Mi with .nnvctiui. tl.r viM.m uiuI.t .i ■v l„,.l.-iji.- i; lu.t s.. k.rn a. with th.- pui.ii .•.mtrart.-a. M..r..„v.-r. ,j„. , ilataticn of the pupil, hv l.-ttin- i.. an exress ot iijjht i.r.Mh.c.s a „;;..„„.. ,Wz//.<, To obviate this. .!> ,«..ent "'"y >"; ;f'; ' ' ,„ wear snmke.l glasses as lonp as th.- i .p.ls remam -hlate-l. tin. U.\nii espeeiallv ..eeessary if he is expose.l to l-r.^ht sunh^ht. ■nu. i.'.tie.,t"in xvhon. atropine or hon.atroi.nu- ha., been nis .1 e.| ,houl.l .e warned not to Ir,, lo use his <•//,>■ l<.r near work until the ,1 ,, of the .Iruii has eon.pl'-t.'lv worn off. Otherwise, l.y usu.k Ins :;,:;.:l;;tion when stiu'in a-w.:>kene.i sta,e.he may strain the ,.ve in.l may even eause a eoiulition ol ciliary spas n. .>..((• a ,;„; si . M not use his eys for steady reading f- tlurty-s.x , tter still fortv-eifilit h.mrs affr the last instillation, it homatro- l,;;,;. haril'en used; and not for eight or. still Ix-tter, ten .lays if •iirooine has been use.l. . 1 pen.iK.s, who are so greatly .leF.ident upon aee..m.no.latio ,,' Ivioislv v.>rvnuH.h affecte.l by eyel..i.legu-s. th.-.r sight b.-ing ndeivl ba.l f..r distance an.l near. Myo,H-s, .>n the oth.T hand, o whom a<-e...nm...lati..n plays but little part in seeing, suffer but ''f)b.,"v!<rs'dX"r'"a'go(.(l deal as to the nece.'^.iity of ming cyclople.iic. i,. 1, te mining refraction. In ..ew York they are not so often em- o"s elsewhere, and many practitioners iH-lieve that they can . .;- i .: n'f action accurately without tlu.ir ai.l. 1 .1.. ""'I.^'^'^";'", I" , i > I have s,>en a numb.-r of ca,ses in which the refraction could not ,ve bee. leterinined otherwise, ami in which a s..ru.us error in the .. J :.n W..U1.1 have resultc.l if no eycloplegic ha.l ^;-: ;'>:'f; ;^;^ Mv exiM-rience, in fact, lea.ls me to use a cycloi)cgic in all casts ul ,. 1 c" when the patient is under forty-five years, an.l in s..me . wlie he "bet .voen forty-five an.l fifty. It has been my ex,_H"ri- ., . th aduri g the perio.l fr .m forty to forty-five a cycl..plegic is ;;:.cSw lln^^'ant, L at th^^ tin.e patients are partu-iadyap^U, .v ..t their .iccominn.Uitioii ex. .>s.sively and hol.l ..n to it tenac ousIn. iV ' 1 ii,U le-age.l Pationts I, of curse, take care to ex.- u.le any : . ii. ,. !,f glaucoma! in which th<. instillati.>n of a "'y;^';; 'J . J " ^^ u' disastrous. In mv experience, honiatr..pme properly app lie is ' , . v,st majority of cases, fully as efficient an.l reliabh^ as :,;,.,!,,;,«> I fimt'too! that chil.lren yiel.l rea.lilv t.. lu.matropun- '"i^v.^; mif lu;.;tin'w:M!t;/ complete re,ara,ion from the use ,,CCvcl..pl.'gio This is sh..wn by the fact that the patient will ■ k. <. ine in. .me glas.s. .soinetim..s another, an.l that with the .<ame : t'^vS .1 vad.^, s., that, as he says, " the lett.vrs erne .uul go, ■ he o ";"he tes/ car.l. FurThe^m■..^ the result "f ' j<' "^J-^^; .nuination with skiasc.py or the ophthalmoscope will not agree nil the glass found by the trial case. 8 114 rm: a.)>;. W'licli llii- li;i|i|p<'lis, \M' ti'ivr the cyrluiilcjric liiiilc lime tn act, lillil ill till' iiiciiiiliiuf iiislil it -I'MT.il liiMcs a;;;iiii al -\\ny\ interval.-. It' this fails, we sliiillld ll-r al|ii|iiii(' ill I In 1 .."> per I'f'llt. snliitiiill -cvi'nil tillK's ilaily t'nr a snir- of ila.ss. Miit it is vriv i;ii'ciy, iiidi-cij. that ri'>uit iim-t lir liail III ilii- cxitciliciit Keratometry. Placido Disk Determination <f Corneal Curvature in AstigmatiHm by Keratometry. 'I'lic cnnica acts kr ;i cdiivcx niiinir, ,1111 1 w ill iicncc irivc a siii,ill. erect rellectinii of an . 'iject. ~iicli as ,i disk, |)lacei| in t'lciiit III' it. The inure cimvex the c<irne,i, the siiiiiller this rellectiun i<. \\ hat is true nf liie ciiriiea as a whnle, is true i>f each >e|i,'irate ineriiliaii nl it. If, then, all the cnriieal ineriiliaiis are ei|iially ciiiivex, the rellectinii nf a circiiLir disk will al.sii In- circular: hut if some inrridiaiis are inure cmivex than nthers -that is, there is corneal astii;inatisin the relleclioii will he oN'al. aiiil the siiiall diaineter of tif o\al will lie in the nieridi.in of jireatest ''urvatiire or >;reatest refraction. This |irinci|>le is utilized in the a|i|ilication of the I'luviilo ilixk. This is a white disk heariii}: a series of concentric hiack riiijis painted on it. (I'i;;. 2.) The ohservi'r, huldinji this iM'fore the patient's eye, anil looking: thr(iw>;h the hole in the centre, .sees the reflection of the disk in tlie cornea. If the retlc'ii'-,. is circular, there is no corneal astij;- niatisni: if it is oval, there is lemilar corneal astipnatisni, the meridian of j;r''!it''^t curvature lieiii'j in the short axis of the ov.-il. If there is irrciiular corneal astifiinatisin, the reflection will he irrejiularly dis- torted, or will change its shajie abruptly when shifted from one part of the cornea to the other. Since the corneal reflection of the I'lai ido disk ^rows smaller as the curvature of the cornea hecomes greater, and also liecomes more oval as the corneal astifjinat' ■ increases, we may, hy iiM-asuiiii}; this reflection accurately in its itilTereiit diameters, calculate hoth the ;iclual curvature of the cornea in all its meridians and the jirecise amount of its ;istii:inatism. Both determinations are much more rapidly inaile with the ophihalmometer. which in principle i- a spe- cially luodihed I'la.'ido disk. Ophthalmometer, The ordinary type of oplithalinouieter is that devised hy .laval and Schii'itz. ' l'"ij;. .')).'! The o]ihthalinometer i I'i;:. .IIM coiisis -. .' .i telescope, .1 containing a doulile-refrai'tinir prism, a jrraduatr I di-ik. //, havinji a hole in its '•(•litre thro'iyih which the felesco|)e o.-isse ; and an arc, ('. hearing two slides or mires, I) and E. The are (' is ;ittaclied to the tele- scoiie, which is so mounted as to tu'ii freely in the central hole of the disk li. and as it turns carries (' aroviiid witii it. The hole is hijjhly illuminated, usually hy artitici:il liiihl. Tlie p.itient sli^adies his head on the chin-rest /•', and looks into the larfre end of the telescope: the iili<i'i\-er. oliservinir at the patient's eye tlimu;:!! the other end of till' telescope, will see the cornea, and upon it the reflect i(i;i of the disk ,in(l slides, hut because of the douhle-refnictinj; jirisin in the tele-cope will see two imafics of eacli slide. The two central imajies itEi n.\rrivi: uniiovs is ui:si:i:m. 116 -I /» Mlhl /•-', whicll ;itr ••li'^i lop'tlliT. ululif mIv nlivivi'd, llir two „,i,.f c.iHs iM'iiiK iirulci-tiMl. Kai-li (f lli.-f im.mr^ is liiMM-tr,l l.v a I ,,k lin.Mtii.l ilictflrscu|«'i^rcv..l\c.l until llir.laik Iiimm.I uiif iiiia^c - ,|,l,n,\iii..ilclv < linii.iiis with tin- .lark lin.' "f tln' ..llirr. Tin- I,,,,', roimcrtill-i'llir •^\'V••' \- IIh'H ill ..lir nf tlw piiliripal IIKTlillalls ,,l ,hr cuiii.a. that i-. ••itlicr lli-' iii.Ti.liaii nl' ^ivatot <ir llu' iin'ihliaii ,1 |,:,-I niivatiiri'. Tli"' min- aiv imw Ah\ In ami ' aidr,' lli'' arc Javal-Sclii"tz's o'lhllmlmonieter. , „„til til., images of I) a.1,1 E just tnu.-li. Tl.r l.-l.-scnpr is tl,.;,, . v,,1v.m1 thnni-h '.»(»°, wlu'M the line .•onucctuiji tiic slides will l»' m ;„. other i.iiu.ipal inrriiliaii of the coni.-a. ll the niiajK- /' : 1 /'. ,w n. lap or arc separated, tli«'re is a e«nieal asliiiniat ., <-. :" nun propoi ■lioiial ti their distaun- apart. uodel of op' Ihaliiioi ..ilappiiiiiof the ii....^'e-^ is lueasurei ueter shown in V\X •")■•. tlie . I (lirectlv. l> is a par: .'rata, m &'i' IIG 77//; j:yk and A' is a tifiuri' witli a scries of notches or stops. Tlic instrument is so urailiiaU'tl tliat tiic iiiiiiilx'r of steps l)y wiiich A' overlaps 1) re])resents tiie nuinher of (lioi)tres of conieai astijtniatisiii. In anotiier niodi'l, when overiappinji is present after tiie telescope has been rotateil into tli<' secoml i)osition, the slides are separated until thev just toucii aj;ain. The amount hy wiiich the slides have liei'ii moved to aeconi])lish this is read olf on a scale behind the disk. In both varieties of the ophthalmometer the radius o/ nirvdliirc ot the cornea in any meridian can be detern.ined. In the first model it is read off from the arc <\ beius shown by the distance l)et\veen the slides when they are separated so far that their imafj;es on the cornea are just in contact. In the second form of ophthalmometer the radius of curvature of the meridian examined may be read off on a .scale behind the disk. In both forms of ophthalmometer the index shows the .situation of tlie meridian wiiose curvature i.s beiufj; meas- ured, and in th> case of the ])rincipal meridians it indicates the axis of the correcting cylinder, which nmst lie in (>ither one meridian or tlie other. The oi)hthalmom"ter does not show what khid of astigmatism— hyperopic, myo|)ic, or mixed— is present. That is, it <loes not .show what is the absohile rvjriwtiim of the principal meridians, t)ut only which of the two is the more refractive, and the difference in refraction between them. Moreover, the ophthalmotneter indicates simply the corneal astig- matism anil its axis. It does not reveal either the amount or the direction of tlie total astigmatisin, except in aphakia, where, the influence of tlu> lens being removed, all the astigmatism is corneal. In any other cas(> tlie result is only an ap])roximation, although often a close approximation to the true findings. OPHTHALMOSCOPY AS APPLIED TO THE DETERMINATION OF REFRACTION. Direction of the Emergent Rays when the Fundus is Illuminated. When we throw light into the eye with an ophthalmoscopic mirror, and thus illuminate the various" points of the fundus, these points themselves si-nd out rays that <liverge in every direction. On their wav out these rays encounter the lens and cornea, which alter their course to a greater or less degree, according to the refractive l)ower of the eye. The eye being l)ut a combination of lenses, the actual course taken by these emergent rays will be determineil by the law that governs the direction of rays passing through lenses. Tiiis law, called the Utir iij ciujiifidlc jiiri. may be thus stated: If a lens has such a strength that rays emanating from a p>int /i". are brought logellier al a point .V, tlieii rays that emanate from the iMiint .V and travel back through REFRACTIVE ERRORS J\ (lESERAL. 117 ih,. l.Mis will he hrnuuht totjether at R, and will form tlicrc i» rciil iiivoited iniMficof .V. (Fifi. 1!>.) _ „ , ., .,. U tli<- lens is of such a strength as to focus i)anillcl rays at A (1 ifj. l,!). then rays oinanatinp; from .V will, after i)assinfi back tlir.)u<;h the Icii-i, enierRe jximlM. i. /. ,i , If tlu- lens is of su-.-h a strength as to focus at A rays I) [ , that ■,re coiiverftinjj to the point R (Fig. 50), the rays emanatnij; from A will, after passing back through the lens, direrijv as if they came jrom /,' and will form at R an erect, virtual image of A . To apply 'hese i)rinciples to the eye, we may say that m emme- tropi'i theVays that emanate froii' the illuminated fundus will emerge from th(> eve parallel to each other; in hyperopia they will diverge from the far point lying back of the eye: and m myojna they will converge toward the far point lying in front of the eye: and m either ,-:ise will form at the far point an image of the portion ot th^ fundus ihat is illuminated. , , .i The behavior of emergent ravs is the same, whether the eye is naturallv emmetropic, hyperopic, or myopic, or whether it is made Ml by the addition of a convex or concave gla.ss placed betore ttie Determination of Refraction by Direct Illumination. I f . when we <tuid otV fifteen inches from the eye aiul th.'n throw light into it, we .,v a clearlv dehned image of the optic .lisk and vessels, we know ih.t this is the image formed by the eye itself at its far point, as .hown in the prece.ling paragraphs, and that this ima-e must be ,.i,lu-r between us and the eye (myopia of (i to 7 D. at least ) or behind il„. eve and close to it (hyperoi)ia of 1 D. or more) ir 'as we look into the eve, we move our head, this image ot the lund'us will move in the opiu.site direction m myopia and m the sMue ,liivction in hvi.eropia. This is because we refer the movement ,;, ihe plane of the' pupil which lies behind the image m myopia and ,„ front of it in hvperopia. It is the same experience that we get -u ■! railroad train When, lookuig out of the window, we see objects m i|„. foreground apparently running backward and objects m the tar li>laiice running forward. « .,. j , Determination of Refraction by the Indirect Method. In using ■he indirect method, we should hold the object lens with it.s prmciiml „ru< at the anterior focus of the eye. that is, ab.uit halt an inch „ front of the cornea. Hence a two-and-one-half-mch lens shouli i„. i„,i,l three inches from the .>ye. When we <lo this, the size .. !„. object seen in the fundus is not altere.1 by the presence ot axial ivperopia or mvo|.ia, and the distortion j.roduced by astigmatism - relatively slight, .so that tlu' optic disk, for mst.anee, ajipears iiiniallv round. , , , If h-.'wev.'r, we carrv the lens closer to the eye, then the api)arent r uf the disk diminishes in myopia and increases m liyperoi)ia, ;,ii,. i„ ...nnu'lropia il r.•main^ the sanir. If we carry the g n<s aw.'.y mi the ev.-, the reverse change takes place, the optic di.sk Iwcoming '--^.i-: :"Z:.^: i' .-^ 118 TlIK KYK. .mmrontlv smaller in hvporopia and largor in invopia while in oniinc- trTr as Ihw' it ron>^ns\.n..l.an„-.l. In n.ark...! hyiK-rop.a an.l If V , vunin' a pati.-«t witii l,vp.-n.pic or n.y..pK' ast.g.nat.sni sMtli L n .- ' ... ii- .lisk will loclk iiko a horizontal ova wh.-n our XX W.^ tJ th. oyo, ronna whon vvo carry tu- , lass hack o U S n.lara positi..n, and a vertical oval . wo ^^•' 1>'>'-='^V "' -f v^rtic a J- t -r n astigmatism apainst the rnle, th<> disk will h. a x.-rt ca ; V when th(> jrlass is clos.-, and heco.n.-s a horizontal oval when th lluit ^Sthdrawn. In marked astigmatism these changes are very '"DTe'Siation of Refraction by the Direct Method As ^v.;ha^•e se.Mi if we illuminate the fundus of an emmetropic eye, ra>s will ^ . iire f om iaralh-l t.> ..no another. If w<. ourse.ves arc enmie- „ < or ■• k,' o rselv,.s so with the proper gl. -s and relax our rrnn o I it completely, wo may, without additional ai.l. focus !'"- 'T?r'^'•'s^fSs"''";Fi:;';. ;;s:;';iu 'liph^;^;::.'": ^.t u'di^^mct image of ti. fundus if wo "t Tt^ • t;::;;',^;';t have ...w sin.p,v touring hefo. ,h IStJ^'le of .he ophthahnosoope that lens -l.-h w. corn-c. h s .Muetn.i.ia an.l thus render hnn onnnotropic We shall thus a> '.,!': .fundus distinetly. XW thus arrive at this rule: Ihv of the line vess.-ls. nrefcral.lv near the niarula. or a l-a^t n,n nuL t tl e emporal sille of the disk, and aseeHain the g ass with win,;, won'., see it ...ost .listh.ctly. A ...ore satisfactory test object still REFRACTIVE ERRORS IX GEyEIUL. 119 i. ,\,, tine granular .narkin.s „f the fun.lus in tho vicinity -f th.- vfllt)\v spot. . roii.lcr the nationt cniniotnipic l,v puttnif? up any •> tlio HJ»f"t'' K ncrfcM-tlv distinct view of „;„s,.opo. cnsciuently wo c-ann,.t o» tan '^ _^^*^^^^ ^. •„,; , „„. ru'naus. Tin. nu.st Nve can ^J^'V^'^^^^J,^ 4 D. „ i.U.„s omnjetrojn. ^^I^PPJ^^ f tdllii^V i^cropic 1 D. .As with th<> rule, an.l t» '»* h»^^ ^"^J^^ ^ „phthaln,..sco{K> his vertical s,...!! as we put up a -'-1 U. ^^Jj' J"* .1 , ,„. ,^,,^,,,1 „,. hcri- . „„„.i,lian will .e/-.nmetropic ^J f J^^ .f ^.^ ,, ,,,. ,„. into it. .ontal lines distinctly. As he sus out o, > ^^^ ^^^^^.^^^^ j^ettinfT the same kind of view "^ '» f^^f f t e horizontal vessels iK.rizontal ones very hazil\. , j^^ j .^j.tig„,a- This example shows ^^T^^^'^Z^J. runnin, in the ,is,n the ijUix. that gives us ^^^"'''JJ^ ;,„,„,,, „,, rvirmiim of :;r,i;ri,5';;x'i;iL, ^. -2 n «..„ .j .h.. .^ ,uon.i™ .> -1 n- direct method ar follows: p„,rected bv the proper 1. Our own retractive errors ^'^^ ;;.,: ^^^^^ ,!.ss and our accommodation '-"P' " ,; . ;'^ ,, H,, i haVe seen „,is vari.s in .lifferent ^ople. ^ j , J^ .^ ,u,l,,,,l„.ists, that "f the -''--P-^;;-'::: irrl ' . 5.^^'ly -;l- -ntrol as they ihcir accommodation is stiii u i lu'lieve it to be. chmild be conii)letelv relaxed. It •_.. The patient's accommodation ^^^^^}^^IU^. -^ .xM.nine.l in a i- ,. Tlu> patient saccomm..m.^™.;^.^ .^ ^^^^^„.,„.,, j, , fTHierally supposed that h« ^ ' •■ '■'•^^ ' r^^^ ,, i,v „„ means rk room without anything to hx upon. lius Iwavs the cas<'. . . , „,,_r„ptiii!r class shou :i Tlu- ophthalmoscoiH. c^ntf "'"f^^^'^'^r"','!"*' f:f ; .j i^Uf ,..1.1 at the anterior focus of the patients eve. this is a :hould be inch „ L'n; '^1 ot" "i1,;m>' «i"-i. <-'i "- ' "- ■' "■'■ m^ iww^mrm- lliO rut: EYE. pationt's accomnuKlation, tlie findings siiould i)0 ciiaractorizcil as approxiinatr only. The direct inctliod is inuch used in estimating the relative refrae- tion, and iiencc the rcUdire dcplh aitd pmminenvp of tiie diiTerent portions of tile fundus. Thus if we see tiie Ixittoni of an exeavation in the disk witii a —4 I), and tlie edge witii a +2 I)., we k\w\\ tiiat tlie deptii is ap[)r()xiniately 2 mm., eorresponding to this difference of (1 1). So also an exudate or a detaciiment which we see distinctly with a ^4 I)., while the surrounding fundus reijuires only a +1 1). to make it visible, is 1 nun. liigh, corresponding to the difference of .] D. SKIASCOPT, OR THE SHADOW TEST. Principle of the Test with the Concave Mirror. If we stand off at 1 m. from the patient and throw light into his eye with a con- cave mirror — for instance, the mirror of the o])hthalmoscope — we shall see a light-red reHex filling the pupi' Then, if we turn tiie mirror siightly the light will gradually lea.e the pupil, and darkness will succeed it, until the ])upil becomes efUirely black. The direction in which the light moves in passing from tiie pupil depends upon where the far point of the eye is. If the far point is between the observer and the patient, (he light will move off the pui)il to the right when the mirror is turned to the right, and rice versa : that is, the light will move \rilh the mirror. If the far point is not between the patient and the ob.^ierver, that is, is either I)ack of the head of the observer or of the head of the ])atient, the light will move miainsl the mirror, or to the left when we turn the mirror to the right. Instead of watching the movement of the liiht, it is usual to watch the movement of the dark area or shadow which follows it and moves with it, hence the term skiascopy, or shadow test, applied to this method of observation. If then, stan<ling at 1 m. we see the shadow move with the mirror, we know that the ])atient's far ])oint is between us and him, and lies within I m. of the eye. He must then be myopic more than I I). If we slowly approach him until we reach a point when the shadow begins to move against the mirror, we know that at this distance we have just passed his far point, so that it is now just back of our head. The point at which this change of movement from with to against occurs is called the point oj rerer.'^nl. It ob- viously coincides with the patient's far jioint. Instead of thus moving up to the patient to ascertain his point of reversal or far ])oint directly, we usually stand at one distance, gener- ally 1 m., and, by putting glasses on the eye we are examining, change its refraction until the .sune reversal takes place. A\'hen this ha.s 1m en effected, we have put his far point just Ivsck of us, that is, jtjst beyond 1 m. W ith the next weakest glass we should have ■ ut his lar point just at 1 m. and made him myopic ID. iiake him Jk RKI'RACTIVE ERRORS IS <;ESER.\L. 121 ("iiiiiictrnpip, \v<' should now give him — 1 I), in addition, since any inyo|)(' of 1 I), will l«' made an cnnnctropc l)y a concavf glass of iliis strcnfith. If staiiiUnR at 1 ni. wo pet a inovonient of the shadow against the mirror, we know that tiic patient's far point is between us and iiini, I hat is, lie is not myopic 1 I), or more. He may l)e hyperopic, enmie- iropic, or myopic less than 1 I). To determine his refraction and its precise character, we now add cojivcx glasses, thereby increasing his refractive power, until we finally get a movement with the mirror. We have then ju.st brought his far point down to within 1 in. and have made him myopic 1 I). As before, we make him emmetropic by giving him — l" D. in addition, or by subtracting 1 I), from the convex glass previou-sly put on. The actual practice of conilucting the .shadow test may be stated as follows: We stand slightly more than 1 m. from the patient. If. usmg a concave mirror, we get a movement of the shadow xcith the mirror, we add concave gla.sses until the movement just goes against. The last gla,ss (highest concave) with which the shadow still moves with the mirror is the ri'versinq f/la^x. If the shadow movement is nfininst the mirror to start with, we add convex gla.sses until it just begins to go with the mirror. The lirst gla.ss (lowest convex) with which the .shadow moves with the mirror is the rcrer'^iiifi (/lass. \,l,l ji _i n. to the reversing glas.s, and the sum will be the oiircctinij (ilo.-<s recjuired. Thus,' if we get a movement with the mirror, and if by addmg a —2 1). we get a movement against, while a —1.75 D. still gives a movement with, .ve know that the patient is myopic -1.75 + . _i) „r —2.75 D. If, in anothe- case, we get a movement against, which tinally is converted into a movement with tlie mirror, by :i 4-;{ I),, the patient's true correction is +3 + { — D or +2 D. So also a movement against that would be just reversed with a 1 I), would indicate emmetropia ( + 1 D. + (—1 D-) = 0); and one reversed with a +0.25 D. would indicate a myopia of 0.75 1). 0: -1 = —0.75). Application of the Plane Mirror. Many use a plan(> mirror instead iif a concave. This gives a brighter illumination and a better marked movem(>nt of the shadow, but, as I have r-^peatedly found, from the wry largeness of the movement, tlie plane mirror is likely to give I confusing result in determining the reversal in astigmatism, and I iiri sure that I have gotten more accurate results with the concave mirror in the.s(> cases. With a plane mirror the motion of the shadow is just ojiposile ■iml ohhtnicd with a amrnve wtrror. That is, when t,i. far i)oint is iirtweeii us and the patient we get a movement against the mirror nd the rules above given should simply be reversed, the word with " behig substituted for "against,"' and vice versa. !b^.ttii>SIMai. 'S?""ia!Hi 122 THE KYK. Distance at Which Test is Made. Wo may stand at any .listanco in niakii.n tlx- sliadow t(>st. W.' should then make a pn)i)()rti(.nat(> addition to tli(> rcvcrsiiif,' glass in order ♦■> obtain th.- proper cor- n-ction If, for instance, we stand at I m., the glass with which we obtain reversal at that distaiiee puts the |)atieiit's far point at 5 nj , that is inak.'s hii.i nivopie 1.50 I). Hence we shall have to add — 1 .■)()!) to the reversing glass to obtain the true correction. N), also, if we stood 2 in. we should have to make an addition of only — OoO D. to our reversiiifr 'lass, which in this case will make the patient niyopic f)..')() I). In liie majority of cases a distance of 1 m. is most practicable. Testing the Result. To prove the result, we put the reversing glass before the eve, and, standing at 1 m. or a few inches beyond, note that the shadow goes with the mirror. We now approach a few inches. If our reversal is accurate, the shadow should now move against the mirror. , . , , a Character of the Reflex. If the ametropia is very high, the reHex is very dull— in fact, we scarcely see any light in tlie pupil. In proportion as we add correcting glasses and get nearer the reversal, the reflex lieeomes brighter, becoming very brilliant and white when the reversal is reached. Hence when we see a dull reflex not attrib- utable to opacities of the media we add strong glas.ses at once (several I) at least): and if the reflex is still dull, change the ji'.ass for one wiiieh is I or 1 I), stronger. As soon as the reflex becomes bright we make slight changes (()..")() to 0.25 D.) in the glasses added. The Test in Astigmatism. To determine astigmatism, the shadow test is made as follows: We l)ut on glasses, + or — , until the move- ment in one meridian is reversed. When this occurs and the astig- matism is of anv amount, the luminous reflex is converted into a well-defined band of Uqht running precisely in the direction of the meridian that we have corrected. We then proceed to correct the meridian at rijit angles to this. We may do this by adding more spherical glas.<e until reversal is obtained in the second meridian also. When this is done, the band of light will be seen again: but it will now run in the direction of the second meridian, or at right angles to its formi-r direction. The difl'erence l)etween the reversing glas.ses of the two meridians will give the astigmatism, and the direc- tion of the band of light will give us its axis. Thus, suppose that at 1 m. we get a movement against m all directions. With a +2 I), we see a band of light running at 7.5°. By careful a<lditioii of glasses we find that +2.25 I), just makes the shadow go with the mirror in this meridian. In every otlier direction the movement is still against. Making our mirror now move pre- cisely in the axis of 1().5°, we find that when we put on a +4..50 I), the "band of iigln Hes in this axis, and when we put on a +5 D. the shadow just begins to go wi(h (he mirror. The reversing glass is then -^2.25 1). in one meridian, and +5 D. in the other, an<l the astigmatism is the ditference between the two, or +2.75 1). Adding REFRACTIVE ERRORS IX OESERAL. 123 _1 I) for the (listaticc of the point of reversal, we have as the tru(> curreetinp glasses. +1.25 D. un.l +4 I)., respeetiyely, an.l thejotal -rlass .■(.rreetitiji the error woul.l he +1.25 _ ^2.;.) cyl. ax. <o . " \ i.u.re aeeurate way to eorreet astigmatism is, after \ye hav(> „h'taine.l reversal in <.ne meri.lian. lo leave on the rertrsinu ,,lassand ,ul,l ciiUnders with their axes in the line of the n.rreeted men.han Thusin the ease stated we should, after Hn.ling that + 2.2o reversed i„ the .n..ri.lian of 75°, leav- this glass on, and ad.l + 9;'."»'^':%^).'il' t'l.-ir axes at 75° until reversal was obtamed m the meridian ot lb.j . I'n this e:,so, if our eorreetion is accurate, we shoul.l get an even rever- sal not oiilv in the m..ri.lian of 165°. but in all meridians alike for our Kla.^s, if correct, abolishes the astigmatism ami makes the patient siiiiplv mvouic ID. , , , X i. MI u„ f...Uir ( )ur estimate of astigmatism by the shadow test will be f uilty unless we move the mirror xtrictb, in one of the pru,n,ml meruhnn^i. If w.. swerve from this meridian, the shadow will make an obli<iue .novment, apparently sli.ling off the line in which we swing the narro- Hence if we do get an obli<iue movement, we shoul.l change th.- direction in which we nu.ve the mirror until we get it g'-mg right in the plane in which the shadov -nds to move. n <'t "T ^^ords we should so manage the mirror t. .. when it moves the shado^ %v. ,„„ve precisely with or precisely against it, and not slide off dH '"tIus same tendencv of the shadow to make an oblique or sk<-w movement is notice.f when we apply cylinders in making the est, and happen to have placed the cylinders .somewhat out of axis. When this occurs, we shoul.l shift the axis .,f the cylinder until the (ibli.iue movement ceases. . i i „. . h irrequlnrastir,n,ntism we get all sorts of irregular m..vingsha.lovNs, forming kakn-loscpic patterns on the- P"P'',,.^"^'\Vwe In'.v V „..t necessarilv in.licate an incorrigible .•..luliti.m f..r ^u' n u > !)> pati."nce .letermine a more or less r.'gularly m..vmg sha.low m a.l.lit ion |,;use.l by a regular astigmatism which is susceptible of correct...., ''•'ceiiS'andPeripheralShadows. ^." '"'''•''''''"'''V'nTf.trllilerT the ornea has a .liftVrent ref.action ... .ts c..ntn> and at .ts H...ph.r> , g,. a .loubl.- sha.bw. Thus, with the ,H.r.ph<.ry .•...metrop..^ and l,..'ent.-e hvperopi.' 0.75 D., we will with . - 1 D. -f';;;^ ",;;>;; s.>e a sha.low start fr.m. the t..p of the pupil ami ^^^^^'"^y.^^, move ..ur ...irn.r .l..wn. .\t the san.e t.nu- we w.ll n..t..;e a h...- ^lul.l..^^ "vllrZn son.e ,...i..t i.i the lower half of the pup.l an.l ...ove upwar.l, '"'^ITi;;;^!?;' i;:^:> put ..n a +1.75 D. .m this contrary n,oven.ent of 'the .■e.itral sha.l.nv be abolishe.l. so that we get a umf..nu .n..N.- in.Mit with the n.irror clear across the y.up.l. u,..a,,w,u„ , 1 „.^,. ,,f thk «iirt we find two sha.l.)WS .level.)ping n..ar the centre of th.' pupil a.i.l going t.. ...eet each ..ther. like the blades of a pair of scissors (sciss.ir movement). 'ttJFils 124 77/K f !'/■:. Tsuallv in such casos the truo r..fn,r.ti.)n is tiuit sli.m-n l>y tl«' ,n„n. ii,t".'ri..r sluulnw. and not l.y the i,...iph..ral ..lu'. Hms m lu- (.•is(. just c'it<>(l, tiic (•..rrcctiiij: jjiass would i>r<.l)al)ly Ix- +().<;) i^.. ....rrospon.liuK to the hyixsn.pia of th.- inon' (••■ntrai an-a ol th.- pupi . Skiascopy as a Conflrmatory Test. O.u- of th.- most us.- ul ai.]. i- c.itions of the shadow t-st is in cufinnin!,' th.. K-ass louu. l.y sul.- i,M-tive .-xaniination. Suppose, for instance, with tho tnai case we Lvo found (-1.50 1). sph. 2 +''-v>-'-;'-^: '•"*■• "•' ;;;;' % ':: class f I D., .ual^inR +2.50 D. sph. Z +\-J:\ O;!; i'^- '•" • , »*> ^" doinjr. we nial^c the l.atient n.yopie I 1). WiWi this cias., when w.j „.e a concave n.irn.r an.l stan-l at a little bey.m.l 1 m. we should iret a movement with th<- mirror in all meri.liaus. Then, by r.-uik X few inclies near.-r the patient. W(. should get a movement aRamst the mirror in all nu-ridians. If this r.-versal .Iocs not taUe place for •dl meridians at the same instant, hut occurs a few mch.-s nearer the patient for one than for anoth<-r. the astiRmatism is not properly cor- rected, an.l we shoul.l change the strength of th<- cylm.l.T accor.hngly „„til tiie r(>v.-rsal is ,ierf.Ttly oven f..r all m.-ri.hans alike. It, apun. th.> axis of the cvlinder is not corn'ct, we will observe that the.sha.l..w makes a s..mewhat obli.iue m..v.-nu-nt, which is eorr.-ct.-.l wli.-n we set the cvlhuler at th.> pr..p.-r axis. iMnally, it the spL.-rical glass is n..t cirrcct. e. ,,., if in the .ms.- .-it.-.l it were +1.1'.. mst.-a.l .. - l.oO, wc sh.uild fin.l that with our trial glass the ivversal woul.l tak.' i)lace rather nearer than 1 m. . . ,, The Use of Cycloplegics. In using the sha.l.)W test it is generally es^(-ntial that the acc.)mm.Mlati.)n be relaxe.l with a cycl.)pl.>gic, alth.nigh in manv cas.-s w.. may get .[uit.- an accurat.- .ieterminati.m without this. Ma.le with a .-y.-L.pl.'gi.'. skiascj-y is an extr.-mely accurat.' test. Tf .Ion.- with suffici.-nt care, the refraction may l^o estimated up t.) within one-eigiith of a dioptre. SXJBJECTIVE TESTS £& GENERAL. Varieties of Subjective Tests. In all subject iy.- tests of refraction w.' an- .l..p.Mi.lent up..n the inf.)rmation furnished by th.' patu-nt hiniM.lf as to what he sees. .V mimb.-r ..f such tests have b.-.-n .l.-vised. the use of elaborate apparatus, calle.l optoni- of th.'in has superseded tiit of the trial cas(>. has to 1)0 rosorte.l t.i in any event ■iubiective tests are of use some of which r.'.|uir.' tne use oters. refra.'toin.'t.M-s. etc. None . which is ii.it .mlv the best sub.ie.'tive test, but wliicU wh.'tlier .)ther m.'thods are used or not. In general it may bo sai.l that tiiese .ither little service or else are sui)erf1uous. _ _ t i-i Direct Detenninatio.! of the Far Point in Myopia. In high nivoi.ia we mav form a rough id.-a .if the .■.m.mnt of the error by de- t.'rmining the "fartlu'st .listancc at which the patient s.rs Ime print. If f.,r instance, he b.>gins t.) ni.l it at 3" from the eye. we know jtEfRACTivi: Kiiiiiu:s rs (ikskral. 125 that his fur ixuiit i^ .i", or that liis inyoi-ia is \:\ D. This nioth.MJ, c.r course, is of very liinilc.l a|iplicatioM. and jjivi's only a roujtii ,i|iini.xiniation. . . , , ■ r ^i Astigmatic Clock-face. The astijimatic clock-fiu-.' is friMiumtly ummI as a sul)i«'ctiv(' test. Tlic clock-face, or fan, consists of lines or l.iin.il.'s of lines radiating from tli<" c:'iitre of the dial, as shown in j-jir (il. If a man having hyix-ioinc astigmatism with the rule looks at such a dial he will see the horizontal lines (those running from III to I\) most di>tinctlv, as his vertical meridian is most nearly ..mmetropic. If he has mvopic astigmatism with the rule, he will »'<' the vertical lines nmniiig from XII to VI most distinctly: and it he has ()l)li(iue iistigmatism, die correspoiKlin" ohlKiue meridian or the meridian at right angles to it will be dearest Tjic^c differences come out most sharply when one of tlie i)rincipal ,„eridi:ins is emmetropic or has been made so by a glass. Ileiice inaiiv II order to determine astigmatism, proceed as follows: Ihey Fia. 61. Klu. »■'-. Astigmatic clock-&ce. ray's a.stlgmatic letters. ,.ut Oil spherical (preferably convex) glasses until one hue m the '.l,,ck-face is perfectly sharp. Suppose this to be the vertical ine, nid that the spherical gla.ss ust-d is +2 I). Then, with this glas.s, ilic horizontal meridian must b(> emmetropic. Successive cylinders lie now added with their axes horizontal until the clock-face appears uniforinlv sharp, so that the lines are iM>rfectly defined. Suppose it ,.jk,.^ .1 JLi 05 t.yl is()° to do this. The combined sphere and cylinder '^■2 ,ph. - _r.25 cyl. ax. 180° or +0.75 sph. 3 +1-25 cyl. ax. 90 -liould then be the correcting glass. , , , , , , If this 'lethod is adopted, the gla,ss found should always be ■..nlirmed bv a trial made with the test types . • u • Personallv, I have found that patients differ so much in their Mimates of the lines seen most distinctly and of the effect upon li<tin.-tnes.s produced bv adding glasses, that I do not use the ■Inck-face as a i)riiiiarv t(>st, but rather use it at the end of the exami- ati<.ii, to confirm the result obtained with the test types, ami see it m 1'2(( 77/ K KVi:. till- jilass I liavc fouiul witli the latter tnakes tli • clurk-larc appi-ar |,. rfcctlv unifoiMii. V Mi.MlilicatK.ii of tlu' clnck-facc is /'m//'.s ustiuwuhr /■'//<rs w... i. arc block IcttiMs made iii. ..f horizontal, vertical, aii.l various ohli.iu. lines • III To the patient with astininatism. some ( if thesi- letters look .itc black aiul some urav.acconliiiK to tlu- axis of the astigmatism. Testing with the Trial Case and Test Cards, liy lar the In'st examination, ami one which should never lie 1m' use<l at all, is exiK'rimental testing with the method of subjective examination, a nejilected when it can trial case am 1 t -St typ The trial case contains convex an 1 coll cave spherical glasses from L'.") 1). orO.l-' I). to.'O I)., and cylindrical cl: from ().■_'"» I', to (■>, or in some case N 1). It is alwavs best to have these glasses in pairs. The trial case contaill^■ also prism when the other is Wmfi examin (li.sks containiiiK stcnopa'ic slits or ix'rforatioiis, etc blinder for covering one eye 1, red anil other colored fjlasses. The trial frame for holdiiiR the srla.sses us«'d in testing should be I steaily. It has two, or, in some frame>, three cells on are slijiped. In a good frame these stronji an each side, into which the glas.sc •lis mav be readilv moved in and 'Uit from the nose, forward or back tov.aril the oyo. and up or down We are thus enabled to centn; accurately th'e glasses placed before the oyos; and we should take care to do this in everv .'ase we are testing. General Rules. In tin- examination witli tlie trial case the following general rules should be borne in mind: Rli.K I. One ejie should he tried ut a time, the other being covered, not clos«'d. The vision of tlio ove losted should then be taken. Ih i.K II. The streHijth of the ulasn ice tnf before the eye .should be selected according to the patii'Ut's vision at the time. This i.s true both ni the glass wo begin with in order to get the first approximate cM-rection. and of the successive glasses we add to this ap[)n)ximate correction, in order to gi't nearer and nearer to the true result. Thus, if we have a patient with vision of 20 2()() or less and we feel liretty sure from the objective (-xamination that the poor sight i.s due to his refractive state alone, we would begin at once with a spheri- cal gla* of from -i to •'> D. ( + or — as the case rcMiuired). It would be of no u.se to try a niudi weaker si)herical or any cylinder, as a patient with this vision would not appreciate the diR'erence made by such a glass. If the vision were thereby increased to 20 70 or 20 20. we wouM add a si)herical glass of I to*2 D. When the vision had become 20 10 or 20 .iO \\i- would add 0.75 spli. (or if applying cylinders a l.(M) I).) to the con.cting gla.ss alr(>ady in. With vision of 20 .W + ,„. o() ;i()_ w(. would adil 0..')0 i>. (sjihere or cylinder). Finally, when the vision had become 20 20 we may add a glass of 0.2.') I)., as then the patient may be able to notice "the very slight difTereiice that a glass of this strengtti jiroduces. This rule no longer holds good when the patient has poor vision due to opacities in the media, or in the retina or nerve. Then REFRACTIVE ERRORS IX (iEXEJi.lL. 127 ,1 weaker uku^n tlmii that imlicatetl l)y this rule will often produce an iilH.reeiaWle alteration in r*in\\\. Hut in such cases ii is itest to |)roceeil ;i('(or(lin); to iiri.i; III. InnervousandtidjjetyjMTsons. or in chill Ireii when they ;.'(t tired and inattentive, or in any case when, from defect in xUv rye its"lf or from lack of mental training, the patient cannot tell what he sees, we should (/r()/> llic Ivstiitti irillt the trull r<i!<v altogether, instil liomatropiiie and deternune the refraction carefully l>y skiascopy. Wiien we have made as careful a determination as possil)!e hy this method, we may then, with the ulnan thus found, resort to the trial (•;,se to confirm our result. llri.K 1\'. hi vxtiiiiiiKitiiin witltoiii a ciidofihjiv we select as a meas- ure of the n-fraction the hij;hest + and the lowest — glass that pives die patient the b'st vi.sion. It is evident that a man having full use (if his acconunodation and seeing eiiually well with a +2 I), and a • 2.25 1). glass, should have at least +2.25 I), hyperojiia, for if a f-2 D. reallv maile him emmetropic, the addition of even +0.25 D. would hlurhis sight. So also, if a patient can .see as well with a + 0.75 U. as without it, he must have at least 0.75 I). hyperoi)ia, the iMtter being measured hy the highe.^it + gla.ss that lie iicnpti'. -Vgain, if the patient were myopic 1.50 I), he would see well iiot only_with a — 1.50 I)., but l)y using his acconunodation, also with a —1.75 I). or a —2 1)., which' would over-correct his myoi)ia: hence the lowest of the three glas.ses would 1h' the real measure of his refraction. IUlk \. When, on the contrary, we examine wilh a qichplenir, we select as a measure of the refraction the lowest + and the highest - glass that gives the patient tlie best vision. l{i I.K \I. As we have seen, the strength of a concave glass is dii;iini.><hed and that of a convex glass is increased when the gla.sa i< carried awav from the eye. For this rea.son when testing refrac- tion witli lenses in the trial frame, we should be sure that they are nt Ihr sniiir distnitcv from the eyes that the patient's glasses will be when lir wears them; oth nvise we will make an error in our estimate, an error which iiiav I of .sensible amount. If, for instance, the trial fr.ime stanils out too far from the face, our estimate of a — glass will be too strong and of a + glass too weak. In the case of "strong '.'lasses the error will amount to a whole dioptre. Hn.K \II. If, in the course of the investigation, it becomes ■I). parent that the rision cannot he rendUij hrouijhl to nnrnidl hfi (uvj ■:!nss tried, it is best to re-examine the eye with obii(|Ue illumination ,iid with the ophthalmoscope, to see if any opacity in the media, liM'ase of the fundus, or marked irregular astigmatism may not be irsent, causing an incorrigible defect. X'ery often the u.^e of a :vdiiatic is necessarv to reveal such conditions, es])ecially in the ease : lesions in the vell'ow «pot. Examination of the field of vision is -., often very helj^ful, ns it mav reveal less of central vision 'due rliaps to tobacco amblvopia, etc.) or a marked and increasing con- ation of the field, ind'icative of a neurasthenic state that cau-ses S" 128 tho aiiil)lytii)ia. <if ail I'Vf tlial is s(|uiiiiiiin Tin: EYi: Wv A\on\<\ also I..' on tin- lookout for tin- aml.lyoj.ia •III cvo nun IS snuinliiiK or oner was Mil.j-ct to ^.niiiil. Routine of Procedure. My owm ,.ro..,..lun- ... ;'-'''«;';•'";;:';" flllloWr I til-l "/'/''.'/ ''"■ "/'/"■"•'■"""''' "■"'■'"' ■tiitii. ili't<'niii..t'il l)y tlic c.irsorv I'xaiii.i.al.oii ..lai inoscopi This corrci t.o.. «o. Ic will. skiasc(.py or will, tl.f opiiii.ai- .il.l, ill j;i'i.fral,"l><' a spl.rrical j;iass, .1. ami a cvliixli'r. H. Scco.i.l, I ailil to tiiis rorivct.oii a s«-r H'S o f \th SCl('( t.'.l llccnrdl.lH to what I <'all ■'""■ aiiotlirr c|iiickl\ roll III I 11/ tlif ' -ial cast-. That is, 1 a.id oi.f after 1. A cuiivcx sphi'i-t •_>. A coiivfx (•> iiiiclcr with its axis in th(> axis of li ;{. Thi <ai.ii' fvh.i Icr with its axis at rinhl aiijlli's to li 1. A concave cyiiiiiler witii its axis 11. the ax.s ol li. iiiider with its axis at rini.t aLgles to H. .'). The same cv (i. A coi.cave sphere, These adilitioiis form a series o pi-acticaily all chai.ces that can ., ,i co.iihiiiatioiis which represent lie made ... the sphero-cyhnder .1 H. Tims, i if A and li ai-e l)<>tli convex the additions made will: 1. Add to A and leave li alon •_». Add to li and leave .1 alone. ;{. Diminish li and ad.l to .1. 4. Diminish li and leave .1 alone li a.id sh .1. ,'). Incri'ase li a.id dnnmi- (). Diminish .1 and leave li alo..e. _ iM.r exanipl.-, if +-'■>»> Z + ^■^■^ '■>•'■ '»« ''''''' '": P'^ ^'"P'"-'' ">: in the frain>. und a J .ss of .",0 D. were added i.i makmft the;' .-ound, the successive ad.litions made and the comlmiaiioiis resi.iun!; tliere- from would be as follows: Additiimi. + Tn) liph. -.- O.Sll I'vl 9C + o.'iii cyl. it-u — .'lO cyl. '.*) — o.Mi cyl. ISO — o.:«i "I'll. RaalUug ^wnbinfitiim. + 3.U0 ■ 1 ■-••'> cyl. «i° + 2..T0 ^ l.T.'i cyl. 90 f- a.OO • 0.7.1 cyl. 90 + 2..'*) + 0.t:> cyl. !>() + 2.00 f 1.7.1 cyl. 90 ,- 2.00 f 1 2.1 cyl. <M) The streii<;tli of the successive glasres added in making this round will lie {Toverned l)v Rule II. , • • 1 Third, as soon as l.v makiiifi the round I reach a combination that iiiMirove's the sifibt, l suhsllhile tins nnr nnnhinatiiDi for the old one. With this new "combination as the approximate correction I .start •iL'ain on the round of the trial case, not usually, how.-ver, from the be.rinni,!". but ad.linji a glass similar to the on.- that gave in.prov.-- me.it before. Thus if I before got iniprovemeiit by crossing with a — cylinder. I keep on crossing - cyli.iders u.itil I fail to improve; then I try liie nex( niaiinMi\ .'<• of the round. Hv making successive ~ ,bstitutio.is I soon get a glass which i.s not improved by any add.ti ;is (+ 01 — sphere or + or — cylinder). nt.fiucTiVK Kiinous is uesehal. 129 Tlii'U I iiiiikc minutv va iriatious iti llw «/(n «/ the cylinihr aiul ><•«• if litis is ju 4 rijjlit- ( H'lcri tilt" putioiit ciiiiiK >t iiidiratc tli«' axis witli prrMision, saying -taiirf, that lie sci-s (•(luaily \vi liii' III 7(1^. Ill siicli :i ••:isf 11 with tlic cvliii'Ur at citluT mf i>r I turn llif cvliiKlcr up (toward 'Mf) ill itii till vi,i„„ i- .-vidrntly l.l.irrr,l. tl.-n l.;in^' it Lark until tlir sijjht U'^jins 1 thfii til'-" till- ifailiiiK. Suppose this to he .M to (Itar apiin, aii tatc tin- cylintlir down (towan 1 now ro hluis. tlu'ii oiK't- inon npanam. ,-)(t° aiK I (1°) until aiiaiii the si^lit S()° ,„ hriiiR the cvriiidiT Lack until thr sijiht Hears Supp..se this to 1k' at :.(i°. Then the axis inu.-t lie l.ctween Working iM'twcen these limits, I try apiii to find at just what point l„.l„w MPandat just what point aLove ^(1° the si«ht rearhes t-^ j;:catest clearness. Sup] I can thus narrow the limits down lo l.t an< I 11 Then the axis o f the cvliiuler in all prol)aLilily ies niidwav Letweeii these limits, or at 70' When this point is s( ■ttli'il satisfactorily 1 may assume that my sure o (•orrection is jx-rfeet, Lut, to Ix -hiiihiir ti-"! in the way already deseriLed f it, I usually /'nuc i 7 hy tin The ehanp's and successi ive siiLstitutions in this roun< vhile 1 (vf the trial ileed. atte i<(. are made with preai rapuiiiy, umk.m, ...... .. • alnio>t me- ,l,;,„i.-allv, and thus in a very short time the ,. roper filass can he ,,„;„,,,„;„;.;,,„„,. i„ parti.'iilar, we can Le sure that no other ^lass than ,1„. ,,iie we have fixed upon will answer as well. ,,■,,,,,. I„ order to determine wh.'ther the vi.hu >r>lh the pupil ddoUd L> , .v.loi.lefiic rc.presents what the vision will U' when the pui-il c.n- ,,;ts o its normal size, 1 slip a disk with a 4 mm. a,K.rture in it ;: . ,„e cnrectin, ,lass in the trial frame. I thus, m ''T.^t, roduee ,i ,, ;, ,., ,h,. normal size and eliminate the disturLin^r efk-ct of the ,avs'p!issin,r throiijrh the iH.riphery of th-. pupil. M often are n.-t 1 lik.' thos.' passinjr th-oiii:!. the centre. In most ca.-es this rcfrai'tet disk will iniprovi i'lten look sharper and blacke the sifiht, and, in jiarticular. will ii that the correction is the jiroper ivduction in the spherical compone lake the test If tills is the case, I feel confident line, and will, after any necessary It, Le accepted when the efl'ect >t lh( cycloiile)iic has suLsidi It should Le iiote( '.(.-1 re 'hat we ■1 tiiat the test at 20 feet does not ahv.iys fiivt the .ults for jar distance. It is well, therefore, to .ry the fila have found Lv havinft the patient look out "f '<' ;^"';'; hether a — 0.2o D. added nd then to oLserve w ilo the far distance a uis not sharpen the sifjht matt uies of Lricks and mortar, etc., in riallv, defining, f r instance the listaiit luiuses Lr-tter. If it does, iiied lie CO .!■ distance rre.spoii.linf: reducti'on should Le made in ih.' glass detern Alter I have determined the correc WvA it :H! ndvantaire. especia ■i-ii ctiiifi glass for each eye separately, llv ill testinc hy]>eroiM's without cycloi lesricto put the eorreetim, for each eije w the jra !\nd h tient look at the tt ■A cards with both eyes at once. It may if 130 tlu'r* turn f)iit tliat THE KYE. lill take sdiiic julditidii to tlic cmT.-ctioii in (ilir eye or liiitli wliicli he iliil not take hci'div. Tin' IckI I'lir iKiir is made .-iiii]ily by piittiiij; on cacli eye its |iio|)('r correction atnl llicn niakinf; the iiaticiit use hotli eves, and find what d ;rlass li adiiiiionai f;iass lie ncciis lor Ins rcadiiifr <ir working; distance — i.e.. we make liic patieiil csseniiaily an eininetrope l)y glasses, tlicn con- duel tlie exainin.iiion in tlie same way as I'or eininetropes. (See Cliapter II.) Tliis examination, of course, should he made eitlier hel'ore inslilliiifr the cycio])e};ic or else some days after the effect of tlie latter has suhsided. An exaiii])!!' will indicate iiKtre clearly the method of procedure. A patieiii not under a mydriatic has vision of L'O L'O. I put mi him + ()..")(), then i 0.7."), then * l.(K) I)., which he accepts: hut he rejects a 1 1.1'.") 1)., that hlurriiif: his sijrht a little. !,ea\in<; the r I.(M) s|)h. in, I :iM rO..")() cyl. ax. first at !»0°, then at 1S(P. Both are rejected, hut tlie former ^ives less hlurrinjr. I then -mM — ()..")() cvl. 1N0°, which coiiverlsihe l.tKlinto • tl..')() ~ *()..")() cyl. ax. <l(l°. This sharpens thesifrjil coiisiiierahly.and 1 immediately substitute -r()..j()^ -t {)..")() cyl. ax. illP for the +1.00. As the iiatieiit shows astifriiiiitlsm with the rule. I follow the lead that he indiciites hv now addim; successively + 0..")0 cyl. ax. <)0°, and -0..".() cyl. ax. lSO°. With neither is the .-ijlht hetler, nor, in lact, is it as <rood as without the jrl:i.-s. Now makin<; the -round" with .-i • O.L'.") I), sph. and cylinder, I liiid that the sphere improves more than the cylinder, indicatiiif; a correction of +0.7.") sph. ; ;()..")() cyl. ax. <I0°. The jiatieiit accepts no further chanjre. I now rotate the cylinder .and find that the sh;iriM'st vision and also the complelest ei|uali/,ation of lines of the a.-tiL'matic clock- face .are ohtained with the cylinder at ,S0°. The linal correction, therefore, is ^0.7.") si)li. ~ • 0..")() cyl. ax. S0°. The oilier eye tested in the same way shows -().,")() sph. ~ ' O.7.") cyl. ;ix. KHP. With lioth eyes together he accepts an addition of + 0,.")0 s]ih., and for reading:, takes ;i further adilition of + ((.7;") sph. His (Mstaiice jilass, therefore, would he R. + l.L'.") sjili. ~ ^ 0..")0 cyl. ax. ,S0°: I,. . l.Ottsph. Z 0.7.") cyl. ax. 100°. His rea.liiifr jr|;,.sses would he H. - L'.(K) s|)h. " *().,")() cvl. ax. S(l°: I,, i 1.7.") sph. 3 + 0.7.") cyl. ;ix. 100° Take another instiince: .\ jiatient under homatrojiine has indi- c;iieil hy the iiph thai moscope and the shadow test a fjlass of ahout '1.7.') s|ih. ~ f l.(M» i-yl. 7;")°. With this he }r<'ts 1>0 10 vision. I add in succession fO..")Osph., M),.")0 cvl. 7.")°, 4 O.ilO < 100°, -0..")0 cyl. 7:)°, — 0..")0 cyl. 1(m°. and 0..")0 sph. I find , ,, of all these comhinations, - 0..")0 cyl. 10.")° improves tli<' most. I suhstitute the rorrespondinj; comhination, ^ 1.2.") spii. ^ i l..")0 cyl. ax. 7.5°, and now jret I'O.'iO ^ vision. I asain add — 0.')0 cyl. ax. l(i")°, hut fail to improve; then ^ ().,J0 cyl. 7.")°, with the same" result. -()..")() sph,, however, .seems a little lietler. and when I try the "round" with 0._'.') n. jri.'isses f fret im|)rovement with -O.'J.') sph. .Makiii<: the "round" airain, no ulass a<lded helps. I change tlie axis of the cylinder nin-UAvTivt: khroiis is aEyKHM. V.'A I fail to p't any certain result, tiie patii^nt's answers Ix'iii^ am ratlier -l.jO cyl. 7.")" -l.oO cyl. ax. 7")° and apply the shadow va>;ue. The jiatient, therefore, seems to 1 lave l.tMl sph. _ tlie liadow moves w I'o prove it, I jnit in tiie trial frame a +2.00 sph. _ test at 1 m. I find that lirections. hut tiiere is a it olihque mov( itli the mirror in all i iiient which is corrected by rotatinji the cylind( , , ,1 it stands at ()0°. I then hnd that 1 fret comi)lete reversal in t! i, ■.•ridian <>f 00° when I stand just within 1 m., hut do not get rever.-al ill the meridian of l.")0° until I >:o hack some distance heyond 1 m. The cviinder then needs streiifitheninfj. Suhstiiutins + 1.7o cyl. ax. (iO° for the +1..")0 cvl. already in, 1 now find that I get complete even reversal in all meridians alike at I m. The correction is, there- fore, + 1.(K) sph. C +1"' <■>■'• *'<>°- ^^'*'' ''"'^ "'' ^'"'' *'"' 1'"'"'"^ now' gets 20 2()-r,"and the astigmatic clock-face is perfectly even. He gets even sharper sight when I juit up a diaphragm with a 4 mm. aperture, which, in effect, restores his jiupil to the natural size. Hut when he looks out of a window he sees far distant objects better with — O.2.") added. Hence his full correction for distance is finally determined as -f 0.7") sjih. C +l-"'"» ''}'•■ t'**"- Rules for the Prescription of Glasses. It being supposed that we have found a patient's total refractive error, we now have to determine what glass to prescribe for him. This de])en(ls ui)on so many factors that no rule can be laid down which will cover all casei. The following are the general princii)les that I follow: 1. I correct all the dsligwalisw that the patient has, unless it is over (i 1)., in which case he is sometimes more condortabl ' and -rets (|uite as good vi.sion with the astigmatism slightly under- '(•orrecte<l. I do not. however, hesitate to prescribe cylinders of more than (> !).. when these give ai)preciiii)ly better sight than glas.M's ot less stliMlgtll .\stigniatism of only 0.2o or O.oO 1). I do not i>rescribe lor. unless the symiitoms (astheiiojiia, blurring of sight, etc.) seem jiarticulaiiy to call for the correction, or unless the jiatient has to use his eyes for very close and continuous ne;ir work, or finally, unless the patient is going to use a glass anyhow, in which case I regularly add the cylin- drical correction that he reipiires, however small. 2. I correct the full amount of luijopia, and, wherevi-r I can, have ihe patient use the same convction for liistaiice and near. If he is much bevon.l the age of forty years, this is, of course, imiHissible; an<l even" below that age we may have to give the myope different glasses for reading and distance, jiarticulaiiy if he has not used con- cave gla.s.ses before for near work. But in myopes under forty years of age 1 make th<> attempt at any rate to gel iheiii to use their full lorrecting glass for all jnirposes, and I find that 1 generally succeed if the patients are at all faitliful in following my instructions. I consider it particularly important to corn'ct myopia, whether of low or of high degree, m children, and to make them wear llieir glasses constuntly. 1 am verv strongly of the belief that this course 132 ti'iitls inon TUE EYE. tl.un anvthinp ."Is.^ t.. n-tanl the further a..vel..i..M.-nt the myopia l.M, <if very fiicat iinportaiico ti) corrof It is a to insist upon tiic l)atit t fiiUv the myopia, am nfs using his glass for all purpos. ilior a eonvcr ia wliich 1; rgciicc-insutHcicncj V. Tho . videnc'cs < wlicii he )f this will 1)0 an cxo- mueh more ma rked for .lear than for ilistancc, an( !:;;,;;;,.;;;.; ;o"nv:;;sion .>f th. ...ar point of n-morg-noo .n.li..a^n|g \, ; ,„, ai,ili,v to n.aintah. binocular hxat.on at n..ar pomts .s f^^u img^ \ \Lh a <-iso the use of fuUv crreotrng coneave glass.^s foi both !,t,an':.'ana n.^ by sthnulating the aeeonnnodat.ve power, may . , , ti„, (levelonmont of a divergent siimnt. ' \;;;;;,i .f ve hif:h d.-gree n.ay have to l>e under-eorreeted on ac-n .f le annoyance that the very strong glas.-s often produce. Hut I believe that we may generally prescribe P'--;; "I' ; ^ J^' and in certain cases mav give even stronger glasses with adxanta^i. i I correct all the absolute and all the mamt.'st hmHropm. The latent hvperopia I umler-correct according to: , T le .v/r of he pati.Mit. The older he is the less .n general «e ,, 'l. ;.. /.ncorrected. No absolute rule can be l''"l ;'---;/ ,nv 1... stated that in children un.ler twelve years of age, fn.n •> of latent hvperopia may often be disregarded: trom t^^el^e to rw'.ntv-five years of age. 0.75 to 1.25 I).; ami from twenty-hve to fortv vears of age, 0.50 to <)./•) U. ,, , , . i • I, Th^^nnuUtions u„.hr ichich he works. If he has to use his .ves ex . Js ve Iv, especially at s, ni. trying kin., of near work, and V rticularlv if bv artificial light. I should give him a stronger glass 5,,;, if he were using his eyes mainly for dntance and by da>- '""c ' His ..,nnptow.^. A patient with asthenopia, hea.lache. and other evidences of evestrain, will require a fuller correction ot his hyi-er- o i than oae-who has no such symptoms. So, also one suf ermg om accommodative weakness, .hie e ther t,. neuras hema or to le effects of recent .lisease, will iv.,uire the correction of nearl> or .luit. all of his hvpen.pia, even if of low .legree. ,/ Th.' nn.sJar co„litin».^. A patient with esoi)hona. ami, still ,n.,r.> ..ne with an actual c.nivergent squint, due t.> c.nvergenc.;- !x,,-s sh..ul,l wear c.mstantly the full c.rrection of his hyperopia or within 0.25 D. of it. lAp.Mi.M.c- has shown that it "; .-"ly 'V ;«; persistent ami long-contimu-d wearing ot the full c.rrection that tht he^t results are obtaini'd in thi>se ca.ses. • , , Per c.ntra, a patient with mark.".! exophona aii.l particularly an exoplmria .lue t.. onvergenc-insuHiciency, often d<K>s letter if his hvpen.iMa is mo.lerately un.ler-corrected. \ -.imple hvperopia of 0.25 t,. 0.75 1)., or. m ch.l.lren. of even 1 m 1) mav in most .-ases he left uncorrecte.l unless it is producing blurring ..f sight, asthenopia, or a converge!ice-exces.s In .Lo,.Li,ia. whenever the sight in both of the eyes can he brought ui. to anything lik.> the normal. I try to either give th.- full BEFIUCTIVE EKHOna IS UEXEUAL. V6S • 1 ,1 ,r „i<„ v,..liu-c the full corroction by un tniual there is /»«"'^,Ve1,a en reiK^ « ^^"^ "'• '"'" "^'^'^ safer to have the patient rtpori loi (t ,,. c;Tec/,s 0/ t;r ^^? TA IndS^orLtL^^^^^^^^^^^ tl/cyclo- eaoh eye the ful sphero-rylindnca < ""eeuoi ^^ ^_^^^ ^^_ plegic ancl,havmgthe i;;:^;;\",tange tKpherical glasses (but.if if he iloes not get full Mt'ion, ^ , "t, ,,til his sieht is brought to possible, do not change the ?jl^'^^l^'^^^^^ .lifference between this and t^^ g^a- prescribe for him will be the manifest .,o, the amount of his as. '''"^l^'^^'^^uint. I pav no attention to If th.- patient has a J^^.^^^! give the full, or practi- '^t'to'iJl:::^^, no mlZr^wheth^ the patieiit has poor t.„„s. Persons with '^^t.gnjatisnu I ^ o ^ M -^^ l^ .^ whether low, moderate, or high ""'' ^7/ ^V; !; ,„^P, of eyestrain. sutUeie,.tlyhiglUooccas.onast^H^^orc^h r ^^ .hould wear their glass.>s a ™ J^^,;^ {..^ the patient to use them ,hiss..s are to be^vorn at '•»";;,/^, ".;*;;; .Jt pn-scribed simply for ,...,..tantly. P'T?;;; ;''^;::;r "' c^ -^'I^cll or cylindrical glass presbyopia. \Vhen, lioweyr. i i ^^i,p„„pia occurring s of ^light amount an.l >^ P^''"'';'^ i^rmtte to do without the solelv in near work, the patu'ut may be J^^^IJ^^^^ ^he patient ghiss for distance. Y.-t even '" l> ''"^^J ; '^^;Vy o doing he will to wear the glass con uu.ous y f-'^Ji f- ^- { ^^^^^\^,, tell such a..,.„stom irnnself to it much -^V^" t\ ,, the time for th«.e or .tients thMt they should ^v™; ''"^^^'^.f '"^.'^f.. j ^um f.rr distance if «^i'i^ ji-^^: 1-34 THE EYE. own vulitiim coiitimic to wear tlic jihisscs constantly— wliicli will, on tlic wiiolc, he a jrood tiling. A cunstaiit wcaiinj; of tlic coiToctinf; jtlasw is particularly iiulicated wlnii tiMTc is [(I) a convcrficnco-insuliicicncy coniluncd with myopia, or u convcrgcnci'-cxccss (•oinhincd with hyiMTopia. or (/*) a s|)asni of accommodation, or {<■) a licgiiining myopia in childhood, or (d) a pronounced asliicnoina with its attendant symptoms of cycachc and headache, or (c) ue" nia with eye symptoms and sometimes, also, when no eye i i ns are jircsent. Difficulties Encou^beied in Wearing Glas&es. .Many ])e()))le (>xpe- rience ililiiculty when they jjut on glasses for the first time, (ienerally speaking, these difficulties vanish after the glasses are used for a few days, particularly if they are worn constantly. Hence, if a patient d(H's come back two or three tiajs after getting his glasses and complains that he cannot see well or comfortably with them, ho should be told to put them on and wear them steadily for at least a week, and that he .should not be discouraged if he does not become perfectly ;u-cus- tomed to them before the week is over. In fact, we should, as a rule, not think of changing a glass simply on account of the difficulty ex[X'- ricnced in using it until constant use for at least three weeks Iwis l)roved it unsuitable. In the great majority of cases it will be found at the end of this period that whatever trouble the glasses occasioned at the out.set will have entirely disappeared, pre ided proper care was taken in prescribing the glasses in the first place. The difliculties experienced in using glas.-<es may arise from changes they produce in the .^/^c of oiijects. .Myopes often complain that their glasses make objects, es|M'cially objects close to them, look too siuidl, so that they hnd difficulty in reading, sewing, or doing any tine close work with the correction ])rescribed for distance. I'sually this difliculty jjasses away after a while, and. in the expectation that this will take place, we should always encourage the myope to keep on with his glas.ses for a week or two at least, in order to see if he will not gradually get accustome<! to them for all purjKJses. If. as exceptionally hai)pens, he cannot get used to them, thei! we .shall ha\e to give him .-i weaker glass for near work. How much weaker must be determined by experiment: but in any case, if he is under forty years of age, wo try to get his reading-gla.ss as near to his dis- tance-glass iis possible. Hyperojies sometimes complain that their glas.sos make near ob- jects look too large and co;irse. This difhculty is prof)ably always remedie(l by m<ire i)rolonged ns(> of the glas.ses. (■lasses also cause trouble by altering the .v/zo/x' of objects looked at. This is i)articiilarly the ca.se with cylinders, which often make a s(|uare appear oblong, or. more fre(|uently still, trapezium- haped (narrower at the top than at the Ixittom), and mak(> liorizont 1 sur- faces appejir slo|)ing. I'rismatic glasses have the same eltoct, and so ;"') spherical glas.ses when the wearer look il)li(|uely through them or sees through their e(|ges. This distortion produced by glasses is ■'■ ■' ■ — -"— ■■ IIEFIIAVTIYE ERRORS L\ UESERAL. 135 iftcii (luito iinnoyiiifi, hut usually jjasscs ;)H' soon (within a week or two ill most cases tlic strcnfitli of tlic jilasst ). X'crv scKloni we have to obviate it by retlueing \'.otl.n- .lisujireetihie elTeet pro.luee.l by glasses is an alteration i.i ,f „t,jeets looked at. HyiHMopes often eoniplam ot the iliKlindncxx o the blurring produe.Ml by their convex glasses when thes<- over-correct even by a v( ^ very prolongeil use of the gl TV little/ their manifest hyiK'ropia. Sometime even ;isses does no t obviate this, as they hold on very teiiacioush ;lv to their accommodation, and so do not allow anv furtl ler amount o ,f their latent hyi)er(.i)ia to become manifest We should in such a cast three or four \v( that the excessive accomnu make the patient use his glass steadily for ekl If at the end of tiiis time there were signs xlation was giving way, or, m any case if the blurring was not verv annoying, we should conti.iue the glasses for a further period of three weeks. If, however, the blurring con- tinues and particularlv if it is causing the patient much annoyance, we nuist then weaken 'his glass somewliat, telling him that later on he will need to have it made stronger again. In particularly obstinate ca.ses, where the proper glass causes persistent blurring, and where the weaker gla.ss that would give better sight is not sufhciently strong .. relieve the asthenopia, we will have to use a course of atropHie (1 to 1 5 mn- cent .solution instilled three times a .lay, for a week or two). ' ()uite the same blurring is fouiul in myoi)es with a spasm of acconi- modation. But here we shoul.l by no means yield to the patient s desire for a stronger concave glass, but insist upon his wearing the i.roper correction as found under a cydoplegic. If the accommodation remains still in a state of spasm, we should, as m the hyperopes, use atroi>ine, instilled three times a day, tor two weeks. . Blurring is often noticed with convex glasses that have been pre- scribed for near work, whether in liypero,j(>s or presbyopes. I this persists, we should alt(>r the strength of the glass accordingly, being '•areful to test the patient as nearly as may be under the same con- ditions as those under which he works. ... Mvows and astigmatics sometimes complain that their vi.sion is ),;„ ku-n with their glasses. They miss the mitigating haze that formerly invested all objects that they saw. They soon, however bec.me used to the new conditions, and learn to enjoy the increased detinitio" and clearness of everything they look at. Vnother wav still in which glasses cause trouble is l)y altering the ymm-uhir rdntinn^ of the eye. .V convex glass, by doing away with the necessity for using the accommodation, may cause a t<>mporary convergence-insufficiency, which produces a tendency to diplopia and con.se.iu(<nt blurring of sight at near points. If this does not as is usually the ca.se, soon disapix-ar with the continued use of the glasses, we may have to exercise the c()iiyerg(>nc.> with prisms, ba.se out, or i„ ^omi' eases even have to .liminish the stnMigth of the convex g ass. Tl.(> iirescription of prisms, base in, for constant wear is "I'^i'lvis- in these cases, since, although affording temporary relief to the f** mm ^ warn i^ipquRi v.m Till': KYIC. iipt to cause a progressive increase in the devia- syniptoiiis, It is tioii. So, also, a concave f^lass, l)y compelling the us(> ot the accoinnuxla- tioii, which Ix'fore was not in use, may produce a temjjorary conver- gence-excess, and this may likewise cause slight diplopia and blurring for near vision. This, if persistent, may be remedied by practising the divergence at near ])oints vone foot or less) with prisms of 1">° or 1()°, b;i^e in. The prescription of prisms, ba.se out, for constat'* wear is not advisable- in these cases. If a muscular deviation is already i)resint, the troubles to whidi it gives rise may be accentuated by glas-ses. This is particularly the (!a.s( if the deviation is such as to produce diploi)ia. This diplopia may not occa.sion trouble .so long as one or both of the double images are faint, so that one of them can be readily ignored. Hut when tlie glass makes both images distinct, they can no longer Ih> neglected, and both obtruile themselves di.sagreeably upon the patient s notice, causing a .sen.se of confusion ami uncertainty that amounts to abso- lute distress. Lastly, a disturbance in muscular relations may be produced by the prismatic effect of the glasses. All gla.sses act as prisms if their we;;rer looks through their eilges instead of their centres or if they are decentred. If he looks nearly through the centre of one gla.ss and through the edge of the other, or, if the glasses are of different strengths, and he looks through the edges of both, he will, in effect, have a different prism before one eye than In^fore the other, and will hence tend to see double. If lie aetually sees double, his sight will be ccmfused: if he overcomes the diplopia by nmscular effort, he is likely to suffer from a.sthenopia. This often hapjxMis with strong glasses which, owing to their weight, are apt to .sag and get out of adjustment. the remedy for this is to see that the glasses are very carefully centred, or, if decentred, are so disjxjsed as to produce an ecjual |)rismatic effect. These various difficulties due to glasses are, of course, more a()t to be produced with slromj glasses than with weak ones: yet it has l)een my ex])erience that very strong s])herical glasses, and in par- ticular, very strong cylinders are borne without much difhculty — in fact, ((uite as well as those that are much weaker. Some of the greatest ditticulties are experienced in anisometropia. Yet even liere. if persistent efforts are made for a couple of weeks to use the glas.ses ]ir<iperly correcting both eyes. th(> ditticulties will, in mixst ca.ses. ultimately di.sapi)ear. and the sight will be much better and more satisiactory with the glasses than without them. The Adjustment of Giasses. It is important, as we have just seen, tliat gla.-?es, es})prial!y if at a!! slvoTtg, should bn .'iccurately centred— /. c, their optical centres should lie oi)p()site the centres of the i)U]iils. Moreover, the nose-piece should be so adjusted an REFRACTIVE ERHOUH IS OESEHAL. 137 ,..,t to allow tho glasses to oscillat.- or l.e,-onu> tilt.Ml. <>thorvvi>.j, the glasses may i)ro.luc(' a prismatic or a cylmancal i-f.cct xxhicli was not ii'ti'iuU'd. , . .i i .. :ii TlH' frames should, in general, bo so a.ljuste.1 that the glass(>s will stan.l at the ant.'rior focus of tlu> eye-i. e., about one-half inch in front of till' cornea. i i 1 1 i i ( ilasses inteiute.1 mainly or exclusively for remhng should be droi)i)e(l some 5 or 6 mm. and tipi.ed fonvard about 15°. so that when the gaze is ,lin>cted down, as it is in rea.ling, tl><' I""' "^ '^'Pl't ""»>' ;;|"''«^ ^iu .rl-iss at right angles and pass directly through its centre. Moreover, ?he' centre of each ghis. should Ix' carried :i mm. in tovv^ird the nose : „therwi.se the eves when converged, as they are m n>a(lmg, will look through the inner edges and not the centres of the glasses. These are points that the optician who makes the gla.-ses usuall> attends to carefully. Vet it is always well for us to verify this ad- tustmeiit personallv. ami satisfy ourselves that the glass is just of h rength we ordered, that it fits properly, and that it is steady. Otherwise, we mav, at times, be blamed for troubles produced by the gla,sses, but which are due to faulty fitting, and not to any error m ''"sil.m'times''our patients cannot go in per.son to the opticians to be fitte.l Then we have to send along with the prescription, measurements and .lirections showing how the glasses are to be ""For"jictacles these mea.s^rements and directions are as follows: mThmcf betw(>en centres of pupils (interpupiUary or pupillary Stlwbrilige (whetherC bridge, sa.ldle-bri.lge, or snake-bridge). Height of bridg<-<. c, height of top of bridge atove the line connecting the centres of the pupils. »:;■;;:,:' 'nt'otS. in t™, <•< .. «„.. *» .™,„e <i„ ease the glasi^es are to be s(>t in or out from the eyes). Style of temples (whether .straight or hooks). Length of temples. , , ■ i ^n Material of frame and style (whether rimless or not). In the case of eyegla.sses there should be indicated: Size of glass. ^y?;SS^:"^h"in general has to be .lone by refen^nce to a catalogue or to certain standard forms.) Width of nose-'.ip at top and bottom. Distlmce by which ghusses are to be set in or out from the general plane of the frame. . - , *\ Material and ,<tyle of frame (whether nmless or not^ Most of the trial frames have scales marked upon them, by the i:!8 Till: EYt:. aid ol' wliicli \vc arc ciiahlfMl tn make the iiKirc imiHirtaiit of the aljuvc-Miciitioiiccl iiicasiirciiiciits. Analysis of Glasses. In olficr woik we arc dl'icn callcil updn to examine the ^'las.-cs a patient is wcari ;:. and find out wlia* tiiey are. Tliis is Ix'st done in tlic i'oli()\vin<r \va\ : We hold the j;Iass to he exaniincij six or .• ."veii inches in front of our eye- and look throujrh it at a riKJit-an^lcd cross (c. 7., that formed l).y two intersecfnif; window sasiicsi on the otiier side of tlic room. Wc then rotate the jjiass al)out its centre, and watch the effect ])ro- diiced on the arms of the cross. If, as we rotate the j;hiss, the arms of the cro.-s appear neither displaced nor distorted, hut remain quite unhrokcn, we know that the Kla.ss contains neither a i)rism nor a cylinder. If in this ca.se we move the filass from side to side and uji and d<iwn, and no movement of tlie portion of the cro.ss seen tiiroufih the <riass takes place, the Kla.s.s is iiUinv. If movement does take place, the gla.ss is .-ijlurical, heing ■I II in I)i>ti>rlion prcHliiTOl liy a oyHncler. I>etermiiiHii.in uf the mis of a c.vlinder. A right-angled cross. .1 B CD. if wen throuKli a Ela.«.s cnntaiuinx a cylin.ler. If (li the axis of the cylinder dm^s not eoiMcide with either .1 H or r /», tlie eross will appear twisted, .so that the arms no lonRer make a right angle The cross, honever, i .,t disi.laced as a whole either to one side or the other It now the gla.s.s is rooued nnlil the ax,- l the eylind.-r eoimides with one arm of the erowi-f ;; A U (Mi-thi. cros.s will ap|.ear riBht-aiiKle.! and iinl.rok.n. The same I'jing will happen if the glass Is rotated '.M= more (III I. «. that the axis of the cylinder coincides with I l>. convex fjla the cro.ss is aholi concave if tlu' cross moves in the same direction as that in which we mi>ve the glass, ami convex if the cross moves the opposite wav. In either case, we neutralize with glasses of opposite sign, putting "V<'r concave, and cur versa, until all movement of The strength of the glass that pn'ci.sely neu- tralizes the movement will e(|ual the strength of the glass examined. If the glass contains a n/Hndir, the two arms of the cross will hend toward each other as we rotate the glass, so as to form an ohiique, insteail of a right an>jle. Th(> cross will, therefore, he distorted, hut will not he laterally displaced. If we kecj) on rotating the gla.ss, we shall find the ili.stortion first increasing, then diminishing, until finally a position i> reached where there is no distortion—/, c. where hoth horizontal and veitical aniLs are unhroken. The same will he the ca.so if we rotate the gl/iss «M>°, so that the vertical arm occujues that meri.iian of the ghrss which m iiEFHArTiVK r.iiiiiiits IS <ih:st:i!M. V.VJ the liorizoiitiil ami occupied lu'lorc. In citlicr positinn of tlic pla.s.s the 'ixis of (lie cylinder will lie precisely in the line wliere either the vertical or tiie iiorizuntal arm of tiie cr(),xs traverses the glass. Now, holding the glass in either one of tiiese two jMisitions, we move it up and down, and, as we ve it uj), note wiiether the hori- zontal arm of the cross also moves up or moves down. In eitJM'r ca.se we neutralize the apparent movement of the cro.ss with the appropriate spherical gla.ss ( -r if the cross moves up, and — if the cross moves ilown). (Fiir. (>;}.) Weliavc thus made one meridian of our glass plane — /. v., have converted the glass into a simple cylinder. Leaving the neutralizing sphere on, and still holding the glass in the .same posi- tion, we now move the gla.ss from side to side, and, as we move it to the right, note whether the vertical line of the cress moves also to the right or moves to the left. In the former ca.se we neutralize with convex, in the latter with concave cylinders, the cylinders lieing lidded to the sphere we have idready put on, and having their axes in the meridian we have already neutr.ulized— /. < ., in line with the vertical arm of the cross. The sphere and the cylinder together will neutralize the gla.-^s in all meridians, and will indicate the strength of its spiioricai and the strength and axis of its cylindrical ( ijxment. Thus, suppo.se that the cross looks unbroken when we have rotated the glass until the vertical arm of the cross coincides with the meridian of 45° on the gla.ss. The axis of the correcting cylinder must lie either at 4.5° or VMf. Now, moving the glass up anddown— l c, strictly in line with the vertical arm of the cross — we see that tiie horizontal arm moves in the ojiposite direction, going down as we carry the glass u|). A — l.(M) I), spherical ijlaced over the glass neu- tralizes this movement. Leaving this — l.(K) I), on, we now move ih(> glass from side to .side, still keeping it with its corrected 4,i° meridian vertical. The vertical arm of the cross moves in the same direction that we move the glass. We now ])ut on + cylinders with the axis at 45°—/. c, in line with the vertical arm of the cross— until this movement of the cross is neutralized. rsui)i)ose it took a + L75 I), cylinder to ilo this. The neutralizing gla.ss is then — L(M) .sjili. :2 ^1.75 cyl. 4.5°. and the glass examined is, therefore, a +1.00 >i\A\ Z -L7.5 cyl. 45°. We mighi in the case cited have rotated the glass so that the meridian of L'J5° coincided with the vertical line of the cross (in uhich ca.se the cross would have again appeared unbroken), and then iiave neutralized this meridian first. Then this correciion would h.ive worked out to —0.75 sph. 3 + L75 cyl. 1.3.5°, e(iuivalent to the ne given above. If the glass is a simple cyhnder, instead of a s])hero-c}'linder, pre- i<ely the .same procedure is adopted, only in this ca.se we shall find ;:it the nitivciiifnt along meridian is already nil, ,so tiiat we have ' :i|>ply no correcting glass to this meridian, and all that we have do is to add neutralizing cylinders with their axes hi this meridian. IIH Tin: i:yt:. If the s:l:i-s ciilitiiili I" iMc 111' lintli am .f tl ic en > \M II !)(' (li>|il:nT,l, tlir iKiriziiiital arm hciiin viTtical arm liiiiin carricii t • "iic siilc. Iis|>laci'mi'iit uf niic arm will iiicrca« tlirnwii i.ji nr ilnvMi, ami tin- As \vc rotate tlif t'la-s. the ;,n(| tliat of till' "itlicr .liminisli. hii't li'nwi'vi'r we ruiatc the ^lass. tli.' arm- m'.ii tlimmrli it will always ivmaiii parall.'l r<< fli<-ir ..riiriiial ain-ctiKii-tli.' vcrti.al arm n'maiii- iiiit v.nical. til.' linri/.nntal arm lioriz-mtal. H<w." tiif ir..s.-. altli'.u>rli a^M .iiiiiir l-rokcii, is not .listnrtcl. That is. <i jin.-'m shijts. l.iit « oilniilrr tiri.-ls. i rig. t»4. i , \Vr keep oil rotatiiia tin- gla:-- until tlir liorizmital arm is no lonpr .[i'plawl-/. <., until tlic |>orti..ns .-(■.•ii outsLlf an.i iiisi.lr ol tlic cla-< form an unhfokon lin.'. Tli.- aj-'x of tli.' i-rism cont unci in the glass will then Hi' in the .lin'ctioii in wliicli the vcrtiral hnc is (lisi)lanMl; ami the point which this apex occupies on the circum- yi'i. '"-4. "I K^ X, ^ II III DlH.laonn.-iit i.r,.lu,i-.l bv u iTi-ii, lM>Tiiuuuii..ii of the mis of a pri'-n. A nKht-»iitflf<l rn s-, 1 /; , /) 1- v«-n thr...,i!h h k!.i" c.T.ia.i.n u- k prism -I- Thr apex "f the l-rism does not lie .ii line with clthiT «rra ..f the rn.-s. txiiiit li. lac-t .iirectcd to«8r.l /;. B-.lh arm!. ..f the cr,« will «l.t,-Hr .liM.lai-i-.l l».inv iK.t wia ii..t be nvi.te.1. The amount of .li«i'lapement of .4« ii"licate« the lateral efe.! an.l the .i.sp «i'«-'ment ..f C l> the veniral elTect of the pri«m when in this po-iiion If now the Kla'S i- rotale.l. l-th arms will a»i.,ar to shin, but each will slill always remain mrallel lo Its (.riL'iiial i«»iiion. .Ill The b1.is« hii> Uin rotate.) until the ai*x of the prism i..iiii« inwat.l ''. tiJ ap(«.ars mihroken. while ,1 K i- ,li-plawl 'owar.l r. an.l the am..unt of Its displn.Hiiient n..w in.liratt.spre.i.elv the L.tal s,re.n:th ..f the prism. .111 The glass W rotated W)". The lin.,- .< B m.w api«>ar. uiihr..ken, an.l e /.,. .i, Ke.ie.i t..»ar.l A The ar*i of the iTism i..ints t.,w,.nl A. an.l the am..unt..f .lefleeii.m.if r/i .■..rre.^i...nds precisely t.. the -trenifth ol the pnsm. |!i fereiice of tile glass will he indicateil l>y the point where the horizontal arm of the cross cuts that circumference. Thus if the apex of the pri^ni was at 4-")°. Iioth arms of the cross wouM ajipear broken when the gla.-s was lieM in its onlinary position. When we rotated the gla>s so that its 4.")° meiilian was horizontal, coinciding thus with ?he horizontal arm of the cross, that arm wtnild ajipear unhrokeii^ l)U' the vertical ,irni would lie disiilaced outward toward the 4."r ]i(iint on the glass's circumference. The strriiuth of the prism may he mea.<urod either hy measuring 'lie ..ctual nuiximuni disp!:>cement of oiu' of the -ross-arms on a |)rism-scale, such as Ziegler's (the apex of the prism iM'ing placed in line with the scale', or more readily hy neutralizing the displace- mont with iirisms i)laced over the glass with the ajiex directed tin r^T!r?ff"sa?? REtU.\< ri\ !■: kliUollS l.\ ll'SKItM. 141 nllicr wav. Tin- slri'iitilli of ilic iifiiti-' ; iiir priMii rentals lliald' ilic inisiii ill llic >;lass. I'stially the strcrijtili of the prism lliat a class cniitains laii Iw ilctfTtiiiiu'il only after iiciitraliziii}; any splK-ro-i'viiiiilir •that il may aisn contain. Ill llnis ni'Utraliziii}: {.'lasses to lieleriiiine the spliere, cyrnnler. or prism liiey may eoiitaiii. it is essential that we look preei>ely through ihe eeiitre of the (jiass examined, ami also that we slionid hold the neiitrali/.inn {ilass in close eoiitacl with it. HYGIENIC TREATMENT OF REFRACTIVE ERRORS. In /')(/"/«", particularly when pro^rressiv.'. aii<l especially, therefore. ill children, we .should he careful to jrive jirecise rules as to the amount Mu. tM. The Chandler »i1jii«lBlile «e«I and <lesli. d kind of work that the patior.t can <lo, and insist upon proper htinj;, proper hours of study, and plenty of sleep, with a jiood • .tint of out-<)f-<loor exercise, I'se of the eyes by artificial litrht ould he restricted, or. in the more aspravated cases, eiiiirely for- Ideii. It is also a jjood plan to have the pati(!iit suspend his reading »«?«a*<i:..«!, i;. H-2 Tin: t:yi: or (itlicr work i-vcrv (il'ttcn niimiti's i>r so. fi r !i lew tiinrTiciifs, aiiil iliirini; llii- iiittTval of ivsl cillicr sit iTirt or ii< tually sl.iiul up, ainl look otT into ilic far ilisiaiicc. Tlic iPMlicnt's atfitiiilf in rcaWiiiK or writing slimilil he can fully looked after, lie siiould Hot ije allowed to heiid over at hi.- work. nor. oil the othnr hand, should tho desk ho ."^o iiigh as to hrinf; hi.s work unduly clo.se to the eyes. Fijis. <).5, <)H, atid 07 illustrate a fonn of adiusi:tl>!e de.-k we!! .-.dapte:! for sehool j)urposes. Those alTecied with i)rogressive myopia should he diseounifted from ui:in.irrivi: luuious i.s ueslum. 1 4;{ iiiMliTtMkiriK ;iii> very fine wnrk. siidi as IxMik-kfcpiiiK or Hwiiij;, ii'<|iiirin)t finsc Mild cniitimicil npiilicatiuii. It is piirticiilarly imp.ir- laiit to have thi- point in iniiHi ulicii sclcctiiiK a Iwy's Cutiiri' life-work. In very liiyli myopia, partiniljiHy when tliiTc" arc -viii|.t s of retinal irrilalion. total alisteiition from near work is often n i|iiirei|. In the trai 'it myopia proWueed hy ,v/w/,vm nj iicntminnila/iiin, complete alisn on from near wurk may Im' re(|uire<l. comhined often with the instillation of atropine three limes a day for sev<'ral weeks. !3 ' Km. 87. .\(Jjii^lnieiit of seat. Ill all eonditions of refraetion the iUuii)in(itiim should he attended to carefully. Tiie ideal ilhimiiiatioii is that alTorded hy diiriise day- lisrht. When artitieial lifciit is iwd. this also should be as ditl'use as |ios.sil)le. Hence, it is a mistake to have a hriiliant iiftht, j»articularly :i shaded lijrlit „v,.r the desk, and have tlie rest of the room in coin- panitive darkness. There should he at lea.st one other light in the room, and more, if neces.sary, .so that the illumination may Iw pretty evenly .listrihuted all over it. The hriliiaiicy of an electric or a Welshach lifilit often needs tempering, and this is best done by ;i Mfv light amber or yellowish siiade. I'aticnts ronipiainiiig of iihuloiihoJiin should not be permitted lo wear smoked or colored glasses unless there is actual di.sea.se of the lundus, or unless the photophobia is due to some quite temporary 144 THE EYE. cnuso, ;is dilatation of tho pupil from instillation of atrojjino. Other- wise, the ahiionnal sensitiveness to lij;lit will he afiRravated by the use of the ^hi'^f^''*. '""I t'"' patient l)eeoine more and more ineapable of usinji the eyes. In iDjpcropiii and (istiffmali.on we sometimes, on aeeouiit of the asthenopia and other symptoms, have to diminish the amount l)y wliieh the eyes are used, and increase the amount of open-air exereise. Hut. in general, hyperopia nnd astifimatism furnish no absolute bar to eyework. and it is usually a distinct mistake to yield too much to the patients complaints. We .should not, in tlie absence of orfranic disea.se of the fundus, encourajte the patient to disu^i Ins ctjes simply becau.se the use of them is painful. Hy .so doing we may initiate a vicious circle, ami pro>rre.s.sively increa.se the patient's di.sability, instead of removing; it. On the contrary, moderate, systematic, and increasinff use of the eyes for near work is the rule in such cases. The ophthalmoloftist himself shoulil fiive careful and preci.se din>c- tions as to the amount and kind of eye-work to be done, and deter- mine by experiment how nipidly the work may be incn-ased. I'inaily, it .should always be borne in mind that in treating refrac- tive errors we must constantly h.-ive r(>j;ard to the ijoicrdl condition of the |)atient ■■md to the state of the organs other tiian the eyes. In many cases in which the symptoms seem to l)e due entirely to the eyes, treatmeii! directed to the general condition, to the nose antl throat, or the |K'lvic organs, will often relieve an a.sthenopia which glasses ii.iM f;iile<l to relieve, and in not a few instances will render it Uiineces.sary to u.se gla.ssf>s at all. PLATE 111. Cii|)sulc 1)1 T. '111)11. ( Moia IS.) CHAPTER IV. THE MOTIONS OF THE EYEBALL AND THEIR DERANGEiMENTS. By CASEY A. WOOD, M.D. Anatomy and Physiology. The ocular muscles are divided usually into internal or intrinsic, and external or extrinxic. Although it is necessary, for convenience of reference, to speak of the individual extrinsic muscles, both the single and a.ssociated excursions of the eyes may be regarded, in every case, as compounded of movements due to actions of all of them. The iridic and ciliary muscles com- prise tlie first class, while six others, the external rectus, internal rectus, superior rect , inferior rectus, superior obli(|ue, and inferior ()i>li(|ue, make up the second. These, with the single exception of the inferior oblicjue, form a cone, whose aj)ex points toward the foramen opticum, while its base envelops the eyeball in front of the eijuator. According to Weiss, if the axes of the orbits are projected backward, they fortn an angle of from 20° to .37°, depending upon nice, age, :.iid the fiecuiiarities of the individual. These considera- tions also govern the conformation of the mu.scular cone, affect the degree of its divergence, and mav even determine the shape of the eyeball. (Plate III.) The glolx- itself has a centre nf rotation around a point in its antero- poster >r axis. In the emmetropic eye this is about 14 nmi. ijchind the cornea and If) mm. in front of the posterior surface of the sclera. The prinmrfi poxilinn nf the ej/e is that in whidi, when the head is held erect, the gaze is directe<l straight forward in the horizontal plane. The vertical meridians of both eyes are then exactly vertical and parallel. It is from this starting point that the movements of the ey('l)all are consid(>red. The innervation of the extrinsic muscles of the eye is easily remeni- iH'red. All of these, as well as the levator palpebra- sui)erioris, the ciliary muscle, and at least one of the iris nuiscles, are supplied by the third nerve, except the external rectus, which is sujjplied by the sixth nerve, and the sujK'rior obli(|ue, which is supjilied by the fourth. \\hil(> we recollect that every excursion of the globe is attended by moH' or less contraction or lengthening of most of the extrinsic muscles, and .sometimes by action of the internal nni.scles, we have i<> s|H'ak of the probiible action of tlie individual extrinsic muscles. The observations of Swanzy apjx'ar to give the most satisfactory arious and comi)licated movements of the evebalj. ^P ni]) 10 the ey (I45") 146 THE EYE. both sp]);iriito and associate, and conseiiupntly they are adopted for the purposes of tliis chaijter. Donders i)roved exiM-rnnentally that it is only in the primary position and when tiie eyes arc turne( directly outward or inward, downward or upward, that the vertica meri.lian maintains its vertical direction. When the eyes are turned in other directions, there is always a sort of wheel-motion given to the "lobe and the vertical meridian of each nornially balanced eye is inclined at about the same angle. These various pos... .is of the vertii-al meridian can be understood best by a reference' to the actions of the various muscles in the associated movements of the eye and by a reference to the figures. The author just (juoted points out: Fia. 6«. R» Lp ^tiowirg attachment of the orl.i ml muscles. K(. Extenml rectm. R». Superior reotu.. Ip Leva- t„ri».li«!'>™- *. rr. Si,|«rlor oblUiue with Its pulley. Km. Internal rwtiu. Oi. Interior oblique. /'/. Inferior reetus. 1 III the i)riman- position all the mu.scles are ])ractically at rest. 2 Motion of tlu'cveball directly out wan 1 is effected by the external rectus alone, and m()tion directlv inward by the internal rectus alone. ;{. Motion of theeveball directly uinvard and directly downward is effected mainiv bv ai<l of the superior and inferior recti. At the same time these muscles, acting alone, also rotate the eyeball directly inward and give a certain inward inclination to the vertical meridian, which, in this Dosition. should be upright. ronse(iuently. in rotation of the globe .iirectiv upward the inferior 'hiitiue, which rotales the eye sli-rhtlv outward as well as upward and incline.', the vertical meridian ouUvard must be as,so( ". ,ted with the superior rectus in order to MoriOXS OF THE EYEBALL ASD THEIR DEliAytlEMEyTS. 147 roiiiitoract, in thesse particulars, the tendency of its action. In rota- tion of the eyeball directly downward, the inferior rectus must be asso- ciated with the su|)erior"obli(iue, which acts antagonistically to this straiftht muscle, in res|M'ct to rotation inward anil to outward wheel- motion. , ,1 1 • 1 r I 4 Rotation upward and outward is effected chiefly f)y aid of the superior nrtus and external rectus; but the latter muscle has no inffu- (Mice over wheel-motion, while the former produces wheel-motion inward: yet the inclination of the vertical meridian is outward in this position, and therefore a third muscle, which will supply this inclina- tion in a high degree, is retiuired, namely, the inferior obliciue, whose |M)wer over the wheel-motion of the eyeball is greatest when the latter is turned ujjward and outward. 5. Rotation downward and outward is effected chiefiy by the rectus inferior and tlie rectus externus. Inasmuch, howe\-er, as the former iiiduies the vertical meridian outwanl, while the latter has no influence over it at all, a tliird force is required which will bring about the neces- sirv inward' wheel-motion, namely, the superior oblitiue, whose influ- ence in this respect is most powerful when the eye is turned down- ward and outward. . • a , ^v. () Rotation upward and inward is brought about chiefly by the rectus sui)erior and the rectus internus; but the effect of the former ui)on the inward wheel-motion (,." the eye would be so great as to inter- ivw with parallelism of the vertical meriilians of the two eyes, that of the (.ther eye not being inclined outward in a corresponding degree. A third force," therefore, is retpiired which will, to a certain extent, ccjun- tcract the influence of the superior i-ectus in this resjx'ct, and this is found in the inferior obli(iue, which, in this position of the eyeball, has Init slight power over its wheel-motion. 7 Rotation downward and inward is chiefly the result of contraction of the inferior rectus and the internal rectus. The powerof the former over the outward inclination of th.- v.-rtical meridian would, in a similar way, be too great, and must be similarly correctt vl by the action of the superior oblicjue. , . „ , ■ -r. The position of rest is probably .livergence and, in all probability, even a slight degree of convergence, as well as parallelism of the ocular iixes, is maintained by more or less effort. _ The internal rectus arises from the tendon common to it and the inferior rectus, at the inner aspect of the optic foramen, and runs tuAvanl close to the inner wall of the orbit, t" be inserted into the -clera l>y a tendinous expansion 9 mm. long and UH i""'- wide, 6i mm. rioni the sclerocorneal junction. The external rectus arises from the greater wing of the sphenoKl by two heads that become united and form the body of the muscle, which !uu^ forward close to the externa! w,-d! of the orbit. It is attached to ihe sclera by a tendon, 3.8 mm. long and 9.5 mm. wide, about t nmi. iiotn the linibus cornetB. 148 THE EYE. The inferior fciau ari cs from the tcmlon (•(Hiiinon to it and the iiitoniiil rectus, fin' runs foi "anl on the Hoor of tlie orhit, and is attached to the ^ilo'.j,- !■> an uponeun.sis fi mm. long, 9 nnn. wide, and about 71 mm. from the seierocoriieal junction. The superici rectus arises from the upj^er edge of the optic foramen from the "ommon tendon. It jjas.ses forward just beneath the levator paipebru' superic-i.s and is inserted into the sclerotic X mm. from the sclerocorneal junction. Its tendon is mm. lonp and lOJ mm. wide. The saperior obliane arises from the lesser wing of the sphenoid, passes forward along the inner wall of the orbii. where it becomes tendinous and forms a pulley-like adjustment which play.s within a <il)rous ring situated m the trochlear fossa. The direction of the Rat. eit. Horiamtal section of the vye in the urbit, showinR the relative Kitaehnient of external ami interiiHi recti. muscle now changes, and it proceeds backward, downward, anil out- ward at an angle of o"j°, ])asses beneath X\w superior rectus, and is inserted into the sclerotic between the cornea and the optic nerve about 17 mm. from th(> corneal limbus. The width of the aponeurotic insertion of this curious muscle into the globe varies from 7 mm. to b') mm. It is one of the principal factors in globar rotation, turning the u|)per part of the vertical meriilian inward. The inferior obliQue arises from the anterior third of !he floor of the orbit, in a pit situated in the su])eri<)r maxillary bone. It then ]>roceeil-i outward, backward, and upward, beneath th" inferior rectus muscle, to W- inserte<l into the sclerotic between the inferior and external recti on the [)osterior half of the globe, 17.i mm. from the seierocoriieal junction. W M or loss OF THE EYEBALL .\Sl> THEIR DERANOEMENTS. 14» Tenon's Capsule. That wo may tho bottor undorstand the attaoh- iiiciits of the various cxtriiisic imisdos, it is 'locfssary to say soine- tliing about the flowed sac iviiowii as Tenon's capsule. This luein- LCVATOR FfttPC- INT. RCCTUt MUSCLC CTHMOID, CELLS 'TtMPORaL MUSCLC .LACHHVMAL OLAND V < ICXT. RCCTUS osLiauc MUSCLC INF. nCCTUS ICTUS I CLC iN^S TAL NCnVE Vertical section tbronnh the orbit. C^")' n <-.. -:i ?ihem«llc repreaentatlon of the Iniertlon of the extisocular miiKcIen into the globe, showing the ii-i.iiiiicif ihc same from the comesl llmbus. I. SuKriof aspect of the globe. IT, Medial aspect. 11. IiUirior asptrt. IV. Lateral aspect. «. Rect. sup. i. Kect. inf m. H-oi. int. /. Rect. ext ■ oil sup. oi. Obi. Inl. (b 150 77//; EYE. Kio. 72. l)raiu' oii\ lups tlic frrciitcr portion of tho cychall, and is uiiito<l Ih'IiIikI, as well as in front, to for i closed cavity. It is attached close to ilic optic foramen, and, passing' forward," heconics loosely iidliert"'t to the sclerotic. Anteriorly it is attaclu'd to the conjunc- tiva liy connective ti.ssiic, and extends to within .'{ nun. of the corneal junction. Its cavity forms a larjje lymph space lined hy endothelium. The tendons of all the extrinsic muscles, the ohliipies I.ehind :ind the .-traifiht muscles in front, pierce the capsule willmut interfering with its function as a dosed lyni|)h s|)ace. The ciliary nerves like- wise pass throuj;li Tenon's capsule, which, let it he noted, also com- municates throu^li the .sclera with the suimu-horoidal and perineural lymph spaces. In thi.s way it comiects the iiitercorneal Ivmph spaces with the exterior of the eye. When a mu.scular tendon or nerve trunk passes through this mem- brane a portion of the latter extends along its external surface, thus streiiftth- eniiift their coimections with the sclera. « We may then rcfjard the combined tendons of the straight muscles, in con- junction with Tenon's capsule, as fonii- inj; a complete envelope about the eye- ball, and tills fact nmst be reckoned with in o|K>ratinf; o!i the former. .\n incision sometimes fails to reach the muscular tendon, because both layers of the cap- sule have not been divided, and becau.se, al.so, it is not borne in mind that pro- lonpition from the e.-ipsule it.self .•md what are known as the " check li,i;;iments " niav interfere materiallv with the results desired. ( rijr. 72.) This is e.speciallv the ca.-^e when tliesehjiaments are abnormally develoiKMl. It is not" an uncommon experK'iice to find, even after tlu' most com|)lete division of the tendon, that relative jM.sitions of the globes are unaffected bec.au.se ot these connections between the mu.scular ten<lons. the capsule of Tenon, and the check ligiuiients. .As a rule, however, the .■letioii of the check lig.'unents is a normal one: they probably prevent or retard overaction of the adductors and abiluctors, as .shown in Fijrs. 7;} miil 74. The bloo.l supply of the mu.scles is derived from the oi)iithaImic artery, through the minute musciil.ir branches, shortlv after it enters the ()rbit through the optic foramen. The.ve capillaries are tortuous and loosely attached to their surrniindings. so that the movements ot the globe und the .shortening and lengthening of the mu.scles tliein- .-^eives do not interfere with their coiifimiitv. It .•sometimes happens that cuitmg of these small ve.s.^els gives rise to i)rofu.-;e IiemotThage. liuf this is rarelv. or never, a .serious matter. Th A. Internal check ligament. B. Ex- tomal elifcl ligament. (Ua.S'seli. and Kkiikk.) (laiiied by veins of the same n.uiie. ie arteries are accom- MOTirys Of rill-: EYEUALL AXD TlJEIJi DEIlAXaEMEyrs. 15] Nirve Supply. It is (Icsirablc to say .something; fiirllicr alxmt the iimcrvatidiis of the various iiuiscjcs. Tlic areas in the cortex asso- riated with the iiioveiiieiits of tlie eyelnill are not, as yet, preeisi'lj located. Tliey are prohahiy in front of tlie iarpe motor area, close to the neuron that presiijes over the facial muscles, and undoulitedly have a near association with Hroca's speech centre. The basal nuclei are re<;arde<l fieiierally as lyiiif; well within the pray matter in the aqueduct of Sylvius and on the floor of the fourtli venlricle, nio.st of them just heneatii the corpora (|uadrijtemina. According to the arranjiement of Stuelp, the subcortical nuclei of the internal eye muscles are situated in the ante-ior portion of the third n(>rve nucleus. These fibres supply the ciliary muscle and the sphincter iridis. Imme- diately hehiiid them are the nuclei of all the external mu.scles supplied by the third nerve. Still further back are the nerve cells which con- stitute the nuch'us of the fourth nerve that supplies the .suiM'rior Flii. 73. Flo. 74. /. C. J.. K. C. I. I. C I. E. C. L. Fiii. 7:1 -The check ligaments during |>ar(ial inutrai'lion nf the eiternnl rectus inuiicle. the in- tenmt i-huck ligament i /. C. L ) being in a state of maximum relaxation, and the external (A', f, /..) somewhat stretclied. (Motais.) Fk.. 71— Diagram intended m show how, during full eontraction ot the external rectus, the cMernal check llijament (f. C. L.) is stretched to its maximun. lenulh, and the Internal (/. f /. ) i> slightly stretched also. (Motais.) ublii|iie; and, finally, .still behind the.se are the nucleoli of the .si.Vth nerve that jroverns the external rectus. .Ml of these nerve centres are connected with one another by nerve fibres that run from one nucleus to the other. It should not be forpitteti that minute ner- vous connections probably exist between the motor neurons govern- iiij; the various eye muscles, and all the other nerve centres. That the individual may fix both eyes with ease ujion objects dis- tant and iu>ar, and ohtdin liiiinciilar n'sinn in (til juirts of thv jivkl oj visit, ti. it is necessary that a certain balance exist between the forces that rotate the eyes in various directions. Moreover, both eyeballs must be xkwHvd in their fixation. We must l)elieve con.setpiently that all the external muscles are, during the waking hours, in a ,state i:f imconscioiis tonic contraction, .-uid th:if every act of sight is acc<>m- paiiied by more or less exiieiiditure of nerve force. Convergence. A state of divergence of the visual axes being the linibable condition of res', parallelism and convergence recpiire more m a?? » : ili 152 TllK EVE. or lt's.s luTVdUs cffDrt. Tin- axes inay, however, he made tn cross uiitii they form a very wiile alible, estiinaletl to vary in indiviiluuLs from 45° to ().")°. When the eyes converge there i.s not only con- traction of tile internal rectus, but of the superior and inferior recti, I of the iridic and ciliarv muscles. It is very likely, also, that am other nmscles of the i-ye, as iM-fore noticed, take part in this act of convergence liy a sort of mi>diHed contraction, so as to steady the eye. One method of measuriu}; convergence is hy means of a prism, ap<'X in. placed before eithiT eye — prism convergence. (See page 159.) Divergence. It is very likely that in a state of absolute rest tlu; visual axes diverges" to 10° from parallelism, and this may lie <lemon- strated by making use of prisms, apex out. Ilideed, it may with truth bo artirmetl that convergence .^ihould be regarded as beginning at this point. Hence, we have the term uvijtttitT loiinriidirc, becau.se from a state of divergent rest we proceed to parallelism and then to convergence. The nearest point at which a very small object can be .seen singly, with both eyes, constitutes the fusion near ]x)iut. The divergent power in any individual may be measured by finding the higlx'st prism, apex out, that can be held before eitiier eye without imxhicing double images of a candle fiame G m. distant — prism divergence. DeoTsumvergence. When the eyes are turned downward it is mainly, as we know, through the contraction of the sujierior obliipie anil the inferior rectus, and this act is termed deorsumvergence. Sursumvergence refers to the act of turning the eyes upward. Associated Movements. So far, refer;M,t:' h;is only been made to the fact that it is neces.sary for binocular vision that both eyes be rotated in precisely the same direction. With properly balanced imisdes, every movement of one eye is as.sociated with an instant and e<iual rotation of the other eye. Thus, it is impos,sible to turn one (\ve up and the other <lown, or both eyes outward, as that would produce an amioying double vision and interfere with binocul.-ir sight. On the other hand, owing m.-iinly to an arrangement of the nerve fibres in the central neurons |)residing over the various (>ve muscles, the associated movements of the eyes are so arranged as instantly to fix corresjxinding retinal points upon images perceived by the brain. Accommodation-convergence. With every effort of convergence there goes a certain amount of acconmiodation. .Mthoiigh within reason- ;ible limits accommodation and convergence are constant, o?ie may be increased or diminished a little with n'fereiice to the other with- out disturbing symptoms. For example, before the normal eye of an individual a concave glass may be placed, and yet, with a slight effort, an object at, say. thn-e feet ilistance will be readily and distinctly i^een. In the «atn<' way a convex glass: still c!i;ih|("; m person before whose eve it is ])lace(l to sec, with both eyes togethe:, the same ol)ject distinctly and at the sanie distimce. For the more di'finite measurement of convergence eiforts the term metre anqle is MoTioMi OF rut: kyehm.l ash their i>Eii.\.\GEMf:yTs. ir^i used. This is the alible whirli the victual litic makes with the niofliaii line of tlic face, tlit- latter \)f'inii lirawii at riglil aiiRles U> the base line (iiiteroeular ha.se line) joining the centres of rotation. The anjrie formed hy the median line and the visual line at a |>oint 1 ni. distant from the base line is termed I metre ancle. An ol)jerl si'cn ' metre distant from the eye would re(|uire twiee as much con- vcrp-nce as th't seen at I lu.: convergence, therefore, at this point, would he 2 metre aiiRles; at \ m. distance it would Im- 3 metre anjlles, at J m., or 25 cm., it w(mld l)e 4 metre angles, etc. On the other iiand, an object .seen at L' m. distance would re<]uire only one-half the amount of convergence to fix it at 1 m.; convergence here, tilt II. ('(juals J metre angle — in other words, V. = J m. a. Where litith rjii's (ire normal and emmetnipie, as many metre uncles of con- venience are reijiiired as there are dioptres of aecammodatum. The anijle finrnmn is that formetl at the centre of rotation by the optic axis anti the line of fixation. It should not be confused, as it sometimes is, with the antjle alpha formed at the noilul point by A' Flo. 75. Antflr r>i.ltni liiii' indicate* direction which tlie projected beam Hikes. (UaKSEtL and Kpber ) the visual axis and the major axis of the corneal ellipse. In meas- uring the angle gamma, it is well to make use of the |)erimeter. The patient is placed in the primary position, with his chin on the chin- rv<\ and gazing at the fixation point. A small candle is moved along the perimeter arm until it is reflected from the exact centre of the cornea into the eye of the oh.server gazhig at it iiiimediately behind ilie llame. This point is read off in degrees ii])on the perhneter arc. Tiie angle varies from 1° to o°. Prisms. One cannot pniKrly und(>rstand the contractile or rotary power of the eye nmscles without having a proper idea of the effect of ])risms upon beams of light and upon the position of the images (•a>t upon tlie retina. .\ ])rism is a piece of glas.- whose refracting ~url'aces are inclined toward each other so as to form an angle whose 'liiircc is commonly emjjloyed to ilesignate its particular prism. This ■a\^" !'"nns its (>dge or apex. The angle sul.'tends the thicker portion •n- liasi' of the pri.sm. A ray of light, instead of i)a.ssing through uiichaiiged ill direction, is bent in its course from the j)erpendicular •iwanl the ba.se of the pri-m, and if the eye be placed in the path 154 riii: i:vi "%• H ihf li'.'lit I'.iv Miter it li ~-ril ilirmi^li ilic priMi! liicli ii ciiiMii;!!!'.- uill ni'i lie <('(" ill it- In li'd III •Villi tin lici l\ frmii will ill till' (lircciii>ii (if iiic vi>u.il line I 'I']''! ill ;i<'('<iiil,iiici' willi the 1,1 ' III' |ii . niv of li'^lit til ;i r.'ilsc pu-iiiiiii nil 'lie nliiia, .•iim tln' i in il e'cifscsft^ |i(Tcci\c the tilMi'<'t :is cuiiini 'li 1.11- '• llllllll!ill|-i .<itiiifi, lull - Tlii, is iriijcfli til-- iiuiii a straii'lii liiif, th •iitini: itiofi f till' vi>'iial a\i>. \\ lien |iii-iiii i- iilariij in trout nf mii' I'Vc iti-i till' '. isual iiiiaj;!' i- tlnw | 11 ;i 'Inl upiiii al. illilis II n I i iirr i h, •ilnr III iiiirr II 'inn inn II n i III/ Ihl III II.' If r II iitri'.-' <ii III iiiliiis iial "art "I j ic rc na. '/( I III -'11' ■\ of li ilislr ' i-^ll lie ilificfcil iiiiiiiciiialfly iiiwanl, ti'' ta.-K oi ::, i .n iilisliiiijr tl. - i.- Ian ii .'h t iiiu-fli~ tiiat rotatr Uc < \c iiiwai'l :lii iiltiii -i-, lli' iliicf whii'li I-; til"' intcriiai ..clii-. \\r know fi-'Wii rxi'i'ricitfi' iliat aftci a I'l • -rials ilii ni ' =-tors of iiiriiiai I ye- i-aii ovi'i iiiii- in lis ^ av tin- ili|.:'|iia thai voii ntlicr- wisc iic |iroiiii('C(l !iy iirisms ,, hi^in as 411° or .'id N'l n il < m-liiiii 1- tliu- sail! to Ix' a!"iiit |n"or.")(P. ( »ii the co! iraiy. wi n ii . ■< of till' iirism is uiicri -I iimiii Jiati'Js- oiitwani li' ri' ■ ' n yes, till- task of ovi I ■omiiju,- till- ili|iio|iia iimst Im- in !'• -rlcs that nitato ill" I'M iilwanl, iliii'tly the cxtcrnai ■■(•tii- AIh kHiih iiica-iirc'l 'i\ |irisiii~ is in the iioiiiial cyi' alioii' ■-foiir'^ it '»f aililiu'tioii, ^ iiiii'l,> . )<•" I'i til' - iiiif \va\ wi- Il !iat '■•'■ aii'l siiiii-iiiliii-i ri iprisiiis ii|' 'ir .lo' ' ! ori' ■ i'_\ in . i iiicasiin'il i'l ■ I 'IS of ilic [11 r n'i(i..icil vcrcoiii- i' ■ ilii lop thai wmilii ' isn l)c prodiii .'(1. This van uirJ" 4°. AlMlucti'-!. .1- iiinlat thclir-t oi'irccxaiiii; mii. 'm.. v constan' .iMil in iioiiiial r> - will rari'lv fall lii'liiw 7 Tii' alio ixtw^ ai luctioii III, I aliilni tioii iprism li l'cih'I' |i \\\ h't ' friiiiS:! ■ 1\:\. No arliitrary -'aiiilah r: In iixn simply lii'i-a I-' the liiiun - thus lai -ri'il ha i' l-'-i-ii larfii'lx ■ i- of pcrsonni i-.|iiaii.'ii. Field ot Fixation. An ''xainiiiat • il il iiio\' • ■ nts o: ' i- -llnlljil ili'liTililin 'li- !alill- - ' (•■-..' When tlll'Si ■■Xtiv ir 'illls li ■' limy 1 iiiistituti' th. iiiiiiiiir /'- yi'ars au'o. ailjustcit tin- p<" "tiT ' of haviiij; an nliji'i'l alt' I ill iln- usual way, lir i -imp of till' iilolii' ill aiiv iliii i- rapi strips .if iin"la/i>ii par. '11. tit paper \ ■f twi ii'tti'i- r'.rr('s])oiiiliin 'o .iacs;<'r .\ ^ :.s wi'i IS Im'Ii.u tiiruri- rri iiliiijc ilic [K-ritii. ti'r arc- These striji- re toifi t' am: -f the j-^'riiiu'ter ''i;r. ''-. '''•■ prill posilioii, and he i- a-i^ed ' I'l frm - eel; e MS possili- rin f ti isele n! ach t'liUli'i I ei.iii led, Tl ler.' eral Il .ry. Instead il I ill. rimeter -trm •li\- .■ ro'; ioll \ me' il. lour 'lined . ■•! Is i .VI I'lii., plai ''II I. ^re. - of latil' the plai'i'd in posit II a i -ii the ;..t.t',, l>,,.j,j Ijcjjiir It; the le lower line as far away ijisheil, he is reiiue'-ted to .. Awim'iiitiou, I'^'Jil. .t/"/7o.\^ III ri!' h:\iuM.i i.v/> Tiiiii: hi:t:AS'.i:Mi:\ r^ \:,-, i iieiii'- ft»r till- mea?«uivnient .^t tl--^ n.^nwulHr •!. i.| ut" ii\atu)p ■ v iiu-flMs o( ih- !«Tiineter, 156 TUK E YE. flivc tlic fifiurc iil;u'0(l iihovo tlio word just rorojinizcd, and to try to rcail fartlicr out additional letters on the fifjure line. Karii word beyond repn-sents about one def;ree on the scale, and the numlHT of words so read added to the previous tifiure fjives tiie limit, in desrws, of the field in that direetion. As each (piadrant of the circle is passed over, a slip of paper is removed, revealing the next pajjcr, whose lettering, being (hfferent, suggests nothing to the person under e\amiiiatio:». After many perimetric examinatioi - with this device, the limits of the monocular fixation field were fomul to corre- spond closely with the figures of Landolt : IHrfctly out 4 IiirtTtly in i- Dirucily (iuwu frf liircctly up 43 Out ami down 47° I ,|.„ In mill up 1"'° ► ' " m»vvn nntl in :i> ' ( -« I'pand out 47° > ' Fig. ■ Stevens' tropometer. The binocular field of f\xntinn is by no means identical with the field of binocular .singl" vision, alihimgh its borders are about the same. Duane finds that the upward limit of the monocular field to be about 45°, downward about 70°, right and left 55°. The.se rota- tions vary with age and with the form and positiim of the globe. [)iiiibtless the Ix'st method of measuring the rotations of the eye, and, conse(|uently, the field of fixation, is by means of Stevens' tropometer. (Fig. 77.) .\s we shall hereafter find, it is neces- sary to know, s(j far as it can be determined, whether a particular MOTIoy.S OF THE KYICIiALl. ASh THEIR nEUASCEME.STS. 157 muscular iinbalance is due to weakness or spasm of some |)articular muscle or muscles. For this purjjose the rotation power of the glol)e ill all directions as measured by the methods just described will Ix' found of extreme value. .Vnother u.s«'ful instrument for the meosureinint 0/ rimvenjence and Us relation to dircrnriice is the Landolt ophthalmodynamometer. In it we [losse.ss a method comparable to the measurement of the amplitude and range of accommodation by noting the relative posi- tion of the punrtiim proximum and the punchim nniotum of conver- gence. This device consists of a black metal case fitted overa candle. Tliis cylindrical case is pierced by various openings, the most valuable of which is a narrow slit through which the candle-light can be seen as a streak of light. .last below each one of the openings is a hook to Pig. 78. Ijiiiilnlt's opIillmlmiHlynnmometcr. wiiich is attached a tape-measure marked in centimetres, anil on the wilier side the metre angles corresponding to them. The candle is iicld directly in front of the patient's face, graiiually approaching it. until the light streak becomes doubled. The tape indicates in ceii- liiiii'li-es this di-stance (which is the punctum proximum of conver- u'liice) as well as the amount of convergence in metre angles. We have seen that the number of centimetres distant from the in- !i idculiir ba.se line to the point of doubling divided into 100 give.* ilie number of metre angles of convergence. If the double vision "icms ;it 10 cm., we know that the patient i)o.s,sesses 10 metre angles 1 ronvergence. The punctum remotum of convergence may be ■':.t;iincd by having the |>atient, with his head in tlie primary \nm- i'lii, lix a point of light, say, a candle flame, at 6 m. and find the I longest prism, apex out, before one eye, that can be overcome 158 witlioui pnuluciiifi iliplopi piisin ill (Icf^rci's rUi: EYE. ,„i„,,, \Vc tlicil divide tilc llllIulHT of tllilt 1)V seven, and tluis olitain in metre an},'ies tiie aniouiit ni iwiititiir eiinverjuent has O.S.) iiK aiisiles, and so on com of eaeli eve. If tlie prism be H", lie trc allele; if 7°, 1 metre aiisle, and if 'J°, 1.2S metre -I'l — . •■■•")uiu of eonverf!;enee in tiie norma! ri le averap' aiiH litioii is about 10 metre angles. Maiiv are tlie devices tiiat, in addition to tlu ineiitioned, have been (Miii)loyed for estiniatin-; tlie exeiii-sion powers ( if the ocular mil: isde l'robai)lv the best of these are the itisley rotatiiif; prisii the Maildox ro( Is, tl le mo nocular phoroineter of Savajje, am 1 th Could and Noyes prism batteric Heterophoria, Heterotropia of the mention / uw..», — r Deviations from the normal balance mus('''les ha%-e nwived various names, and we have only to ii'iiilfi Hrii'iini or wrakncss <>/ tiinirrijnivt to indicate one phase ibalance.'' f what (ioiild has verv properly termed ' muscular mi ■lature of Stevens has been most widely accepted The iioineiu Normal muscle balanci he terms orthojtiutrw : abnormal balaiu or 111 ibalance, heterophoria. lliipcrplnn-m is a tendency < i _^_ _ if the visuHlaxirof one"eve\o'd(>"viat(- above tli;it of the other; linpoplioria is -i teiideiicv of the visual axis of one eye to deviate below that of the aihi'V. ' isophoriii, a tendency of the visual axes outward; rvopAnnVi, a tendencv of the visual axes iiiwanl; hmirnxophorKi. a tendencv of the visual axis of one eye upward and outward ; hifpo- cvophor'in. a K'lidencv of the visual axis of one eye to deviate" down- ward and outward; 'l,iip<-n:-<„phnn,i, a tendency ot the vi.sual axis of „iic evi' to deviate outward and inward; hipinsi.plmnn, a tendency of the visual axis of one eye to deviate downward and mward. ^\\^ this list. Sav.i<ie has added iiisuiliciency '' the (.bh(|ue eye muscles, or ciirloph.n-u' ; and Diiaiie, a defect of | ,>-er of some jmr- ticular eve muscle— A(//x*/./'H'.-'^- -excess in action ot a particular ,.vc~/(///i'r/,/)/CNM— while irrejiular action of an individual muscle is ^[yU^i\' piiniLinrsis. Where th.' visual axis exhibits somethinp: more than a Ifwkncii toward abnormal excursion, the terniination " tropia is used instead of "iihoria;" thus, in (.votrnpin the visual axis, as compared with that of the ..pposite eye. does visibly turn outward, It somfliines happens that in the same individual there maybe, for example, a hyperphoria for near Hxation, aii<l a manifest hyjiertropui Alien he nazes in the distance. The term " iiisulficieiicv of the ocular muscles " corresponds to v(m (Iraefes <hp,',nur .•.■lmhi.'<nni.'<. Tli.> test which in v • Craefe's tiiiio was commonlv made of the convergence i.ower is ■ i , le one: The i.itient is asked to fix an object held directly in fn- • -\ is face, at a .listaiiceof 1 ni. This is gradually •ipim.ache.l to wit, ^ .or 15 cin. of the r-yes If there be weakness of converneiici', the eye \> ith the weaker internal reclus usuallv turns out. .\r.othtT well-known and useful t.-st is to ask th<' patient to fix a dot upon the card held a little below the horizon :'■) cm. from the ev<-s, ( )iieeye is then covered, and the other MUTJOys OF THE EYEBALL AM) THEIR DERAXilEMESTS. I59 eye is wiitchcil to (Icti'rniiiic wlictlicr it, bcliiiid the cover, dcviatc's i)\it\v;inl, inward, upward, or downward. If there be no deviation after first one eye, and tlien the other, has Ikhmi covered and uncovered, one may decide that there is little or no imbalance of the rnu-scles. For testing the ftmctions of the muscles that produce Tertic' J ezcui- sions, a 10° or 15° prism is placed, base in, before either eye, taking care tiiat the prism axis is exactly horizontal. If the double images thus produced at 20 fu:. 79. feet or (i n. are on the same level, there is no hyperphoria. In nmch the same way, //)(■ jinictiniis of the lakrnl muf:chs may, iiniier similar conditions, be tested. A 7° or S° prism is placed base up or down, before one eye. This produces vertical diplojjia. If one image is seen (hrectly over the other, there is no excess of divergence or conver- gence. There are several methods of testing the hdhmrc i)f the musclcx at the near junnl or ordinary working distance, which varies ac- cording to the occupation from '25 cm. to 40 cm. l"or all practical purjxises we may employ it at :{<) cm. A card having a small dot and a fine line drawn through the latter is placed at this distance, just below the horizon. N'ertical diplopia having been indduced in th(> manner just mentioned, the double images will be found, in e(|uilibrium, to stand directly above the other. When crossed or homonymous deviation is pro- duced, we know tha* th.re is insufficiency or excess of convergent power, and the prism that restores the images to their normal position represents the amount of imlialaiice. .Viiother useful method of determining the pinrrr t)j ailditctioi) or ])rism-convergence, .iliduction or prism-divergence and sursum- duction, is by finding tb" strongest prism which the lateral and vertical muscles can "vcrcome. .hhlttrlinn is tested when the patient, with his heu' in the primary position m. from a candle or other flame, endeavors to overcome the double images produced bya pri.sm, aiK>x in, placed lx>fore one or 1 he ■ ii her eye. ( )ne shouM begin with a weak prism, and gradually increase ii unti! the diph>pia is such that no effort on the part of the [)atieiit Micceeds in fusing the double image?. It should Im' remembered Could's ) . m battery. 1«0 THE EYE. c- tluit the ailductive power is often greater by several degrees when the prism is placed before one eye than wlien it is held Ix^fore the other; that the images should always be kept in the same horizontal line; and tiiat the eye should be encouraged to fuse them by bringing the candle fiame to within 2 or 3 feet of the patient's face and gradually carry- ing it U) infinity, or 20 feet distant. Another method of inducing fusion, and thus measuring the tf)tal adducting power, is to ask the patient to fix the end of his finger, heiil 20 cm. in front of his eyes, and then, immediately afterward, to gaze at the more distant candle flame. The average of adducting power at the first trial varies from 30° to 50°, in patients with normal eyes. Gould and Lippincott have described the space between the least and greatest power of adduc- tion as the "region of iliplopia." The power of abduction is in the same way tested with a prism hori- zontally placed; it will then be found that in normal eyes a prism of from G° to 8° will be overcome. In measuring sursumduction, a prism is placed with its base up before one eye; the highest degree that can be overcome is noted. In all examinations made at 6 m., the ametropia should be corrected for the distance, and, in the same way, when a near test is employed, reading-glasses should lie used. A very convenient and useful method of gradually increasing the strength of the prisms in measuring the power of rotation po^,- sessed by the extrinsic muscles in aparticularca.se, is the prisrn fmt- tery of (iould, modified from the one first suggested by Noyes. (F'ig. 79.) A series of prisms increa.ses on each side of a central slide by 1° up to 20°, then by 2° up to 40°. The prisi.is may be revolved upon a pivot so as to present bases up, down, in, or out. Red Glass Test. If a red glass be placed Ix'fore one eye, binocular vision is overcome in most cases of heterophoria, and two images, one rod and the other yellowi.sh, of a candle or other flame are ob- served. The n'lative positions of these lights is a fairly reliable indication of the form and amount of the imbalance; indeed, it fur- nishes an easy though rough test of the heterophoria present. The prism needed to fuse the two images furnishes the degree of the latent deflection. (Plate IV.) Instruments u.sed in testing the balance of the extrinsic eye muscles are based mainly upon the foregoing methods That is to say, the impulse for binocular fixation is imllified as far as possible, so that each eye may be rotated to a point which represents the strength of its nmscles with other factors eliminated. The Phorometer of Stevens. Double vision is produced by a prism, base down or up, liefore one eye, for the examination of the power of the lateral nmscles, another prism, base in or out, being used for measuring the |(ower of the vertical muscles. It is, in effect, a more accurate application of the prisiri tests just described, and may be emploj'ed for examination both for the distant or the near point. PLATE IV. n fl XL n n n n n ft n ned Glass over Right Eye. Exophori.i 5 Left H yper-esophoriii. E-.ophorin, LeH H y perphtiriH, Rii)Iit HyperphoriH, H. Right hyper-e-'ophoriii 7. Rinht liyper-ex<)()hiit 11 8 1-efl hypet-exophririii ic MOTIONS OF THE EYEfiALL AND THffR DIPANO-ML^rs. 161 Knowine its limitations, and allowing for its !iabi;»y t<) cm. it is probably the best instrument that we possess for mepsunng netero- phoria. FlQ. 80. Stevens' phorometer. The Risley Prism, consisting of tw.. supcrimiwscd prisms with ti," ba«>s in opposite .lircctions, may be ascd with the rial frame, -n is is ^v application of Herschers plan, who show..! that by rotatmg tvo prisms n opposite ilin-ctions we can produce the effect of a S;;iri.™sing\lrisn. With this device the amount of ad.U: t.on, abduction, and sursumduction may readily be measure.1. Flu. «l. FiO. 82. Risley'a roUry prtani. Maddoz TnulOple rod. tnrou) when tiKrffluSluT,;^ £:u,^r;.y. u o„h„phoHa, U'2 rUE EYE. the ciiiiillc flame (s<>('ii as a streak of linlit l>y tlie eye In-fore which the ro<i is phu'etl) piisses tliroujili •!"' caiiilie Haiiie seen by the other Vw. H3. Mad'lox's nid-ttitt fur borlsDntal deviation; tlie nxl is before the right eye. A. Ttie line ikkscs through the flame--<>rthophoria. 8. The line paHses to the riu'ht of the flatne latent— convergence or esophoria. c. The line paiKex to the left nf the ttame— latent d'.Tergenre or ezophorla. (dc StHWKINIT/. anil Randai,!..) Fl«. M. ABC TO 5 Maililiix'ii n»l-te«t for vertical deviation ; the rod is ln'fore the riRht eye. .1. Tlie line p^^»e!. thmngh the fianu'— ortho|ihoria. H The line )*»ses Vielow llie ijiiine ; llie upper iniiiKe tielunKS to the left eye -ristit iiyr>erphoria. C. Tlie line |W!«e« alnive tlie (lame ; the npi^^r image belongs to the rlRht eye— left liyiicriiiioriii. (he Si HWi;:MTznri<i Kandai.l,) MoTIoys iiF THE EYEUALL ASP THEIR JiERASOEMEyTS. ]«.•} vyr. Ill tsoplioria wo have hoinonynious diplopia, the streak l)oiiig oil the same side as the eye fixing it: in exophoria it is on the opposite' side: and in hyperpiioria, either i)ei()\v it iir al)(>ve it, as we have to deal witii a right or left hyix'rjjhoria. Assuming that the rod he ))laeed before the right eye, Figs. N;{ and S4 show the position of tlie light streak and the candle Hanie in normally and almonnally halaneed eyes. .\nother well-known test is tiie so-ealled ixinillitx kst. This is made at the usual (i in. distanee, and is carried out with a light on a dark liackground.eaeh eye being covered alternately, so as to remove the desire for binocular Hxation. As the cover, plao'd first before one eye, is being carried liefore the other, the patient is a.sked whether tiie recently uncovered eye notices any movement of the distant tiame. If he does not after a few trials, one may Im- certain that there is no marked heferophoria. When ajJiiarent motion of the candlo ihime is noticed, the patient will siiortly be able to describe Fig. bii. (>rtho|>boria. Heltrophoria. The convex «pherical tt^t. its direction and its extent. Kxophoria is indicated if the light moves ill the same direction as the cover is carried from one eye to the nther: if in the opposite (Urection, esophoria. If the light moves downward wlu-n tiie right eye is unco.ereil, there is a right hyper- phoria; if it moves in an upward direction, we have to deal with a left hyperphoria. The prism that neutralizes the movement measures tlie degree of the heterophoria. The Convex Spherical Test. A strong convex glass do D.) is covered, except at its optical centre, and iilaced before one eye. The distant candle image api)(>ars in the shaiM- of a blur of light with a -eeond image, that of an oniinary candle flame. ' .he muscles be nnnnallv balanced, the clear candle flame will ... situated m the i;i.ldlc of th.' blurred image. In heteroi)horia the clear image wi 1 MMx^ar in various parts of the blurred image field, or, m the high Iru'ives, will he separate.l from it. The relation U-W.nHi the tw;, i'-LMges and 1h- prism re(iuired to bring the clear miage into t tie ■ rntre of the blurred one. deteniiines the measurement of the heteni- 164 THE EYE. phoria. Hansoll and UoIkt holicvo tliat, when [jroiM-rly rarried oiit, tl»is U'st i.^ sii|MTior to tliost' in which |)risins ahmc arc usi-d, anil tluit it |)()ss<'ss<'s all till' advantaRcs of the Maddox hmIs. Symptoms of Heterophoria. Thcrt- can Im> no douht that a marked dcKiw of almost every form of muscular imbalance (as measured l)y one or mori' phorometers) may exist without giving rise to siM'cial symptoms. The state of the nervous system, the habits of the patient, the condition of the dig<'stive and other organs influence the symptomatol< igy in tl.ese muscular anomalies. On the other hand, Ijoth local and general symptoms an- commonly I)resent in the majority of ca.scs of heterophoria. Inasmuch as ame- tn)pia is intimately a.s.sociated with heterophoria and with hetero- tropia, and since we know that the correction of the one may greatly n'lieve the irritation proiluced Ity the others, it is not strange that one has ditficulty in differentiating the eyestrain symptoms of ame- tropia from those of heterophoria. We shall consider these nmscular anomalies separately. Fio. 8«. ImagiMnovement In heterophoria, ezophorla, and e»)phoria. (Coi.Bi rn.) Ezophoria. The tendency of the visual axes outward is generally a passive condition, and is commonly the result of lossof convergence- power or convergence-impulse, and it may range all the way from an insignificant defect to a true and almost constant exotro|)ia. It may be due to structural defects in the insertion of the recti interni or their opponents in the too divergent orbits of wide skulls, or to .some other anatomical anomaly. .Moreover, an insutHcient innerva- tion of the interni may have something to do with this condition; occasionally a developmental defect in one or other internus may bring about an undue tendency to divergence. The exophoria may be paretic from the beginning, or the nerve supply having been par- tially restored in an exotropia, the remaining iml)alance is not notice- able unless tests are applieil. It will thus be .seen that both exophoria and esoi'horia are the resultant in m.-my c,i.ses of iHspusos of the most oi)posite character, affecting one or more of th(> nuiscles that take part in normal divergence and convergence. .Anything which affects the tone of the nmscular system generally, but in particular those MOTIOys or THE EYEBALL AND THEIR DERASUEMESm. 165 imiscli's fiij<iiji<''l '" potivorjtfncc, is likely ti> prixluce an cxophoria. We iviiow lx)th fnun ()l)^<orvati()n aiul exixTieiicc tiiat the most active (•(incoiiiitant of exophoria is myopia. In this fonii of ametropia till' coiivergcmc' muscles are not frecjuditly calietl into play; the hcailiis- impuls*' to converge is usually lacking. In time loss «)f the convergence im|)ulse takes place, and thus, iiulin'ctly, e.xophoria is produced. The symptoms caused by cxophoria do not ditTer from tluw that accompany the ametropic condition .md the accommo- dative anomalies with which it is so intimately associated. These arc (•(iiinected nearly always with attempts to do near work— blurring of ilic print, pain in and alM)ut the eyes on attempting t<< read or write, confusion and running together of print or of the notes in nmsic, h(>adache, fatigue of the eyes, and a sleepy fe«*liiig- all these may accompany a pure exophoria, even after a correction of the refractive errors that accompany it. Treatment We know that in many instances exophoria gives very little trouble and produces no .symptoms after the correction of a simple or compound myopic astigmatism. It sometimes ceases to lie an irritant when an acute or chronic disease has been cured. It is the belief of the writer that the condition of the general health and the correction of all fonns of ajjtigmatlsm, and esfn-cially of a concur- rent myopia, should be the first consideration in this condition. de Schweinitz advises, as a routine of practice, tincture of nux vomica, fifteen drops, three times a day, increasing the dose by five daily drops until forty-five are taken or until toxic effects are noticed. When, after this hai been done, exophoric symptoms still remain, attention .should be directed to a permanent relief of the condi- tion. The most important of the non-operative procedures is regular prism exercise, either bv means of the Noyes-(iould apparatus or by means of ordinarv square prisms set in spectacle frames and placed before the eves. " The strongest prisms, ba.ses out, should be used. The patient fuses the double images while standing four or five feet Irum the ix.int of illumination. He then slowly backs across the r.H.m. fifte..., or twentv feet away. This exercise is to be performed for from thrw- to five minutes at a time three times a day. 1 he strength of the pri,sms is gradually increased, but in no case .should the patient make use of such strength as to cause pam, vertigo, ur other disagreeable svmptoms. This ealisthenic performance may alsu be cmducted bv ordering square prisms with whici, the patient luav exercise his conve ,'ence at home. If, for example, the conver- ireiit power be 15° an.l the adduction 7° or 8°, three s<iuare pn.sms inav be prescribed, of respectively 15°, h'. and 3°. The patient uses the" hrst for a couple of days, until fusion of the double images at twentv feet is easv when it is placed l)efore either eye. The next day i,e .....piuvs, f..r the .same purpose, the 15° wd the 3° prism and so .ni.tinues until he can overcome the compound IS pnsm l-maiiy, all three are together used, and this combination, which is about equal IM lllk KYU. to ;i siiijjlc 2'i° prism is cxr.liaiigi'il for nnothcr series, -iiv 2.'i°. l(i°, ami .")°. In this way, ilii'ciiii\cr>j<'nt |M>\ver iiiav Ik' iiu n ,-i-.l until the patient can readily overcoine at least a ()U° prism, t aiTl'iil ilirec- tions tor their i.se shoiihl always Ix' jiiven, aii<l eontr^l e\|M-rimentH sli;>ulil Im' maile from time to time in tiie surjieonw olliee. No opera- tion s!i;<iil(| '»■ thought of until the mejisun's just alluuiil f" havf iM'en sullii'ienliy tri'-<l. ((utijoor exercise-, a nutritious cjiel, and as litt'e nr'ar work as pir-silile. slmulil .ilways Im- incule;iteil in connection with fhi-' "I'-neral treatment. Alliiou'ih the constant wearing of prisms occasionally ^ives rr'lief to the symptoms iinl'iceil by an i-xophoria. the writer cannot con- scientiously advise them, except is a ti'inporary ex|)eclient. If worn for some tiiiit', tl." effort of conveiijence is mon- and more lelt in ahey- iince, ait(i there is no re;il attempt at a cure of tin conditions that Kl<i. «7. Imo^-movenient In liyiKW-toi-tK-ria. hyitvrphorin. uid hy^<,<viio|>horta. iCoLBrRN.) uiidi-rlie the exojihoric sl:i!e. When a prism correction is attempted, not more than two-thirds of the total amount (divided hetween the eyes) should he presented. Three or four de,iri'<'.'s of exoplioria rarely iv'iuire any correction, and as it is usually durins; ne:ii- work tli;it symptoms are set up, ;ind since (he exoplioria is most marked at liiat time, it may he advi.sahle to f;ive a stronjjer |)risni for readinp or desk-work. When all means fail, an operation upon theeyp mus ■'• i- iiulicated. In this ,-':ise the surgeon may teiiotomize one or tmih externi, or advance one or both interni. The writer, while syiiip;ithizinji with Liiiidolt's preference for advancement in all cases of weakened con- vergence, has not been able to obtain the best results with it a section (partial or complete) of the opj)osin>: external rectus. \\ neve the apparent exoplioria is really deiiendent upon the presence of hyp«Tphoria or a hypertropiji (as Stevens affirms is frequently the Muiioys (If Tilt: i:)i:iiM.i. .i.\h riiEiR pkuasi tMtsTN. i67 •!i.M«'), lie "inrnic.'il iiitorlVn^ svitli the cxniiliMria i- .iu>tituil)l( until VlTtlC aiKiiiia Iv lia- I'll corrected. Whetlier uiir or Iwitli til imeriii reiiuire ailvanceiiii ami wlidlier acciiiiii>aiiyiii): sections ~lioiilil l>e .lone on ilie CN ■mi. will .l<|M'n(| upon tiie n-Miltf i>f « not relieve. 1 hv glasse^. nie.l, ili.i i^je oiK'raiion. I'mlial)! an e\.)plioria. jiymptoni.-i ..I "liii-li a sli..nlil 1m' corrected !>> the a.iva n, liyjii icemen and prism ex.Tcise, t .f hoili inlernal recti, wiiii- .iiit tenotomy the loriner tail, the operator irtial or coinl^lete) of one ( )r hoih externi. Hut, if I not hesitate to have recourse to he additi.mal ..peratioin. Tli' ticliiii.|iie of all these o|)erations will ideied under the allied coiiilitioii— stral>i.«mus )i8opboria As ill the cas<' <'t' ex.>iihoria, tiiis coiuliti.iii .I(K's not jlive rise other ..rr.iun. (•arsici<nes- ; .li-tnrliancer to .listinctive symptoms. I'liotophohia. not i^i'laine.' on Is, iilurriiiKof the juint." pan.iraimi" vertipo and naus<'a, -, with headache, nervou.snes-. aii.l .iigestivo fcrre.! I.i it. As Han-ell .in.l U<'l)er have lid seasicknes re I Hen n is the ner^dUs pointi'd out. a curious symptom ii.itice.l i)y esophoru irritation pr.xluced hy the patient's seeinjj his iioi^e, not ..nly v hen r.'.idinii or writing, hut when lookinji in the .listani •1 I ule, p.itients ^u^■erillp from esop t.inis lint III iiroliiiuivil "-* ihori a are much more likel> to have .syin|(- c/yc^ in ijiuniii nl disiatd nhjt'cl.^. as, tor exaini)le. in atten.litif; the theatn', t'oiiiK lo church, in riiliiif: on ilev.ite.l trains or in lookiiiK out of the win.low of a nioviiift car. A small amount of esophoriti may give rise in susceptible in.livi.luals sym|it.>m~ w hen the same or a larger amount is W( 11 hv )atieiit with a stable m ■rvous svstem anil good iligesti.m. The neu- su tt'er fr< 111 insoiiiiiia rotic anil the neurasthenic— i)articularly if the; .ire much more likely to complain of esophoria pure ami simple 1 ,11 the healthv individual, hi^t as exoi)horia is coininoiiiy asso- ,ted with myopic stat in'sciit III al ) w e fin 1 esophoria more fre(|uently legrees of !iyp(i..pia and hyperopic astigniatisn Treatment. Kirs! ■ill con •ectioii of anv refractive error uld he made, ami I f- i'.^sary, gla.sses (usually convex shouid III' worn con <tanth Willie if atropine for severa tl 1 .lav lie eves s or weeks. are kept under the influence At tl le saiiu' time, anv .^•ct ill the general health should l)e renuMlied. Tlii' habits of the ,tieiit should ha-.- attei.tiim, as these are imi.ortant in dealing with it from work, can-ful dieting, "]: form of heterophoria. Tdiiics, re change o f air. will often help to effect a cun'. In the writers ex]ieri .'III'.' , p-.isni exerci.se has t that value which it pos.sesses in exoi ihoria. trea nervous hvoscvam t it should he prescribed in conjunction with the foregoing the etTect of soothing the irritated ti: t. Reni(><lies having •em are in anv o of value, and of these the most important is if its forms. When it is impossil)le or not con- -,d.M.Mrde..^;rai.le t."- instil atn.piiu-, a .single drcp '-.f a one- or t\«>-2rain M.lution of homatropine should be dropiM'd into the eye an hour or two b'fore bedtime. Cydoplegia produced by this agent passe'^ off 168 THE EYE. ;'•:< (] befire the next morning, while accommodative quiet is reflected In esophoric relief. Prisms for con&tant wear may be of occasional value, but as their tendency is to coddle the weak muscle or muscles, instea!d of strengthening them, this plan ought not to be encouraged. As a means of bridging over a temporary (lifticulty, or to allow time for improvement of the patients health, their use may be justified, but for a permanent cure they are inadmissible. When other means fail, a market! esophoria, say, of 10°, for the distimce, is a defect pn)per for operation. As the operative treatment of heterop!ioria is practically the same as that of true strabismus and other forms of heterophoria, a description of the tenotomies and advancements proper to the latter condition will be found under the appropriate heading. There is one exception to this statement, in that jtartial tenotomy and partial shortening are restricted, by those sur^-eons who employ these means, to heterophorics ami to cases exhibiting minor ilegrees of heterotropia. The writer has occasionally had patients who were benefited by partial operations alone, after non-operative means had faithfully been tried. Partial Tenotomy. This may be either central or marginal, the purpose of the fonner being to lessen the tension of the muscle operated on, while a marginal tenotomy is done both to moderate the tension and to influence the action of the nmscle upon the rotation of the eyeball. Savage' thus describes the two operations: The instruments needed are the same as those nnjuired in doing the complete operation. To do a central, partial tenotomy the lids most be well separated by the speculum. The patient .should look as far as possible in the direction opposite the muscle to be operated on. The conjunctiva over the insertion of the tendon should be lifted in a meridianal fold with the forceps, and this should be snipped with the scissors. Through the cut in the conjunctiva the forceps should be made to grasp the capsule of Tenon, which in turn should lie snipped throvigh the ojiening in the conjunctiva; the central fibres of the tendon should then be grasped with the forceps and slightly raised from th'' sclera, so that they may b( caught with the •scissors between the forceps and th>" attachment, as close to the latter as possible. Thus the tendon is buttonholed. If the ofx-rator is certain, from the resi.stance he feels with the forceps, that he is not too near either margin of the tendon, he may divide a few more fibres in both directions, while still holding the tendons with the forceps; but in doing so he takes some risk of doing too much. Now the for- ceps shouM be laid down for the small (Stevens) hook, which should be passoil through the buttonhole in the tendon, first in one direction, then in the other, beneath the uncut fibn>s, so as to determine the resistance. Guided by the hook, the operator now divides fibre after fil>re with the scissors, until the lessened resistance warns him that he hius gone far enougli in that direction; he then repieats this step Prom the advance sheeU of '■ Ophtbalmlc MyoI(«y." MOTIOSS OF THE EYEBALL AND THEIR DERANGEMESTS. 169 toward the other margin, in the same careful way. To get the full ftfect of a partial tenotomy, the capsule of Tenon must be cut coex- t('U-;ively with the <livi.sion of the tendon. The cut in the conjunctiva m:iy or may not be of the same extent. There is no necessity for inaking either a very small or a very large conjunctival incision; but for those just beginning, a large conjunctival incision would make the t(>notomy both easier and safer. In a marginal tenotomy the initial cut of the conjunctiva, capsule, and tendon Ls made as for a central tenotomy, care being exercisetl that the buttonhole in the tendon, if not in the centre, shall be nearer that margin which is to be com- pletely severed later. Still holding the tendon with the forceps, the srissors may be passed in the direction in which complete divisioA is indicated, and be made to cut all the fibres at once. Hyperphoria. In this anomaly there Ls a tendency of one Wsual line to project itself higher or lower than that of the other. Hyper- phoria i« by no means a rare condition, and, although it may be present to a marked extent, it iloes not always excite symptoms, particularly if the individual possess a sound nervous system, a good digestion, and does not abuse his eyes. The principal symptom, not only in hyj)eri)horia, but to a greater or less extent in all the muscular anomalies, is, in the writer's experience, sensitiveness io light. In the case of hyperphoria we find also the usual reflex symptoms: hj^per- icniia of the lids giving rise to smarting, burning, and a sensation of heat in the eye; confusion of images, particularly when the patient is walking along a crowded street, looking out of the window of a car ill motion, ascending in an elevator, etc. It happens not infrequently that hy|)erphoria of slight degree produces more ocular and other nervous; symptoms than one would crpect. Not only in this form "f hot(>roph'»ria, but in all the others, the sjTiiptoms are not in direct proportio'i to the amount of the defect; indeed, just a« it is impossible to say liow much hypermetropia or astigmatism is required for the Iii(KK:>ti')n of syniptoms in a particular individual, so is it difficult to iiidicate the amount or kincl of annoyance likely to accompany a irivfii amount of hyperphoria '"i a certain patient. This defect gives rise, not only t<i what liennett has termed "panorama" symptoms -as shown by headaches, vertigo, and occasionally vertical diplopia— liMi also evidences of ne^^•ous irritation on attempting to use the eyes I'll- long-continued near work are rarely absent. These are, in par- lif'iilar, dizziness, ocular pain, and photophobia. The patient is .'ivcii to .stiuinting his eyes during both near and distant fixation; !uiro-.vs or ridges may be usually detected alM)ve one or both eye- liriiws. or the eyes may present a st.,.i.ig appearance, or there may -' (111 to he an apparent ptosis of oni lid, with a wide-open condition I the other. This peculiar wrinkling of the brow is .seen in its exag- ,(iatcd form in true oculomuscular paresis, but its meaning is the itm in hyix-ri)horia. Thf head, also, is verj' often carried with a iU away from the hyperphoric eye. If the vertical defect be not (> I 170 tup: eye. PKces^iv.". this parriasc of the luvul nuty h.' sutf.ci.M.t to ..vom.mo .h.. wliolo of th.. l.viu.rphona. un.l it is a oomn.on ^YT^'Z ^1 any lu-iMTl.h..nc.s .hvsi.-ally vv.ll .lev.>lo,,.Ml succh-I ,h.nng tia r Xiv om.,.ati...J in ..l.taiuinfi <-o.ufort by thus ,..utrai./.ng all, r ^ r V all. of an ..tlu-rwis. intoK-ral-l. l.y,K.r,.hona. Lxophorm s ^m- n' ,,-. tlv a.-ociat..a with hyiH-rphoria, ami as S .vons ,H.u,ts ou? onv tio.i of the on.- n.ay issue in cure ..f the other. I.ulm the writer is eonvinee.!. fro.n an exan.inat.on of a larg.- nun.be f IJ' ases, .hat hvperex..phoria a.ul hyix-resophoru. -re often esult« .,n ...te.iDt on the part of the lateral muscles to relu .-e Mie \er- th-:^ .Sn -rhis point shouhl always l. .leci.:..li.et..re a.| !.^,t M, t is nuule to correct either anon.aly. Both -supraduct.on and ;;i;;:;iuction. as wen as abduction and -|''--»'"";^'>;;; ' ,^;:;f "i^ measured with an.l without correctn.g-gla.s.«es . the lateral d vm ;.„. are found to be in nornml relat.on t.. one another an.l the v'.'Iical ex.-ursiuns are abnonnal, ..ne n.ty conclu.le that the case is csseutiallv one of hvix'rphoria. i » i ... Tests for Hyperphoka. Th.-se have aln-a.ly be.M. referred to bu it is well t.. sav. in .i.l.lition. that sin.- sn.all .l.-gnH-s-.i this .lefoct •m-'of greater inip..rtance than minor am..unts of .>xoi)horia or eso- 'phoria, care shoul.l be .-x.-n-is.-d in .-liciting its pr<>s.>nce or abpice. Tl ,' mrallax or the scr.H-n test will be h.un.l of i.art.cular vahu- m the .iVt.'ction of this an..maly. A.-c.rding t.. Duan.-. .•ynstant prac- tice will .-nabl.' on., to d.'t.rt as little as a .[Uart.M- ot a d.-gr i ''■'Treitmlnt.' First ..f all. tlu-n- sioul.l be a tlu.r.mgh .•..rr.-ction. nnd,>r a cvclopl.-gi- (wh.-n that is n.H-ossary). ..f al'r..fract. v.- errors. Thi< willbe fomid suth'-ient, in many cas."s, t.. make th. pati.-nt so ,.„,nfortabl.- that further interfen-r..'.-, for the tnn.- at l.-ast. is uncalle. fur If r.,„T.M-ting leiu.'s are foun.l to b.- insuHicu'i.t, prisms shoul.l 1„. worn. It must bo .•.mtVsse.l that it is not ..a.-<y in th.' hrst instance to <,v what proi)<)rti.)n ..f the .l.>viati..n sh..ul.l !..• irpivsent...! by „ri<!n'< V-^ a rule, most pati.'Uts will not tolerat.' moi.- than oi.>-hall ,|„. full .-orn-ction, divi.l.-.l betw-.-n the tw.. eyes. Tl..- writer .s exp<- rien-> is that it is b.-st to ..rd.T the prism .M.mp.um.h'.l with the cor- ivcting glass, an.l lu- d...'s not Hn.l that fn.nts ar.; comfortably worn It i. bett.T t.. have tw.. pairs of glass.-s if it i> d.>ci.l.>d tu use different I.ri^-matic -tn-ngths for distant and n.-ar w..rk. Th.- iH.w.-r ot mfra- ,|u.ti,.n and sui).aducti..n. as n..-a.sure.l from tmi<- to Urn.-, shoul. ,!,.cid.- wh..th.'r tl... i.risms thus constantly w..m are t.. ae docrea.so. ,„ in.-r.'is,.,l. Th.' constant w.v.ring of prisms is ..f greater iH-neht an.l mon- justitiable in hyperphoric .-on.litions than m t iios.' of .-so- l.l.oiia or ..x.mhoria. an.l th.-y often pr...iu<'.' brilliant r.'sults. rviyag.' ;„lvis,.s ..x..rcise with vertical prisms, aft." the mann.-r sugg.'st...l for prism-training in weak-'iu'd .■onv.-rg.-nce an.l .liv.-rgence. but the ri'sults ar." not satisfactory. The sam.' rul("s a|.i.iy in tlu- ..p.'rativ.' treatm.'nt ..f liyiH'rphoria MOTIuyS OF THE EYEBAIL AXD TUEIR DEBAyOEMESTS. n\ that wore lai'l down for esophoria and exophoria. After all otlur |.l;ins (correction of ametropia, attention to general health, etc.) liMve failed, tenotomy of the overstrong, or rather overworked, muscle is indicated. Can- should Ih- ol)s<'r%'ed not to o[M'nite in pan-tic cases. When in doubt the tropoineter or any of the other means of tncasuring tiie rotating [jower of the individual nm>cles will lie found of great value, it is not always easy (owing to the si'condary con- tractions following even a slight paresis of a vertical nni.scle) to decide whether we have to deal with a non-paretic hy{)er])horia or not. When the latter is constant in amount, and Ls found to be due to insuHicient powei of one of the vertical mu.sclps, the proper procedure is an advancement or a mu.scl"-shortening: where the defect is due til overaction, tenotomy is indicated. If there he a field for partial tenotomies, it is in low degrees of hypen'^i'Tia due to overaction of ■1 particular muscle. But the sjime objection to the tenotomy of a muscle is as pertinent in hyperjjhoria MS in other muscular anomalies; it is always Ix'tter to strengthen a weak muscl'> than to weaken a strong one, i\cn when balance of all the muscles is the ()bj(>ct sought. Cyclophoria. This is an uisuifi- rjrncv of the oblii|ue muscles, .ir a 'Irfcci (if til normal torsion or wheel- iiMilion, which occurs when the ob- liiiuc muscles es]K"cially are called iiiii) action, we are indebted for iiiiist that we know of this subject to S.ivage. He attributes a muiiber of -\!iilitcin'.s (commoM in .ametropia and other forms of heter(ii)hor'a) i'> this condition. It may be detected by co\ Ting (iiie eye and placing over the otii "r a Madtlox double pn.-m. Tlie patient fixes a horizontal line drawn <;n a white card eighteen isirhes from his face. He sees two lines. The second eye, the HI' being tested, is now unco'-eivd and a third line will be seen ha!f- vay between and |)arallel to the others, if all the niiiscles are properly ■alanced. In imbalance of the oblicpie mu.scles the central line is 'lied, in n'ialioM to the others, cither up or ilowii. If the middle lire "■ nearer the bottom than the top line, or riir nrs<i. there i> a hyp( r- !;'>ria: <ir. if the middle line extend more to the right or to the left, '"luction or ;idduction is at fault. Treatment. Hhythmic exercise of the insufficient obliin'.e muscles iicdniplislied by the method of ."^aNage. This consists of the rota- ■II ot convex or concave cylinders before the eves of the patient li". meantime, looks at a distant candle flamiv \\'e have had .so Mje experience of the results of o|K'rations upon the obliiiues for the lief ipf cyclophoria, that it can only be .said that the matter is .still 'I I inilirc. Maddox double prhm. a. Front view , 6 Sectional view. 172 TIIK EYE. Strabismus. Squint. Heterotropia.' In this cnmhtion the vL.ual ■xxo. an- so .lirect.-l that tho hnago ..f tlu- ..hj.>ct .loos not fall ui^n th.. fov.-a of 1.0th CVS at the sa.no tnno. Th.;n> ,s an al.sence of bin- ocular vision, although tlu- rotating powor ot the uulivulual nuiscles is not to anv great extent iinpaire<i Internal or Convergent Strabismus. ("'•Ny^-«''^-^7 ,^f '^ij, j'^""; TKdiM V The visual axis of one eye is directed toward that of its fellow , so that the image falls uix.n some portion of the retina m the deviating or s.,ui.iting eve outsi.le th- f.m>a. Convergent strabismus may be n.on'eular or" constant, binocular or alternating. In the former .ase one .v." is c.mstantly us<h1 for purp..ses of hxati^.n. vdule the secolul eve turns in. In the s<'cond ca.se either eye is used indiffer- entlv for fixation, and the opposite eye S(iuints. There is pricticallv no definite line of demarcation between .sciumt and heterophoria. Some f<.rms of heterophoria may represent an (.■iriv <:m^ of strabismus, or the same inu-scular imbalance may at one time be properly called .s.,uint, and at another time a mere insufh- ciciicv of the muscles. , • .1 • • t Monocular Squint or Coustant Squint. Not only is the vision of the strabisnic eve def.n-tive. but ihe amblyopia generally dees not orrespo.id to aiiv ophthalmoscopic .lefect, although the visua held tVe(|u.'nllv is c.n'tracted. The error of refraction of the amblyopic j. often much tli.' same as that of the fixing eye, so that the ametropia alone cannot account for the lowered visual acuity. Probably there i< a true nmhhiniiia ex oitopsin: although in the majority of cases the vision of the non-fixing eve is not to any extent improved '>y correc- tion of the refractive error and cure of the squint. Whatever be the ori.'in of tlie d.-f.'et in sight, it is probably the main cause of the het'^Totropia. Without discussing the various theories from time to lime put forward to explain s<iuinting eyes, one may say that the brain centres hav.- a disUke for th<' vision that results from an eye that sc.- plainlv and one that h<m's indistinctly, and that in the effort to rid the nervims sv-teni of this source of irritation Ihe defective eye j.; tinned in the directi md kept in the jxisition easiest to obtain •iii.l maintain If. however, we are enabled by any m.-ans to improve the vision of the s.juintiiig eye, we to the s.-une extent remove the ubjectior. on the part <.f the nervous sy>i<'ni to eyes of unecpial vision. If in addition to this d.-sirable result, there goes a restoration to parall<-lisHi of the visual axes, we may obtain not (mly binocular .sight, bul also ( .inii'ortalde vision with both eyes. Diagnosis. In>pection of the eyes will generally show an abnormal direction of the visual axes, aiul the sclera wili be found more exjiosed in one s<'gment than in the corresixinding portion of the opposite eye The eorn.-a will, in most ca-^es, be seen to be dcfh'cted toward tlu' 1 snme H.nhnrliK* pMVr the cxi.n.«.lo.i Mrrni,„i,ia for »11 f..rm...f lMil«l«n<« of the mawl.- in »lil.h liliLKiiUr (Ixation Is lo»t. discarrtliiK the tirins • slrablnmu.," " p«ralylio squint, etc DniiliiU'w, In linu'. Shi" niiinTOCltttMri- will prevHii MOTIOSH OF THE EYEBALL AND THEIR DERASGEMEXTS. 173 Fia. 8». iioso. This apparent deviation of the visual axes is noi always to be relied upon; the angle alpha may be abnormally small, so that although there is no muscular imbalance, there is an ap|)arent eso- tropia. The best means of diagnosis in cases of doubt is the cover test. If the fixing eye \yi? excluded by a screen, the cornea of the deviating I ye will be seen to make an excursion outward. The eye that Ix'fore turned toward the nose, now attempts to fix, and in doing so the cornea is rotated so that the rays of light may pass through ami fall upon the foveal region. Owing to the high grade of aniblyfi|)ia in some eyes, it is not easy to measure the amount of scjuint with j)risms, and for the same reason the use of the double images of a diplopia in the various phorometei*s usually fails to furnish any information. The false initi()e is .sH/j/wc.s.ved ■•'n nwst ruses (if coHverijent and other forms of siiuinl. The amount of exces- sive convergence in sfjuint may, accoriling to the method of Lan- (liilt,be measured on the perimeter. The patient fixes with the better lye while a eand e is carried along I lie arm of the perimeter until its ii'flection is sei'U by the obser\'er fruni the centre of the pupillary .Ilea of the opposite cornea. The angle thus subtenile<l is read off on I he arc of the jierimeter. (Fig. 89.) Treatment. Since convergent -tnihismus usually is a.ssociated with, and is by some said to de- pend in most cases ujkju the |)res- '■nceof hyiM'rmetroi)ia fas an indi- rect lesult of abnormal accommo- l.ilive etTort, we have increased attempts at convergence), paralyzing ilie accunnnodation with an effective cyeloplegic, like atrc.jiine, is in- licated. M first the s(|uint is usually relieved, or it may not undergo Miy sensible dimimition for some days or weeks. When the patient's ■iiiiiiiiiiodation is thus thoroughly paralyzed, a full correction of the ■ yperopic error should lie ordered and worn constantly. The lect of glasses may Ik* much increa.sed by the continued u.«e of tropine. Th,' writer's plan is to instil a single drop of a 1 per cent. "luliun of atropine sulphate into each eye after breakfast: this is 'iitimied for two weeks after the glas.ses liave been ordered. The Miopiegic is then stopix-d for two weeks, or until the patient's pupils '■f no longer <|i'ated. If the glii.s.ses are not fully accepted, or if iTc IS no impn)vement in the stpiint, the atropine cydoplegia is Meuurement of squint with a perimeter. (Lanijoi.t.) 174 TJIJC EYE. ciitinucl for anotlicr fortiiinl.t. and so on altcrnutoly every fort- nijilit fur from tlinr to six months, durmp winch tnn«> additional attempts sliouiil l)e made to I'ducate th<' faculty ol tusion and to promote binocular vision l)oth for distance and near. One ol the iM'st nieaus of accomplishinj; these hnportant results is the use ot the Mcreusrnnr, usinfi with it. for example, the pictures ol Kroll. Ihe meth(.d (.f Landoit, in which lh.> vision of the better eye is dulled, .so that it more cl..selv ai)proacli.'S that of the s<iumtmn eye, i.s t he one pref.'rred bv the writer, and, alliioufjh much patience will be reiuiired bi.tli on the part of the surj^eon and of the dnld. fjood results are often obtainabh' by the use of this simple histrument. As con- ver'-eat strabismus usually sets in during childhoo.l, several tpies- tions arise in connection with this fact. In the hrst place, how early shall weattem|)t medication? The answer is that atro|»ine .sliouhl 1h> used as soon as the S(inint apix'ars and attemi.is at monocular fixa- tion an' made. The writer has fre(iuently bejiun to triMt a conver- fjeiit strabisiims in children two years of ape, and has had them wearinj; glasses with benefit Ix'foro they were thire years old. If we shouhl fail in obtaining paralleli.sni of the eye, or should so far succeed in our efforts ;is to convert the monocular s'luint into )l occasional <-sotiopia, an operation should l)e done— the (>aiiier the better. In monocular squint that h:us defie.l milder measures, advancement of the (>xteriius with tenotomy of the internal rectus is the o|H'ration that will gent>rallv be recjuired and that will usually be successful. ( )ne often finds ainipward (U'viation combined with the inward s(piint. and it is usually necassary in such case.s to tenotomize also the superior rectus of the .s(iuinting eye. Alternating Convergent Strabismus. In this form of convergent stiuint th(> nerve centres .seem indifferent as to whether vision is con- ducted by one eye or the other; sometimes one eye fixes and the other .s<iiiints: sometimes the hitherto scpiinting eye sees, while the fellow eye turns in. \ision is usually about the same in each eye. and it is usually easier to restore binocular vision than in constant s(|uiiit. It is sometimes dilficult to explain tlie origin of alter- nating strabismus, especially examples of it where the-r seems to be^an objection on the part of the cerebral centres to binocular fusiim. One mav at least postulate a congenital defi'ct of co-ordina- tion in the fusioii centres. These patients invariably have a hyper- metropia of mon- than 1 IX, and we may ass-nne that the incentive to accommoilalive <"ffort and the .•ibiiormal us(> of the convergence have something to do with the scpiint. Diagnosis. This is practically the same as for the constant form. It is easier, however, to induce dii)lopia with prisms or otherwise, and so n-cogni/.i> thi< relation of the fals(« to the true image. This is. of course, much more dillicult in children, but with a little coaxing and the exercise of p.atience, it can often be demonstrate(|. Hyper- esotropia is a coimnon variety of alternating .s<iuint, ju.st as it is m MOTWSa or THE EYEBALL ASD TllEtll DEHAXdEMESTS. 17-) the constant form, and in the imx-cdun's undertaken for its pure this lunu of the defect should not !)<> overlooked. The tr 'atnient of alter- nating esotropia is practically that of the constant variety, and, although the writer does not entertain the enthusiastic ojunion coin- iiionly held as to the higii |)rop.>rtion of cures in l)inoeular strabis- mus convergens, then- is no doubt that j)arallelisni and binocular fusion nioH' fnHjuently result from juiUcious treatment than they do in the constant form. External or Divergent Squint; Divergent Strabismus; Ezotropia. This is the antipodes of esotropia, and is usually a.s,sociated with myopic eyes. It is an ac<iuired condition, often dependent u|M)n tlie same causes tliat brin>? about myopia, such as asymmetrical orbits, lonft-eontinueil near work, insutiiciency of the internal recti, etc. The etiolopy of many cases is t)b.scure, but the lessi'iied demand on ;ii'((>mmodation ami convergence, and tlie consecpieiit relaxation of the interni nm.sdes that accompanies the ac(|uisition of axial myopia, ,ire largely respcjusible for them. The eye turns out constantly in the monocular form, and alternales in this position with the fellow eye in binocular exotropia. Proi)ably the diseas«' Ix-gins with a ten- dency to <l«'viation (exophoria) and emls in a true exotropia. For tills reason divergent S(|uint is rarely se<ni in children, but is an anom- aly of adolescence. The tendency of myopic eyes toward divergence is |)artly due to tiie enlargement and comsecjuent elongation of the 1 yeball, rthich ad<ls to the weakness of the adducting muscles. This train of causes, with the decreasing convergent i)ower, brings about a true divergence. Small degrei -i of <!ivergence are readily detected l>y the cover test, while a high degree i.s re.;dily seen on insjiection. Occasionally the si|uinting eye in constant exotropia is amblyopic, Imt the deviation itself rarely sets up symptoms, because the image if the divergent eye is suppressed and diplopia is not a sy.mptom. Treatment. The optical treatment of divergent strabismus con- -ists chiefly in the correction of the accompanying myopia, with or svitliout the ])rescri|)tion of prisms. As full a correction of the myopia I- liie patient will tolerate .should Ix' given, and the accommodation -hdiild be further stimulated by instilling a weak solution of pikicar- iiie into each eye three times a day. If the exotropia be associated ilh hypennetn 1' I, the latter shoulil either not Ix- corrected at all, or 'ii' we.ikest workiiig-gla-ss should Im- u.^sed. In this way ()n<' may hojK' • ■ ixcite the action of the ciliary muscle and amuse a concomitant nnuiation of the adductor mu.sdes, and thus lessen the divergence. luw degrees of exotropia, or in those cases where the af;iremen- 'iied treatment is successful in converting the <>xotropia into an ■■;ili<)ria, prism and stereoscope training sli<iuld be iriiide use of. \fter a fair trial has Im-cii given these remedies, and par.'il- 'i-in or binocular tixa'ion is not attaineil, u|H'rative measures are I'd for. The remaining deviation shouKl be overcotii- by ;idvance- iit of till' internal rectus of one or both eves, not forg«'tting the 176 Tim EYE. |i ! vertical deviations that soinetimps accoiiipiiiiy this form of wiuiiit. Whfii the patient has onco possessed the ik)W.t ol l.ii.oruhir v.si,.i. the oiH'rative tn-atnient is n.ucih more likely to Ik- successful, although aperi.Mlof stereoscop.. training may properly occupy several montlis both before and after oi)eration. Hypertropia. \ertical deviation iimountmn to sciumf is u>uaU\ associated, as has b«M.n mentioned, with ex<.phona or .snj.horia: in anv event it n.av l)e tt-garded as a late sta^. or exagp'rated forn. o hvix-rplioria. Viany i.atients exhibit a deviation in the vertical hue which mav at one moment present a liyi)erpli<.na and at anothe. a hvpertropia. "As long as th.' patients fusion iK.wer is sutficieni a aiiv tune to brhig about bhiocular vision, the former condition obtains; the moment this fails one eye turns up. and we have a ver- tical s(iuint. What has been said cf hypoi.horia is largely true ol hvwitronia, both as to causation and •reatment. _ Anaphoria, Anatropia. Oataphoiia. Oatatropia. ht. ..us wa-s the first to describe a class of ca.ses in which l)oth visual ax.-s deviate either above or b,-l.,w th.> horizontal plane. If the condition be pn^ nouncMl and re.,uirv careful te.sting to prove its exist.'iice. he desig- nates the anomalv mmphnrin, when there is a deviation ot both axes UDward. or mUiphma in deviation of both ax.^ downward. If the uiibalance Ih' more mark.-d. we have an anatropia, or a catatroj.ia Wlnteser be th<' nature of tliis unusual condition, it is .liscover.>d bv means of the .screen or cov.t test. In anatropia the right eye turns ui) behind the scn-en. while the left eye fixes, th<- left ey.- rotating UDWird and not .lownward iis in hyi)ertropia, the moment the cover is transferred to the other eve. In catatropia a downward excursion is noted inboth eves with thec.ner test. Stevens attnluites a numlH-rof evil conse.iuences to these coiiditions.which he remove^ bv ..|.«"ration. Paralysis of the Eye Muscles. .Mthough for the purpose ot mves- ticution it is desirable to .-on-^idei lh.> -ular palsies apart Inim b( tero- iroi.ia and the various forms of s<iuint, it is often .lithcult t=. ditleren- ti-itc <me from th ■ otlKr. .lust where f-inctional weakness of a muscle emls and paretic insufficiency In-gins is, uiK>n occasions impossible t. ^ demon.strate. Muscular paralysis may lie of mtr:;. ranial or orbital origin: in .)ther wor.ls, tlie nerves and nerve centres upon which th.'ir function depends may be attacke<l in the cortex (cortic:i, nirilv^'-t hi both cortex and nuclei (cortico-nuclear). in the nuclei aione (nuclear), within the cranium and along the p."riphery icranio- periph(M-ai), or within th- orbit (orbital). The c.-ntral causes (>f these ormnic lesions are conrnonly constitutional, especially lues, rheum:.- tisMU and tulKTculosis. Thev are often associated with talx-s, paralysi> of th.' insane, brain tuin.)rs,basil;ir m.-ningitis,an.l .ith.-r proc."s.ses m herent in the vari.)us forms .if intoxieaiion Uiberculosis, diphtheria, hvsfria, nei.hritis, diabetes, din-ei anu ii.dir.-.-t iniury, <>tc. /"/<;"- genital paralysis, /</<»>-•/.- is th.' most .oiaiuon sign, while paresis .>! tn.' e.xternal rectus alon." is frciuently ^'ncountered. MoTIoyS OF THE EYEUAl.L A.\D TIIEIR DERASUE3tEyTS. m gymptonu. ( )cu!ar paralysis sets in without warning, I'.ulcss it be hcii'lachc, or ilv,' syiiiptoias of disease (r^enerally of the nervous sys- tem), or liauinatisni with wliieh it is so often ass«(eiate»l. Double lisio'n if usually the first indieation the i>atient has of an attaek. It is extf^inely annoying, particularly if it \v' ohli(iue or vertical. The iliplopia persists (luring the attaek, and is often iussoeiated with ier//;/o. ,iiiii.-<e(i, iKrnsioiKil vnmitiiKj, mintul nmju^wn, uncertain yait. and a ,v, H.vr of insf.uritjj while walking alM»ut. The eve under the iiifluenee uf pan-lie niu-eles do«"s not see objects in their proper (wsition, and to tills jnlse proki-lion are due the uncertainty in walking and grasping lijects anil other disagreeable eonse(|ueiices of the jjaralysis. The iiMial innervation effort put forth to assist the disabled eye to Hx is till" source of the error. It was employed by Craefe under the name ■ luuch test" in testing for the |)aralyzed m-Lvles. The patient covers ilir sound eve with one hand and with hv." forefinger enileavii:-s (luiekly to touch the tip of u l)eneil held In-fore him with the other. He will direct the fiiigiT tip to the side of the pencil corresponding 'i the paralyzed muscle. In time, however, the jjatient learns Dy expe- lienee to make allowance for this error, and for him the test is value- less. After a time the patient learns to close one eve, so as U: s'mt uiit the confusing second image; or if i>tosis set in, the same •'■> < served. Ilventuallv, also, the head is turned toward tlu side (,: • paralyze.! muscle (iipward in elevator, downward in d<t)ri<s„r m- ■> p,iralysis),as this action corn-cts or at least duiiini.shes the double vision. These unnatural [Misitions of the head as.>*i.st the surgeon in making a diagnosis, although it shouUl not Im> forgotten that .similar poses are seen in heterojthoria and in some other forms of hetero- Diasnosis. When a single muscle in one eye is recently paralyzed, it is easy from the svmptoms and by in.spection to say at once where till' t rouble lies. Mon" frr'iuentlv, however, a careful insiM'ctimi of all \hv excursions of both glolies is neces.sary before a correct diagnosi.s 1- ,i. he made In anv event the i)atient should be placed with his head ill tile i)rimarv position and asked to follow, first with each eye sepa- i:i!elv and tlien with both together, the poiiii of a pencil while it is .MvriiMl in various .lirections in front of his face Many an> the M lirmes that have beiMi devised for detecting the character o. p.".ra- Iviic s,,Mint l.v making use of the double images invariably pn-iluced 11. some i.art of the field bv even a slight muscular i)aresis. ( )l lli.-s., i.r.bablv .\Iautli.ier-s (Fig: 00) pictorial table of single muscle paresi.s :- the simplest There are several reasons why it is so often dithcult . determine bv means of tiie dil.lopia test alone what mu.srle or iiiiscles are affected. ( >no does not always have intelligent patients . deal with: the pare.sis niav affect more than one muscle, or i ma> - omplete in one eve and incomplete in the other: or. wiiee one ve alone is affected," a single muscle may Ik- completely pan.lyze.l . liie others are only partially affecte.1 Moreover, when the cr.>e is 12 178 TllK KYE. of limR -^t^indiiiK, ciitrartums of tho aiitnsonist iiiiisrW aro prntty miP' In -t iii.an.l tli.-r." inaviilso Im- in such (•as«"s a sur.-rwful .•ffort, ina.k in the interests of ti.e n. rvoiw system, t<. suppn's-s <-i|tirely the iinane in the .leflecte.1 eve, v i.reviotisly existuip miisele inibalam-e or I inarke.l .litTen-nee in the visi-M of the two ey.-s also acts as a dis- im.infr factor. There niav h.. n.. -quint wh.-n tlie eyes an- turned away from th.- paralyzed nuisele, hut it is readily |)rodu.-e.l when they Fill. '.«• Belatioss of thb Double Images in Pasalysis of the Otplar MrscLEft (The True Imajre i* Barred.) KiUTmU Kectut. rioublt TUlon on looklnu i"W«nl the iwrnlyzed ililf. The lmiwf-'*'ii«r»tl<>n Increue* with »bdafUon of the panlywd eye. ^ I Hternal Rectut. Donble virion on looking toward the unaffecteil side. The iiei«ratlon of the imagea Increases with the adduction of the paralywil eye. Supfrior Xeeliit. Double vision on rotating the eye ui>- warl. DUtance between the Imagea In- creaf ■•< when the paralyzed eye 1» ralscil and abducted. The obll.iuliyof ihelalae image U Increased by adduction. i> f 11 ; Intrriw Rfctut. Double vWon on rotating the eye.lowB- wiird. IHslauie between the Image!, in- crca.«e«when tlie i«ralyaedeyc is lowere and gWucL-i. Tlieohlliiuityof the liiNe image Inoreases on adduction. \ Mauthner-s scheme f.r ilie dele.' tin . f tl"- ""cctol muscli* in ocular p«l»y. MOTUISS OF TllH EYEBALL ASlt THEIR DERASnEMEyTS. 179 Doable vtRi'm nnnitattiigrxiMlownuiiril. l)lt>tjtiic« betwei'ii liiiflKi'H iiirri'ue* when the |«ralyn*tl eye bt Uiwi-rvil and vldtirteil. The i>hli<|iiliy of tb* Atlie linage lnrre<«e« wltb tbductloo. Ir\tfrior Ohlique. Double TlaloD on rotating eye upward. Dtstance between Iniagea Incrcaiea when tbe eye Is imiiie<l and aililucle)!. The ob- liquity of the falte imatce lnrreaic« with abduction. TV lateral 'littanre between the Images Increases as the icralysed eye Is ralml and abducted. Mauihner's wheme tor the detection of the atftcted mnsdea in ocular palsy. an' nitiitctl towani the scat of paralysis. The deviation is more marked tlio wider the attempted exeursioii, while the hniitation of iiiuvciuent notieed can usually l)e referred, without ditticulty, to the \>ii>\H'T muscle or set of muscles. // the affected eye fix an object ilirectli) in front of it and the .sound eye be covered, the latter xrill dei-iale In a qreater extent in the Kame direction than the jHiralyzed eye. This ^viimditni squint is an overaetion result arisiriji from the excessive iiiiicivat'ioii effort needed to allow the affected eye to fix. This fact i'^ to lie remembered in the differential diagnosis between functional .uid (.rtranic esotropia; in the former the primary and secondary 'lcviati'iii.« Mil' eipial. Unilateral Paralyses of the Orbital Muscles. Paralysis of the External Rectus. Abducens Paresis. Paralysis of the Sixth Nerve. \'W\< \> llie cmiiiionest form of the individual palsies. The long ■uiir.<e .,1 the .sixth nerve through its bony canals renders it jx-cu- !i;,rlv 11 d.le to diseii.se from the various meniiifiitic and other proces^ses •l,,,i' niav oc.'iir during its pa.ssape to the external rectus ma«cle. !i i< often round as a part of rheumatic, syphilitic, an.l traumatic .nditioiK as well as in ilisease of those central neurons with which i.r sixth nerve is a.ssociated. Wood says that wh.-n the paralys's MHM-ipheral it is likelv to he due in adults to syphilis when not ri^iiii.tly of rheumatic'origin, but that it is generally tulx-rcular in liildreu. MICROCOPY RESOLUTION TEST CHART .ANSI and ISO TEST CHART No 2: ^ ^'^PLIED IM^GE ^^. '"^-^ i:.j5' Uij.n SN*et — _» Rochester. fv*w roftt li^a t'"6) *8^ - C300 - c- 180 THE EYE. ( Third Nerve Paralysis. This is next in order of frequoncy of the one-sided i)areses. The most common sign is paralysis of the levator palpebru' causiii<; pUms, with a loss of the normal skin-wrmkhng of the affected lid, although the latter can he partially raised by contraction of the frontalis muscle. When other branches are implicateo, the plobe is defective in all its excursions except the downward, upward, and outwanl movements. The eye deviates outward and downwanl owing to contraction of the unaffected superior obluiue nm-cle, and the upper end of the vertical meridian will be plainly seen to turn towanl the pose. There is cxoiMialmi>s from relaxation of so many recti muscles; dilatation and immobility of the pupil, as well as jwralysis of acconimodiition from *he uivolvemeiit of the iruhc and ciliary fibres. The mijdrnms, which may be further increased l)y atropine, is unaffected h\ lif!;hl, converfjence, or the consensual test. ^ ision both for distance ••md the near point is affected about as it would be if a cycloplejiic were instilled into the .-ye. The dii)l()pia is crossed the false imajte being higlier, and its upper end is inclined towanl the i)aralvzeil side. Paralysis of the thinl nerve is often incomplete, and it may be associated with the same; affection of other nerves. If the ciliary inuscle and iris aie alone involved, we have an iiiternnl ophthnlnw- pleijin: if the (>xtrinsic nmscles are all affected, an cxUmal ophlhiil- mopk'fiia: if both external and internal muscles are paralyzed, a total op'ithnlmopletjia. . „ , , ,„ + j ij ; .\ form of recurrent oculomotor paresis, calle.l by ( harcot optitlwl- nvmhjic mlqmim', attacks children and young adults who suffer fr.m seven; headache (atteiuled by nausea and vomiting) on the side of th;" paralvzed muscles. In the intervals of the early attacks. which last from a few days to a few months, the muscles regain their normal functions, but the paresis l)econies more marked and at last it ni:iy be perman -nt. The disease affects both sexes e(|ually, and is" accompanied t)y ccmtractiim of the field of vision and lowering of th(> central aoiitv. ' Its real natun' is obscure; some writers believe it to be hysterical, Others attribute the symptoms to a lesion of the nerve n)ot at the base of the brain. No treatment is of avail. Paralysis of the Superior Rectus. This is not an uncommon unilateral paialvsis. With it there is Hmited movement upwanl and towanl the unatTecteil eve, accompanied by diplopia in the up])er hall' of the tield of vision. When the patient looks in this direction divergence is the result. The face, in fixation, is turned up, while liothU and the head are incliiie<l towanl the sounil side. The n'la- tive position of the true and false images will be seen on consulting tlie chart (pagi- 17S). _. ^. . „ , - _iu Paralysis of the Superior ObUque. Trochleans Palsy. Fourth Merve Paralysis. Thi - mu.scie is rarely panilyzed alone. The diag- Mosis p^n u-u:i!lv W luMde in n-cent cases by the diplopia-scheme test (page 170), or bv n'membering that there is homonymous diplopia on MOTIOSS OF THE EYEBALL AND THEIli DERAHOEMESTS. 181 lookingdown, that the false iiiiagf is lower, with its upper eii-l iiieliiied toward the healthy eye. It is a very troiiblesdine form of paralysis, and the patient is comjx'llod to close one eye to avoid the double vision in the lower half ol the field. Unilateral ami v<olaled paraly.sift of the inferior rectitu, inlirnal rectus, (ir inferior oblique is extremely rare. \\'hen any of these does occur, it can, especially in recent cases, he diagnosed by the symptoms and a study of the positions and relations oi' the diplo])ic iinapes. A fairly large percentage of ocular palsies afi'ect the associated movements of the two eyes, and while, as before stated, almost any or every combination of paralysis of the muscles of the two i\ <s may occur, there are particular examples that call for mention. Paralysis of Convergence. This may result from true nuclear or supranuclear disease. It is not necessarily followed by diplopia, but the patient is unable to fix with either eye at the near point : the optic a.xes remain i)arallel in all movements. Conjugate Paralysis. Inability to move both eyes toiri'ther, either to the right or to the left, while the convergent jjower is jjreseryed, is not hifre(iuently seen. The lesion in this case is probably cortical, although it is also claimed to be near the sixth ne;-e nucleus— s;i id by some observers to Ix" the centre for the a.ssociated lateral moti. iis of the glok'. It Ls often a distant symi)tom, as in hemorrhage into or disease of the cortex, pons, internal cajtsule, etc. It usually lasts but a short time, because disturbance of the centre in one side of the brain is soon ((uelled y the unaffected second centre. In deMructire lesions with this symptom the ejes turn from the paralyzed side (Swanxy) when the cerebrum Is the seat of the disease, but toward the i)ari!lytic side in pontine disease: the eyes turn toward the con- vulsed side in irrita'ire lesionx of the cerebrum, but away from it in irritation of the pons. Conjutiate parah/sis of both ujnrard and dovmvard morement, due to disease of the thidamus opticus and the corpus striatum, has also been recorded. Prognosis. As a rule, the periph Tal paralysis (due to exj-osure to cold, rheumatism, injurv) gets well, but where the cause of the palsy is intracranial the prospect of a cur(> Is necessarily more remote. The first attack of ocular j.aresis that heralds the api)roach or forms a part of talK's dorsalis mav disappear, only to recur and become per- manent. Indeed, it may well be remembered that an attack of ocular paresis occurring in a man over thirty-fivr years of age— particularly if he has had earlv syphilis— should arouse susi>icions of a prob- ai)le posterior spinal scl(>rosis. Probably the paretic cerebral com- plications of syphilis (gumma, local periostitis and the like) are as am.'uable to treatment as anv paralysis of central ongin. In most cases manv weeks or months mav elapse before uni)rovement or cure rrsults. the longer a paralysis has existed (with or without treat- iiuiit) the less the hope of eventual cure. K 182 THE EYE. So far as possible the cause of the paralysis shoulil Treatment. be removed. Where tlie . 'iii ol tne xroume i^ „,-.. ........ ■••-•;. ^ lici Ten t.) twenty g .in.^ thre.. tinu-s daily, has, in the writer s h. u b n ouml inore .lesirable an.l more rea.iily borne than the sXvhtes This shoul.l be oomi.ine,l with an antirheumatic regimen V ,7r baths, and copious .Iraughts of lithia water. Injuries should ha e the ca e proper to them. All the other cas..s. unless there i.s s-mie contraindication, should at once ho ordere.l a -u-' "f -*^^ <^ p.,tassic iodi.le (or both together) in increasing i oses. to be gn n 'between meals and in a large .,uant ty (pmt '>^.;;7' "f 7^*' ', • ^, ;^. patients will tolerate M) or 4(M) grains .ally with beneht. lli> .> , supplemental by mild me.rurial inunctions, and - I « " ^ should neantime take, three or four times every week, the Turki.sh o he o liurv sweat bath. For the b,-nefit of the ..hange (as well as the hot vat,.-)- patients .lo well at various h..t springs hen> and abroad. Coincident with this, the treatmeiit i-I-"V'\'" ui ^th' 'b m^:^' tubercle, and brain neoplasms is ">'li<-ate.l altlu.ugl m m .^ instances it will not be followe.l by any good result so far a^ th. ''":;ISi?v;V";"':k'n!rn.nt ,2 to o milliamperes) of the interrupted ga vane- -urrent will br found of use-the eathode over the dose, Hd ,;r on th.. eo,.ainiz,-.l seh-ra. n.'ar th.- ius..rtioii ..t the paralyz,>,l muscle, the an,)de at the nape of the n.'.'k. , i... Michel's plan ,.f grasping the cncaimz.'.l CMiijunctiva an.l scl i. will a pair ..f HxatiV.n t'.rc,>ps, an,l f.)rcibly ..xercismg tlu- ,.nfe,^bl.-.l uHc le bv n.tating th.- glolM' back an.l forth in the .lirecti.m ..f its ^^ .MLut ; mhiute 'ich .lay, is ,.f s,.me value. Other forms .. cx,-rcis.., with prisms ..r Hxi.ig a n.-ar obj.-ct f..r a few nunut.-s at . time s..v..ral times a .lay in all p.issibl.. .lirect.ons, nu.y hn-..> the eff.>ct of i.rev.-nting s.coii.larv c.ntractuivs an.l of stiniulating dm periph- Z\ n.-rv.. lilm-s. SomVtim..s, when the paresis is slight, correcting pr'isms reliev.- th.- .liplo,.ia an.l the vertig... In chn.mc paralysis I,ft..r the foreg..ing tn-atiiK-nt has b.-en ai)l.lie.l with..ut success, when ■the pairtic muscl.- r.-tains son.,, cntractile pow.-r a.lvancem,.nt of lu- w,.ak musd.. with Tenon's capsul.. may be tri,;d. N>ction of the antagonist will always be iie,-.le.l. If th.- paralysis be c.mpl.-t.-. no oi(.-rati.)n sIduI.I be un.lertaken. ri»,„K«.i Paralysis of the Extrinsic Muscles in the LocaUzation of Cerebral Diseases. Third Nerve Paralysis. H..aring in mm.l the nucl..ar an.l corti.-al centn-s of the ,-y.- musd.s. unilaUral ,>los,.i^oiH- is n,-arl>- alwavs ,lue t,. impli,-ati..n ..f the ,-,.rtical (associat,-. ) centr,. m th,. opp„Vito upper ,.xtr.-nnty of the ascen.ling fn.nta cnvlution- ,i!.,. th,. arm centr.-. Is.,lat.',l pt..sis is. h.-nc... <-all.-.l cen-br',1 ptos>. \\rr<\< of th.- l.-vator palp.-bra- .occurring ,-/* the saw, ./c as the le.iu,,, whhout implL-ation of th.. oth.-r hranch.-s ..f th.; »>''>' V;?'^'';:"'^;' „' dis,.-,.,. .,1 the po.is Varulii. Iii d,-tn.<-t.v.- 1,-sions of the .-n s «lu r, there is crosse,' -paralysis, pt..sis is usually present as part of a totiil MOTIoyS OF THE EYEBALL AND THEIR DERAyOEMEXTS. 183 third nerve paralysis. If, under these circumstances, only the branch supplied to the levator be affected, one may diagnosticate a lesion of the peduncle. When oculomotor pare.sis is found on the same side and alxjut the same time a.s a central lesion shows itself, with loss of sensation and motion (including facial and sometimes hypoglossal paralysis) of the opfMisite side of the body, we have a " crossed hemi- plegia" that almost invariably means destructive disease of the crus. Lesions affecting the basal neurons are, however, the commonest of the oculomotor paralyses, and these are usually comitlcte. It is not always easy, from the character of the |)aralysis alone, to differentiate between disease of the crus and purely basal disease. If there is no other paresis, or if there is an incomplete hemiplegia with the third nerve })aralysis, the changes are almost certainly at the base of the brain. Om'' must not forget that oculomotor jKiralysis may occur as u distant (pressure) .symptom, especially in brain tumor and tlirom- l)osis of the cavernous sinus. Paralysis oi the Sixth Nerve. Owing to the many connections formed bv the abducens during its long course from the liain to the external rectus muscle, it is subject to jjaralysis in lesions not directly reaching its nuclear origin. Cerelx'Uar tumor is an example of a dis- tant lesion especially prone to affect the sixth nerve in this way, and one or both nerves "mav lx> compromised. \\'hen abducens paralysis appears as the onh/ focal sign, it usually means basal disease, and, apart from fracture of the petrous portion of the temi)oral bone, is likely to be due to svphilv . particularly if it be bilateral. When iiara'lysis sets in with" an opjmslte hemiiilegia and other evidence of cerebral disease, the lesion can be referred with confiilence to the pons. A hemiplegia due to a lesion in the cortical motor area furnishes much the same symptoms, except that the i)aralysis is on the same side. Owing to the close relations of the nuclear centres for the sixth and seventh nerves we often have facial and abducens paralysis occurring together. When these an- associated with a crossed hemiplegia the lesion is in the pons. Paralysis of the Pourth Nerve alone is a very rare occurrence in cerebral disease: when associated with i)aralysis of other oculo- motor nerves it is practically impossible to separate^ it as a localizing ■<i.'n In the former case it is the result of a basal lesion: when it s.^s in with third nerve paralvsis it indicates a lesion of the peduncle. \s Prevost has pointed out, and as we have iust seei', m conjunnte deviation of the globe due to paralvsis of the as -"i:.ted muscles th<- cy.'s ar(> turned toward the sitle upon which lie central lesion is -ituated. , , i *i Spasm of Accommodation, The constant demands made ujion the • iliarv muscle and the habit so engen.lered are such that, in young p.rs„ns esiH'ciallv. relaxation of the nmscular contractions does not alwavs take place, so that the true state of the refraction is masked. If the patient Ix' hvperopic, he may apjjcar emmuUopic or myopic; it l64 TUE EYE. or somt wise \V( (Miiinotropic invopic, ami if myopic the myopia may seem to he Kmitcr than it really is. This fact "furnisiit's the reason why a patient may pri'sent perfect distant vision iis measured i)y test-tyi)es, and yet have a fairlv hif^ii degree of hyperopia or astigmatism, or both. In other cases the spasm is so marked that a hyperope may have greatly diminished distant vision and ai)]3ear to be myopic three, four, or five dioptres, ('oncave lenses may, in such instances, be accepted and aiJi)arently restore the lost v; 'in for a time, but visual acts will i)e painful, and all the other signs of eyestrain (heatiache especially) are liki'ly to b<> present. The occurrence of acconunodative spasm teaclies us the n<ed of paralyzing the ciliary muscle with atropine, other cycl(jplegic, before measuring the refraction; otlu-r- cannot be certain of the condition we have to ileal with, unless the patient be past forty years of age. .Mon-over, it is wise to assist in breaking off the spastic habit by ordering the patient to wear the glas.ses bef<jre the effects of the cycloplegic have passetl away. Spasmodic or Spastic Heterophoria. Just as spasm of the accommo- dation occasionally arises from strain of the ciliary nmscle, so may we have oveniction and cramp of the straight mu.sdes. In their efforts to overcome a nmscular imbalance some particular nmscle may be s.) stimulateil to overwi '< that the real nature of the heterophoria is completely masked, fhis is the reason why a complete correction of the refractive error should be made, preceded or followed by mus- cular rest, before dealing with the heterophonc defect. It often hap- pens that an apparent heteroi)horia disappears and the patient is made comfortable after glasses are ordered. The relief afforded the ciliary muscle is reflected upon the tasks of the orbital muscles. For exampU", an apparent esophoria for near may bc'comean orthophoria to tests when convex working-gla.sses areem])loyed: or a right hyjier- phoria may dissolve into a left-sided vertical defect after the use of prisms, or >f leases correcting the ametropia, or from the employ- ment of both. Certain forms of manifest hyptwxophoria and hypoesophoria are either pure hy|)eri)horias or pure horizontal deflections, the impulse for binocular vision so affecting tiie related muscles that they come to tlie aid of the defective ones and bear most of the burden. It beh()ov(>sthe surgeon, therefore, to n)ake a number of tests at hiter- vals before deciding in doubtful cases, and, if possible, to keep the patient for a week or more under the influence of a cycloplegic. When persistent contraction of a mascle has lasted for months or years a form of timic cramp arises that may retpiire. in adtlition to these measures, tenotomy of its tendon with or without shortening or advancement of the op|)osing nui.scle. Operations on the Eye Muscles. When milder means are found insuin ■ietit to restun* binocular fixation or to r<-lieve spastic str.ijn, operative interference is indicated in most cases. The chief point MOTIOyS OF TUE EYEBALL AXD TUEIR DEBASOEMESTS. 185 to be borne in mind is the need of conserving the rotating force of tiie ocular muscles. It is conseciuently better for the future of the patient to strengihen a weak nmscle in our attempts to bring about the necessary balance; of power than to accomplish it by reducing the effectiveness of the stronger muscle, even if we know that its overuction is ilue to spasm. The kind of operation suitod to the case in hand is important, and, although it is not po.ssible to foinmlate precise rules for every contingency, the following aphorisms may be of value: 1. A simple tenotomy of any one adilucor or abductor muscle alone is rarely useful anil seldom recjuiied; as a rule, rist under a cydoplegic combined with a full correction of refractive errors will relieve the spa.vn of a single nmscle, and so avoid the necci^sity U ir a solitary tenotomy. 2. Tenotomy of a single sursumductor alone is freijuentlv of value. 3. Advancement or shortening of a tendon, with or without tenotomy of the chief opposing muscle, should b(> done in most caot-s of abnormal deviation in the horizontal plane. 4. Where advancement (or tendon-shortening) on one side is insuf- ficient to correct the error the same operation on the other eye is preferable to tenotomy. 5. When possible, operations should be done under a local amesthetic, ami that method chosen in which pro- vision is made for increasing or diminishing the operative effect both during and after the operation. 6. The probable effect of the opera- tion should be tested (red glass, cover test) during its progress. 7. Whether an overcorrection or a partial correction of the deflection is preferable will largely depend upon the refractive condition and the occupation of the patient. 8. The more the cajisular attach- ments, check ligaments, and muscular fibres are disturbed or in- cluded in the tenotomy or advancement, the greater will be the effect upon the rotation of the globe. Duane lays down the following rules, that differ m some respects from the foregoing: (a) In convergent sijuint due to overaction of one or hv\ interni, tenotomy of one or both interni: when due to weak extt nn, advancement of one or both interni, with tenotomy of the latt'r; ib) in exophoria due to overaction of one or both interni, tenotdmv of the extend; when due to insufficiency or paresi.« of one or both "interni, advancement of the latter, combined, if necessary, with temitomv of the externi; (c) in non-conutant hyperphoria (whore the angle of the two visual lines constantly varies) due to weakness of the superior or inferior rectus, advancement of the weak muscle: when due to overaction of the superior or inferior rectus, tenotomy of the overacting nmscle: when due to insufficieii<y or l)aresis of the superior oblique, tenotomy of the inferior rectus of the other eye: when due to overaction of the superior dhlique, advance- ment of the inferior rectus of the other eye: when due to weakness of the inferior oblicine. tenotomy of the superior rectus of the other eye; .„„1 when due to (!ver.iction of the inferior obli(iue. advancement of th superior rectas of the other eye. When the deflection of the ■'Mm: 186 THE EYE. !(i noii-fixiiig eve has constant relation to tlu- fixing eye (coniitant hypcr- phoria), tlu'"l)cst ronicdy is generally tenotomy of the superior -ectus of the higher eye.' , ,, , , . Every operation on the eye muscles- should be done under aseptic conditions. A 2 per cent, holocaine solution or cocaine (4 per cent ) is the ideal local aiuesthetic, while adrenalin (1: 1000) or somi' other suprarenal capsule preparation will give an almost bloodless tield of operation. It is as yet undecided whether these agents favor a post-operative hemorrhage that may interfere with the success of the operation. Tenotomy. A speculum (or two '" retractors held by the assist- ant) is iiLserted and a fold of cor' va and capsule imnH>diat<'ly over the central insertion of the c-le firml'j grasjjed by fixation forceps having at least four tcH'th. I'he underlying structures are now drawn sligiitlv awav fioin the globe and an incision is made with \\w tenotomy sci.ssors, care being observed not to cut through the tendon itself. Sufficient space should be given to enable the surgeon to pass a strabismus hook above; or below the exposed tendon, so that ita point presents at the oiiposite border. A snip of the sci.s.sors, one blatle of which is also passed Ix'iieath the muscle, now severs the tendon as near its insertion as i)ossible. If he prefers it, the operator may proceed as for partia' tenotomy (making a 'Hnitton-holo" or entirely central opening in the ten.lon) and complete the central incision toward each in:irgin. If, on testing, the first result Is deemed insufficient, the wouiul in the capsule and conjunctiva is enlarged and the supplementary fibres on both sides of the tendon arc carefully and gradu'dly divided on the hoak, several deviation tests being mean- time II, itle. .As a rule, 5 to 10 prism tlegrces of deviation (or less) are obtained by a simple tenotomy where the retaining lateral fibres an; undisturbed. If the capsular attachments and check liga- ments are undermined and divided, a greater (and unknown) effect follows even to marked limitation of the excursions produced by the muscle o|)erated on. It is not neci-ssar\' to suture the wound. The after-treatment consists of cold applications every two or thr(>e hours, followed bv a simi)le coUyrium. such as two gratnmes each of boric acid and borax in 100 grammes of a 1 : 10,000 solution of mercuric chloride. If, not later than forty-<'ight hours after the operation, an oyercor- rci'tion be found, a suture in.-luding the cut end of the muscle, Tt ;on's capsule, and the conjunctiva, should be so placed that the over-defect is reme<lied. If excessive bleeding occur, it is better to iwstpone the operation, chieflv becatise it is then difficult to estimate the final effect of the tenotomv. Bandages are objectionable since they prevent the use of the (\ves in binocular fixation— an exercise that should begin iinmcdiatelv after the operation. Advancement. The tendinous insertion may Ije brought fonvard with or without resection of a portion of the tendon itself, or the latter I Ara.Tii:*iiTi'Xt-b.>.>knf Disease* iif tlie Eye, 1S99, pp. Jil-'CJ. MOTIOXS Of THE EYEBALL AXD THEIR DERASOEMESTS. 187 may be shorti'ned by making in it a "tuck" or "knuckle." Of tlu" numcroaM operations for simple advancement, the writer has for many years been satisfied with a nioditieation of the weil-known oiK'ration of Schweigger, combinetl with the Black method of tying tiie sutures. It is usually done under a genera! ana'sthetic. A full carved needle is threaded with No. 3 iron-<lyed silk, bringing the en<la of thread together and tying them in a small hard knot, or both ends of the thread may be pa.s.sed through the eye of the needle at the same time, leaving the end of the suture iii the form of a loop, in- stead of a knot. The neeilJe is now |)a.'<.><e(l tiirough the conjunctiva, iaking a good bite into the .sclera close to the cornea, as indi- cated in Fig. 9;i. After the thread is j)ul!e(l about half-way, the needle is pa-ssed through b'tween the threads on the other side of its entrance into the sclera, and then drawn home, thus affording a firm point of fixation. A shnilar suture is fi.xed in the same manner U])on the <)])posite side of the cornea. The conjunc- tiva and Tenon's capsule are now well divided over the muscle, the latter being thoroughly exposed and well cleaned of connective tissue. Two strabismus hooks are passed underneath themu.>icle (one from each side I, or an advance- ment forceps (Prince's or Clark's) is made to grasj) the nmscular body, so as to hoKl it steady and away from its bed. The sutures are now passed through the muscle from below upward as far back Advancement of a inuM'ie. Kx> poeure of tb« mii'^ele. (Uan^ki.l and Rebeh ) Flo. 92. Prince's advancement forcei«. as is believed neces.s.arj', and pulled about half-way home. The muscle, still held with the hook or forceps, is now cut off just in front of the entrance of the sutures. The piece of tendon attached to the globe is grasped and cleanly dis.sected out. The sutures are now pulled home, and both grasped between thumb anil finger, while the glolx* is fixed with forceps on the nasal side of tiie cornea and turned outward (in ojM-rating on the external rectus), wliile the nuisele is advanced to the desired position. The stitches are now tied in a surgeon's knot over the muscle, as indicated in Fig. 04. The original ojiening in the mucous membrane is stitched together by fine sutures. Th(>re may be some reaction following this "[MTation, 'requiring the froijuent .applic.-.tion of hot fomentations, but if proper precautions have been taken this is unusual. 188 THE EYi: m ( )no of \h- !i...st ftTcctivc inn liods of slwrlrninn the muscle, by takiiiR •I "tiu-k" ill it-i iciitloi.. is comprised in an ailvancfnicnt o|HTation '.Icvis.-.! iu part l.v Frank (". To.l.l. Sui)posinB th.^ nitcrnal rectus, to Im. opcratcl on. a" Hap of i-onjunctiva and Tenons eapMiie is dis8.Tte.l vip and turned bark, so as to free.y expose the tendon. ( KiRs. (id and 97. > The ui)iH>r and crossed prong of the "tucker" is inserted In-neath tiie ten- don and the arms of tlie instrument sei)arated l)y tiie screw-nut to produce the desired etTect. as shown in I'i;^ '.»o. Catgut sutures are passed above and below, tln-oUL. the I'ln-ee layers of ten- don and tied, as in Fig.OS; two double- threaded black-silk sutures are i)a-^>ed (one al)ove and one below) through the looj) in the tendon, thence through the conjunctival fiaps and epi.sderal tiss\ie on either side of the cornea to ose the wound, and act as guy-roiies while the healing process goes on. Nystagmus. This svmptom consists of mvoluntary movements ot the glolK', either rotary, from side to side (horizontal nystagnms), up Adraneement of a muscle, liilnxluclion orsutureii. (IIANSKII. nn.l Rkber.) Flii. M. First step. Sft'on.l stc('. Iiuroiliiction of siit\ire8 In advancement operaUons. (Black. ) •ind down (vertical), or a combination of these excursions. The sec- ond is [\:r rwinnionest variety, and it is often found in those Ix.rn with defective sight— e. 7., in albinos, in coloboina of the choroid, and in other developmental anomalies of the visual apparatus. These patients ffm M(>TIOXS OF THE EYEBALL ASD TIIEIR DERASdEMEXTS. 189 arc unconscious of tlio oscillation of the glol)o, and do not complain of it as such. That this jwculiar condition may Ih' hereditary is well .shown by many nh.siTvers. The writer' reported a family of twenty- three children and grandchildren descended from a pronounced hlonde male ancestor, with ix'rfectly healthy eyes and nervous system, and a decided brunette with myopia and conpenilal ii\ stafimus. Two descendants oidy were Sruncttes; they were the subjects of marked congenital nystagmus, while the other twenty-one had healthy eyes. From these and other considerations it sedans justifiable to a.^sumc tliat there is some fault of the co-orilinating centres in most of the Flu. 95. Flo 96. Flo. 95 Instrument fur placing a " liicH." in miiwli'-shorteninK. (ToDD.) Fio. 96.— Muscle-ihortening with t Todd " tucker.' Fjr>t Muge congenital cases. While visual defects are fre(|Uciitly present, yet not everyone with congenital visual anomalies has n.,stagmus, and, ill some 'instances, the eyes, ajjart from the irregular globar excur- sions, are practically normal. Acimred nvstaginus is present in M per cent, of all cases of sclerosis in ; 'tches, and it is also noticed occasionally ui those who work in abiion-al or strained attitudes. A well-known example of the actpiired variety is " miner's nystagmus." Here, to the uniiatural positions these work, rs are obliged to assume for hours at a time, is adiletl insutiicicnt light; the ocular centres of co-ordination are not 1 North American PracllUoner, April. 1«92. n * i I 190 Tilt: Ai'A' ,,rn,,.-rlv stiim.hito.l. ovviiiK to a lack ..f ,l.-linit.; r.-lu.al inmpcs aiul tl... unvvont.a >liain on tlu- obli.,u.' imis.-l.-s in |.arti.'ular cihIs ni irn'Kular n.ov.-n.rnts of tlu- >ilol«-. W." thus l.av to .l.-al with a ,,rof,-ssi..nal inro-or.linatio.i of a class akin to wrifrs cranip. m m.livi.luil ^<» atlVctcd In-inn l."tli conscious of an.l annoy.'.l l>y tlio trouble l-atcr on, his nervous system a.lants itself to the situation, iust is'in tlu- case of congenital nystagmics. The treatment ot the congi'iiital variety is to iinjirove the vision, if possible, and to correct no. w. Km. »n Third auge If this b Mii»cle<hortenlng with the " tucker.' staKe. muscular errors. done, improvement often follows. The nystagmic patient usually holds liis head in a peculiar posi- tion while fixing for both distance and near; he should bo allowed to continue this practice (unless it Ix" ilue to imbalance of his muscles), a.s he often succeeds thereby in steadying the iwcil- lating eyeballs. Patients vitl ac- 8»eonii (niired ny.stagnius should abandon their injurious occui)ation. and give their eves prolonged rest, correcting-glasses being ordered for distant Hxation. A cure generally f<.llo -^ if hygieiuc measures are "faercise of the Weak Eye and the Use of the Stereoscope in Heterotropia. Sf.il less than formerly is the ophthalmic surgeon content witi mer^'lv "straightening" the crossed eyes of his patients^ \s we li'ive «een loss of binocular vision is involved in all cases of s.,uint and in some cla,ss<>s of heterophoria. We have conse<iuently, not .lone our full dutv until we have ma.le every effort to rest ore or to enable the patient to ac(iuire the capacity for seeing with l)oth eves together. • . , . , , i. • ' In .luit.' a few exami)les of strabismus this desirable result is neces- sarilv imi)ossible. The squinting eye may be congenita !y defective to a'de-'ree iiicai)able of vision with the fellow eye, or there may be •m uncoiKiuerable aversion to binocular .''ight upon the part of one ../0770.V.S II. Tilt: E\EI}M.I. ASU TllKlR HKItASiiEMICXTS. 1«)1 iir Ixitli eyes, tin- iiiituro of wliich wi' 'in not kimw. I'xcti t tlml il |H((l):il)ly |)i<'<li(':itrs a lack of dtvcloj I'lit in soinf one or ollin f tin- ci'iitial neurons iniplicati'd in tlic visual art. Again, l)inocular cinjtlc vision may l><' unol)tainai)it' on account of iucurahif lesions (corneal hcbuhc'intra-ocular disease) of the strahisinic rye, \v'ierel)y siplit is jiennanently lowered, although it may )><■ good in the tixing eye. Fortunately it happens that in a majority of instances hinocular vision is to a'jtreater or less extent possible after the relief of strabis- mus. Moreover, the eyes that acquiii stew -icojiic or single vision are usually those wliose excursions in all • ctions are normal and remain normal. The ideal result, then, f i the surgeon's stand- point differs from that of the |)atient in th. , while the lattci is alone interested in the cosmetic aj)pearance, the former is concernid in the <|Uestion as to whether the hitherto useless eye can he made to take part in the function of sight. The old device of covering the Letter » ve, so that the "ak (or s(|uinting) organ may Ix- CAerci.sed and strengthened, is ■: .pful before operation, or as adjunct to other treatment, if car ' ' out regularly, say, for half an hour at a time, three or four tmief. daily. With a little patience, children of tender years can Im' induced to'wear a light bantlage over ♦! am])lyopic eye, and use it, even while a' play, to great advantage. As it is highly desirable to begin the tr. atment of infantile strabismus at ns early a iKTiod as possible this plan should be carried out. in conjunction 'with the periodic use of atropine and tinted glasses as soon as the child begins to walk. A single droj. of a \ per cent, solution of atroj)ine instilled into each eve three times daily for the Hrst few days of each month certainlv helps to relieve ihe early s'.iasm of he mterni and cil arv muscles and to check a convergent S(|umt. In quite another fashion do w' endeavor to fo- the two eyes to functionate as far as possible in unison after , i-mployment of means (glas.ses, atropine, operation, etc.^ to corr the strabisnms iiroper The best means is the eniploynipi :. of the stereoscojie. Landoit Worth, and others liave invenl.-u v.nous miproved mstru- nients and while these are ' ' .Ivantagf , .-iwially m private prac- tice none is absolutelv nece> r Tlu o..':nary slereoscoj.e is pro- vi.led with a card on which a.e oravvn or !.>rint-d pictures- two such dissimilar objects as a s.iuare and a circle will do \.Ty well-one oppo- site each ev«'hole. The patient exercises f(,r a few seconds, hrst of all, th<' defective eve alone, and then, uncovering the sound eye, looks at both obiwts through the in.strument, endeavoring to see them singly if possible. At first it is well, as Landoit suggests, to we.aken by ni.'ans of lenses the vision of the better eye, and so further encourage the defective organ. Such ex.-rcises should 1k« employed immediately after oi.eration, and ought to Ik- continued several tinies^ daily for w,..-ks or months. Tnev shoul.l also !«■ supplen.ent<>d by the exercise of Kin;;!e vision in the distance. A red glass is placed before the better eye while the patic-nt attempts to fuse the red and white images of a candle placed 6 tii. away. i 1 CHAPTER V. DISEASES OF THE OHBIT, LACRYMAL Al'PARATUS, AND LIDS. Hv u. A. ki:eve, M.I). THE ORBIT. Anatomy. Tho luiman orbit consists of two pono-.shapod cavities, ■ilM.ut .)iu' and thivc-iuartcrs inclios dcop. which sliftlitly convorp- toward or another, as may he s.mmi hy the accoin])anyniR h-iurc. (Fig 09.) Kacli orbit is composed of a number of bones— (. <>., tne frontal, the superior maxiUary, tlie malar, the palate, the lacrymal, the sphenoid, and the ethmoid. Hv reaM)n of the orpin which it contains, as well as th(> close con- uection which it has bv means of its thin walls and its foramuia with the cranium, the ethmoidal, the si)lienoidal and frontal sums- ati(l the antrum of Hifihmore, the orbit may well be regarded as .n,e of the nio.st imixirtant cavities of the body. The posterior portion or ap(>\ of the orbit contains three uuportant apertures- the optic foramen, for the tran.smission of the optic nerve ■md the ophthalmic arterv, the superior orbital fissure, through which l,.,^s th(> nerves which supplv the nuisdes of the eye, and the first branch of the trigeminus, and the inferior orbital fissure. The second briiich of tl-.e trigeminus passes through this opening. The supra-orbital notch is found at the upper umer angle for the tr insmission of the supra-orbital artery and nerve, while a canal just l„'.|,,w the inferior rim of the orbit contains the artery and nerve ot tli( same name. . The orbit is relatively large in chiKlren, Merkel being authority for the statement that at five vears of age the ba.se of the orbit lack.s oulv •' mm or li mm. of its adult height, which it gains usually ni the" next two vears. Its full breadth is not attained, howev(>r, until somewhat later. Th<' jieriosteum cov(>rs the walls of the orbit, and the fissures are closed in by membrane. The orbit con- tains' the evcball and its attache.l muscles, the ojuic nerve, the vessels and' nerves, and the lacrymal gland. In addition to these structures there is a cushion of fat which fills in the interstices be- tween them, and a dense fa.scia which connects all the i)arts and is expanded along the wails of the orbit, upon tiie ocular muscles, and, finally. up'>n t!t<' eveball it.-^elf. For tiie protection of the eye against injury, the orbit is b(«unded superiorly by the eyebrows, externally uud iaferiorly by a strong rim, IHL" I DISEASES OF ORBIT, LACRYMAL APPARATUS, ASIJ Ln>S. 193 and intornallv bv the no«>. Tho oyobroxN-R vary in toxturo, diroction •uul size in difforont individuals, hut as a r-ilo they are coarser and more marked in men than in women. ,. , , ,, . Tie fosure whirl, is n>ade by the opening of the hds. the s,)-calle.l miDchral fissure, is oval, averapinp fn.m 25 to 30 nun. m length imf from 12 to 14 nun. in breadth. If the eyeball be protruded. Fig. m. UrmirJOT Antero-lateml region of the skull. (Cbykr.) „„,,;„;,„l «. Iho fi!.«.n- >vi,lc„.; if it rcclo., ™.pM»ta«, the exophthalmic goitre. (See page 208.) 194 THE EYE. Enophthalmos. Rccfssion of the eyohall occurs after injuries in wliich cicatricial contraction of the orbital tissues has followed, ()r atropliv (>nsue<l, from nerve lesions, anil in cases of Iracture with , replacement of the tloor of Xiv „rl)it (Lanji): when the orbital con- tents havi- i)eeii reduced in the course of operations or m cholera (from excessive drainage), and in marasinus: also in i)aralysis of the svmi)ath<'tic involving MiillerV li.l-muscle: after the spontaneous siibsidi'iice of pulsating exoiihthaliiios (Brenner), and in the neurotic atiophv of the face. , , . Knophthalmos also occurs in a class of cases recently worked out bv Tuerk aii.l bv WoifT, in which then^ an> coiiRenital shortness, hxity. and inaction of" the external rectus of one or other side. Iroiii "par- alvsis" (really aplasia). The normal tonic contraction ot the internal rectu* draws'the eve slightlv backward, and causes narrowing of the oMliiebral fissure, owing to loss bv th<> lids of the u.-^ual support o the globe. In atteinpte<l adduction the retraction is more marked •md the fissure narrower, and the glol)e is apt to be turned up or down Treacher Collins savs the tonic contraction of the orbital muscles (which are congcnitallv short) is not comp(>nsate(l, owing to the absence or insertion too far back of the check ligaments; henc. the enophthalmos. Diseases of the Orbit. Cellulitis. This may be of a. mild type, and soon abate, but much more often it is .severe or phlegmonous, and ends in suppuration (abscess). The earlv symptoms are redness and swelling of the lids and chemosis of the conjunctiva, with deep-seated pain and sonie tenderness. The mobilitv of the eye may be imjiaired. At this point resolution may begin (first group), or the disease may be arrested and recovery set in; but in the usual course the mfiammation goes on steadilv and rapidiv, the temperature rises, and the i)ain becomes intense. As earlv as "^the third or fourth day the greatly swollen lids nciv be distended or even imshed apart by the highly engorged and eheniotic eveball. which is now <iuite prominent and immobile. The lids become brav.ny, and soon there is indication of pointing, and spontaneous evacuation of pus may occur. The vision may remain good, or it may become defective, owing to optic neuritis, etc. The degree of stretching of the o])tic nerve from jn-optosis (for- ward disi>lacement), compatible with normal vision, is often a matter of surjirise. Etiology, rellulitis may be caused by exposure, cold, etc.: trauma, blows, penetrating wounds, especially with se])tic invasion, lodge- ment "of foreign bodies: lacrymal cystitis, erysipelas, anthrax, etc.: sejitic emboli <>f the orbital veins, as in pya>mia. metria. etc. : periostitis and osteitis of one or other wall, as in sinusitis of the ethmoid, frontal, i.r antrum, and suppurative i)eriodoiititis: metastasis, in which the DIi>i:AS£S OF ORBIT, LACBYMAL APPABATUS, AND LIDS. 1J>0 nncuiiiococcus is ho active agent; also septic phlebitis and thrombus ill thrombosis of ti.. f-avernous sinus. There are at times points which aid in the diagnosis, e. g., if in a case of purulent rhinitis (m- tiuenza, la f^PPf")' ^^'^h ensuing a-dema, mainly of the iimer end of th( lid.C'hemosisand impaired adduction, acute cellulitis should de- velop it might fairly be ascribed t" ethmoiditis, which would cause ■in exudation on the'inner orbital wall that would cripj-le the internal rectus So if the lower lid became first affected, the eye being pushed up and rotation down restricted, disease of the antrum would be -suspected. If the cellulitis is synunetrical (double), or that of the second e-. follows after a short interval, a diagnosis of thrombosis of the cavernous sinuses, likelv septic, would be warranted. Treatment. If the case is Wn early, the ice-bag or iced compresses ■AunM be ordered, with local depletion by leeches or wet-cups at temple- if the leeches are applied at the inner canthus. the bleeding is more effective. The patient should b«' put to bed: small doses of calomel with anodynes and salines may be given, and any faulty condition of the nasal passages attended to. If relief is not had, the hot fomentations should be substituted. And if there is reason to su.-.ect the formation of pus, or the eye itself is suffering, deep inci- -.ions should be made, preferably through the conjunctiva, but if the lid cannot be pressed back, then directly through the lid. Creat care mu«t be taken to avoid the globe, the point of the long narrow scalpel or linear cataract knife being pushed .'.lowly m and tle<>ply along one or other bory wall of the orbit. The adult orbit is one and tiiree-duarters inches in depth, and, as pus sometmies forms near the apex, the knife should go deeply if needful. If pus does not escape, a second or even third exploratory puncture should be made at other points. The wounds should be kept open by tents, and if pus pre- sents svringing should be practised daily with 1: 3()00 solution of ,„.rch'loride orl: 40 carbolic acid, etc. Where empyema of the eth- inoi.l is found, it is desirable, in some cases at least, to o|x>n a passage l,v means of a strong probe or trocar into the nasal fossa through the ethmoid. .Irawing the drainage-tube through by nieans of a thread at tache<l to the eve of a probe. In this way more effective irrigation of the parts can be made. Necrosed or carious bone will require (Miretting, and any disease of the antrum, frontal sinus, lacrj-mal sac, etc.. should be treated. „, Periostitis and Osteitis. These maybe acute or chronic. The acute form mav be caused by extension of inflammation from adja- rent i.arts, mo^t often the ethmoidal or frontal sinuses, the signs indi- cating the probable point of origin : also by blows, foreign bodies, etc. the iH.int of impact determining the site, generally m the region of th.. orbital bonier. Slight injuries may be effective in young scrofu- lous subjects, in whom osteoperiostitis may also appear to be k lo- pathie. 'Svphilis may set up an acute localized periostitis, ami cellu- • ', ;, inTitr. rii't-itistitis sud osteitis mav 60(1 in mis mav also cause it. Acute pdioMiii:! .ttm . , resolution, but more often suppuration (abscess) develops, or they 196 THE EYE. become chronic. Thronic periostitis and osteitis are, as a rule, due to syphilis (tcrtiarv). The orbital rim is t' ? most i-ommon seat of the at Hrst ill-dehned doughy tumors (nodes) attached to the bone, wliH'h are attended by characteristic nocturnal i)ain or increase of pain. The infiltration and pain soon yield to large doses of potassium iodide. Left alone, ulceration and caries may set in, causing sinuses in the fascia and lids, with final deformity (ectropion, entropion, etc.). Nodes may also undergo eburnation, either from chronic periostitis (periostosis) or condensing osteitis with hyijertrophy (exostosis), k deei)-seated periostitis now and then occurs, mostly syphilitic and tertiary, which causes paralysis of the orbital muscles by involving th(> thiVd, fourth, or sixth nerve, and it may also cause exophth-dmos, partly hidden by the ptosis. When at the apex the optic nerve may also be involved, the i)ressure or neuritis causing amblyopia. Peri- ostosis mav ensue, and in this event, or if treatment be too late or inetTective," there will likely be permanent blindness from seconilary atroi)hy of the optic nerve, with ptosis and other i)aralysis. \ ery rarely i)eriostitis at the apex with some cellulitis and pure proptosis are due to empyema, etc., of the sphenoidal sinus. Secondary am- blyopia and contracted field, or optic neuritis, atrophy, and blindness are ai)t to occur, and may be double. Pain in frontal, tempt)ral, and occipital regions, variable vision, and the results of rhinoscopy and ophthalmoscoiiv, may point to the diagnosis. In i)eriostitis ])ressure on some part . the' orbital rim causes nmch pain, and the (cdema of the lids develops less regulariy than in cellulitis proper. In the former, signs of the disea.se are much more a])t to be localized, e. g., one lid or even part of a lid may be swollen, etc., and the bone oidy tender beneath it. (Fig. 100.) In cellulitis ])ressure (m the gl(>be it.'ielf is apt to cause deep ])ain, and pal])ati(m just within the bony rim shows that the parts are firm, tense, and tender. Wry rarely acute rf(7f((.ve periostitis occurs, and cell- ulitis ([uickly ensues. Tlie systemic disturb- ance is greater than in acute cellulitis, and the condition is much nxore grave. As suppuration is apt to f)ccur rapidly, with added risk of necrosis and burrowing siiuises if a))or- tive treatment fail, eariy incision to the bone is indic:ited, and several will be needed in the diffuse form. Periostitis of one or otliei wall of the ori)it which stops short of exciting acute diffuse cellulitis is not uncommon. In chi^onic. quiet cthmoiditis with i)urulent discharge from the nares, osteitis of the os planum, and secondarv periostitis by extension im the orbital side, the cellulitis and exudation may be limited, the crdeina being mainly in the na.-al half of the ui.per iitl. with impaiml ndductinti ami prob- ably slight displacement of the eyeball outward, with diplopia. In "the same way periostitis of the upper orbital border may follow no. 100. PeriMtitis of orbital marsfin. DISEASES OF ORBIT, LACBYilAL APPARATVS, ASD LIDS. 197 osteitis of tlic floor f.f the frontal sinus in c'rronic or acute sinusitis with soco'ularv (I'dcMna of only the upiK-r lid, mainly at the inner ha f. Under these conditions pressure on the ho-iy rim is paniful, and the eve mav he disi^laced slightly ilown and out. If the antruni is the m'"it of the i)riinarv disease, the lower margin of the orbit wil be very tender and (cdeina mostly of the lower lid will develop, movement of the eye downward bci ig restricted, or the globe may be tilted up- ^"Twatment. In aduHs local -lepletion by leeches or wet-cups, the ice-hag the Lciter coil, or compresses wet with the lead-ami- spirit lotion, rest in k'd; in rheumatic cases sodium or strontium s'llievlate in frequent tloses witii or followed by potassium or sodiu- • iodiiie, and in these subjects dry hetit by Japanese hot-box or h. ■, fomentations mav be more comforting than cold; in secomlary c-ises a short active course of mercury by inunction or internally, with potass, iodid. in a>eending doses, and in those p1 the t. ary sfiL'c pot or s(k1. iodid. in doses of fifteen grains, thirty grains, to siMv grains every four hours. If signs of pus show, early mcision t.; the bone is indicated, followed by a course of gentle syringmg with antiseptics, e. g., carb..lic acid 1 : 100 or 1 : 40, hydravg. p<«r^ chlorid 1 : .3000, etc. Svringing should be kept up as ong as there : anv purulent discharge, an.l a tent or lube used until it is evu ent tlie d'isease is spent. In so-called scrofulous cases syr. fern lodid. ,"l svr. c-dciJ lacto-phosph., syr. phosph. (Parrish), ol. n.orrhua« th the best hygiene, are indicated. In case of osteoperiostitis ere here has r,een spontaneous opening the probe should be used Jul y so as not to'di.sturb unduly nature's barriers and cause further "complication. All rough bone is not necessarily necn/ic, and i should'be given for necrosed tissue to 7-"^^ -«' ' ^^^f surface to heal over before one actively mterferes. Then, if nee<l ul, ,he sinus shoul.l be enlarged by sponge tent or mcis.on, and ihe iiirctti" miiiire etc u^d xecumlcm nrlem. Teioii 8 Th is, as a rule, a mild type of inflammation ..f the .ap'dani'rtion of ti.e orbital fascia 7''-y"M>torns are ,Wsis :n 1 exophthalmos, which may be slight: P^'/'';' /' '^^f, ^ / J pressure with impaire.l nmbility. (Ed.^m. of the l^'/ ^ f . ,"^ ' lifiht cases, an.l is not a marke.l feature of any. Th. is •>« P' "'t i.rdiagnosi; between tenonitis and .-'^lU'lit. M'roiH^r-m the a e the u'dema of the li.ls is marke.l. Tiie chemosis of tenonitis s also , s- ,i c and at times .leci.led. and is always out o^ .P-P- j''" ^^ ^ „.d,.ma. The reverse is the case m cellulitis. It is 'I '^Jylj J tisin -md srout mild sepsis, ami erysipelas, an.l ah ajs f.)ll'.ws ;ano,i;;halmSk which may also excite cellulitis; it 1. sometimes I,,us,:.| l.v injury an.l, now and then follows t™"t""'>- . , Treatment. In the tenonitis o: rheumatic ..r g..uty ""K'" ." f^'^^ .u,l "ee,ly relief f.-Hows the prompt ..n.l full -»"»'' •-j'f;";;'; ,', str..n{:uni) salicylate with or witlumt colchicum; P"^' ^f '" " ,^™ io.ri.le, aiul lithia being given at the same time or later. Pilocarpine -^ I'.IH THE KYE. or jal)oraii<li in doso suHicioiit to cause free sweating, daily for a few times, may suiJice alone, and it may be used as an adjuvant to hasten recovery. Topically, tiie lead-and-spirit lotion may l)e useful, and. where dry heat is ])n'ferred, the .Japanese "hot-hox. " Injuries. Foreign Bodies, etc. I'oreign bodies most often enter between the fjlobe and the roof or the inner wall. A larjre foreign body may enter and be impacted and the eye escape. Hence an oft- hand ojunion shouM not be given, especially in view of the tolerance of the socket for intruding non-s(>|)tic Ixxlies. Many notable examj^les of the latter could be cited, curious, interestuig, and instructive. On the other h:! 1, the possible risk to life from secondary processes hi seeming slight uijuries should be kei)t in mind, and therefore, as a rule, a guarded prognosis be given, especially in view of a jxissible medico-legal bearing. The jrrimani effects may include injury or los,s of the eye, or lesion of the optic nerve, with sudden blindness, or true aneurism, or aneurismal varix, or free liemorrhage with infil- tration of the tissues, proptosis, etc. The orbital wall may l)e pcnv- trated or fractured. Following forcible entry of a jKiinted stick, foil, etc., especially from below, perforation of the roof with lesion of the meninges or brain is ar-t to occur. Bullets may enter through the temple and cut the optic nerve, or plough their way through globe or lids and on into the anterior ;»i middle fossa. Severe blows may fracture one or other wall of the orbit or of the optic canal, cause hemorrhage into the .sheath or direct lesion of optic nerve and blind- ness, without external sign, or bleetling into -he cellular tissues, with extr'ivasation into the lids, when fracture i-^ almost certain; or may open rommunication with one or other sinus, causing ei.iphyseina, with much swelling and crackling crei)itus. Some large foreign bodies lodge in part in adjacent cavities, as the sphenomaxillary tis.sure, nasal fossa, etc. The nvcondary results of injuri(\s are orbital cellulitis (generally septic), with possible optic neuritis and airophy, antl blindness; paralysis of one or more ocular nmscles, periostitis, a'ld osteitis, with consecutive meningitis, Ijrain abscess, and death; also throm- bosis ( ■ the cavernous sinus, single or symmetrical, from the septic orbital ph'.. bitis of cellulitis: and enophthalmos. It should be borne in mind that i)enetrating wounds with lesion of the roof are treach- erous; a ([uiet interval of several days or even weeks with fair promise mav end abruptly in grave acute symptoms with speedy death. One may get .some clue to the lesion from tlie nature of the accident and the svmptonis, and by the careful use of the probe and finger. C.reat pains should be taken and will be rewarded, while care is had not to add to the trauma. Where an interval has elapsed, a sjiongy '•icatrix, a wound which will not (luite heal, or one which reopens, is significant. At times several foreign bodies may be lodged. Some > iifreotntoiies: knifi'-bliulo, 3S mm. I.iiig by « mm.. In lower pert of orbit thirty-lwo >■»". ""•' normal vision and perfect movement of tlie globe, (r. Holmes.) nrsic.isKs OF orbit, l.'crymai. apparatus, am) lids. I'M ,.as,.. arc not (.bscurr, e. ,,., tni iiuiuu-fii splinter m thj- ou cr wall may ■.ripi.l.- the oxtornal n-otus, causing ,,ain in attcn.i)t(Ml al«luct..,n, with Zlvv^rouX s.iuintana dipl.-pia. A skiagrai.li aftor t ,.■ improv.-.l ,u,.ti....ls of Swwt. ]):-A-ia.on, an<l others is, of cours.-, -lecsiv.- as to the site of metallic missiles or other foreign bodies opa-iue t- tn< '"Twatment. Small bodies unless easily got at are best left in situ if not causing trouble. Large bodi.>s should Ih- removed promptlj, oting on a tVial attempt if the glolH- is dragged upon Some reemg " reful dissection mav 1k> .u.-essary, th.. wound being enlarge.l, and i c so of in.racted-arrow-shafts or a large splinter stn.ng for- ; ' ,; e roMuired in lieu of th. sequestrum or crocodile if .rn wh 1 1. allv suffices. Iced compresses, c.ld lead-an.l-sp.rit lotion le^ , S salines, etc., will t.'nd to ward of=f undue reaction If pan !„u Iswe ing persist or liglit up, with pyrexia, in s^.te of these am ,;;;i de Iletlns, and pus seems fornuiig. hot fomentations should 1,P u-<ed and incision made as in cellulitis and periostitis. P^satiut Exophthalmos. This is a condition larg.-ly due to rau ma, i,.^S^^L and pulsation of the 'eyeball a^dou^ul^c^- .,n<l audible tinnitus are leading symptoms. The <>' ^'^ '"" .\';^..'l,^ "t hi etiology is not now held, for there can be no doubt that u m ost otm cL to intracranial and not orbital lesions, he "hang^s the rbital contents Ix-uig secondary and ^y"'Pt«?-'^'r;. " ^^^^/^ Vvv cases in which the mischief has been prove, to be orbita th^e haveti^n found true aneurism of the ophthalmic artery or of some ,,f its branches, traumatic diffuse or cir- emnscribed aneurism, and arteriov<-n«)Us aneurism, aneur=sm by anastomosis and aiigomata, or telangiectatic tumor. Ot intracranial lesions, the most common is traumatic aneurismal varix in the cavern- ,ms sinus, the carotid artery pumpmg into ihe sinus through a breach m its wall, muI s„ into the ophthalmic vein, etc. ; aneunsm ,,f the internal carotid, aneunsm of the ophthalmic arterv at its point of origin s;:';.:*i Xs s.:vr : a^=.^r;n.p, u. iiresent in many cases. _ „,„,i..p,i with inability to Obifctivk. Proptosis, sometimes very marked, ^^ '^"^ "V^^^^^^^^^^^^ ..1., "he eve, a.ul at times displacen.ont -^-:f;;\,f /^^^ ^T-ll with impaife.1 motility: convergent -^^"^^''^^ff^^^ fbr"" fore- abduction; eyelids dusky and much sw.:- n, and veins Vio. 101. J ^ 1 2(K) Ti/A' £rf:. hciiiland temple notably (listende.! and <iuite sinu< lus; a tense Imt sil)le vascular tumor at inner en( I of l)row— iliiateil ophtlialmic ooinnressinie viiMuiiw lu...... ill • - . vein-giving a strong impuls.- to finger-tii); vessels ot ey.-hal niuci engorgea an.l eonjunetiva eluMnotic; caruncle large and t^eshy an, nrotru.rmg. (Kig. 101.) Palpation of lids an.l globe yields a thnll luul distim-t pulsati.m, the latter visible. There is a loud bruit with ear to sid,. of head ..r at any point of it, loudest '.vith stethoscope at inner end of brow, with instant almost startling quiet on com- pression of common carotid. The latter stops all thnll and pulsati.m, lheevci)all readily yields to pressure, and the finger may 1m> dipped deei>lv int.) th.- Hacci.l ophthalmic vein. The sight and hel.l ..f visi..n mav be normal or but little atlVcte.l. The fun.lus sh.)ws hyperainia ot th."" optic .liskand pulsation of the r.'tinal veins, which an; apt t.. be greatly dilated an.l t.)rtuous. There are at times papillitis an.l reti- nitis, etc. . ,. , . . Etiology Pulsating exophthahmxs may be idiopathic or trau- matic The former occurs mainly in females, the latt.>r most otten among men : while in some of the traumatic cases the symptoms api«"ar i.uicklv, in others they .levelop slowly. In the idiopathic varu-ty th.'V are apt t.) be su.l.len in onst^t-pam an.l a great "crack or "snap" at the start, an.l in a few hours gmit swelling of lids, .clema of conjunctiva, proptosis, an.l pulsation, with most disturbing tinnitus. When due to trauma, an early if not the first special symptom ii. s.)me cases is a high n.ite as if there were only a small hole in the vessel wall The loud, |)ulsating, an.l roaring tinnitus may not ensue tor some days or weeks, and the same interval may mark the other mam svmpt.ims. Aneurismal varix in the ii(>ck may cause jnilsating exophthalm.)S bv damming the venous outflow from the sinuses. (Gifford.) The .liagn.isis sh.mld be much ai.leil in the i.liopatluc cases bv the rapi.litv anil fulminating nature of the sym])toms. The fact of trauma, m'"'" or less severe, and of the tense pulsating sac at the upper inner iwrt of the orbit, at once made flaccid by stoi)|)iiig the caroti.l flow, shoul.l .listinguish from orbital growihs. esi)ecially vascu- lar malignant forms, which also cause i)roi)tosis an.l pulsation. Then, paresis of the w/cr/i'// rectus, with pulsating tumor .)n the i)i«(Tsiile of the eyeball, is significant. .Some points in the patholixm have already been cite. 1. There are some an.mialies; the absence of aneurism ..r other vascular lesion has been shown in a series of cases by autoi)sy. An.l in vari.ms instances of true aneurism of the internal caroti.l in the cavernous sinus, as proved by ])ost-m()rtem, pulsating exojrhthal- mos hail n.)t occurre.l. R.'lief of pressure on th.' .)phthalmic vein thr.)Ugh the setting up of collateral circulation might ex])lain this. Treatment and Prognosis. In view of the fact that th<>re has been spontaneous recoverv in i)r.)bal)ly 7 or 8 jht cent., some surgeons f.iUow an .■xp.Ttaiit course, giving pot.i-ss. io.lid.. and enjoining quiet etc. (:onipressi.)n of th.- common carotid has cured in a still Larger number, and rightly is held w.)rthy of trial. It is resorted to by snme merelv as a safeguard before operating. If kept up for nrSE.lSES OF orbit, LACBYMAL APPABAl'LH, A.SD LIDS. 201 :i short time ovorv day for weeks or iiiontlis in idiopatliie caws, it may siieeeed: in trauniatie eases it should Ih> applied eoiitinuously for hours dailv. (Sattler, iu Noyes.) In a ease of the writer's, of suide pulsating exophthalmos due to trauma, in whieti ligation of both com- mon carotids proved ineffeetivi-, it was prefern'd to test first the etTeet of i)r('ssure in conjunction with a cours(> of potass, iodid., iM'cause there were no urgent symptoms present: the; sight was good, there was no pain, the i)rocess was seemingly at a stand-still, and eompression had availed in variou:} cases ; while, on the other hand, ligation iiad sometimes failed, and was itself not free from risk. Ligation of the conunon carotid is the most reliable treatment, being etfective in al>out (M) per cent, of the cas<-s operated on. Death has followed iu about 10 iM>r cent, of the remainder. Ligation of the second conunon carotid has now and then l)een curative in failure of ligation on the affected side. Ligation of the external carotid on the affected side after failure of that of the com- mon carotid has sometimes been successful, and in the writer's opinion it is a step that should be taken in preference to ligation of the second common carotid. There seems ground for the view that treatment bv prolonged compression militates against the success of lisration As a rule, life is not jeopardized, although rendered miserable in cases which have been left alone. The attempt t(. plug tiie oi,hthalmic vein bv a firm, deeply placed clot by means ol gal- vmoinmeture the positive pole (needle) being passed farm, is worthy of trial and it should prove useful, if not ;)er se, at least with com- pression, medication by potassium iodide and ferric tannate, or when- ligation has given only Jiartial relief. ^ , . ^ . . l)r Argyll Robertson reports^ two cases of pulsating tumor of the orbit with" bruit, in which electrolysis was used. Thrombosis of the cavernous sinus causes venous stasis in the .„bit. with g.'i>eral infiltration and .edema of lids If due to sepsiss a^ is th.- rule, phlebitis and thrombi with cellulitis to low, with marked .edema of li-ls, (>x..plith:ilinos, an.l immobility of gl..lK>. He- Inn- tl,.- .-veball Ix^eom.-s tix.^.l. paralysis of the thir.l ai. sixth nerves ,nav be ma.le out. The pupil is g.-nerally .li ate.l. There may lie irrrat tortuosity or thrombosis of the intra-ocular veins, with mipaired -iijlit or blindness. . . . . Etiology. Thn.mbosis of the cavernous sinus is generally se,)tic in ovWm and -hie t.. purulent ..r carious foci, likely infective, in some part of the h.-ad or neck: nu.st often a se.piel ..f inf<>etive mHammation l,i the lat.Tal sinus, with septic thrombosis fn.m sui-purative otitis, with or without caries of the petrous, l-rysipelas may set up throm- bosis thn.ugh the medium of orbital phlebitis or cellulitis; also septic to,.; mav cause it in the nasal f.issa, lacrymal sac, ..r cheek, as m u.ihrax or malignant pustule. Thrombosis of the second cavernous 1 Transactions of Ophthalmologtcal Society, IS9!1. , v-,„.»inm »ni tt ' TranMctions of the OphthalmoU.glcal S<K-ie.y of the fD.ted K.ng.iom, vol. ix. I ' ao2 rut: t:Yh:. siniH occurs l,v cvtonsion froiii thn first throuKh the circular smus, or .lircctlv, as in '•■rvsiiH-las. This continpMicy ad.ls a l<-atuiv ol jtravit y to fncial crvsiiM-las wliich siioul.l Ix' borne in iniiul. lii throinLosis tlicrc woul.i 1h' the Rravc Roncral con.lition, weak, .lUick puiso, tcm- ,M>raturc sl.ouiiiK stcci)-iK-aki>.l chart, with prol)ahl.- rigors and hchctu.lc, tlic liistorv, likely, of chronic otorrh.eu or recurrent ot.tm witli .ideina and teiulerness over and behiiul the p(,stenor edjje ol the mastoid, an.l double o|)tic neuritis. To make a correct diapnosw is to cive a ba.l i.roRnosis a.ul to avoid tlu- error ol treating he ,..,ndition as cellulitis i>er se, for s..ptic cases an', as a mle, sinvdily fatal , and when double, death is the m. .re certaui. In the early stage antitoxin treatment, or the use of Credo's omtment, coUargolum, etc., mav ijrove of value. _ . ■ i *• Tumors. The anatomv of the orbit, its constituents and n;lations, ren.ler it prone to lHT..nu- the seat of neoplasms and to be mva. ed hv growths of adjacent parts. Any change in tli.- bulk o its contents „r its capacitv is apt to alter the position of the eyeball, which is a sort Of movable plug in the 8t>ptum orbitie. Hence prominence or Fig. Wi. F.0 102.-?«reon,a of orbU. Twenty K,ne tncte, in circnmferenco^ Wel.-h.. thr^-e ponn.l.. Fio. lu:!.-.v .ry i.x.».io»ls of F. Sinus an.l orbit witti murkf.1 exophthaln..*. protrusi.m of Mie globe, cxophthohm., is the most common sign and l-,.suli of orbital hvperplasia an.l tmnor, and it .,ften .lepends u.o the same changes in adjacent caviti<-s, with disteition, etc \\\nn the glob.- is push.-d straight forward or in the line ot axis, the tern, ,,ro^osi. is used; displacement is generally lateral ..s ^vH ^^ ' ^^ '1^ \ . isnlaced eve mav fiuictionate normally ami give no t n.uble. but ;.rip,.lin.r of <me or other of tlu- orbital muscles, directly by pressure or invasion ..f its fibres, or through the motor nerve, at once causes disabilitv. The ease with which paresis is m.luced renders ,t a coii- ,non result of orbital lesion fas well as intracraman In add Hon to exophthalmos and defective motility, <v<lema of the lids ami at times great stretching are incidents of orbital groxMi lam, wluci is o'Jen wanting, may be most s.>vere and annoying if there ,s much tension of the parts. . Tumors of the orbit may. as e'sewhere, be benign, recurient. or malignant. To the benign class belong fibromata, osteomata. e>bts. DlsKASJiS OF ORUIT, LACIIYMM. M'r.m.Vri.s. AMi LUX. •2(t3 Fill. ICH. Sarcimie of orbit. Encf|.haioltl f nicreiiin LlviiiK tblrtetii jcars antrwanl. No ncur- rtiice. vaspular tumors (anRioumta, oto, ami lymphoinata or lyiiipliailc- luiinata. Malignant growths, j;li(iiimta, farciiHiiiiata. sarcomata, tic.. arc, of course, apt to recur, tlu- rouii<l-eell xareoma of eliildreii praet-- cally certain; but nrurrcnce dues not stamp nialinuancy, for \ascular ami" cystic neopla.sms are prone to prow apain unless ermlii-ated. .\ fatal result is hroujrlil aliout liy extension to the brain along ' optic nerve, or tliroupli the splic- noidal fissure, or through tlie walls, e. (J., roof by caries or l)y metas- tasis. It is often delayed, and may l>e averted in orbital tumor from the preat tendency in such cases to prowtli outward, i. c, forward. (Kips. 102, 103, and 104.) The division may 1)0 arbitrary, but is useful, of orbital tumors into those arisinp within the socket and start- ing from the cellular tissue— the main seat, the walls, lacr>-mal pland, optic nerve or vessels— and those invaiUnp the orbit from ad- jacent i)art.s or cavities, as is often the case in osteomata anil sarco- mata. In the latter in younp sub- j,.cts with.mt i.ain or pyrexia, there may Im> no sign un. ev.phtha- ,s shows, and then there is rapid growth. One should --^'^^^^ ---]] such points as the condition of the pat.ent the s,7.e and tlu- rat f prow h, site or origin and attachn.ents ot tlu- ....oplasn.s, whether fixed or movable, hard or soft, smooth or m.dular, <-'i;>-<-'' ; ",.nder or pulsating: the kiml and degree of displacement of th,> g e anVof anv paresis, the acuity of vision, state of the f.tndus oculi and of the idnexa an.l accessory sn.ases. As growths Nar> :.' nudtln nature, and if .n:dignant should ^^rfy^^^^^^^ at all it is advisable to employ every diagnostic au 1">1'" ' ,di,e careful use of the finger can tell one much. "^ 'J ; '^ i. pn-ssed along and just within the orbital run ••*»;7' ''• "^ Letlveen it and the globe, testing the floor of >»;i7'; ;;'";,; J region of the ethmoid back on the ir.ner wall, of t""> "; P'^' ' owl of the antmr-. Cvsts mav feel hrm when well packed sett, : .d-c^U s^:^a if encapsulated., ttuiy stretch the Kig so igh ly ts to sp,.m quite hard, ami a subperiosteal mass of the same, or . n( n . u : may simulate' hyperostosis. Hence the .>eed " -P ;; f ^ ^ i„, sion to determine the true state of thmp., espma h. , co deep for palpation. Under asepsis it is ree from ^^P.'^ "'.J r|r'fX it slould'alw'ays be made in cases of .l"ubt , A--. . is c^ fully made through the skin m line with ^^'^^''^ J'f"'^'^ T'^,:,,^ ' ;„„ within the Jrbital margin, or between the ''£ -^l'^ '^f^fb^ S deeper and slowly, and if beyond one's ken the mirror ma> be aeci, i I n ii 20^1 THE EYt:. i,lso tl.o r.ttlr liiw-r a...l prolK^. Kxplorutory ,ninrtur.. at tiiuos (jivt's 11 U!*t till liini, aiul till' iiiicriiscopc iiiay Im" \uv< ili'tl to fix till tliajjiii iis. Knuilfiii's ujttcf "plastic rt'sci tioii of till' outer wall of the .rbit has 1 ii ur>£<". 1 ami UK*'. I for (lia>!iiostii' purposes It I las pn \vi )V(M th tl 1 useful ill exposing ami reiiinviiin leep-seateil neoplasms le leas t risk to the (ilohe, optic IK rve etc. lives iiiav ie(|Uire (I 1) ,., 1„. s.erilice.1 l.v n,HTatiiiK from the Iroiit which couM U- sav.-.l l.y 1,.. Kr..nl.Mii metlio.1. This Kraiite.l, K"«»<1 ^..rk can U' <lone a.i.l 1. ^owths remove,! I.y u.eisions through the li.ls. It ,s important uXL the state of the n:usal imssa^es l,y ant.-r.or a.ul posterior i ... ' ■ -.aiulof themaxillary sinus- at l.-ast by exclusion-I.e ore Ki\inK ■ .. prognosis .)r resortiuR to o,K.rat.ons. Iraus.i uimnatu. . mVv Ik o Iryirv. for if the antrum or fn.ntal smus f^il to light up there is iikelv a growth or other iiusrbid condition. "' . U" ,„„ may '.gin in the li.ls an-l dip into the orbit a.id . .nay .tart in the orbit and invad.- the li.ls, mv.>lyi..g also the lacry. nal g ! id aiul re.,uiring sacritic- of the latt.T m the extirpation (de Schweinitz). The ran- e,u-n,,snM rarenu,us variety of ='"{^';'""' ^ iMtes tumor of the ..ptic nerve, but vision is unaffected. It is remoM.l I'.v careful, lissection. The Kroiilein method is pr.-ferable ■ ineurism hu AwiMomosk. Subcufcuieous na-vus is a species ol •mltioma in whi<-h congeries of .lilate.l arteries fnmi a mass that yie ds ,,ulsati..n an.l a t..ugh au.l .loughy fei'l on pal|)ation, a.u.l gives a bluish tinge to the swollen lid. i. -i . i To a varietv of angioma, vnric.- vein, in th.. ..rl.it. is attributed th.- rare inlrrmillrni exophthahnr.., in which protrusK.n ..f tli(. eyeball ,„.c..fs wh.-ii th.' h.-a.l is depen.leiit, an.l n'cession m the erect <.r reciiiiibeiit p..sition. • it ;- mtro- l umnhiiiKiiomn is allie.l to caverm.us angioma. It is retro ocular encapsule.l growth, an.l is similarly treato.l by extirpatmn. rare >m,lo>nn ...•.■u.-s n..w an.l th.-n as a ...ft ..r .l..ughy ..ncai.sule.l tum..r. ca.ising ex..phthMlm..s, etc.. an.l sh..uld Ik- .lissecf.l ..ut. h,mphm,„ ..r hr,pl>'"f<-'^'>">'' '^ ^'' ..eeasi..na iim..c..nt lu-oi.la.s.n simulating .•lini-'ailv an.l l.ist..l..gi.-ally small-c.;ll sarc..ma. iH't.y.H' " i ,g t.. a bill .-.urs.. of ai-s.Miic. This reme.ly sl,..ul.l have a hu tri .1 in ail .l..ul.tlul cases as should p..tassium i.,.h.le wlu-nevr there .> tl e lea.st susi.icion ..f specific ..rigiii. ♦! n Li,. J, or ......apsde.l fatt:. tumor s ..very slow gn.v.th. . <mall. it mav b.- tVlt as a soft, elastic, nu.vabl.. tum..r: •> '^''^Y,'' eve an.l li.ls will be m..re ..r less pn.minent. an.l the atter yu'H a flVshy f.«l. Ii is very rare, an.l excision is the only treatia.-nt. Fibn.-an.nolii.oniM is ii.it unusual f\V. A. H..l.len). rhnn.ln.ma or n,rl,ondnm,>. .a j.ur.'ly cartilaguu.us tumor, is ex- cee-linglv raiv. It mav spring fn.m the sphenoi.l, an. , gn.wmg ver> slnv'ly cau^r- at !.i,gth gro.Mt exonlitholmo.s. N.)W an.l then ehondr..- saroma an.l ch<.ii.lrotibroma oecur. i . „ ,„i„ T>nmr of thr Optic Xrnr. Th.- f.-atures are sl.,w an.l, as a rue, painless growth in a healthy subject, gradually increasing proptosis, 'im'mm DISEASES OF ORBIT, LACRYilAL APl'.iliATUS, AXD LII>S. 205 .,tly ill thi' line of tin- axis of tin- orl)it.' Imt willi i lohility of the Imll prolial.ly H"<«l. "I't"" "•'uriti'^. or "atrophy, " aii<l visu, curly I or lost.- Ill some cases iiiarkcil liy|MTimtropia develops inos iiiipam from flatt«'iiiiiK of thi- y^My^' l>y retro-ocular i.ressure. I'alpatioii may not make out the tumor if small. Removal is indicated. The iplasm is encapsulated and non-recurrent, and therefore the projj- neo, , - .. Leiy a much higher i>erceiitape succiiml) to "iiiiracranial extensi..n— possibly after a loiij; interval- than is «ia«|M-cted. Filiromatosis e.xpri .sses the patholojiical character ot these growths, which histologically are es.sentially mesobla.stic in nature iHvers). (See page 4r»4.) Oi'KK.vrioN. Kxtiri)atioii may Ix- done by careful deej) dissection till the inner or outer side of the glob' with the hnger-tip as a guide (11 Knapp's method), tlie closed sci.ssors" jwiints being used to s<'p- arati" parts and to i.solat«' the gnn.th. Hie externa! n-ctus and outer caiithus mav with advantage Ik- cut to gain access (Lagrange), to be reunit«'d after removal. The optic nerve is cut clos«- to the •iiH'X traction is made the neoplasm detached from the gloh<- if m contact, the ner^e then divithd next the ey«'ball, and the gro\yth brought away, tninie prefer to section tlie ner\-e in the r<-vers<- order. The eve sometimes is saved, and remains cosmetically g(K.d, but •■ lort' often "it is either sacrihced or finally shrinks. Th.' Kronlein method ■ ives fncr access to the orbital contents than the above method, ioiig in vogue, and with less risk of excessive hemorrhage anil of loss "' Kuonlkin's Method. A slightly curved incision is made al..ng the outer bonv marg.n of the orbit, dividing the periosteum. I he peri- ..steum Hniiig the iLrsi.lc.f the lateral wall of the orbit -retracted t.g,.ther with the soft orbital content.s. and the '"t''"<'r «;rl.itaUsMir( localized. From th.- anteri..r en. oi this hssu.v the «'"">.;;'"; the orbit is cut through with a chisel along two ^<''-f-'";.P " ^^ :^'^ one pa-siiig up and out to the exiernal nngular process ot the ront.i I,! ,ne urJx\.l -v in th.- suture lH.tw..n the great wing of the s,.l,..noid Mnd ille malar bone, and the other in a horizontal plane V^^^ ;,nd forward. api.earing on the .-xfrna surfa.-e of the a ar Ih i„ , |i,„. direc.tlv alx.ve the inserta.n ..f the zygomatic "rch Ihis we.lge-sluM>."d piec.- of bo. with its muscular and '^^^^f^^^: nuiits is stronglv forced backwanl. giving fn-e access to the orbi T,p;.riosteunil- incised inahorizontal .lirection (.Mno d H. KnapP • .Nftel- removal the bone and overlying soit parts are ^'Pla - U I - !,,tt..r earefullv .suture.l. The electric circular saw makes .lUickir and hett.^r section of the b.me than the chisel. Oleoma. The ivorj- exostosis, osteoma ehurnea, which is the one most often met wi(h in the orbit, is of very slow and pamles. growth a.ul as a rule gives n<. sign u:. exophthalmos 'M>P«;ars. It is at lime, well borne until there is decided malposition of the glof^e, and > About 60 per cent 70 per cent. (Byers). H -: ? !H It! 206 r/Zi? EYE. so llisKllou IS is its growth tii;it lliis is tlic case f'\ ,-on whon it has startod II tlic fniiital (or t it. When it involves or invai other syiiii)toiiis thiiioi(lal) sinus and pushed the orbital wall before les the cranial cavity, cephalalgia and [ire apt to sot in, and optic neuritis may occur. I'alpatioii ;ho\vs a hard, li.xed, nodular tuiiio ir on the orbital roof or inner \va a rule, am 1 a smooth, hard, licmisi)herical swellinjr t is in the sinus. Hut exjiloration, as stated, is necessary if the -ea to a correct diafjnosis. riie etiology is indefinite; rheumatism. g( )Ut, ihili etc., are of uncertain wei ht. Trauma has a jjlace. In three fronto-oi bital ca.ses o if the writer's— two osteomti ebunica- traunia in earlv life was almost suiel\- a tactor. Treatment. This is extirpation, which is a safe procedure, and the eve as a rule c-.n be .saved. The same may be said of sinus-ori)it ri<es if the proper method is followe.l The attempt to remove only the orbital part bv attacking the body of the tumor is unsafe, and is not now made. " It has been replac(>d by the method of " subi^erios- teal enucleation ■' of H. Knai)p, after Maisoiineuve. Flie first step in the operation i)roi)er, after reaching the site by incision througli the li.l septum orbita', etc., is to divid(> the periosteum over the tumor and peel it off to the basal wall; the latter is then carefully chiselled through close to the tumor, and the latter is gra.sped and rotated, ami then lifted or shelled (mt. If the tumor be of the smus- orbit kind-e. r/.. growing from the frontal-the wall or walls will re.iuire chiselling in order to release the growth from its bed. Alter removal an.l careful cleansing, etc., the periosteum is reunited by de.-p sutures, and then the wound closed. Packing or a . ! rainage-tul)e may be used temporarily, ami after-treatment is according to general i)riiiciples. . . Kmcuhahrcle is a congenital, fluctuating, nearly always pulsating and compressible tumor, found at the inner-ui>per part of the front of the orbit, ami at times is of large size. It is a hernia of the bram and membranes through a hiatus, which may at times be felt at the site of junction of the frontal, lacrymal, and superior maxillary l)ones, and is often double. It is extremely rare, and is inoperable. Its diagnosis is onlv imi)nrtant if the subject lives— the exception. Siircimia is the most common growth in the orbit, and occurs more often in children than in adults. It may originate in any intra-orbital tissue or invade the socket from adjacent p.arts, sinuses, etc. Sar- coma of the choroi.l, like its congem-r, glioma of the retina, may beeome extra-ocular and then virtually orbital. In som<« cases the growth forms a large mass, which is covered but partially by the I'reatlv stretched lids— so-called eiicephalui.l or fungus lia'inatodes. Kven'.it this stage radical relief may follow exenteration, and this is the more likelv if the tumor, though large, be movable and the periorbita unaffected. Prolonged immunity from pain and recnides- eeiice at least, mav be ha<l in seemingly desp.'rate ca.sos; but this applies almost who'llv to adults and to mixed forms-c. f/. adeno- sarcoma aiul fibrosarcoma. The latter, which are encapsulated or VIHEAHLil OF ORBIT, LACBYMAL APPARATUS, ASD LIDS. 207 oircumscrihcd iuul of very slow growth, yidil pood results t(j thor- ough cxiMsioii. (This holds also in rogard to carcinonia. which has occurred onlv in tlie laerynial gland and on the optic nerve.) The consensiis of opniion is against operation in orbital sarcoma of ciiildren, in whom, as a rule, it is of the small, rouml-cell, most malignant tvpo, and decidedly if growing from a sinus. It is lieKl It, he inoperable in the sense that recurrence is almost certain, and death is ha>^t<'iied rather than retarded. The relief ()f i)ain or other Miecial indication or condition may warrant opeiati(m. KxKNTKH.vTKJN (ou Kvisckkation) o¥ thk ( )iiHiT. Complete exen- teration means the removal of all tli- contents of the socket, includ- ing the perio.-^teum to the apex, and also at times ablation ol one lid ,,r both liils when involved primarily or in course. The outer caiithus is divided bv a cut to the bone, the lower lid is drawn .lowii, and an incision is made in the retrotarsal fold to the bony luargin from the outer to the inner canthus, and then similarly to the upix'r orbital rim, i)assiiig l>ehind the lacrymal sac if it is iiealthy. The closed scissors (strong and curved) are then iws.'^ed deeply along one or other bony wall and made to sweej), if feasible, aroun.l the ma-^s Traction is made, and the tissues cut as close to the apex ;,-l)ossibie: bleeding is stop])ed by pressure: the periosteum is treed rn,m anv remnants bv the scissors and sharp curette, and the stump trimmed ;'iid treated with 10 per cent, solution of zinc chloride. Ihe outer canthus mav 1k> restored l)v .'futures, \\hvu oozing has ceasec the cavity is cleansed and packed with medicateil gauze anointed with steriiize<l vaseline; a compn>ss is aj.plied over the lids and s<>cure( bv a bandage. The outer dressings should be replaced on the second <lav but the ixu'king niav be left four to six days. If the growth is adherent or the periosteum involved, the latter is detached at the margin of the orbit all around and from the walls, so as to be removed entire as far as mav be when the tissues at the ai«'x are severed \nv di-^eased periorbita or patches of bone found are curetted and treated, as well as the stump, with 10 per cent, solution of zinc chlo- ride, or th.' chloride of zinc i)ast<- applied on lint. If the floor of the orbit is carious, it is advisable to explon^ the antrum, and thorough removal of the contents of the latter is necessary if it has been in- \aded It is wi.^er to sacrifice the li.ls in i)art or wholly than to l(;aye anv suspicious tissue which mav be the nidus of new-growth. Ihe l.icVvmal tfland is alwavs removed: and if the sac is nnphcated, it -hould, of cour.-^-, be cu\ awav and the nasal duct carefully curetted. If die lids are to be sacrificed, the first step is to cut through the skin • . tile bonv rim. and follow this around. Recn-ery is much (luicker ind after-tivatm.'nt simpler if the denude.l walls of the orbit are at ,nce lined with Thiersch skin-flaps carefully adapte.l and su].ported !.v iK.ckiiK' (Mickulicz and H. Friedenwald). The Thiersch grafts niav also b,. ai)plied later with advantage to the ((.repare.) granu- latmsr surfaces ( liusachi). Tlu- .•xlieme retraction of the luls is thus ixerfd and a special form of artificial eye may be worn. li 208 i! THE EYE. blood, scbii •icrouR. 1)100(1, sebaceous, dernioul, hydatids, echhiu7.'.eeiraml fvsticerci. Tliey occur mainly in the front of the orl.it are mostly c.msenital and ..f slow prowth.an.l are pan.less unless very 'large They may be firm on palpation, but on exposure elastic, f not Huctuatini. Hydati.ls are yery rare in Anu-ru-a: .J.rmo.ds are not unconnno.i. Th<> latter may lie dormant durmg adul K-ence, sLyins as a circumscribed swelling at sonu' pomt just ^v.tlun the . ital rin.. and th.-n at puberty begin to grow. Their contents may be yaried, as thev an- ,1.> where. It is well to beam, nund that c>. ^ are often found "to dip deeply h.to tlu- socket and to n.terp(n.etra e ,.,rts f. a degree not siisp.>cte.l before they are explored. .\n.l a> the> „ay be unit.^l to th.- she -hs of the muscles or of the opt.c nerye or glube itself, their remoyal may requin- careful an. 1 deep dis.section, wit risk to healthy parts. Hence some pn-fer ohhteraom by mcision, 'v sceration, in hydaf-d.s as w<>ll as dermoids, etc., an,l light cauteriza- tion of the sac-liuin;; l.y means of arfj.-nt. n.t. crystals, or so . t.nct. dine etc.. applyi.rg cold to less.-n un.lue reaction, and keeping "um.th open until the walls become fused ( BulU-r. Mathew.soi, 8t ui.lish. et -.1. Antiseptic inj.'ctions are us.-d to the same end (Swaiizy^. Others ,lo an.l adyise extirpation (Berlin, Nettleship, ^^Eiophthataiic Goitre (Parry's Disease, Graves' Disease, Base- dow's Disease). This dis.>ase, as the name suggests, is marked l.y j;it " and enlarg..meiit of the thyroid gland, which, with tachy- rar 1 a and tremor, form the so-calle.l canhna symptoms Ihe wei<rht of eyidence points to the f.xic action oi abnormal thyroid s.-cn-tion as the cause of this strange symptom-comi.lex, with a basis "'BrAoX^'^i^ullySO per cent. ..f the cases are females, and about T? 1) ' 'ent. occur in the third decade; it is rare early and late m lif,. The acute form follows fright or other strong emotion, which gives color t.. th.- claim that it is primarily a pure neurosis. Ihe usual chronic type is offn pn-ceded by a i.er.od of care, anxiety, o, other nery.ms "strain. Heredity plays a part in .... far at east as „,.ur<.sis is an ..ti..l..gical fa.'t.-r. Central l.'sions (m he me.lulla. etc ) inyohing the sym|.atlietic, which hay.' b.rn r.'giir.le.l as causa- tiv.. an- h.'l.l by I'ntnam an.l others t<. be nx.st hk.^ y sec.mdar> Th.>'.-seiic.. of the dis(>as.> is s.mie fault in th.- thyroid (hyp.'rthyrea) whi.'h pn's..nts a sort ..f comp."nsat..ry hypertropln with perverted secretion ((ireeiifi.'ld, Moebius, H.irsley, etc.). Symptoms. On.' or other featur." of the clinical picture may w lacking, an.l the ev..lution of th.^ symptoms is lu.t constant. Ihe ';,l.ot % generally gra.lual an.l the disea.se chrome. Th.- signs ot ,|,.,.id,Ml fun.'ti..nal .listurbance of the nervous system are, as a rule, clearly in eyidence. . . , , ^ <■*„„ TachumnlHi. Car.liac palpitation ami rapid pulse an^ most often t,,; initial symptoms. The pulse runs from 1(X) t.. 140 or more^ There are marked throbbing of the carotids and a yascular murmur DisKASKs OF onnir, lachymal AvrAnArrs, axd lids. 209 ov(>r the thvn.i.l. KnUirRonu-iit ..f tli(> thyroi.l is fjoiuTally patent when till' ..tluT principal symptoms arc present. There is visible Dulsation, and a thrill may be felt. Kj-oMoIwo.. The pn.ptosis, which .3 almost always .louble •unl but rarc-lv absent, varies acc.nling to the .lepree ot va.sculai tur.'.-cenc.- of the orbit from sllRht .IcRrees to marke.l protrusion. So^iireat is the latter at times that the cornea n'mains c.mstantly ,„ore <.r less expose.l. It is then apt to ulcerate, with loss of the eye •It the time, or later by secondary glaucoma or septic invasion an.l 'innoi.hthalmitis. Hyix-rplasia of the connective tissu.' and increase ,f the orbital fat delay recession of the eye m favorable ca.s<.s. There are other ocular symptoms of mten-st: '«\ ..{>''.'-.'/"'/'''' '^ .inn ■ retraction of the upper lid from tonic spasm of Mullers fibres. T is'..aus..s the notably starhifj look of such cases by exposing a .irin of -rlera above the cornea. It occurs without jm.ptosis, and Ml Is to the effect of the latter when present. (7,) Slelhrag. sujn : m- ;>„ueiit and imperfect winking (a a.ul I, may be due t.. loss r^ sen- ti 1 f the cornea and conjunctiva and <.f the reflexes (('. Wood). " Vo araclc-ssi,,n: loss of the consensual descent of the upper a i , I .wnwird movements of the eye. The upper lid lags behind le sclera mav be exposcl. In not a few cases tins is absen iJIsutSiency of convergence fn.m .Usability of the mternal recti is (il'tcii oresent (Moel)ius). , ,. i /, > u i _\ ^ , aneous pulsation of the retinal arteries on the disk (( ). Becker) .,1 o' , uJs bu is not constant. The n'tinal arteries may be rela- ; V 1 la ^>; but the fundus is practically normal, and visum is uiiaT- H , ;i l)rvn.-ss of the eves is a not uncommon source of discomfort T : .v'i^Jance of the bi.dy to the electric current is grea ly re.luced (NNolfenden). Profuse sweating, pulsatory t.nn.tus hea.hjche, ana - ,ni., .m<l mental dei.ression are common symi.toms. A(ut. cases . - 1. t ,. acme in -i few davs or weeks .in.l recover as .luickly, ;;r n 1 h As a nile. months may pa - ..efore the pal,.itat.on , I u k i are followed by exophthalmos or Dalrymple s sig^i ;.;; . S frlm. six months to one, two, or more years before roco^ery oiKiiiw or the disease mav i)ersist. . i i "'i^^::ni:; Rest, mentil and physical, - ""J-;;-* ; J';; j;; ,l„.n,,v '.nd massage are of serA-ice: iron an.l .ligitaos an olt. n : ; n alia-mic ca's. an.l the tiiu^ture of ^tn-phanthiis i. a car. .c „„•,,, ,,.lUul..ima. i...line, co.l-liver ...1, an.l ';'"''''; 'r *f * i;'^^^^^^^^^^^^^ l„.l,,tul. ()sl..r, wh.. a.lmitsthe m.c.-rtainty ''V'"''''''' „ ' 're ",, n 1 .lecries v.. atrum viri.le an.l a.-..nite. says, "no ""'''^.'^ ' . ' ' 1 '■.. sful as protracte.1 n>st in be.l with an u-e-bag 'M'l'l""l ' '" u..usiv bv .laiover the heart, or, what is sonietunes •';<;" .''^--f;; „v..rthe' l.,wVr part of the neck ami '"'"';''^"''"V ™. '■ known tl... puis,, t.. be nxluce.! in this way fn.m l"** J'' ■«^- T!,.. svstematic use ..f the galvanic current has; been ff^^"^' servi..o in manv cases: a current of from .K5 to L.> "'; '^ Ij^; { ^ from .,1... t.. ihree minutes on alternate .lays, the cath.^.le at the 14 210 Tin-: EYE. aiifilc of the lower jaw, first one. then tlio other, with the anode at tile l)aci< of the neel<. Persistent farailization or jtalvanizatioii of tile thyroid f;laiid with stronf; eurrents is eertainly userul, whatever its mode of aetioii iJ. J. I'utiiaiu). Thyroideetoiny has been of undouhted value despite the larjte mortality hitherto attendinjj it. Of svnipatheetoinv there have been favorable reports and unfavor- abl<>.' Local Tukatmknt. When the cornea is partially exposed, the sini])li>st expedient is the wearing of a light proteetive compress, at least at night. When the whole cornea is uncovered, tarsorrhaphy should 1k> done: and this failing, the lid margins should be made raw at corresponding ])oiiits. and be united broadly in the centre or at several points, sutures being inserted sufficiently far from the free edge to hold firmly. This is esjiecially n^iuired in |)rogressive exojih- thalmos, and may save the eyes from destructive ulceration, or arrest the latter so as to prevent utter loss of sight. In a few in- .stanees removal of the eye has been necessary to relieve the sufferer from excessive pain due to ulceration, panophthalmitis, etc. Diseases of the Accessory Sinuses. i Many ciuses of subacute, if not acute, inflammation of the frontal sinus recover spontaneously, or under intranasal treatment of tlie exc.ting rhinitis, etc.. without orbital mischief. Orbital periostitis and cellulitis (which see) are sometimes set u]) by acute sujjpurative inflammation of one or other of the accessory sinu.ses. which in turn is likely caused by the invasion of pyogenic org.-misms in the purulent riiinitisof influenza and ethmoidal and antral emi)yema, pneumonia, and the exanthemata. Again, chronic cmptjvma of the frontal sinus is at tinu>s a .sequel to the acute form, or is latent in its onset and course and without external sign, complaint being made only of browache and nasal discharge, vvhicii. however, are jiresent in ethmoidal emitvema. In case of retention from im])erfect vent, ulceration of the periosteum and caries and perforation of the bony wall may slowly c' sue, and the mucopurulent contents held by the orbital pi'riosteum and fascia, form a tense swelling along and beneath the lirow or at its inner half, whicii fluctuates under pressure. Now and then spontaneous fistula occurs beneath the brow, as in periostitis: but unlike it in that the jirobe enters the sinus and the discharge is mucoid, i-'istula orbila' may occur also in chronic enii)yema of the ethmoidal or f'-onto-ethnioidal cells, which, imleed, sometimes form one cavity with the frontal sins. Ill chronic mucocele of the frontal sinus, which some embrace under chronic empveni.M. though only yielding mucus, stenosis of the frontonasal canal and n^sulting retention and distention cause gradual depression of the floor (orbital roof) and prominence of the .'interior bonv wjill with exoiuthalmos downwar<l and outward, im- wmmmm wmmm liIUKASKS OF ORlilT, L.ICRVMAL .ll-PAliATUS, ASI) LIDS. 211 |)aii(Ml motility, diplopia, ptosis, etc. The smooth swelling which (lips back aloiifi the oihital roof may fool hanl or may yield to firm pressure, and the purulent nasal (iiscliarfie of emi)yema is wanting. Treatment. The general inilicatioiis are to open the sinus, remove (iiseas<'d contents, secure permanent frw drainage, and thci carry out medication, provided the oi)eration does not j)rove radical. Oi'KK.vrioN. In acute empyema of the frontal sinus, other treat- ment failing, an incision is made in the inner third of the eyebrow to the side of the mot of the nose, the periosteum sejianited overa lim- ited area, and a small opening made with drill or chisel through the wall just below the sujjra-orbital ridge and external to the me.«ial line, the lining membrane opened, and the cavity irrigated with 1 : 40 carbolic, 1 ; t(MM) collyrium of mercuric chloride, etc. The sinus is then exphired with tiie i)robe, which may carefully be ])assed into tlie frontona.sai canal to test patency. I'rotargol. b per cent, solution, may then be injected, and medicated gauze inserted. The latter should be changed from day to day, and irrigation and injection practised if there is secretion, the protargol being increased to 10 jjcr cent, or .-stronger if jius continues and there is no undue reaction. The external wound maybe closed aft<'r several day.- if the discharge has ceased: otherwise a short tent, jilug. or flanged "style may be u.<ed. and medication con- tinued as rei|uired. Ill (•/(/•"/(/(■ wuvixrlv the ojjeniiig at the end of the brow in the bony wall sliould be made sufhciently large to admit a curette or large trocar, .\fter irrigation and careful curetting to remove hyper- plasia, mucous polyi)i, etc.. a free o])ening is made to the infundibu- lum with trocar, gouge, or burr. Until recently' the rule was (as lii empyema, which see) then to insert a good-sized rubber (Irainage- tube'. the free ends being fastened alxive th • brow and without the nostril. resiM'ctivelv,^ svstematic use of antiseptic and astringent solu- tions forming the" aft'er-treatment. This may cover three, six, or twelve months. .\fter a time— one or two montiis— when the lower canal seems .smooth and healed, the Uuig rubber or metallic tube is replaced by a short tube. plug, or .<tylet. and worn in the sinus and hidden by plaster. .\s a rule, the orbital roof gradually rises, the brow recedes, and. the eve resumes its proper i)lace. In chronic etnpvema of the frontal sinus freer access to the cavity must be had than"is needed in the acute form, or in mucocele i)roper. The effort is now largely made to render the operation really rmliml. .laiisen makes an incision under the brow and cuts away the bony floor, witii after-treatment by repeate<l packing. In Kuhnt's opera- tion the aim is to obliterate the sinus: the whole of the front bony wall is removed and the mucous lining scraped away. To le.><seii ' Some form nl' ■' miiiofti " operation la now in vogui'. - Ill twi-hf ni«-». ini.liT UK' Clin- ol llie wriltr. of ,Iir.iuio iiiuft-rf-,-;,- ,ir cmrvc— r.. \r::h raiifgr- int-nl, n-ipiirhiK o|»'rmi..n. ilii» pmowliir" was fiillowecl. The trefttmciil liuited from a few wefkn to"vi>lviMnoiitti«iir loiiKir. In only six ca«e< wm It lairl>- tested. »nil in I tie»e the result wassalis- fa. ory,— CHnadian rmctitionc". May. 1H87. 212 THE EYE. ih'forinity, tho ju-riostcuin is now- left.' To the saiiio ond, Kijip spares the upper orbital iiiarfiiii. In H. Tillev's nioditied Kiilmr operatio • heVosn.etie result in tli(- majority of cases leaves notlui.f; to be desired, and the purulent discluirg.' is permanently eured W it un three weeks from the operation the patient may. as a rule, be lUs- eharped The incision is made from just abov,' the internal palpe- bral li<'ament, eomins upwanl and outwanl just below the line of tiie evi-brow to a little bevoiid the junction of the inner and middle thirds n'r the supra-orbital ridse. After retraction of the periosteum a Rood deal but not the whole, of the anterior wall is removeu. After the usual curetting to the i)eriosteum, "all crevices or extensions of the siuus must be .searched out with a small curette or sharp sijooii. Then a free opening is made of at least one-iuarter of an inch lumen into the nose bv means of curved burrs or a curette. To eflect this and remove dis..ased ethmoidal cells, a small sepnu'iit of the nasal nrocess of the frontal bone is cut away. Hcfore packing with anti- septic sauzc, the sinus is dried a"d swabbed out with a solution of zinc chlori<le, S per cent., or pure earbolic acid. The soft parts in- cluding the periosteum, are sutured, excei)t at the inner end where the gauze projects. I>ater a curved silver wire is in.serted. and daily syringing with weak carbolic acid lotion, etc., is i)ractised. I'lnally, partial obliteration of the sinus is secureil by firm external pressure. Corre'-tion of intranasal (Usease is an important adjunct, if not pre- liminary; the middle sinus and turbinal recjuire special attention. (Jriinwald amputates the anterior half of the mi.ldle turbinal. It may be advisable (or necessary, Turner) to remove the whole. Ihis is the more im|)ortant where, a.s is often the case, combined antral, ethmoidal and frontal siimsitis occur. Tille\ rightly warns against septic osteomyelitis of the frontal bone, which he ascribes (in eight or nine fatal cases eoUated) to non-i)ro- vision for free drainage into the nose at the time of the «ipcration The external wound had been tightly sutured and septic phlebitis ol the diploic veins was s.'t up. The writer ha." und(>r his ran- a serious ease of burrowing subperiosteal abscesses over the calvarium from a neglected frontal sinusitis. _ r , r . i \iiother form of op<'ration, the osteojjlastic opening of the frontal sinus- (S. S. (lolovine. after Czerny). which, the author says,"ensim>s a "omplete cure, with no dei^ression and scars searcely visible is ilone as follows: A cutaneous incision about 4 cm. long is made along the upper edge of the internal half of the eyebrow, and at its interna ,.xtn-mity another incision is made ol)li.|uely to it following the fold of the e.'.rrugator musrle of the eyebrow. These two ineisions form the letter T placed horizontally, and in dei)th they reach to the i)eri- osteum The soft tissues forming the ui)per border of the incision can be detached and lifted up. An urc!ir>l iueir^ion of about '2 cm. 1 1„ tw.ntv-tive (.perRllmis. tl.irlwi. on one side, and twelve on l>oll. si.le!.. the case, were cured in from ten days to two weeks. A number were not dlsHfjured by wan.. (KOPKE alter Kl'HNT.) .: Archives of Oplithalmology, vol. xxvii.. No. 8. 'f9'^T''V'T'fT^ DISKASEii OF ORliir, LACRYMAL AVPARATVS, ASD LIDS. 21:} ill l,..idit is then iimdo throujjh the iH'riostciiin. the base of which .•„nvsp..n(ls to the internal tliinl of th.' upper orbital ridge. I'oliovv- iiis: the line of ineisioii made in the periosteum, a small proove is liol- L.Vved out with a chisel which .l«..es not penetrate farther than the diploe Then, bv means of a thin, flat, and very wide chise., h<" d „l'li„uelv, the bo'ne is cut out without <lanjrer of entermp the skull. This little niece of bone formed from the anterior wall of the smus ,..,1, be raised an.l turned back like a small shutter, X\w periosteum nnd soft tissu.' serviiifr for hinges at its base. The result of this is an 'oncniiiK suflici.-ntlv large to admit '.f complete examination, an( ..inbling one to perform a thorough curettement. A dram is passed through the nose, the small shutter is put back into its primitive place and the w..un.l is si ture.l and <lressed. Daily lavage through the drain with hvdrogen peroxide is the after-treatment. (lolovine has also used deam as a caustic injection in eini)yema ot the frontal sinus, jKLssed thrcugh a very small trephine-openmg at the upper inner angle of the orbit or through existing hstula llie i„H,.,i',„ of the steam should last from one-ciuarter to <me-half of a ,„i,u,te. and mav be repeated ufter sev.-ral minutes. This otters a MM-e though slow obliteration of the sinus-five or six months tune, i^team mav also be used as an adjuvant m oi)erations. Ethmoidal Sinus. l-:thnioidal diseiuse, /wr se. not myoiving the orbit . is tn.ate.1 intranasally. Secondary orbital I'';""^;."'''..''.'''''''*!'; and abscess r.-quire oarlv dee], incisions, etc (See (ellulitis.) In ,lHonic mucoc-le or empyema of the ethmoid with distention and tumor-like projection into the orbit, a curved incision is mad. tr m iust under the inner third of the eyebrow to the inner canthus. ke p- ing to the inner upper side of the pulley of the superior oblique (H Knapp,. One mav thus explore, curette, make dramway into nos apply ..arbolic acid, an.l insert tent, the wound tu'ing then (almost) (.{.mM Aft.-rwanl irrigation of the ethmoid from in front is , ..ne daily or at short intervals, an.l tli<- tent renewe.l until th.' parts h.'al or iiitraiia.sal treatment suffices. , , ^ .,, i •* ,„ Sphenoidal Sinus. The sinus may b.- reach.".l from the orbit , m th.. ethmoidal .-('Us. an.l this has now and then been natuir s pa h«a> „r r..li.-f: but except in so far as ..rbital p.-riostitis an.l celh. . s (xvlmh s.>..) are s.'t up by it, th-^ operative treat,n...t oi ^l''''''"' * ; ' ,.n,pv.'ina has b....n alm.)s^ wholly intranasal. Many cas.^s ..f sphen- oidal em,.v.-ma have b.-.Mi tr.-at-'.l with a high pcTcntag.- of success an.l fairlvi-n.mpt r.-civery by ..pening the anteri.,r wal , "'"■«"'?. and m.ulicating (after ablati..n of the mi.l.Ue turbinal). In f'"■t^-h^'^ eas.'s in thirty-four patients the time f.)r cun- was ii.'ver longer tha.i four months (Griinwald;. 214 rni: i:yi:. THE LACRTMAL APPARATUS. Anatomy. Tin- hicrymal uijpanitus cdiisists nf the lacryiiiiil rIiukI, wliicli sccri'ti's the tears, and the lacrvmal passajjcs. throufih t'lc niciliuiii i)f wliicli tlic tears are ilraiiieil into the nose. The lacninutl (jldnil is an acinous gland in two |>arts, tlic larger nf which lies in a depression in the i)ony wall of the upper eMernal angle of the orbit , while the smaller is placed somewhat inferiorly to it, directly heueath the mucous membrane of the fornix. ■^•' o t k,i 'i IWKm' Jm ^jr- f ■ F 1 Section of lacrynial sac. (.\kit,! Both ])()rtions of tlie fjlarid |)our out their secretion hy a .series of small ducts into the upper outer i^ortion (jf the conjunctival cul- de-sac. The excretory portion of the lacrymal .system consists of the puncta lacrymalia and the canaliculi. The piindn are brought into view by everting the lids, and an' seen as small i)apilhe at the imier extremity of the lids at a point where th(> cartilage terminates. T' ;■ ciirmliculi, the two fine canals which are the continuations of the piincta, at first run vertically, but .soon turn into a horizontal axis and empty DlaEAalCS OF ORUIT, LACllYMAL AJ'l'AJUTUS, AM) LIDS. 215 iuti) tho lacryniiil sac The laeri/mnl snc (Fig. 10')) is situated in a fossa at tlie inner aiiftl"' "f tlie orbit ami terminates in the lacrynial duct. Wiien distended, the sac is al)out 12 nun. ioiif; and has a iliaineter of about »> mm. It is narrowest at its t<Tinination into tiie thict, making tliis point a favorable one for tiie develoi)ment of strictures. The anter.or boundary of the sac is formed l)y tlie in- ternal lid lijiaments. and it is believed tiiat the contraction of these aids the natural elasticity of the walls of the sac in the expulsion of its contents into the nasal tluct. Kiu. Iii6, Diict seen through the maxillary sinus. The i.n.jei'tion which the caiml niHkes in this pueition forms a cone with its base below directly continuous with the interior meatus. The apex is directed upward and anteriorly into the lacrymal sac. The axis of the canal is .blique (rom above down- wari. from before backward, and from within outward ; continueil to the dental arch it Is seen to terminate at the second molar, while ita superior or frt)ntal extremity bisects the superciliary ridge J cm. external to the median line ; the transverse line traced over the wall of the sinus indicates the (wint where the canal empties into the inferior meatus. Two pins intro.iuce<l into the canalicuU show the place of common opening into the sac. The duct (Fig. 106) varies in length from 12 nmi. to 20 mm., and in diameter from 3 nun. to 4 mm. Its general direction is expressed best bv a line drawn from the inner cantb is to the interval between the st'cond iireniolar antl the first molar tooth of the upjier jaw. It ter- minates in the nasal fossa below the inferior turbinate body. The mucous membrane of the lacrvnial ap])aratus is continuous, but differs somewhat in the different parts, that of the canaliculi being lined with laminated pavement epithelium, and that of the lacrymal sac and • luct with a laver of cylindrical ejiithelium. Owing to the projection 216 THE EYE. of the iniipoiw iiiptiibrano at ciTtaiii pdiiits. a !»rrics of valves is foriiicil, till" larfjcst of wliu-li. Masncr's vaivc is situated at tlie inferior termination of the liiiet. In tiie liuet tiie nnicoiis nieni- hrane is conneeteil i)y areolar tissue wilii the periosteum, but is seiiarated from it by a' thick venous plexus whieh has the proju-rties of cavernous tissue. ThoURh the moistenin« of the eyeball is chiefly effected by the action of the lacrymal glatid, a serretion is poured out liy the con- junctiva and its nuicous jjlands as well. It is for this reason that the eye niav still be kept moist after removal of the ;;i:'.Md. " After the tears have lubricated the eyeball they are sucked into the canaliculi by the action of the lids in forcinj: the tluid into the iimer angle of tiie "ve and through tl lediutn of the linameuls in dilating the sac. Their passage from the sac into the nose is due partly to the weight of the Huid, but chiefiy to the elasticity of the sac. Diseases of the Lacrymal Apparatus. Dacryoadenitis. Inflannnation of the lacrymal gland Is very rare. It may be acute or chronic. In the ucute forhi the outer end of the ujjper lid beneath the brow becomes swollen, re<l, and tender, with more <pr less severe pain, and inability to raise the liil, save near the imii-r canthus. Th" eyeball may be displaced downward and inward. The focal swelling is not in the lid proper, jis in phlegmon of the latter. The .adenitis may bo symmetrical, so-called lacrymal mumi)s. and occur witii parotitis. It may be caused by trauma, toxic invasion, cold, etc., and it na.s occurred by metastasis in urethral blennorrhea, and as a |)riniary sy|)hilitic ''symptom." It may end in resolution, suppuration, or the chronic form. Treatment. Leeches, iced compresses, hyilrarg. subinur., sudorifics, and laxatives. If the i)."''n. swelling, etc., increase, hot fotus and cataplasms should be :• and on sign uf pointing the phlegmon should be opened, preii . !y in the culHle-sac, to avoid external fistula. Chronic adenititi may l)e subacute in its oitset, or mere'y show slight redness of the upper lid. which is more or less prominent. The swollen gland can be felt below the bony rim. and there is little or no pain or tenderness. Now and then this form is tertiary anil gmmnatous. Treatment. T(H)ically, ungt. hydrarg., hydrarg. oleat.. or tinct. iodin.; internally, j)otassium or .sodium iodide, raising the dose to gr. XXX., or e\cn gr. Ix.. t. i. il., if well borne, and giving pilocarjji.ie in addition in dose to cause i)rofuse sweating, daily or on alternate days, for ten to iifti-eii tinn-.v. in ■•<iipp}iratir(' injlnnimntimi of the accessory or palp(>bral portion of the lacrymal gland there is a tense, tender swelling in the outer upper part of the upper lid, with hypera'mia and loctlizeil chemosis DISEASES OF ORBIT, LAVRYMAL APPARATUS, AyO LIDS. 217 at tho site of tlir small ovoid tumor which imgrcts into the cui-di'- sac. " 'lortiy iHiints and opens into the tissurc. There is iittie systennc disturbance. Treatment, liarly application of the lead-and-spirit lotion on coin- pri'sses may arrest it.' If ineffective, hot fomentations are in order. H3rpertrophy of the lacrymal pland is very rare. It may lie ilue to recurrent inflaimnatory attacks, occurs most of* 'U in children, and may lie coiiftenital. The fjland iMcreas<'s in size very slowly, ami there is a iiotahle absence of exti'rnal sipns of inHammatioii. The tumor is circumscrilK'd, somewhat tirm, elastic, and nodulated. In time it may disjilace the eyeball and limit its movements. Treatment. Treatment by jiot. iodid., especially in adults, in whom the affection may really be a chronic tertiary adenitis, should be pushed, large dos«'.s In-ing piven if tolerated. Kxternal applications of ungt. hydrarg., tinct. iodin.. etc.. nmy Im- used. In genuine hyjM-r- trophy, however, o|MTation is generally reejuired, a part or the wliole of the gland lieing removed. .\trophy of the gland occurs in xerophthalmia. It is said to bo .secondary to destruction of the lacrymal sac, but this is certainly nut a necessary result. Fistula is caused by injury or abscess. It may lie cured by the u.se of caustic or the cautery j.oint, or by passing a suture with two needles into it and on through the conjinictiva, and tying iMitli ends (iver a bridge fif the latter at the fornix, or by making a counter- opening for drainagt .nto the cul-de-sac by means of a suture as a seton. Tliese steps failing, removal of the gland is iiaiicated. In one ca.se in which the writer did extirjiation the tears wen- escaping on the temporal side of i\u orbital rim. Tumors of the lacrymal gland are very rare. Adenoma, adeno- angioma, angioma, epithelioma, enchondroma, osteochondroma, Ivmphosarcoma, carcinoma, cysts, and dernioid growths have been reported: also miliary tubercle in general miliary tuberculosis. The diMgnosis has to Ih' w'orked out in each case as '' tr as may be. and as an aid a tentative course of potassiinn or ^ lium iodide in large doses may be useful, if not decisive. Excision should be done early, sii as. if "possible, to circumscribe the neoplasm. Calcareous con- cretions (dacrvoliths) .sometimes occur in the gl.-uid or duct and act as foreign bodi(>s. They show through the conjunctiva, and should be removed liy incision. Dacryops. Cyst of the lacrymal gland appears as a bluish-pink, <emitransparent, elastic sv.elling of varying size showing beneath the ' ThfIull(iwinK anodyne aslrinKent mlxtare applied on compreaeM or under an ice-biiR i» very useful in inilHUiuiHtioti of the eyelids, tear-sac. or gland : Plumb, acetat., fcm v. Add. sK-tif tii!.. rCi V Atrop. sulph., (tr 'uUyM. Morph. sulph.. er. j. AI:<ihol., SJ Aqus. «d SJ. 'AH TllK EYE conjuMctiva at tlio rul-df-Hac. ami if larp- caiisi's proiniiii-ncc nf tlie uiMKT lid. The swfllinji l)<"( irs at (iiicf ilisliiictly larger if tin- rtul)iirt cries (ir the jjlaiicl is >tiimilateil fmni any ciiise. It is gen- erally <lue to cldsure of ail excretory iliict with retention of tears ami (list('iitiori of tiie i)art of the iluct ami ulainl involved. It may l)e congenital. The trr'atinenl aims at securing a iieriiianent opening I'y incision or the u.se of a suture. l>y which tistula in the con- junctiva is produced. \Vh<-re there is a cystic tumor or hydatiils of the gland, the radical operation may be necessary, or tre t- ment of (lie lining .if the sac hy tinct. iodiii., argent, nit., or acitl. carhol. after evacuation, with iced com|ire.sses to prevent umlue reaction. Dislocation of tlie lacryinal gland is almost wholly due to trauma in young subjects, in whom the orbital rim is ill developeil. In cii.se of lesion the gh. d may present in the wouml, or there may Ik- an almond-like tunu.. at the upper and outer i>art of the eyeball, or a movable fmior under tiie lid. (Iradu.il luxatiori may occur. Treatment. Reposition may be possiiile, and if not, excision may be reiiuired: and, again, interference may not be called for. Epiphora. Normally there is only sufficient lacrynitil secretion to keep the t'Ve moist, and there is no stream of fluid passing through the puncta. .\ flow occurs only where there is hypersecretion, so- called lacrytiiation. When there is much lacrymation the natural lacryinal p'as.sages are inadequate, and the tears collect in the lacus or they overflow— a condition termed epiphora. Defective drain- age does not account for the surjilus often present; the gland fre- quently acts ill ca.se of stricture of the c:i'';,'iculur-- t du<' :'-i if there were a foreign body to 1m' swejit away. .\ most marked ca.se of e|)ipho.a of years' .standing was cured in two ilays by simply opening the canaliculus into the sac. Kpiphoia may result from hypera'mia or intlammation of the intra-ocular tissues or of the con- junctiva, cornea, and lid-edges: injuries of or ton ign bixlies on the eye or beneath the eyelids, when it will bi' sudden; malposition of tiie lid-edges or of the puncta, and atresia of the puncta or eaiial- icn'us; mucocele (catarrh of the sac with dilatation), stricture of the rut.-al <luct ;ind lacryinal tistula: also rhinitis or defect in the tiirbinals. Voiiiig subjects with chronic coryza and boggy lurbinals often have epi|>hora, which ceases when the nasal trouble is cufeil. Lacrymation may also be due to reflex irritation, mainly through the medium of the fifth nerve: syiniiathy with the fellow eye and emotional cau.ses are well known. Eyestrain as a factor is to be borne in mind. Some cases of habit lacrymation are due to it. A rare cau.se of epijihora is blocking of the canaliculus by concre- tions of Strejjtococcus Foersteri. It also arises from notching of the lower lid, and from flaccidity of tin- !id^ due to !o-s of unw- -A the orbicularis, and in paralysis of the latter it is most annoying, the interspace between the globe and lower lid being filled wi'h tears which often overflow— lagophthalinos. hlSKASKS OF ORIIIT, h.lCHYM.iL M'l'AR.iriS, A.\J> LIDS. 219 A!< (ithcr fiiul (<t'ri<>U8 liKTymal trouldcs arc pciu'rally proccf U-d l>y ••|iiplinra, ilM caiiw slioiilil he early foiiiiil out and dealt with. 'I'liis may re(|iiire Home stud.' Two or more of tlii' coiiditiotis cited may coexist, either of which would suffice— #■. </., chronic conjunctivitis and ciintracted or everted jiunctuni, rhinitis and associated conjunc- tivitis, o|>tical defect, blepharitis, etc. I'inuid (inil ('(innliciilii.i Closure of the puncta (iiiresia) is rare It may he congenita! or due to shrinking after intlanunation or injury, malposition, etc. The p'lnctum should lie reojiened and stretched a few times l>y a silver pin, blunt needle, or fine sound. Small, even minute puncta may not caus<' epi)>hora, but it <I(m's occur wheji their contraction arises from thickening of the mucous lining and hypertrophy of the sphincter fibres, due to chronic or recurrent con- junctivitis, blepharitis, et('. The puncta then resist stretching by the fine sound, and grip it like solid rubber— too tightly for mere spasm. If after several forcible dilatations there is but little change, the inner wall of the punctum should be snipped vertically with fine scis,sors, to make a permanent patulous slit, and in atresia prop«'r this has to be done if a trial of stretching fails. Tlie treatment of inversion of tlie punctum is that of the entroj)i()n, etc., which causes it. In ('Version of the punctum due to sagging of the lower lid or to slight ectrojiion, the canaliculus should be slit and its inner lip and a segment of conjunctiva cut away, making a triangtilar raw surface with base out. This in healing often corrects the faulty position and the epi|)hora. Re|)osition of the everted punctum caused by eczema, etc., of the lid generally follows cure of the latter. It may, however, be neci'ssary to open the canaliculus well down on its inner wall with sci>;surs. In paralvsis of the (trbicularis (facial) ni(>re has to be liiine, and tarsorrhai.l'y isce) is ncdrd, and the In'tter to raise and tighten the lim]) lower lid its inner end is made raw just Iwlow the canaliculus, and is stitched to a raw spot at the juncti(Hi of the ujiper lid and nose, or instead two small flajjs are made and stitched to- gether (H. Xoyes). Stenosis of the canaliculi, unless congenital, is as a rule at the im\cr end next the sac, and care is needed in dilating the stricture to avoid making a false pa.s.sage. The lid being made taut by traction with the tinger-ti]) on the malar process, a small probe, No. 2 H. or A T..' is i)assed vertically into the punctum, then horizontally along the canaliculus in the line of least resistance, at the roof. a.s a rule, with a rotary motion, if needed, to avoid piercing the mucous folds. Then, if a slight push inward or downward causes a distinct wrinkling of the skin at the inner canthus, the .sac has not been en- tered, and gentle pressure shouhl he used to force the constriction. Tlie outer wall of the .sac will often yield enough before the jjrobe to mislead the inexperienced operator, and the })oint being forced 1 Theobald's set Is of 16 sizes : No. 1 has a diameter of 0.25 mm. : No. 2. of O.'iO mm. ; and so on to No. 16, whk'h is 4 mm. Bowman's set Is of 6 sizes : " reaching from a line hair probe, No. 1. to one III one twentieth of an inch in diameter, No. 6." 220 TIIK EYE. (lowmvanl, passes tlirouRli tho wall ilsdf, and, it may he, l)ct\vc(ii the duct and the hoiiv canal. To facilitate dilatation of tlic stricture, a horiiif!; motion mav he tried and a smaller i>rol><' or six'Pial sound used (as Theobald's new model). The stricture should be stretched to lake No. 4 or 5 H. or T., which shoulil be passed every day or two for at least a few times. Rarelv the canaliculus is the seat of a fungus (>irei)tothrix), and jiresents an ovoid swelhnp;. with viscid discharfje from the patulous punctum: die caruncle and fold are hypera'inic and the eye irritable and waterv. The fuuRous ma.-is (dacryolith) may be exi)elle(l throujih the n.asal duct bv svriiiffinK per punctum In this way in one ca.-^e of the writer's, witliswelling of the sac and seemin>; inciinem cystitis, a globular mass of the size of a lar<re currant was forced out whole bv the anterior naris, and the one flusliinj;— with liq. hydrarg. per- ciilor. ilil. -sufficed. In another the canaliculus had to be opened: the :umen was found greatly enlarged, and the lining much inflamed. The curette had to l)e u.-<ed. with after-treatiiienl by sol. hydrarg. perchlor. and jirotargol. FIG. 107. Ancl's laiTj-mal syrinife. The Duel. The anatomy of the nasal iluct go(s far to show the ea.'^e with which some fault may arise to cause epipiiora. to wit. the coiitimiity of its lining with that of the n.a.sil mucous membrane, and of its submucous venous plexus with the erectile cavernous tissue of the turb'nals. There is also the fact of the lacrymal tube lying in a bony canal, the periosteal lining of wtiich may i)lay some part— c i/.. in scrofula, syphilis, rheumatism, etc. Engorgement of the submucous caver- iio.^a, e;usily set up. and catarrhal infl.'iimnation of the mucous lining by extension may singly or together close the himen and cause epiphora. Folds in the mucous membnine at the top of the duct where it is narrow, and at its na.sil end, if not in thi> middle, a(ld to the mechanical elTect of inflammation and turgesn'iice. Recurrent inllammation set up by nasal disease may lead to structural changes in the mucous rneinbrane of the duct, infiltration, swelling, hyper- trophy, anil induration, and also ulceration with dense cicatrix, and tmmmmt mmm i>isi:At>i:.s OF oRBir, lachymal ai'I'miatus, aM) lids. 221 ,luis cause jiartiiil stenosis or coiuplctc stricturo, with sccotulary implication of the sac. (See Mucocele.) ( )ne can test fairly well the ])ateiicy of the nasal duct by .syrinsiiifl, the hlunt fine tip of a hypodermic or of a lacrymal syringe (Anel's) (Fig. 107) •"•;•': i .■■■'•.,'." into ihe sac: fluid injected under gentle j)ressure sho i( tind vent by ih' anterior or posterior naris. To give the test val «:•, t ic canalicu'' • should, of course, he patent, and the other punct ,in iiould b.' c >.se(l by pressure. To pave the way for probes, and ■ o ) U-M whether or not a constriction found is due to organic changes— e. g., .:tricture— or only to vascular turgescence, the injection into the duct of sol. adrenalin chloride 1.5 : S00(), with sol. cocaine, 5 i)er cent., is useful. To exi)lore the na.sal duct, a No. 4 B. or T. i)robe is passed through the canaliculus (as directeil) and pushed on until the finger-nail resisttuice of the lacrymal bone at the inner wall of the sac is felt. Then, the jjoint of tlie probe being kept against the inner wall of the sac, its a\is is changed to the vertical, and pressure is made down- ward and slightly backward, to coincide with a line from die inner end of the caruncle to the ])oint of junction of the ala and cheek. A No. 4 Howman jjrobe is safer to begin with than a No. 2, and the length as well as the line of direction of the canal should be k(-|>t in mind, else a stricture at its lower end may not be passed —a mist ike too often made. It is a good rule to gauge the buried part of the probe; it should reach from the caruncle to the edge of the ala. Treatment. The treatment of simiile ejiijihora due to catarrhal conditions in the duct consists in a .short course (of ten to twenty sittings in four to six weeks) of Ciireful probing of the duct with the largest sound the unslit punctum or canaliculus will take, (i Howman or .") Theobald, and gentle svringing with mild a.stringent .solutions— ( ;/ 1 gr. sol. zinc sulph.. zinc chloride, etc. This, with attention to' a'nv conjunctivitis, blepharitis, nasal trouble, or eyestrain, will tide not a few over one, two, or three years, and m cases ot relapse a few visits mav suflice to secure a like respite. Hut should a lair trial of such prolies earlv fail, the canaliculus should be si)lit (see Bowman's operation) that larger ones may be used. In some ca.ses a short treatment every six months may be neeiled to correct nar- rowing, due mainlv to chronic or recurrent rhinitis. Although the ep'iphoia of conjunctivitis, blepharitis, keratitis, etc., is inciilental, one can at times give relief and promote curt by atten- tion to a contracted or (lisi)laceil punctum, or by enlarging the lumen of the canaliculus and <luct bv the use of probes. This course .should not be neglected in some forms of chronic or recurrent keratitis in young subjects as well as in adults, in which treatment also of any "nasal atTection is a necessary adjunct. Si.iTTiXG THK Caxalhv! r« '■ HowMAx's OPERATION), The punctum if contracted is first stietched with the tine conical sound, and a 2 per cent, to 5 |)er cent, solution of cocaine is then injcct<»d into 222 THE EYE. tlic canaliculus, and the patency of the latter ensured by j)assinji a No. 4 B. or T. into the sac. It' tliis be not done, a false passafie is apt to be made above a stricture in the canaliculus. The lower lid beins made taut by traction toward tlu; malar process, and slifjiitly everted, the blunt-tijjix'd or jtrobe-pointed knife (Fifj. lOS) is passed Weber'a canalicular knilV into the punctum vertically; the handle is then dii)i>ed, and the knife with the cutting edge up and in is pushed on jiast the caruncle tmtil the sac is entereil, when the handle is brouglit ajrain to the vertical, the upper inner wall of the canaliculus beinj; divided to th(> caruncle, or to the sac, as desired. In cases of mucocele. whiTe syrinfiing or irrigation and the use of larger probes will follow, a freer opening % Method of inserting Brtwmiii.'s i>robc. (Norkis nnd oi.ivfh.) is re(| lired, and the .«ac should be entered and cut upward. Tare should alvvavs be l.-ikeii not to injUlt- the (Imn of tin- caiiMiiculu.--, which wouhl cause risk Tnot imaginary) of fusion of the walls; traumatic stri. ture is a .serious bar to a good result. (Figs. 109 and mSEA-SKS OF ORBIT, L.WRVMAL AI'PARATr^, A.\I> LIDS. 223 110.) Afiiiiii, if a falso passapo is mado over a stricturo in tiic canal- iculii^. failiirp is coiirtfil, for a few days after the CDursc of i>f(il)iiiK stops, tlic new canal may contract or close. Some ]!refer, as does the writer, to use fine liiit not sliarp-i)ointed curved scissors in lieu of the knife when the sac wall has not to be opened. W'i*' *he lower lid everted and made taut, one i)oint being pushed into canaliculus with convexity toward the eyeball, a sinftle snip makes a curved cut on the inner wall, which is liiddeii from view — a point in its favor with females. The raw lips if kept apart a few days heal se])arately The majority of operators choose the lower canaliculus, but some always slit the ui)]ier. In this case the upjier lid is drawn tightly toward the brow, care being taken not to cut the front wall (skin). Some open botli canals frarely needed), while others — not a few — will not cut either, and u.se only such probes in the duct as can be passed through the intact canaliculi. Fio. m. Rouinnn's iirohe in position. .MiiMcelc. Hut more violence may be done by forcing prolies than by a clean cut: besides. Bowman's operation dot's not interfere with the normal action of the drainage svstem. It also permits of the use of large jirobes, tends to ward off acute cystitis, and enables patients to use the syringe themselves in the after-treatment. Mucocele. This is a subacute cystitis of the lacrymal sac in which the latter i)ecomes distended by the ])ent-ui) secretion from its in- ll.imed lining mi-mbrane, together with tears. It is secondary, as a rule, to stricture of th(> n.asal duct, and this, in turn, to recurrent or chronic rhinitis. Fortimately, it is often one-sided, as indeed nasal deformity or disease prov(>s to be. Mucocele mostly develops insid- iouslv. as does the na.sal .stricture, and there is <<ften simi>le epii)hora of varying degree due tt, the latter, for months, if not years, before • !;,. cv-iiti- "upervenes. The retention of tears and the presence r.f lirganisms in the sac tend to light up hypera-mia of its lining, with secretion first of mucus and later of mucopus, and gradual (listen- 224 TIJE EYE. tioii eiisiu's. The suhjcet then tirids tliat tlicrc is a iloupliy swelling at the innor caiitluis which yields discharge, and, getting relief from rejieated emptying of tin- siie i)y means of the Hnger-tip. eontinues the practice. Inspection and jialimtion show the contrast between the two sides, the lacrymal crest and mouth of the duct heing readily felt on the sound' side. If there is a Imnpy fi'eling after empty- ing there is likely nmch tiiickenuig of the lining, or a polypus. (Fig. 111.) .Mucocele may persist for years, causing ami" ;> only by the epiphora and the blurring of .«ight by Hecks . ..ischarge from the .sac or conjunctiva. Conjunctivitis and bh-pharitis are often present. If absent and the punctuni acting. ei)ii)hora itself may be wanting. Th(>re is. however, always the risk of acute inflammation, and subacute attacks are not infreiiuent. Besides, the contents of the .sac being charged with organisms, infective ulcer of the cornea may occur from slight abrasion, etc.. and the eye be lost. The subjects of mucocele should always be warned of their danger, and Bovvman'H [trobes. where it is present the globe should, not l)e opened. Proper treat- ment should first lie instituted. Many eyi'S have been lost by post- operative sejjsis due to mucocele. In the case of a large duct with ])artial stricture the contents of the sac may escape, or be forced from time to time into the nose. If this avenue becomes closed, or if in confirmed .stricture of the duct the wonted discharge by the caiialiculi is stopj^'d, owing to swelling, the tension of the .sac may lead to acute cystitis or to great stretching with a ca|)acity of a drachm or more. The real size often does not show because the .sac dips backward. As a final .stage of neglected mucocele atrophy of the thinned mucous lining of the greatly enlarged sac may occur, and the latter l)ecome a mere cistern for the tears (the " .\tony and Dropsy" of Kuclis). Treatment. This consists mainly in cure of the stricture by the .systematic use of probes. The first ste]i in a course of probuig in mucocele is to slit the canaliculus (page 221). and then to wash out the sac by syringing with a 4 per cent. sol. acid, boric, or sol. hydrarg. ])erchlor.^ 1: .3(MH). It is unsafe to probe the duct until this is done, unless it holds merely mucus and tears, and even then it is unwise, i i>y.vi,JNAA OF ORBIT, LAVJtYMAL AJTAIIATI'S, AM) LIDS. 225 fur the sac liciiig a favoraljlc culturo bed, orpaiiisms may jjain access to tlic tissues aiKUiid tlii'uujili an al)msi(Hi or false passajje, and set 11]) se|)tic inflaimnation. ()rl)ital cellulitis, optic neuritis, atrophy, and blindness may r <ult. In syriiiftiiifj after probinj;, no force should be used, else weak s])ots in the sac wall may pive way before \(Mit is had by the lUict. Where irrij^ation is used instead of syrinfrinjr. the sac and duct l)eing flushed with a ijuantity of fluid (iM the siplion plan, a method preferred by .some, the patency of the duct should be tested before pressure is made. The object of ])roi)inp is to restore the normal calibre of the nasal duct at the strictured points, with a view to present drainage and future patency, \iews ditTer as to the best method: some will not slit the canaliculus, others will not use larger probes than 6 Bowman. \ot to do the Bowman operation and to continue using jirobes which will pass the intact canaliculus, ignores cases for wliich the best can- not be done unless large ])robes are used, and such cases are not few. Large nasal ducts are often found in nmeoccle, and with one or more ring-like ledges having a lumen of 1.5 mm. to 2 nun., which take the largest Bowman j)robe. (Fig. 112.) Again, the bony duct in the same subj(>ct may differ in .size; on the side of the large canal there may be mucocele, and on the other simple stricture. The latter will probably j-ield to ordinary probes, wliidi would be of little or no use in the former; hence the eclectic j)lan is a safe nile and the best in tlie end. Gauge the probe to the duct, and try large ones when smaller fail.' .After injecting 5 jier cent, of cocaine and 1 : 5000 sol. adrenalin, a No. 4 B. or 5 T. should be tried first : and if it tits tightly, it .should bo left in a few minutes: if not, higher numbers are at once tried, and on the next visit a size larger tlian that last used. Probing should be done on alternate days for two or three weeks, and then twice a week for a month, or until the sac has ceased to secrete, when a few visits at intervals of ten days may suffice. If, after the first two or three visits, probing causes only transient pain, one may then safely use the largest size pas.sed under firm i)ressure, the ])rob('s being left in fifteen to thirty minutes. But if the j)ain lasts .several hours in spite of cold compresses, and there is acliing in the bone the next day, there is risk of periostitis, and a rest of several days should be given. Syringing or irrigation should, how- ever, be kept up steadily, daily if possible, for its astringent and curative effect, not only on sac and duct prr)per, but the lower tur- binal. In young or very nervous subjects, and where one is susked to do the most in the least time (and this occurs too often), general ana'sthe.sia is re(|uired. This allows rapid and, where needeil, forced dilatation, and the insertion of the largest styles taken. This plan ' Tlie'>l!«l'l use? hi" No. !6 " !n a!-.!".! two-thirds of al! cases requlrins preblnff. tneluditis Iho-e in I 'Idren on well as adults, and the oases in which No. 13 may not be iiaed with advantage are ex.remely pare." He reports the exceptions rare to peitnanent cure where this line Is faithfully followed. 22(5 riit: EYK. suits in young f*ul)jofts, the style Ix'inj; left in a lew days at least anil in older ones it can he raisi'd daily, if needful, to empty or flush the sat-. (See Styles.) Kleetrolysis has l)e<'n tried in order to get ((uicker and more" lasting etTect upon strietures than that hy simple probing or the use of styles. The negative pole is cotmeeted witii the prohe in situ, and tlie"si)onge of the jjositive is applied to the eheek or neck, the strength, of the current not to exceed thice milliaiuperes, and time of sittings from two to Hve minutes. The method, which is worthy of trial, has met with .some favor, though not largely u.scd, and it is still "uh judicc. Cataphoresis is also on trial to a limited extent. Solution of nitrate of silver and protargol have been used in purulent bl(>imorrh(ra of the .sac and duct. Less often than formerly strictures of the duct are hrst freely divided to the bone by the Still- ing or other knife, and at once, or shortly, and fmni time to time, the Weber biconical or other large sound is |)a.ssed. .\n after-course of syringing may not l)e necessary when the sac is not large and the secretion scant and free from inis: but, as a rule, it is a most useful adjunct. In view of th(> return of the stricture and of the blennor- rlxea in not a few cases of mucocele, even after careful treatment, some are coiUent merely to slit the canaliculus, dispense with probing, and rely upon svringing of the sac with astringents, etc., at home. The so-calleil Berlin lacryinal syrir.g.>, with bulb and two points, li.ard rubber and metal, is a useful form for tiiis purpose. Sonic excise a part only of the sac wall, and curette tiie rest, or treat it tojiicidly with sol. argent, nit., etc., and shortly allow the wound in the skill to close. This line of treatment suits some cases of trachoma of the .sac or of polypus, wiiich givi- a pulpy sensation to the finger- tip after emptying the sac. owing to a marked tiiickening, etc.. of the nmcous lining. (S«'e Fistula.) In lieu of ordinary extirpation, the sac may Ix' entered and treated from below by removing the anterior part of the inferior turbinate jind the turbinal ci.-st with a uouge, (>tc. (T'assow). Miiriiccic in Injiints. Tie short and patent nasal duct of most infants gives organisms ca.sy access to the sac, which forms a good nidus, .Vcute or subacute dacryocystitis may thus cause innnilent rhinitis shorily al'tiT birth, as early as one week, and the diagnosis is i)retty dear. But blennorrhiea of the sac, which more often results, is a mild proce.-;s. and the flat nasal liridge and relative prominence and width of the inner cantluis tend to mask the real mischii'f, muco- cele. Hence, in very young subjects without n-al or witli but slight conjunctivitis this is at times mistaken'y held to be the cau.se of the l)urulent or mucopurulent discharge found about the eyes now and then during thi' day, or gluing the lids in the morning. The astringent collyriui.i as generally prescribed is, as a rule, ineffective. The cul- de-sac and inner canthus region should be filled with i ni. sol. zinci chlorid. or acetat., or 1 ; 12,(XH) hydrarg. i)erchlorid., and short, care- ful massage of the sac done— this daily or twice a day. It» persistent or recurrent mucocele of infant.s |)eriodic medication DlHi^AiiEii OF ORBIT, LACJIYMAL APl'AIiATUH, ASD LIDS. 227 (if tin' sac !)>■ syringing sufiifcs, as a rule, and should bo tried. A liypodt-rinic syringe answers well, the hlunted and smoothed needle being passed into the canalieulus. and sol. zinci ehlorid., zinci sulph., jduinli. aeetat. of 0.5 per cent, strength, sol. hydnirg. pereldor. 1 : .'5(MK) or 1 : 40(K), sh>wly injected. If the fluid does not i)ass into the nose, oiK' should make sure that the tip is in the sac before diag- nosing stricture. If the sac contains pus, or if there be niucopus after a few injections made at intervals of two or three days, sol. protargol. 10 oer cent, should be used, and 20 per cent, if this fails after one or two trials. Rhinitis should alwa\'s be looked for, and !)(■ treated (as well a.s in older subjects), vW the treatment may prove futile, and this rule holds in all young subjects, upon whom one should be slow to use instruments. In not a few cases the free end of the duct is blocked, as it may be in adults, by a fold of mucous membrane which interferes with drainage, although yielding under the |iressure of the syringe. This emphasizes the need of attention to the nasal pas.sages in lacrymal cases. Proper treatment of the inferior turbinals often cures marked simple epijihora, and is an elTective adjunct to medication of the sac in case of mucocele. In very young subjects there may be stricture of the duct with (and without) mucocele, which re(|uires slitting of the canaliculus and the use of probes, etc., as in adults. Dacryocystitis. Acute inflannnation of the lacrymal sac is gen- enilly a secjuel to mucocele, although now an(' then it lights up primarily as a complication of acute coryza (inllin:iza, la grippe), especially in young infants: also of erysipelas. In scrofulous or syphilitic subjects jicriostitis or osteitis in the lacrymal region al.so causes acute or subacute cystitis. After exposure or in the course of rhinitis, etc.. the subject of nuicocele finds that pn-ssure r)n the inner canthus does not dis]ier.se the doughy .swelling as usual, but that the latter has become hard, tender, and tun;or-iike. (juickly pain, often intense and due to tension, sets ui with hiflannnatory irdema, which in markeil ctises closes the eye and extends to the cheek and over the nasal bridge, involving the lids of the opjjosite side. With the canaliculus and duct closed, there is now a virtual abscess, which if unrelieved within a few days points and opens below the internal tarsal ligament, the pain, swelling, etc., (juickly subsiding. The rapid onset and smooth glistening skin with bright blush have time and again led to a diagnosis of erysipelas, but the history of epiphora and mucocele, and the intense localized pain and ex(iuisite tenderness at the site of the sac, .should give the clue. ( ienerally the breach soon closes, and there is once more nuicocele or simple cystitis, which may later lapse again into the acute form. Very rarely the sac resumes the normal cond.tion. Sometimes the opening in the skin persists, giving vent to the tears and mucopus (hstula lacrymalis), a sure result in bone di.sease, which may be the effect as well as the cause, as already stated, of acute cystitis. In a f(>w ciises there is a dissecting infiltration of the skin down and 22H nit: EYi:. ; (Hit Iroiii tlif iiiiiir caiitluis, furiiiiiif; a doiinliy limad riilf;<' lor I'vcti an iiifli, like a lii'sli keloid cicatrix. In utlicr cases, and rarely, tlie fistula contracts initil tliere is i)iit a very tine (ineniiijj in healthy skin through which tears only can ooze -cai>illary listula. Treatment. In mucocele with incipient acute cystitis the rule is promptly to slit the canaliculus into the .sac when great swi'lhng of the parts does not prevent it. The tension of the sac is thus relieved, vent given, and i)ain relieved. Other step;* are gentle syringing with warm boric acid sol. ;} per cent., or 1: S(MK) merciu-ic chloiitle .sol., if not too painful; also the injection of 10 per cent. sol. protargol, and the u.se of dressings wet with atrojiine, lead-and-spirit lotion, over which a small ice-bag isjilaced, orai>ieceof ice in a small gauze sling; calomel. Seidlitz powders, and pulv. Dover., with other anodynes, may la'ove useful. If cold is not grateful, hot fotiis now and then .should be used. The canaliculus should be kept open and the sac washed out daily with warm boric acid sol. .\ i>er cent., or 1:S(K)0 to 1:4(MK) mercuric chlori<le. and protargol 10 |icr cent, to 20 jht cent, be inj<'cted if pus continu(s. In primary acute attacks in infants, and sometimes in adults, when of a mild tyite, palliative treatment by iced C()mpres.ses. etc., may sullice without slitting. The sac should be syringed with warm boric acid .sol. through the dilated canaliculus, and 10 |)er cent, protargol or argentamine then injiTted. If the c;use is not seen until too late to reach the puncta, aiid the inflammation is jirogressing. one sho\ild anticipate ru])ture through the skir\ by cutting straight into the sac below the palpebral ligament. After gently syringing with boric acid sol., hydrarg. per- chlori<l., etc., aseptic moist (Ir "ssings should be ajjpiied and hot fotus used. Irrigation shouUl be jmictised daily. The canaliculus .should be .slit into the sac as soon as feasible, for vent given in this way promotes thorough cleansing and the healing of the sL.n wound, and I'xiiedites the necessary resort to systematic probing for the cure of the stricture. The us<' of probes should be begun as soon as the active stage has pas.sed. Fistula Lacr3nnalis. This often needs no special treatment, and heals when the canaliculus is opened, or the patency of the duct is restored by i)robing. Now and then fungous tissue within and at the mouth of the canal, or, again, the smooth lining of an old fistula, re(|uires to be removed by cuistic. cautery, curette, or scissors, to ensure healing. But if the sac is large anil .secreting |)us, it should he opened by enlarging the fistulous canal freely, and the disea.sed lining swabbi d with sol. argent, nit. 2 per cent, to 10 per cent., zinc, chlorid. 5 per cent., or tinct. iodin., or lightly touched with argent, nit. .lO per cent., in the form of a bead fused on the eiul nf a probe: or if tr.achomatous. curetted, irrigated with sol. hydrarg. perchl'ir. 1 : 1000, liried, treated with vaseline, and packed, and cold dressings put on. One or other of the above may be needed several times at short intervals before the discharge cea.ses or so abates as to allow closure of the wound. A jiressure pad then jjromotes healing. IHSEASt:.S OF nUlilT, LlCliYMAL AlTAUATiS, AM) LIDS. 22!> vent liciiij: liiid lln(ui<;li the caiialiciiliis jilrcady (ipcriid. An altcr- iM)uis( (if |)rol)iii); is usclul. In tin- event of inii>eri'ect liealin); of fresli oiithreak of cystitis, caries in tlie iluct or wltli internal tislula. will likely tic found rifice of tlie sac, willi careful tlie tistnia or a of tiie lacryina .vitli the probe, a fair indication lor sacrifice of tlie sac, willi car scrapnif; ol the carious sj ts, etc. In 'his condition, however, forced dilatation ( cure nianv case? f the strictured duct has been found l>y Theobald to and this inethoil should, therefore, have jirece- ileiice. Iiarelv a fistula exists at the inner canthus near the sac. but uncon- nected with ilie latter and leadinjj to a carious spot at or within the inner iiiarpii of the orbit, or even into the anterior ethmoid cells, as shown by the probe. Afjain, in nuicocele of the ante rior ethmoid cells thi-re may be a swellinj!; just behind and above the lacrvinal sac which siimilates mucocele of the latter. The absence of lacrymatiou and escape of the di.-ich;irf;e jier punctuin <in pre.s,«ure, and the pas- .sifre of flui<l into the nose on syringiuft, together with deeii paijiation, should distinguish the condition. Stiilis. These may be hollow or solid, and are preferably of soft vir- gin silver oraluniinum: lead wire often isu.sed; some employ gold, and others hard rubber. The crook should be sufficiently long to reach neariv to the i)unctum, lying in the canaliculus, so as just to avoid touching the cornea in extreme adduction, and the stem should about reach the floor of the inferior nasal meatus. They should be made perfectly smooth, so as not to tear the mucous membrane. The stvle should !«• as large as will tightly fit the duct under the u.-^e of cocaine anil adrenalin, and not .smaller than No. 4 H. At short intervals larger sizes can be put in as .stricttire or hyijertrojiliy yields, and when of large calibre that of the crook should be reduced. If too short in crook and stem, the styh' is ai>t to slip down, especially if heavy, as of leail, and the crook become encysted in the sac wall. It will til act as a foreign body, and will need to be cut out of its bed. II .How styles .^lipped into" i)lace over a probe already jiassed (Bickerton) are "useful, but jirominence of the brow may be a bar. Where there is mucocele or blennorrlKca the styles should be drawn up or removed daily and the sac irrigated with an astringent solution. Patients who learn to in.sert them themselves have the best results. In organic strictvire styles should be worn if jiossiblo for six months, •ind if used for other cases arc to bo worn four to six or eight wet ks, a trial resjjitc for two or three days being given now and then. Un- fortunately, in many cases styles are not tolerated, and in not a few the tendency to the formation of gramilatioiis prevents their use for more than a few days at a time. With the proviso" that a fair trial of probing, styles, syringing, etc.. treatment of nasal passages, etc.. has lieon given, the indications for extiri)ati(Mi or obliteration of the sac are: bony stricture of the nasal duct, with constant epi|)hora. with or without nuicocele; recur- rent stricture of the duct and purulent blennorrhcea ; persistent muco- 2;io 77/ A' /; YK. I'liiT i ;)!!' I cclc, with roiicMtcil attacks of ai-iitr iiillaiiimatinii— [ihlcjiiiionoiii: piTsistciit ti.stiila, witli invctcratf miicipci'lc. etc,; markcil (iri>i>sy uf the sac. C. Hdlmi's, will) iirfjcs and practi^'s cxtiipatidii uf tlic lacryiiial jllaiid anil sac tofti'tlicr, oWscrvcs tlic fcillowinji indications for tli<' latter: 1. IniiHTativc oixrations for cataract, glaucoma, etc., in the pres- ence of l)!ennorrlui-a, etc. 2. In patients who cannot devote the time, (ir submit to treatment l)y prohinn, etc. 3. In ail ca.ses where conservative treatment lias faih-d to euro within a rea.xonable time. HxTiiU'ATioN. The canaliciili are destroyed hy tlie jrlowing wire. The lower end of the iia.sal duct is .sealed by packing jjauze under the inferior turhinal. A careful incision is made from a point just beneath the centre of the lower border of the tendo oculi, dissecting obli(|U<'ly inward and backward and in line with the fibres of the orbicularis, exposinj; the sac u]) to its dome The lii)s of the wound i)einfi retracted and the bleedinj;; .stoppeil: the sac is then freed by a blunt hook and cut off at the edpe of the orbit. If this is not feasible, the sac should be cut out i>iecemeal. and any carious bone shouK ' ' scraped, to secure, if possible, healiu}; by first intention. Th I is now curetted and the parts irrijiated. The wound is closed l)y sutures and the dres.sinjjs ai)plied, jires-sure i)einp made Iv' a compress and strapping. The stitches may be remove<l in three or four days. The nasal passage shoulil be kept as aseptic a.s possible until scar ti.s.sue has blocked the way to the soft parts at the top of the duct. ()Bi.rrKH.\Ti<)\. To this end. caustic and the cautery are used, to cause sloughing of the mucous lining of the upper end of the duct and of the sac. and fusion of its walls. The canaliculi should first be sealed by the careful use of caustic or the fine glowing wire. Isually the .sic is cut into just below the palpebral ligament, or a fistula is enlarged, bleeding is stopju'd, .md the sac cleansed: oil or vaseline is applied around the opening and just within.: the cut is made to gape, and argent, nit., in the form of small beads fused on the end of probes or crystals held in fine forcei)s, is freely applied within the .sac; similarly pota.ssa cum calce or acid, nitric, on a small tuft of absorbent cotton may be used: al.so acid nitrate of mercury, zinc chloride paste Clii per c.<'nt.K and potassa fusa. The .sac cavity may al.-io be readied by cutting through the floor of the canaliculi iV. W. Agnew), and caustics, etc., may be safely a])])lied, but care is needed to spare tlie conjunctiva and to avoid the formation of a scar. The thermocautery and gal va no-cautery may also be u.-cd to de.-;troy the sac. but the whole sac lining cannot be so readily reached .-is with ditTusil)le caustics. In either case, cold compresses are apjilied for a few hours to limit reaction, and then warm |>oultices of sli])pery-elm in small muslin b;ig for sev(>ral days. j>isi:a.^i:s df (tiuiir, A.ir/n'.w.i;. .i/'/m/m //■>•, .i.v/> lids 2.;. Tlir I'scluirs sliDuld lio roniovod lis soon as .■•(■paraljlc, and a pn'>s'iri> (•(.itipn'ss a|)|ilit'd over vaseline dressing, to promote healing. This eovers two or three weeks from tiie start; extirpation requires oidy one. The foilowiiin ne<.|,lasms have In'en foiitid in the hicrynial sar; saivoma, epitiieiioina, angioma, tihroina ravernosa, rhinoscleroma : tliev are very rare oxeejit l>y extension in the case of the two first. l";iiipli(>ra"frei|iiently persists after destroying or removing the sac. or it often occurs from siifiht exciting cau.ses: sacrifice of the gland at the same time is, therefore, iirjied hy some !is a rule of practice, and the more hecause under strict a.sepsis extirp!>tion is a safe opera- tion.' Hut lacryination is not always a sccjuel to loss of the sac, and some seemingly intractable cases under the usual treatment are cured hy forcible dilatation of the strictured duct with large-sized probes (Tiieol;ald). Hence the gland may well be spared for a time until this jjrocedure has been tried. KxTiHPATioNoK thkLachvmai.Oi-.vm). The parts being surgically clean, a cut is made just below the outer half of the eyebrow to the margin of the orbit, exposii\g the septum orbita-, which is thendiviiled close to the bone, with just sufficient edging to hold sutures. Fatty tissui' may present, but shoulil oe left. The lower edge of the gland does not, "as a rule, reai'h to the bony rim, but entire removal .should l)e aimed at, and can with care l)e"efTected by scis.sors, hooks, etc., and without injuring the levator i)aliH'l)ru" or external rectus. All bleeding should be stopjjcd. The palpebral iM)rtioii (inferior, second- ary or acces.sory) need i;ot be removed. Careful stitching of the skin wound, the" fascia being first united by buried catgut, and asep- tic dressings under conii)ress, ensure prompt healing and but little after-sign. THE EYELIDS. Anatomy. The evelids are two folds of skin which cover the eye- ball, and bv their me'-nbranous attachments close in the orbital cavity. The lids o'we their iorin and .stiffness to cartilages or tnrxi, as they are called (Fig. li;?); thes<> are the framework of the lid, and when they liave been distorted as the result of disease or accident, inter- fere" seriouslv with the lid performing its proper functions. The cartilages are covered externally by the skin and the orbicular muscle externallv bv the conjunctiva, the borders of the lids are fringed with short hairs, the lashes, or rilia. These are directed forward and are more numerous upon the upper lid. As is shown by the accompanying illustration (Fig. 114). there is a <lepression or sulcufs j\ist below J, which represents the opening of a sebaceous gland. The cilia are ?een at n, with nifMlified -^wovti ,ind Zeiss glands about them. Heneath the skin lie the transversely divided bundles of fibres of ' " Primary Union in Eighteen Caies out of Nineteen." C. Holmes. •J:f2 77//; /•»■/.. Ihi iirhiciiUin" ill). <<( whicli tlin>f |)l;i('ril iiitrriiiilly il>') furni ^Ac m((.vri(/i/.< ciliiiris Uiolant. The jxistorinr part nt" the lid is covfrfd Ki... lU. Helativt? ncwltion^ ami wiw of t'yi'li'l« I M ERK F.I.. ) l)y coiijuiictiva, whu-li is clnscly adiiciciit to tlic tiiisus. The Ml ilioniidn ijliinil.-< luivc tlK'ir urilicfs in front of the posterior ('<lgc of llic lid : al)ovo tiicMi lie till' niiicDiis (/Id mix (k), and still hifjhor Mailer's iiniscif mn\ the Ivralor of tlio lid. The Mcilioitrian illnnil" (I'ij;. lloi arc modified sebaceous };l;ii"l^. !"i"l secrete a sebum wliicli bathes the margin of the lids and pre- vents o\-erflo\v of the tears. The closure of the lids is ef- fected by the orhitiiUiris mitsclf. The fibn's of liiis muscle form more or less of a s])hincter, extend itito tiie subcut.'ineiius tissues surroundinf; the lid. and are iiiserteil into a tendon wliich adhen's to the lacrynial bone. The '.rl)icularis is supplied by the scventii nerve, and v'' 'ii this nerve is jiaralyzed the lids refuse to ch)se, a staring; expi ■ on being given to the eye. Diseases of the Lids. Lagophthalmos, or incomplete closure of the palpebral fissure, is usually occasioned by peripheral palsy of the seventh nerve, resulting from hitracrauiul causes; it may, however, result from narrowing of Vcrtk'H t-'ftiiin IlirotiKli upp-- ■ t'vt'lUl. (SlIAKKR I I)Isi:asj:.s or ttiniir, i.m hvmai. .i/'/m/.m/tn, .i.v/» /,//<> 2;5.J till' lids hy injury or iiiriTalion, or liy tlic inrriiMtiini of cicitric'i's (licitlriniil i'flriii>i<iin, and it may I'lisnc wIh'Ii the cscliall is ('iiiarp'il IT |pu>1ici1 I'lirwanl [iintiilnsis). (i'in. IKi. ) Flo. II.'.. Punrtii huhnjmalia I'ljflltlon of Meibomian ^lao- iAk.sold.) Whfii laRoplithaliiiiis is prcsi'iit as the ri'stilt of an iiitracniniai Icsiun, it may !«' acci)iii|iaiiii'il hy h('iiii|ii('gia of tlic .same nr niiposite side. Thus, a ii-sioii .■"itcriur U\ tlic jMins or ill its aiiti'i'inr pDrtimi \vi!l caiiw jjalsy of tlic seventh nerve of tlic same side as tin; lieiiiiplci;ia. wlicrcas a lesion pustirior to the pons orin its posterior portion will occasion palsy of the (ip|)ositc side. On account of the exjMisurc to the eye which lanophthal- iiios occasions, disease of the cornea and conjunctiva is freijueritly provoked. W'iien the condilion is due to facial pal.sy, active measures should he instituted at once for its relief: these include leeches and hot stupes, mercury and the iodides in siM'cific cases: later the contiiuious current and hypodorniic injections of strychnine. I'ntil closure of the lid has been effected, the eye should he ke]it l)anda<;ei|. If thi' cornea !>e threatened or if the condition becomes pirmanent, a tarsorrhaphy should he jwrfornied. TAitsoiiUUAi'iiv. The simplest way to shorten the palpebral aper- ture is to pare lifihtly the inner lips of the uiijier and hiwer lid-margins from the aufile for 3 to () mm. or more, and then stitch them tofjether without rensoviii-: the eyeiashc- -fde Weckcr, Nnyes). Tar^orrh.aphy is usually done as follows: After gauging the length of the line of union required the lid is slightly everted and made tense — some stntcli the canthus by inserting a spatula behind it. The margin of I.n|fOl»lithiilnios. 234 THE EYi:. i'lifh lid is split with ii fine knife just hcliiiul the row of cilia anil suffi- cicutlv ilccp to iiichulc tlic liair bulbs. The narrow Haps of skni with bulbs "arc then removed bv incisions, meeting a little beyond the coin- iiiissure. The inner lii^s are lightly pared froni the latter to a point several niillinietres bevond the end of the flap wounds. The raw surfaces are then carefully coapted bv silk sutures j.assed obluiuely up ior iown) and in. and made to Kraze tlie inner lip. Traction is relieved bv compresses and J'laster for three or four days, when the sutures are removed. To make tarsorrhaphy more eficctiv, I-uchs cut.s awav the flap with the hair bulbs fro:n the upi)er hd only, splits the lower lid, and frees the anterior flap by a vertical cut at ihe inner end of the slit. The inner surface of the anterior flap is then stitched to tlie raw ujjper wound. ,• i r Tarsorrhaphv is indicated in the relaxed or everted lower lid ot senile and i)aralvtic cases, in laRophthalinos, in proptosis, and exoph- thalmic goitre; it is done often as an adjunct in blephar()|)lasty. Blepharospasm, or spasm of the orbicularis, may be either .s7/m/>- tonmtic of other ocular disease, or essential. The latter variety is rare and is often hy.sterical, while the former is a frequent accom- paniment of manv forms of ocular disease, especially where there is much drea.l of lifjht, as in phlyctenular keratitis, and where a rel ex irritation of the Hbres of the trigeminus has b.en excited. In tins connection should be mentioned the fibrillary C( . 1 raction which occurs s(, frequently in a localized portion of the - umIc. Apart from the annovance which this occasions, it is u.,t signilicant, and can usually be ma.le to disappear by tl' a.ljustment of glasses to correct any existing error of refraction, of similar origin iire the attacks of ''bUnking'' ■'hich occur in school-children. Not inrre(iuently these are acconii)anie(l bv choreic movements in the muscl<'s of the face. In adults blepharospasm often is associated with tic. Blepharo- spasm is due not infre(iuently to hysteria, in which event "pressure points" may Ih> found in the region supplied by the trigenunus, which will occasion opening of the lids when they an' pressed upon. Treatment. Treaunent of blepharospasm will depend upon tlie cau.se If the jiatient be aiwinii', tonics should be administered: arsenic is of value in choreic cases: all errors of refraction should be carefully cor- recteil. In cases arising fnmi reflex irritation of the fifth nerve all possible foci of disease should be investigated and removed, (ial- vanism is useful in the later stagi's. The lids are opened by the action of the levator paliwbra" sujie- rioris and by the sinking o'' the lower lid by its own weight. The levator Mrises at tin' ai>ex (if the orbit and is in-.rted into the upper edge <.f the tarsus bv three attachments. It is supplied by a twig fpMU the third m-rve, and when panilyzed the upper lid cannot be ,..,;.;,,,! :,n,l the condition called ptosis or drooi)inji of the upper lid Ptosis may varv in degree from !i slight droop of the lid to the comi)lete covering of the eyeball. It may b.- congenital, when it is l)J^i:Ali£S OF ORBIT, LACRYMAL APPARATUS, AXD LIDS. 235 usually associated with cpicanthus and affects both lids; usually, liuwcver, it is ac(iuii'ed. Acquired /j/o.v/.v may result from palsy of the hraiidi of the third nerve supplyinji the levator of the lid. It may, however, he due to local chaiiftes in the upper lid, which increase its volume or weight, such, for example, as occur in trachoma and various tumors of the lid. Paralytic jilo.iis may he due to periph- eral or central cause, and is a.ssociated frequently with palsies of other branches of the thin! ner^•e. If isolated, it is due usually to an intracranial lesion. Treatment. Antisyphilitic ami antirheumatic treatment should be tried in suitable cases; galvanism and hypodermic injections of strychnine are of value in the later stages. For slight degrees of ])tosis resulting from inefficiency of the levator, owing to injury or ancient trachoma, etc., the removal of a narrow horizontal strip of skin and muscle may suffice with insertion of the deeply j)lace(l sutures brought out high uj) on the lid. This ojteration is more cer- tain if a piece of tarsal cartilage also is excised, as in the Gillet de (ir.mdmont operation (Harlan), in which case the horizontal tarsal wound is united by buried catgut sutures. Advancement of the levator by the Kversbu.'ich (which see) and the Snellen methotis also gives good results. I'lof^is Atonicn (Hotz). In this condition the skin of the upj)er lid hangs down over its free edge when the eye is open, and, instead of following the upwanl movement of the tarsal cartilage, remains stationary. It is due to loss of the normal connection between the skin and tarsus, and is corrected by the Hotz operation used in trichiasis and entroi)ion. /'/o.v/.v ndiposa. in which a layer of fat beneath the skin acts mechanically and causes falling of the lid, if not overlapi)ing. is relieved by removing tiie ma.ss of adipose tissue through an incision in tlie skin. To ciirrect nnich droo])ing of the lid after tri'choina, Gruening em- ploys a modified Hotz suture. "An incision is made just below the up])er I'dge of the tarsus and ])arall<'l to it. Some orbicularis fib.res may be excised. \\'ith a sharjily curved needle the thread is jjushed .along the surface and upj)er e<lge of the tarsus through the conjunctiva, until il loops tip the cul-de-sac and returns ui)on itself beneath the skill, to come out at the upper |)art of the wound. It never traverses thi' skin. Three sutures may be u.:'d. They are tied tightly and allowed to remain two to five days, according to the amount of re- action " (Xoyes). livers' I- iscli's oj)eration in jiartial ptosis has given excellent results. .\ horiziiiital incision is made across the lid and half-way between the lid-margin and the eyebrow; the tissues are then .separated so as to exiMise a strip of contiective tissue. A strong |)iece of catgut with a (•urvi(i needle at eitlier end is u.sed. One needle is passed into the tendinous tissue as far as ]ii)ssilile and brought out again a few milli- metres from tlie point t\* whii-h it wa.« introduced. Both needles are 2:5(3 THE EYE tlicii passed parallel tn eacli other and al 2 or ^.^ iiini. distance ai)art heUnv the skin and nuisele of thi' lower i)ortion of the lid. alon^ the surface of the tarsus, and hrovifiht out at tlii' free niarjiiii of the lid. Similar loops are next jiassed to the inner and outer sides of this central one. The damp is then remove<l, the lileediiifl stopped, and the edfies of the woinid in the skin hroufiht tojiether with stitches. Hownian hrst sufjfjested the shortening and readjustment of the levator palp, va' (Snellen). In Wolff's oi)eration. in which this is done, the tendon of the levator is exposed hy a transverse incision. It is then undermined aiul two strabismus hooks are pa.^sed horizon- tally beneath it and apart as far as the (hfference in hei^rht of the two lids'. Two (louble-needle(l catpit sutures are put into the tendon at the line of the uijjier hook, and it is then cut across just hdow the latter and is tucked behind the stump. The needles ;u-e then passed throufih the base of the stump and the sutures tied. The skin wound is stitched .separatily. Miles' Opkkation kou Ptosis. To secmc the liftinj: action of the frontalis, Mules' inserts a permanent subcutaneous wire loop, "having its fixed points between the frontalis tendon and the lid car- tilafie. Hy this wire the lid is raised and maintaine(l with jii''"'t ex- actitude at a litie whence a slijiht effort of the frontalis is sufficient to lift it to any r"quired elevation. .\t the same time its folds are re-established and its normal ai)pearance refrained. " Hy means of needles with eyes at their points the two ends of a fine wire (gilded iron or silver), which is inserted at a \w\nX in the tarsal i>late near the ciliarv border are brought nut one-third of an inch al)ove the brow and one-half of an inch apart. The ends are drawn uj) (the next day, \. S. Morton) until the lid is raised as desired, w' n one is run under the skin to the other, and they are then twisted and buried. Result very satisfactory (\V. .1. ("ant, \. S. Morton). MorMs' ( )i'i:i{ATiox. .Motais has designed an ingenious operation for raising the upper lid in congenital ptosis, by resecting a tongue- shaped flap from the centre of the tendon of the superior n>ctus and attaching it beneath the jjalpi'bral conjunctiva to the fascia, so as to act as a lev.ator to the tarsus. PA(iK\»TE(iiKH's Oi'KKAriox. Pageiistecher's method of utilizing the frontalis in paralysis of the levator aims at securing a vertical subcutaneous cicatrix coimecting tli<' former with the li<l. He pas.ses a needle c;irrying .a thick ligature under the skin of the forehead about one-half an inch above the centre of the eyebrow, and subcutaneously as far as the margin of the lid at its middle point. The suture is tied an<l tightene(l from day to <lay until it has cut its way out. (Iradle's modification is the insertion of permai.'iit aseptic sub- cutaneous sutures. {»\\\.c' Mkt?!'!!! Ill this operation, which has pleased many o]ierator«, the skin of the brow and ey(>li<l is steadieil by pressure N'inth IiUcrliMlliiiml ophlhaliiiiilipKiial '■i>rigreRS, 1«U4. DJti£:AS£:i> OF ORBIT, LACKYMAL -l/'iMiJJTLA', AM) LWS. 237 across tlic fori'hciul. Two horizontal incisions arc made, the lower at the orbital margin, and along the toj) of the flap with a slight con- vexity ujjward, and not (juite an inch long: the higher one a littK longer, and at the ui)j)er border of the eyebrow. A tlaj) of the skin and imiscle is now dissected from the tarsus down to its ciliary border, but the sejitum orbita' (suspensory ligament) of the lid is not dis- turbed. The bridge of tissue between the two horizontal incisions is und'rmined without cutting the periosteum or .septum orbita-. The fl;ip is then drawn up under the bridge by means of sutures and fastened to tiie up|)er edge of the higher incision. Wlien the flap is .■<o fixed, the traction tends to cause ectropion, and a suture is therefore placeil at each side, ])assing deeply througli the se])timi orbita' and conjunctiva, but not the skin, and it also is insserted in the upper lip of the higher incision, so as to coirect the tendencj- to eversion. WiLDKKs ()PKK.\TiON. For the relief of complete i)to.sis W. H. Wilder has devi.sed a methotl whicii "consists in fokling upon itself the tarso-orbital fa.scia that connects the margin of the orbit to tiie tarsus and acts as a suspensory ligament for the upper lid." By shortening it with buried sutures the lid may be raised as desired, and in a number of cases the result has be(-. satisfactory. The eye- brow is shaved, an incision one and one-half inches long is matle parallel to the orbital margin and a little above it to the periosteum. The lower lip of the wound i.s drawn down and the skin and nmscle are carefully di.ssected from the fa.scia, and the tarsus '^xpo.sed. Su- tures of fine sterilized catgut or silk armed at each end with a curved necflle are passed in the following manner: The first needle is intro- iluced sufficiently deej) into the tarsus to secure a firm hold at a point about at the junction of the outer and middle third and a little dis- tance from its convex. It is then drawn through, and with it several gathering stitches are taken in the tarso-orbital fa.scia, after which the needle is made to pii.ss tl .')ugli the muscle and connective tissue of the up|)er lip of the woimd. The other needle on the same suture tollows a parallel course in the same maimer, entering the tarsus about •5 mm. from the point of entrance of the first, then gathering the fascia into small folds and emerging in the tissue above, thus making a loop by whicli the lid ni;ty be drawn up. The second suture is p.Ms.sed in the same way, making a loop at the junction of the middle and inner third of the tarsus. The re<|uisite elevation of the lid may be now secured by dniwing on the loops and tying the sutures, which are to be buried in the woimd. The lower lip of the wound is now united to the upper with fine sutures. The slight scar that remains alter healing is ;dinost entirely hidden when the eyebrows grow ag;iin. Ihe buried sutures become encapsule(I and give addition.al strength to the folds of fascia that hold up the lid. The orbicularis is unin- jtuiMJ. so that the patient retains to a certain extent the power of closing the lids. I he movements of the eyelids are both voluntary and involuntary. "l\ inking is usually voluntarv, but mav lie the result of a reflex action. 238 THE EYE. Flo. 117 When the latter is the case, it is aiToiiiplishe.l throusli the fibres of tlie fifth nerve, whicli suiiply the eornea and ocuhir conjunetiva, actinj; U{)()n the orbicularis. The liils protect the eyeball from in- jury and excessive light. They aid also in lubricatinj!; the globe by distrii)Uting the tears over it and mechanically brushing away for- eign substaiices which may have intruded tlu'Miselves under the lids. The arteries of the lids are ilerived chiefly from the ophthalmic artery; the veins are very plentiful, and empty i)artly into the veins of the forehead and partly into the ophthalmic vein. Congenital Anomalies of the Lid. Crijplophthalmox refers to the stretching of the .skin over the orbit covering the eyeball. Colohoma is a fissure in the lid, triangular in shape, with the base at the border of the lid, the apex point- ing U)ward the luaigin of the orbit. It is a rare alTcction, and occurs usually in the ujiper lid. (Fig. 117.) Ejucantluis is the name given to crescentic folds of tiie skin which project on both sides of the face from the inner angle of the brow. I%])icanthus is fre(iiiently a.ssociated with ptosis. Treatment consists in excising an elliptical |)iece of skin from the root of the nose, ''.nitlidplasty at the outer angles will oft(>n benefit the deforniity. Cantmoi'I.astv. .\s a rule, tiie operation fnr the exti-nsion of the palpebral tissuie and the weakening of the orbicularis is not a plastic one, and it is better styled cinthotomy. Cocaiii'', 10 per cent, .solution, is applied on a ])ledget within an<l without the external canthus, the spring speculum is inserted or the liils stretche(i .i|/art, one bl le of the scissors, which are held hori- zontally, is pushed behind the outer canthus toward the bony rim, and a quick snip sulfices. The conjunctiva is freed slightly, and is then stitched at three |ioints to the skin edge, at the angle, above, and below. If the orbicularis is hypertrnphied and eatising i)re.ssure on the globe, the external |ialpebral ligament is snipped, the scis- sors' points being i)Ji.xsed into the wound vertically behind the Miusele, the lid being drawn outward (C. R. .\gnew). When there have been atrojihy and shrinkage of the conjunetiva, it may be Tiecess:iry after the section t" stitch a piece nf transplanted skin into the angle or adjust a small Thiersch shaving— eantho|)la.sty. Caxthotomv is a useful adjunct in some ca-ses of blepharospasm from keratitis, to relieve |)ressure in purulent conjunctiv-*--! and as a inmirthc liils VlilE.lSES OF ORBIT, LACIIYMAL AI'l'MtATUS, AM) LIDS. 2;3S) Pio. 118. stf'p in enucleation or exenteration. It is, as a rule, neee.ssary in entropion, espeeially of the lo\>er lid, anil sutures are always used when a permanent effect is de.sired. The latter is the more sure if, as .Fackson points out, a broad edsiiig of the conjunctiva is taken up in the stitch. Inflammation of the Lids. The integument covering the lids i.s liable to be affected by disea.se connnon to the skin in general, such as erysipelas, herpes, and eczema. When the lids are involv(>(l in erysipelas secondary to a similar condition of the face, they may 1m> ho swollen that the ball is com- ])letely hidden, and at times the process is so active that the inHam- niation spreads into the deep tis.sues of the orbit, causi'ig absces.s and not infreiiuently blindness by involvement of the optic nerve in the orbit. I'rimary erysipelas of the lids is extn-mely rare. The treatment is that of erj-sipelas els<>where in the body, both a.s to local a|)plications and general medication. Eczema of the lids also u.sually participates in a general eczematous eruption upon the face. It occurs commonly in children as a moist eczema icrustn lactca), when it is usually accom])anied by a similar form of conjunctivitis. Di.sease of the lacrymal afjparatus in adults not infrei|uently gives ri.se to eczema, jiarlicularly of the lower lid, by the irritation provoked by the overflow- ing tears. Treatment cfnisists in the proper cleansing of the skin by alkaline washes, followed by the application of an ointment of oxide of zinc or of a solution of nitrate of silver (10 to 20 grains to the ounce). In the chronic form when theiv is much itching, car- bolic acid may be added to the zinc ointment in the strength of o grains to the ounce. Herpes zoster (Fig. US) not infre- (|iieiitly is the result of an inflamma- tinii which is situated either hi the trunk of the Hfth nerve itself or in the (iasserian or ciliary ganglia. A number of vesicles forin along the lermin.'il exjiansion of the trigeminus: at times these vesicles are limited to the distribution of the upper or the lower branch of the nerve: at times both of these branches are affected simulta- neously, but it is rare that the inferior division is affected in common with the two su|)erior. The efflorescences never extend beyond the median line of the face. !'or several ilays preceding the eruption there are seven" pa'"' in the course of the nerve and .some febrile reac- tion, and the skiii be. nies red and swollen, resembling erysipelas. In severe cases an ulcer forms at the base of the vesicle, due to involve- ment of the coriuni in the process of suppuration, and a deep scar Uerpes zoster opbtbalmus. •2A{) THE EYE. l(.riiiM in inildtT cases tlic vesicles .lisapix . r wlilioiit uavi/ip; any mark Analogims affections of tiie cornea, conju.icl.-. .', ano ins may complicate the .lisease and pive rise to cell ul it i> :i'id ..■.••"".t , .vhu'li render the i)rofjnosis most unfavorable. The tr;'a-,m(|iit is |)iiivly palliative, cunsisting in the ai-jilication of a powder of rice starch or of an ointment of zinc, to aid in the dryiiifr up ol the vesicle. Ihe vesicle .should iie%er he opened. If tlu corne.". ixromes affected, ai)i)ropriate remedies should he employed. I.ar^e doses of (luiiiine and «)f .salicylic acid are often of service. Calvanism may lie u.sed for the relief of persistent i)ain aloiift the cour.se of the nerve. Abscess of the Lid. This is generally the result ot injury, although it may he tlue to caries of the orbit, to periostitis, and to (lisease ot the accessory sinus<'s. It inav he a comi)licatioii of erysiix'las. In the first stages there are diffuse infiltration and redness of the hd. ],ater a localized swelling api>ears which points in some casi's, but spn-a.ls in others, involving the whol<> lid in a gangrenous proc.os. In the latter case (extensive damage is wrought to the hd, and de- formities n'sult which may occasion lagophthalmos aiid ectroi)ioii. Treatment If seen in the earlier stages, attempts should be niaile to abort the inflammation by mean.s of ice-jjacks: if induration be present, free incision should be made with a view to checking further spread of the disease. Furuncle, carbuncle, and anthrax pustule are rare. The two forriior present much the same symptoms as abscess, with the distiiictioii of being a','comi)anieil by a small gangrenous slougii or "core;" the latter is due to inoculation by the Bacillus aiithracis, and occurs in i)ersons who are occujjied with the care of animals. Ulcers of the Lid. These may be the result of local cause, such as injury or manifestations of a general disease—/, c, syphilis, lupus, scrofuli', herjM's. The most freciuent of the constitutional sores is the seco'n.iarv ulcer of syphilis. This is usually foum'. ujotii the skin near the margin of the I'i I or below the inner canthus; it occurs late, and might almo.st be regarded as a tertiary lesion. Vaccina and smallpox not infre(|uently give rise to erui)tions upon the lids. As the result of the cicatrization caused by these ulcers itKKhiro.^ls. or loss of the eyelashes, may occur, together with ectnipion. .\ true vacciiu' ulcer ircrciiiin oj the cijclid) may be caused by inlec- tioii from a vaccination sore. The border of the lid usually is affected, and considerable swelling and redness and involvement of the I)re- anricular and submaxillary glands, with constitutional symptoms, accompanv the ulcerous process. In the early .stages the pustules are i'h;ii:icteristie. though later they may res<'mble a syphilitic .sore. (Edema of the lid may be a •<ymi>tom of a neighboring local disease, such as disease of the lids themselves or of the conjunctiva, or orbit, or it may U' a manifestation of sy.stemic disorder, such as di.sease of the heart or kidneys. It may Im' an accompaniment of an active iiiHammation of neighboring i)arts, or it may be due to simple venous congestion. DISEASES OF ORBIT, LACRYMAL APPARATUS, AND I.IDS. 241 Recurrent necrotic adenia of the lids is associated fr('(|ui'iitly with similar swollinps elsewhere, and is to Ik> imputed to a temi)orary dis- turliaiiee in the vascular innervation. Sjrphilis of the Lid. In addition to the ulcers mentioned above, tiie lid may be the seat of a primary sore. An ulcer in this position, with a hard, indurated l)a.se, ap|H'arinji without the history of injury, but followed by secondary manifestations, should always excite suspi- cion of syphilis. Soft chancres also occur upon the lid. Tursilis "mihi- litica is a tertiary manifestation of syphilis affectiii}; the cartilage of the lid. One or both lids may l)e affecte(|. The lid Ix-comes swolleti and ten.si> and the skin reddened; the cilia drop out. In favorable c:ises the swelling prailually subsides, leaving tiie lid in its orifthuil cdndi- tion; in others, however, the tjirsus iH'comes much distorted, and entropion results. Blepharitis. (Fig. 119.) On account of the presence of the cilia and the hair follicles with their glands upon the margins of the lids, this ])ortion of the lid is not infre(iuently the seat of inflannnation. lijipvramio of the margin of the lid usually attends all fonns of conjunctivitis: it is a fre(|uent index of eyestrain, and may be occa- .sioned in certain individuals by slight cause, such as dust, Fia. iw. .smoke, or foul air. The most cnmmon vari(>ty of inflamma- tion of th( lids, lilcphnrilin, consists in a chronic condition wi.icli is a.-;.<ociated with the formation! of scales and crusts at the ba.se of the cilia. Bleph- aritis occurs under two forms: the sii iHT(ici<tl or luin-iilcinitife, and the ileefi or ulccratire. In the first variety the margins of the lids are red and swollen and are covere(| with numerous whitish scales. If these are washed away, a few cilia drop out, but some grow in again. In the second variety the hair follicles become destroyed by ulcers which form alumt "the roots of the cilia, so that the lashes fall out. This may occasion jjermanent loss or ilisi)lacement of the cilia, hypertroi)hy of the margin of the lid, and ectropion. In the milder cases of l)le])hariiis the iiatients suffer but slight discomfort, but when the inflammation has Imhmi of long standing, increased lacry- matioii, sensitiveness to light, itching, and burning render the patient very miserable. The causes of blepharitis may be general or local. .\niuiig the former may be iiieiitioiied the exanthemata, especially measK's, a deliilitate<l system, and unhygienic surroundings: uncor- rected errors of refraction are a fnHjuent cause. The local condition? II! Blepharitis. (Dai.rymtl*.) 242 THE EYE wliicli may dccasidn it csiKrially ire ilisoi cr ill til iTViiiai nitus anil cuiijuiictiva. Mi(•l)haI■itl^ is frt'tiuciitly iHTcilitary. and more coniinnn in cliililicii than in adults. Treatment consists in tlic ri'inoval "f tlic cause The correction of errors of refraction and attention to tlii' sy-teniic condition should he insisteil upon, and in many cases a cure will lie accom])lislie<l without resortins: to other measures. If the hlepharitis Iw due to lacryinal or conjunctival disease, tliese should he coiuhated hy proper local treatment. Before making any applications to the edfie of the liils it is first necessary to remove all scales and crusts adherent to them. This may Ih' accomplished hy washiiifr the lids thoroujihiy with soaj) and water or with water contaiiiiii<: horax. In the super- ficial variety of hh-pharitis a salve of mercury (yellow or red oxide, gr. viij, vaseline .">j; or the aminoiiiated chloride of mercury in the same streiijith) should he apjilied; in the ulcerative variety an appli- cation of a solution of nitrate of silver (1 to .i [mt cent.) to the raw- spots on the lid is often of service. This should he followed liy an i<l)plication of m-rcurial ointment smeared thickly iijion lint ami liftlitly handafred upon the eyes over iii>:lit. If alisce.ss occur, the cilia should l)e removed hy means of ])ro])er forcejis {ciiihilioit). Phthiriasis Ciliorum (Blepharitis Pediculosa). This is an affec- tion of the margin of the lid due to the presence of the I'ediculu.s ])uhis in the lashes. It is fr(>(|uently mistaken for hlepharitis, and usually occurs in children. Treatment consists in cleansing the lids with a solution of mercuric chloride, 1 ; 4(H)0, and suhse(|uently ruhhiufi one ot the mercurial ointments into the horder of the lids. Hordeolum (Stye). This is a hard circumscrihed swellinj; on the lid margin, a grain of harl(>y in size, which generally suppurates. The inflammation occurs in the tissu(>s ahout a hair follicle, the Mei- homian glands not hein mvolvecl. Owing to the tension which is created hy the ])ushet\' en the tarsus and the skin, there is usually considerahle pain until lue contents of the stye have heen evacuated. As a rule, the process la.sts four or five days. Repeated attacks are common. Hordeolum occurs usually in the young, e.s])ecially in those who are aiuemic and dehilitated. lurors of refraction may induce the condition, as well as exjiosure to local irritation, such as heat and dust. Hlejiharitis is a not infre(|uent cause. Treatment. Ice-packs may he used as an ahortive, hut as soon as swelling appears hot apjilications are to he em|)loyed to favor su])- puration. Evacuation of the contents slmulil he practised hy inci- sion as soon as a yellow spot forms. .\lt refnictive errors should carefully he corrected and the general health cared for. Calcium sulphide, one-eighth grain three times daily, is of service in recur- rent cases. Chalazion (Fig. 120) is a chronic dise^e^e of one of the Meihoniian glands as a conse(|uence of the stojjpage of its duct, and results in the formation of a small tumor in the lid. The growth of the tumor is slow, with moderate or no signs of inflanunation until at the end DISK.ISES OF OIIUIT, LACRY.MM. AI'l'ARATCS, A.\D LIDS. 2-13 of ;i l'<'\v Weeks or iiidiiilis it has attained the size of a large pea. Chalazia adhere to the tarsus, Init the skin is nioWile over them, and they are not usually sensitive to the toueli. Tliey may hecoine al>- sorhed and disap|H'ar spontaneously: hut, as a rule, they lireak down, sup|>Mrate, and disehar<r(,' their eonfnts either tliroufrli a skin or oon- lUMctiva! openinji. Chalazia are found in aduhs partieulaily. They rarely oeeasion pain, hut are dis(i>;urin<: and may ea use syniptonis of eyestrain by the pr-ssure whicli they exert uiion the eyeball. Fm. 120. Chalazion. Treatment. Unlcs-s pivinj; rise to irritation, snial' chalazia need not be interfered with; lurff' ehalazia should be removed by incision throufih eitli ■■ the skin or conjunctiva. Chalazion - removed, as a rule, throuph the conjunctiva. The lid is even and the free edjie jires.sed well back, cocaine hydro- chloride applml to the site, and a droj) or two of 10 per cent, solution of cocaine injected hy])odermically. A siiort vertical cut is made from within out, and the tumor, if small, is then emptied with a fine Flo. 121. Deflroarrea' chalazion forceps. serrated or sharp-edjred scoop. When large and with thick wall, the latter is jiriisper! with fine fixation forceps and cut out with a sharp- curved scissors. If only in part, the cavity is scraped to remove acini, and the contents packed at tlie sides. Bleeding is often free, when adrenalin chloride, 1:5(KK), applied early and also presseil into 244 THE EYE. the cavity, is of use. Homnrrhajrc iiuiy also bo contrnHcd ami tlio ticlil of opcrutioii rciulcrcd li!iMMil('s,i hy applying; a Dcsmairi's chalazion forceps. (Fin. 121.) If there are .several chalazia in a l)Uiicli. a lit! clamp or riiij; forceps is ii.sed. If the chalazion is hirni- and hunl, or shows sijtns of pointing e.xternaliy, it may hi' removed through the skin by a horizontal incision wjtli use of clamp. Fine stitches are then inserted. Iced compresses for a few hours are .^oothinjj. If the chalazion is near the free edp', it may be opened with a tine cataract knife through the lid margin, the lid beint; clamped between the index tin(ier-ti|i in the {■iii-de-sa<- anil the thumb (('. H. .\pnew). Tumors. lii'iiii/n tinnrthx include xanthelasma, moiluscum. cysts, warts, and cutaneous horns, and va.scular tumors or aiifriomata. Xdiilhclasnid is a flat yellowish placjue s!i;;htly raised above the skin, which occurs most frei|uenth' in women and at the iinier canthus. These phuiues are often .symmetrical. They are caused by dejien- eration of the muscle fibres. Their growth is slow, and as they occa- sion no bad results otluT than disfijiun'ment, they need be removed only for cosmetic etTect. Mdlliiscnm is a small white jtrowth which forms on the lid as a result of a dis"a-;ed condition of the seba- ceous glands. It occurs in two forms: nmlliisnini <<mt(i(ii<isum, in which variety the tumor is without a [MMlicIe, .and has an umbili- cated depn-ssion in its centre; and ihnlhisrinn simpler. In the latter variety the tumor is ])odiculated, hanging from the lid like a pouch. Cysts. Among these may Ik- mentionetl dermoid cysts, inilia, and antharomata. Angiomata. These comprise tclannicrtnsis and /(/worc.x nirfrno-^i The former occur as small bright-red growths in the .skin of the lid, and an- due to dilatation of the bloodvessels. The latter are dis- tended venous channels beneath the skin. Both \arieties are usually congenital and occur after birth, ('are should be exercised in their removal, to avoid cicatrices. Small telangiectases ni.ay be removed by the thermocautery or by cauterization with nitric jicid: large ones should be .seared to foster contraction and obliteration of the vessels. Cavernous tumors are removed best by electrolysis. Malignant Growths. These include the sarnniHiia and curcitto- iimta. The former are rare, the latter more conuiion. and <K'cur under the form of roilcnt ulcrr.'<. These ulcers are seen ui'on the margin of the liil as a small pimple, which breaks down into an ulcer with indu- rateil walls. These ulcers slowly sjjread over the lids and occasionally dij-. 'lowii deep into the orbital tissues. Treatment of both form.s of tumor consists in their early and complete removal by surgical inter- vention. HlcphunipUist]!. To m(>et the loss of lid-tissue fr(>m disea.se and injury, or its n'Tcs^ary sacrifice in removing neoplasm.-, etc., new material has, of course, to be fjrovided. I'nless the ga)i in the lid is such as permits closure by stretching what is left, new material hvs to be socuretl, either from adjoining parts — the forehead, temple, DISEASES OF ORBIT, LACRYMAL At'PAHATVS, AXJ> LIDS. 215 clicck or nose— l)y iiicaiis of flaps witli ix-diclcs or from other regioiu l)y Ha|)!< witluiiit pcdiclfs or hy skiii-prafts. Flaps with twistcil pedicles are often used after Fricive's method, ill which the base aluits one end of the raw surface. The ftaj) left l>y the flaj) may l)e covered by Thiersch or Wolfe jjrafts, or, if not t(Ki larp'. h_; undermininj; the limitin>t skin and suturiii . the edges to- gether. In the em])loyment of slidinj; fla| by Dieffenbach's method, which has been much jjractised, a more or le.><s vertical and (|uadran- gular flaj), at the side of the pap — which is made fairly trianpular — is slid into |)lace and stitched. Its bed is covered by Thiersch or Wolfe grafts either at once or after a day or twf), or later by smaller dermic grafts. Knapp's method' of stretching horizontal flaps (Fig. 12()) is a distinct addition to blepharojjiasty. Hy it (me may Km ir'. &JS Arlt'a method of tcmoTiog ■ growth from the ctntbui. a i Fiu. 123. Frifku'a method of hl('i>har(>i>lttsty. (Aki.t.) remove a neoplasm re(|uiring the sacrifice of most, if tiot all, of the lower lid, and then cut a flaf), going beyond the bridge t.f the nose, :ui<l a longer ''•• vvith broad base on the temple, and unite them in vertical line. s to restore a useful eyeliil, tarsorrhapliy being also done. The writer, following the suggestion of C. S. Bull, has found systematic ma.-sage of cicatricial keloid and other .scar-ti.ssue a valu- able adjunct to blei)haroplasty. The Le f-ort-Wolfe transplantation of flap without pedicle and the ThiiTsch skin-srafting liave [)r!>ved a great g:iin to blepharoplasty and a boon to op -ra tors, who need not now run the risk that they mar more than they mend. \\olfo"s method was tiesigned sjK'cially for ' Archives of Ophthalmology, vol. xlU. n» TUE EYE. ra-i- in wlm-h fkin is iiffdcil tn rc|ilact' oicfilricial tissue, n' 'lie iaftcr mr< iiiiul-^ "ii;iMiapc(lii. i-andisiiisulficii'iit to supply flaps. Thicrscji sl^ ill-drafts lie -niiu-tiiiiis iiuirf suitable. In tlv peri'drniaiKc of the Wolfe o|ieia!ion, wliieli is especially well ailajited !■ 'a.ses \\ ! - v as a result f liuros or injuiy, the free ed;;!' of one lid has iMvi.nn attached tothi'l)n vor tliicheek, tli lid is freed hy careful dis,Mrtioii. The lid '■ rre<>(' 1 y careful di.s.seetion until liofii lids ( n («■ cti.sily nj»pr<ixii .■,,!. uh<ri thi-y -ire sii'ured at three or f .sr appoj^l points w'K !(■ 'i margins have l*e«>n pared. Th' raw sui laces -tre triniined uh; ! tin \ ire smooth and vascular. "Il.ivinp taken the shaix' o •!!■ Way r^ inired with a piece ,,f lint. I carefully di.^s. ,t ,, piece of kin irofi tl.:- forearm, cutting it larjii-r tl m neces.sary .11 around, .s< -, , m .d'. nv 1 t sli'inkinK. I then turn u ts deep surfac • . and wit, a ,-,'; ' ;i shai scissors pare off evi-rv vestige of suh- cutaneoiife ti.>sue, .s to lej. ve the surface of a jiut white lor. It Ki... las. Fio 124.— Arlt's method when u jiortioii of i he cyeli Fw l-'.'i.— liielTeul)ach'!i meilim! of hlopharopl,i.-iy. IS til tip facrlHcetl. eyelid, to wiiVh it !■- ■iud mouldin;L' it ini > ~urface for ..liout ti is tiien .ipplieil to tlu' gap m ■ h- fine silk ligatures. After pressinsi soaked in hot water is ;ippl!e<l to its It is finally dressed with lint wrung out of hot water ( »\ folds of dry lint arc placed, and the whole covered witli jiercha tissue, and secuM I l>y aii imniovahle handage day the dressing is reim.'.cd, and it i- found that ailhesioi place, the H'lj. looking clean and dry and ^i.irnia!: hiui.-l visible here anil 'here. Tl In Thiersch mettio( superficial layers of the the arm, .ire tran-ferr-d tw tin- ra-. method, ti"' lids being stitcheij tog While makuig the shaving, the part logical salt solution, and the fonnr lAHLT.) :led 1< cc. lint linui' ills In ■ g .It. : ne third iiail taken limv are an, e dressing is repeated daily. t_>f skin-gra'ing. strips of epide -^ and kin. cut gc; r.ally from the hairles- art of ;rfar. [.rejiared i,- in .\.ll'i-V T or the upper t<. the chec! . kep! vet with war-ii nhysi,.- lid (ii! the ra r .ne .icross i>jsi:.iska of ntijiir : mhymal avi.\r /(a. axd irm. 247 till raw 8urf;n( hy its n . all cliils having first Uvn i^ iiiovt^ !. Drt-ss- ijijt '> <'«>ii'' 'I-- iti til VVulf'i- tiH'fluMl. It is \v<ll to Imii. !iig(' Ixitl, cyos, Ifi forty-fipJit i>r t^evpi sty-two liours tlif \>ti arc rari'iiilly cxpowHl iiiiil I■>■llrt•H^■• I utl then from time to tiin Tin iipaturc-i ciii l>c fft'ii- (I ill k. Mon- or k'.s> shriiikiiijj < thefUh 25 to 30 |x'r <i 't.. mtn ' ill (-icatiifuii cfrropiofi f()ll«)wiig hurii>. iu\, in uhirh at iea-t a jMirtion of thf pyi tirow has Ih-o (i(>stroyi'(l. Hotz' has olniatod the iiiK-" iwity of t If ^\|'lf«■ iiM'tho"! the (l;i! j;«>r t r(-<vfrsion of the liil trom shri kag of a Tran.«(iuuit('i flap ir :icnoii of tissupn. Frori. ' <• atlj;. I'l. itri , m itself he tak('s a fi;ij> large eiiouieh to Cf! • the li'^ stirf.H'-f oi: . 1*4. < fixes the np|H'r iiiarjrin of this llap to tt^ ii 'IT t"'' ' ' the i »r-tis." The ra>^ surfae< >l)ove the lids is coM'ii l»> 1 l'- 1 fiiersch grafl^. The cisioii begins Klo. 126. r ? I \ ■ u-;^ h - Knapp'i method of t .epharoplutjr. (K^ ne inn oanthus and ends about (S tnni. i^< iter, and kui a larp in flap, wiiieh is then carefully disse- 'roni the idriving - i-tissue, l;)ut is left connected witli border. ilic lid ; relciised from ihe deei)er scar tisstie ut m he re- pi ' d in its iiorniai pasition. The contracted flap, still, howi ver, in! 'I' eiioiidh to cover the whole surface of the lid, is spread out s: .othly over this surface, and its margin is fixed to the upper b. ndt'r of the tarsus by four silk sutures. Into tb" wound upon tlie lid :i skin Hap, which may also contain a good ileal of scar-tissue, is ti;! I'lanted. 1 I'leiiliaroplasty — apart from a.sppsis and great care — thei' .ire sf ' [loiiits that conduce to success. The flap shotild be a third ' than the gap, should have a broad, thick base, with as good iM-ular supply as possible, anil be noatly adjusted with the least uv -ting, and the least strain upon the sutures. The latter should not be ])iif in until al! bleeding !i.i.°. r-o.'ised ?.r\'\ clots :'.re removed. The thread should be fine and of twisted (not braided) silk, because leaving less mark, and the stitches, which should be closely placed, ' Archives of Opblhalmoloii.v, vol. xxv.. No. 3. 248 THE EYE. shoii'd be rcninv(>(l rarly. Tho flai) for tlic lower lid should ho tiikoii, when it is feasible, froin a hiniier level to |)revent sapjiiiif; "reversion from after-traction, whieh is |)artly met by tarsorrliai)hy. For the nplH-r lid tli(> flap is often taken freni the mid-frontal region. After restoration of the liils the parts should be kept warm and (|uiet, and free from special tension, by means of compresses, |)laster, and baiid- aj;e, .so adjusted as to avoid undue direct jiressure. The natural fohis and creases of the adnexa .should be kept in mind. Tissue, especially conjunctiva, should not be wa.sted, thouph neoplasms should have wide berth. Hence, in this das.-i the importance of early correct iliajinosis and i)rompt excision. Flai>s with pedicles have not been discarded because of th(> Wolfe and Thiersch methods, for these have their drawbacks. Flaps with- out pedicle shrink from :}:{ to ")() jx-r cent., and sometimes more. le original (defect mav recur. Not .seldom they slough in part ,d tl or whollv. aiic lib id tlu y re(|uire mon after-care than twisted or sliding flaps. They have the advantage over the latter that one may u.se the skin of hidden i)arts, the loss of which is not felt. Trichiasis and Distichiai>^d. The former refers to an inversion of one or more cilia, as a consequence of which the (>veball is rubbed and irritated: the latter indicates a double row of cilia, the inner- m>st of whieh is inverted and irritates the eyeball. As a result of the irritation i)ro%-oked by the lashes in both of these conditions, theeveball becr)me.s inHamed, and corneal ulceration and oi»acity are favored. The chief cau.se of the distortion of the cilia is trachoma, the faulty |>osition being given them by the cicatrization of the tarsus and the "conjunctiva wrought by this diseas<'. It may also be (u-ca- sioneil by injuries and blepharitis. Treatment i (insists either in the removalof the cilia or operative measures to correct their faulty position. Trichia.-:!^. When malposition is limited to only a few of the cilia, it may be corrected by excising an oval ]>iece of the tissues near the free edge into the tarsus and stitching the skin wound ( Wolfe) : also by splitting the (<(lge of the lids behind the row and juitting in a tiny piece of ski;; :.r nuicoiis membrane. In so-called scalping, the li<l-margin is s|ilit xeitieally behind the stunted and incurved l;isiies. and the aiiti'rior lip. just wide enough to hold the hair bull>s. is absci.^ed. This is now very lav ly done, being replaced by the Hurow incision, (Ireen or van Miiiiiigeii operation, etc. i which see). Kleetrolysis is now used to destroy misplaced cilia wlirn they are few. .\ fine needle viiegative pole) is passed into the follicle with the ciliuiii as guide. A few seconds closure of the circuit suflices il (here is frothing (Mitch- ell, Hensoii). Sim;\(KH W.M'son's .Mktiiod. An incision is made in the inter- marginal space, and a second one ]>a!:illel to the boidi'r of the lids and above the row of cilia, as is done for their aiiiatioii. 'I'liis strip, ront.aining the eili.a and follicles, is cut across at one end only. Then a .second Hap similar in shajie is made abt.ve the .irst, its free end DISEASES OF ORBIT, LAVHi'MAL AI'PAHATCS, ASD LWS. 249 liciiifl at tlic saiiK' cantlias as tlif base of the other; tlio flaps arc then iiitcrchanpcil ami sutured. Tliis operation is now rarely (lone, except for trichiasis near one or other canthus. In these |)()sitions Fudis considers it the most suitable procedure, hut the Haps are made much shorter than in the original operation, which was, indeed, the jnonecr in intermarginal work. .... Thk .I.\KsrnK-Aui.T ()i'KU.\Ti()N for trichia.sis, which is done under an aiuesthetic. is as foUows: A Snellen or Knapp lid clamj) is applieil, and the lid-margin is spl'* from end to end by an incision two lines in ilepth. which Is met at ' le bottom by a horizontal cut through the skin at right angles, made about 4 mm. above the ciliary border. The anterior flaj), lioliling the skin, orbicularis, cilia, and bulbs, is then cut awav. A small semilunar piece of skin is now dissected rv. 127. Jaeache-Arlt operation on tlie upiwr eyelid. ( Arlt.) oir higher up, and the marginal flap is then stitched to the upper raw v<V'v The effect is to roll out the .'dge of the lid and the eyelashes. TiTmake tlx' result more lasting. Waldhauer trims the excised skin and tits it in the wound, and supports by bandage to ensure union with tiie raw surface. This operation has largely b<-en replaced l,y reconstruction or restoration of the lid-margm (after van Millin- f:('li. (ireell. Hot/,). . . , Entropion and ectropion refer to an inversion and eversion ot the margin of the lid, respectivelv. Entropion may be occasioned by a detVct in the normal contour of the lid as the result ot a disease or JMiurv of th. conjunctiva or tarsus (nra/nnVi/ cn^rf>/«"n), or it may |.; (,.,\wed hv ii "pa-^m of the orbicularis muscle acting n-flexly from a conjunctivitis or keratitis, or from ban.lagingof the eyes, esijecmlly in tiie aged, with lax .skin and conjunctiva {siKismodicentropwn). Tilt: KYE. i On ai't'ou lit (if ilu' irritation w liicli the inturninf: of tin' iaslics iipuii the ill (ilic proviikt lacrvin junctivitis an 1 kcratitis'arc tlic rule ition, jiliotophobia, aii.l the sifiiis c.f con- Treatment consists in n storiiiL' the niarpii of the liil to its pro] .<T p.isitioii If the entropion is due merely to spasm, it niav iften 1> licve.l by liaiiitiiifl t Id ill liaiulafiinn liy applying :i strip of adliesive plast. n avoi( lids. OPKIiATIONS F()l{ troiiioii tends to jiei hf skin below the lid with collodion. It may k L'r th Kntuoimon. When spasmodic or nmscular en- ■Ct in spite of the use of plaster or collodion, etc.. fa horizontal strip of skin <oiue operation is rcMiuired. Kxcision ol a -i,,,,,.,.!, often s ifHc's in senile cases, or of a narrow strip o ,sk.n and luuscl. 1 vn to the tarsus close t.. the free edp. of the lid ((.reen). Many S-slave b,H.n cured by means <,f .leep vertical sutures M trans- iix the septum orbita. n..ar the infra-orbital nu.rfrin '--■"'f .^ ""/'"' ri.cipleoftliellotz..peration((lrueninfr.. 'Ihe (ia.llard-.\r t sutu I als . efiectiv... Four threa.ls in two sets, by n.eans ot d.m 1 threa.led needles, are enteird under the skin o the lower) hd cios.- its edpe and at rifjht angles to it. and an- brought out at 2 cm traidit below. Kach set forms a short loop o-M-.d,- the .skm n.-a. the .-ilia and traction on the f ee ends when lyinp (over a muiH) everts .' d.'sin-d The sutures are l.-ft a f.-w days, so as to cans.' vertical subcutan.M.us cicatrices which ensure permanent tension In entropion with narrowing of the hssure (blepharophiniosis), , jr„ud result mav be had by canthotomy combined with the insertion ;/deep v-rtical -sutures passing from the chary niarp.i ch.se t.. the outer surface of the tarsus and emerpufi high u]. m the hd. lu tinnlv tied lifiatun's are allowed to ~ ii.puraK- out: ui s.mie cases they 1,... (ak.-n out .arlv ( I'ajienst.-ch...). For the correction o s.-.i h- ! ,„,,pion of the lower lid. Theobald uses caustic potash. att.T the n u„ er of the late I'rof.-ssor X. H. Smith. Tlu- cravon is sharpene.l ': ' 'oi,,,. ,„.l is moved back and forth across the lid at ab.nit 4 mm. froii it > marpn, .\ spreading of the caustic action of perhaps _' mm. om ti.e h.; of applieation is to be allov ed tor by simp y causing ,1„. potash to act upon this narrow strip of tissue l.aralle to the hd- margin. and moving it back and forth gentl;. , perhaps a doicen tunes one secun-s a very marked caustic action ,.,.on the tissue. ;vlno > ' '• I,.. ..l„.,.k..d If -lesin-d by diluted acetic acid. As a rule the hd n 1 in.inediatelv stav <.ut in goo.l position; a slotigh takes place, and tl.. cases in wliich a" com,.lete cure is not ,.fT....ted m senile eiitrop.-'n are verv unu-unl The method is not appro|.riate for the uj.i.er lid. Trichiasis and Cicatricial Entropion. To <-orre<t t.ie incutAinfr- - of the lid-margin, bevelling of the inner hp and malposition of tlie ,ilia, eaused bv shrinking of the conjt.nctiva an, the <M.nst.-int trac lo . inwu'<l in theVi-t "tag<- of trachoma, three metiiods may be adopted, that of c.unter-tension. release from tension, and restoration (recn- .tructiont of the lid-margin. The first is the pnncipl.' ot the .\nag- noslakis and ih.tz operation, which has stoo.l t.ie tc-^ of years, la DISEASES OF ORBIT, LACKYMAL AlTAUArVS, AM> Ul>.s. 251 it counter-tension is kept up by usiuR us a fixed iH.int ti.e ti«-sn-url.ital l^.i at the orbital n>arpin of the tarsus. Ihe r-;'"' .;: "^ , „l,j..cts are pained by the- Green operation, very wuiel> u.e.lh ■s he ina.rve,l h.l edp<' and n-stores its u.ner hp, and also b> the . , Mi linpen op..ration. a.ui in a different way, nanu'ly l.y u.ter- sin, b' rior between the skin of tlie lid an.l .ts -"J""<-''-'- .. .. ' ) GUKKN'S OPKK.VrU.N K..H (•..ATUICIAI. l-.NrUOlMuN. A luURltudl- .nl'ineision is nuule through the e..n,iunetiva and tarsus Iron, one ; I the tarsus to the ..ther (after Bun.w). and para lei to and dl; o ;' line or one an.l a quarter line distant Iron, the ree bone the lid \ strip of skin, a little .nor.' than a hae i. \Mdth, an. „ a ine listan fr.„n th.- r..w .,f .'yelashes, is exe.se.l. the l.u.sene.l ; . -S. th.- li.l turne.l f.-rwar.l an.l s.-cure.l n> its n..w p..s.t.on .Mhree to live sutures. The n.-e.Ue carry n.g the sutu.-.; is .na.le ." te a t e e.lge of tlte li.l. in ..r near the r..w ..f c.l.a, an.l .s carn.-.l ,w . s^ u.n.^th the skin u-.til it appears i., the ...taneous wound, s then Plung.'.l .l.vi-lv thr.>uph an.l behnul tlu; hbres of he , rbu- : is nmslle. an.l is b'r.iupht .n.t through the sk.n f-"' » »-,/;; . ■df of an inch almve the upper hp of th." wound. The effect of » '.w s ures applie.l in this way is t.. tilt f..rwar. th.- .nargin of e :^^;^h the hnplUte.! cilia, leaving the l..,.pdvu uu wotnu on ^k- ;t: hi r n^^rrow strip'of skin. An.l -1"- no sk.n ..n be s.njred .ranuhUi.. n is s.,on c.!ver.-.l by sn,o,.th onjunct.va. The u- gianul. .1. . ^^.^ f„r,„atu.n of n.'W t,.s.,ue is crea.se in the in igUi .)i im ''"•",. •. „ i h,,,. ^trii> of ivucous =£,;;;;a:x'S.::;v;;ir;::r:.o..i:;L:2,. m. it,.. ' .; Thr(>e sutures are then put in the (iiiar\ x.ii..u .■ i i'irri.;;;' .1;; t^X^ .i- .iiv»i"i .««« u,.>i ..k- e.,x-". .*- of the orbicularis. 252 77/ i' KYE. ■i \NU-.vo=^T\Kis AM) HoTZ ( )i'KH.\Ti()\. Thp operation is per- form,,! ,M tl>e .ipi.er li.l as follows: Wiiile an assistant fixes tlie skui •It th' sufra ..i!)ital niarpn. the operator, seiznig th<' centre ot the ii,l-l)<'nl"r will, iinfiers or foreeps, draws the lid downward to put its skin well on a streteli, and makes a transverse ineision through ^kin and orlneularis nniseie from a point 2 or ;} nun. above the punc- tmn la<-rvina!e to a point 2 or ;{ nnn. aln.ve the external eaiithus. T\n< incision divides tlu lid-skin in a line i)arall( 1 to an<l a little below the ui)per border of the tarsal eartilage. and is therefore from 4 to X mm distant from the free border in the centre ot the hd. The skin and muscular laver are now dissected from the incision down to the roots of the evelashes, and. wiiile an assistant is holding the edges of the wouikI well sejjarated the operator seizes the forceps aiul ex- ci-;es witii curved scissors the muscular fibres running transversely across the upper bonier of the tarsus. Next tl-e sutures are in.serted. Three sutures are usuallv sufficient— one in the centre of the wouiu and one at each side of the central suture. The curved needle, arine.l with black silk. No.:?, is firs" i>assed through the wound-border of the lid-<kiii, then it is thrust through the upper border of the tarsus aiK returned through the tarso-orliital fascia just above this border, and linally it is carried through the upper wound-l)order. "When these sutures are tied the skin is drawn upward ami fixed to the upper tar- sal bcrder, an<l tliis slight traction is sufficient to turn the inverted lid-bonier and evela.-^hes to their normal position, and as the skin becomes firmlv imited with the tarsal bonier the tension thus pro- ,luc(>d upon the lid-honler is i)erinanently secured. The sutures ^lio"!d, of course, not be tied until all bleeding has ceased and the wound is thonnighlv cleansed; they may be removed on the thin! <lay. liidcr asejjtic dressings tlie wound he.als by first union, even if. "as sometimes occurs, secondary hemorrhage or (edema causes con- siderabli' swelling for several days. Tin; v\\ .Mii.i.iNOFN- OpKUATioN- FOR Tiiu'iiiAsis.' "The inter- maigiiiMl space is split fnmi end to end. as in .\rlt's operation, and sullicimtlv to iiroduce a ga]) '.i mm. in bnwlth at the ci'iitral part of the liil. and gnidually becoming narn)wer towanl the canthii. The gap is kept n\)on bv sutun's pas,><ed thniugh folds of skin on the ui)per lid and by me.'iiis of which the lid is prevented fn)m closing for twciitv-four hours at li'ast. .\s soon as the bleeiling has ceased, a strip of mucous membrane of the same length as that of tii(> lid, and 2 or 2\ mm. in breadth, is cut out with two or three dips of a pair of curved scissors, fnitn the inner surface of the under lid. and placeil :it once into the g;ip at the intermarginal space. It should then be pn-ssed into situ with a iileilget of cotton-wool stee])eil in sublimate solution. Sutun's are sui)erfiuous, and do more harm than good. The operated lid i> tl.-ii covered over with a flap of linen containing a thick layer of iodoform va.seline, and this is covered over ' Ophtlialmlc Review, November, 1SS7, vol. vt,. No. 73. *wapTBP^"?F»a Pl^EASKS OF ORRIT, LACHYMAL APPAltATUS, ASD LIDS. 253 hv .utton-wocl. Botli eyes sh..ul.l bo baiulaKo.l. I invariably us«> sublimate lotion (I: 'Am)) f<«r disinfecting the eye an.l li.l .luring before, an.l after the operation. The baiulape shouM b.. r.-newn once in twentv-four hours, ami tiie sutun>s on the upiier lul shouh not be removed l-fore the second day.'" Some preter a strip of ^kin (from behind the ear. llotz). without suturing'. Others witii sutures. Some, like van MilUnjten. are partial to mucous m<-mbrane ( from tiie lip. We<'l<s),usinfi sutures or not. , •, • Thk Stkkatfkiu. oi-i;uati()N of pr.K.vmg the tarsus vvhen it is thick and misshapen has been modified by Snell.'... In the Str.'at- fcild-Snellen operation an incision is nuule tlirouph the skm ot th( upper lid about ;{ mm. from the marpiii and para h'l to it an.l ex- tending ah.ng its whole length. A strip of the orbicularis about J n.in. in wi.lth is excis.".!, and next a triangular w<-.lge-shap<-d pi.<-e of the tarsus along th.- whole length of the ii.l. Three sutures are then m-. verted in the following manner: A suture arine<l at each end witli '., „,,,lle is to be passed through the upper edge of the mcisiun m the t.,r.i'. an.l both needles are then to be carru.l thv.,ugh the lower ..'.argii'i of this groove and brought out through tin- skin J "^J above the line of lashes, the points of exit lying 4 nnn. apart Thv Um other sutures ar- to be inserted in the ,^ame way, care '•»'>''>Jj"';'' ' that the points of exit are about 4 mm. from each other. A be.ul is e. pasLl over each end of the sutures (to prevent their cutting ,hc skin), an.1 the latter carefully tied, so that the two opposit.' ^.des „f the incisi..n in the t.rsus are accurately approximated. The upi er edsre of the skin wound is left open. r : i i •> I'vnvUnkiikn Opkuat.c.x. The skin of the li.l is divi.led 2 or ? mm ■ib.'.ve'the free border of the li.l an.l parallel t.. .!..• latter, tuii^sior inning the whole length of the li.l Then from the c. ge ;: t Js incision thc^kin is fi.e.l as far ur- as the I'l'l-'^-j'-^f;^ fn-«us and a>= far down as the free bord.'r of the li. . Next, the n u ;„ ,e pe being insert e.l beneath the lid, an incision is ina.le whid, ; n e same wav as in the skin. In this way th.' lower half ,. f r-. 1 with the free bonier of th.> li.l is ma.le reely m.^yabl... an.l V ■ e otaml f..rwanl bv means of sutures, so that the c.ha assunu- ,h,- , o, er lirecti..n. The sutures an- fonne.l int.. loops an.l pass,, d , V hrough the clge of the tarsus an.l th.. tars.M.rb, a hisc.a. an. ;t free 3 of the loop are br.,ugi4 out Ik hin.l the skm o th.. lul a „,„ the intermarginal line, an.l h.^e are tie.l over -^P^^- -J' '^^j^j^^. Th.. (ireen an.l the Hotz ..perations yieh!. as a ml." yix satisiac torv n ^u ts nls. the van Millingen. especially in trichiasis of he wer f ombincfwith canthoplasty an.l .he ^t-;;;^;;'' ;^-J;:; ,e, in.licate.l. In ca-ses of misshap..i j-''^^-'^'}' JJT ^^^^ few it m-iv be necessarv to combine th.> features of two. it n..t three of Ve e ; e iuri ucce s. and this is the rule with operators^ W .-eks ; ; r" favor dSv of a number of ca-ses in which he tne.l a e..mibmat.on of the f..ur-canth.)pla.stv, the van Millingen. the Strrath- M-Sm-ht-n. ^ndHoU-thesutu'ring differing from that of the latter in that the THE EYE. „,.e.llo is iMM.lc to i,ass through tli.> upixT Vu\ an.l to omorRO S mm. al,„v.. th.' .narpn ..I lh.> mi-I-.t Hai.. Th.> writer who can t.'stity to the vihic of the Hotz an.l (in-.-n o|.crations, early lound it advisable (hefore the van Milliiifien operation was in vopie) to eoiubiiie the lii-st at times with the Hiirow tarsal ineision. I ike entropion, vctrnpin,, may either U- cicatrieial or spasmo.lir. , iMir \>S. 1 ( •icotric ' '/, or. as it is sometimes callt'd, onjnnw niropwn, .. ...u. ",-.'. ..■,>■„.. i< ..Lscess of the lid and orbit, ami disease ol 1LS l)oubl>: rii-Htriciul c-nrciiiion. Arlt's opcraiion for ectropion. ( AR1.T.) Treatment. The Adams operation was dev' ,d to oorre.-lclongation a,„l partial evrsion and moderate ectropion. It con.sist.s in the n-moval of a trianpular V-shaped, piece, inch.dinp the whole thiek- ,„..s„f the lid. the base of the triaiifth' being turned tow.-.rd the „u.r"in of the latter and the apex toward the cheek. lh.| .Mges ot the \v.,un<l are carefullv brought togeth.-r by sutures, one ot which is inssed clos.. to the free" edge, so as to prevent a groove. Nmietunes :, harelip pin and sutnn- is used This operation is now i.referably ,,,„„. „„l„. ,1„- outer canthus in conjunction with tarsorrhai)hy. It is .ueciallv udai.ted. for senile ectn-i.ion or that due t.. chronic con- j'mctivitis. for which also the Snellen and the Argyll-Robert.son suture oiierations have been designeil. „ , , ■ i In the Vr.'vll-Robertson operation' two needles thnvided on a long w.xe.1 silk ligature are passed through the skin an.l h.! (me line from its cil'-arv margin, and each one-.|uarter of an inch from the mesial, nasse.! on through the fornix aiul brought out tiiroiigh the .skin one- In.arfr of an iiirh apart at one to one and one-quart.-r inches from the ciliary border. A bunch of fine rubber tubing is i)laced vertically ■ Eillnburgli Clinical ftiid IMlliologlcal Journal, I)«-«iiiber. 1««3. .,vj;i:--.-v'._L, VISLA6ES OF ORBIT.. LACRYMAL APPARATUS, AXD LWS. 255 within tho I....1. on tho (.utsi.h- ..f the li.l. A pioc; of thin sheet-l.-atl n r inoH, mrter inch, rounded off an.l n.ouKl.-.l, is Mipi..-. mto onl .rsTun or the hr.-a-ls, and tho hpaturo is thon t.od ovor ;;: t:^ 7l;:. Img. -xho 0.^,0 of th.. ^^^^^ r volvo imvanl <.vor tho upjH'r od^.- ..f tho pi.-oo of loa , \hi . t ., ■ r tilage is oausod to nioul.l itsolf to tho ourv.M.^ tho oad, and ,;;. ;lv;STt^.,,,•.. oooupios its ..omud po-sltion.- Thos.turos aro not roniovodfor from tivo to ton(h\ys. . .: . , i S.Ul<'n-stiture operation f..r sonilo ornmscu ar octr<.,..o„ ,h li^duros aro pas«ed througl, tho conjunctiva and suhadjaoont isuosud). ought out and tio,l ovor a roll 2 cm. bo^nv ho fr.-o J iC o^Toct may bo increased by tarsorrhaphy as d<>s,rod. _ . In'par a o tn.,.ion with hypertn.phy of conjunctiva, the oxcsum ,'",' . ,,V.,,in „f the latter and closure 1)V sutures may suthce, . f Arl uhirh is Dorforniod as follows: The cicatrix and tho skin that of ^.rlt.;;' •'^ ' "J ™ riangular area boundo.l by the points surrounding it are ^'\«'"':/ " /^"'iV!^^^^ .^ the edges of the denuded "'^t:;^!:^^^^^^^ ^ isl.proximate to d. :;;;;? rSdJ" "ho 1;:^ L is m contact with cd. Harehp pms may '-^^:r^^:Sr^^^^^^^^ it bocomos n^essary to Wl •„, ui iaiX a fl p. This may bo accomplished by either the Pricko t Sm-nJach method. Both of those consist in excision < vf t he oW„„. »n. n»,lo in ll,r«. "'f ■"™' ''JJ f„*;, ^iC thr«: suluro. tlu. pifitriK has been iissected out tho nds an unmu y>i ni 3 -;r;;.r'L:i;ls'Lf«"S'^s=wrf '^^ ^mf !o6 Tut: KYt:. iiiti) raw surfaces, citlicr fri>m hums or (lis«\is<'s of tlif coiijunrtiva, causing loss of tissue, sucli as traclioina and tlipiitiifritic conjunc- tivitis. Treatment. Ankylohicpharon is remedied hy dividing tlii' adliesions het\ve<'u the lids and between the lids and tiie globe, and by covering the denuded areas by iransi)lanted portions of conjunctiva or strii.s of mucous membrane taken from the lii)s. In m.any cases it is of ailvantage to perform a canlhoplasty at the .same time. The ste|is i:i the operation for the cure of .symbIei)haron consist in separating the adhesions between the lid and the globe, and in preventing readhe- -ion.- bdween the denuded areas by placing a conjunctival surface in apposition with a raw one. A number of procedures are available, but that of Himly or Harlan is to be |)referred. The former perforated the b.ise of the" attachment of the adhesion in the cul-de-sac and placed a .strip of lead wire in that position, the wire being i)orniitted to remain until it had worn a groove covered with i-pithelium. Flo. 191. Ecchymosis (Black Eye), .\fter a contusion of the lid there is often a great amount of swelling and discoloration of the skin of the lid and its loose connection with the sublying tissues. Ice-packs .should be applieil for tl-e first few days after the accident, hut these should be replaced by .: >'. comi)resses, *. promote absorjjtion of the e\tra\:isated l)lood. Emphysema indicates that there ha.s been a fracture of the walls of the orbit establishing a connection with the nose. .\s the > is forced into the lid by blowing the nose, the patient should \> w- tioned against this act until th<' wound is heal(Ml, and a firm com., -ss banihige shon! ' !)e applied over the eye. Injuries of the Eyelids. Th(>se may be a mere incident of a more serious traumatism, and hence, if fciusible, the features of tlie accident should be learned. Wound.^ should be explored for possible foreign bodies in the eye, orbit, and adnexa, and one will sometimes be sur- /,mu.>£5 OF ORBIT, LACRYMAL APPAHATVS. ASD UI>S. 257 • 1 . t»«. fin.liiiirx Forcien i)articl«'s should Ix- n-inovcd, aiitl w L wist.-.l silk The lips of vvouiHls .livuhng tlu- .-Ig.-s of th.- r 1 r .1.1 h.. .-infuUv coautfd to av.ml .listortioii ..r a uroovc. A • ; sS' i^ t ,; i -1;^ it-lf is of- us.'ful. If thoipator pa - J^. U-t. Jn t should Ik- stitch.'.l with finr c-atKut. W h.-n skm is ict«(l dressings are helpful. 17 CHAPTER VI. DISEASES OF THE CONJUNCTIVA, CORNEA, AND SCLEHA. By JOHN E. WEEKS, M.D. CONJUNCTIVA. Anatomy. The conjunctiva is si (iciicatc mucous membrane wiiicli cov<T< tl>c posterior surface of tiie eyeiiiis and is reflected onto tiu- anterior half of the eyehail. At tiie marpin of the lids the conjunc- tiva joins the intejiument : it iloes not pass Ix'vond eithiTcanthus. At the inner canthus tiie conjunctiva exteti.is ovit the fleshy glandular mass iinown as tlie caruncle. It is thrown into a crescent i<- fold just beneath and to the temporal side of the caruncle. This told, which is drawn outward on movements of the cornea to the temixiral side, is termed the i>liai sfrtiilunnri.-:. \W its n'flection from tlu' li<ls to the eveball the conjunctiva forms pouches above and Iwlow, which are termcl conjunctival sacs (cul-de-sac). T\u' depth of the upiM-r sai- at the mi.liih' of the lids is approximately 19 mm., of the lower sac S nun. The conjunctiva is divided into various parts, as follows: jxtl- jHhml, that coveriiifi the posterior portion of the litis: jurnix. the transition fol<l; ocular, that cover- inc the clobe. The ))art of the palpebral portion that covers the tarsus is known as the tursal cdh- JKHcliro. M about three millime- tres from the marfiin of the cornea the conjunctiva becomes closely united with the anterior reflection of Tenon's cai)sule. Tlu epithelial layer is stratified. (Fiji. l."Jl.> The tunica propria is very thin. The coniuiictiva ixissesses no lar^e vessels, but it has a very rich network of small vessels, which become prominent on irritation ot the conjunctiva. In the retrotarsal and ocular i)ortions of tlie c(.n- jiiiictiva ili( vrrri. are frwly m--.vab!e over the luulerlyms tissue, \ rich plexus of Ivmphatic v(wels exists in the conjunctiva, those of the upptT onjuiictiva near the outer canthus beinj: in connection with the chain of lymph.itic vessels which pass to the preauricular ( 2.-.S ) KpithiUciiianf itie ImlljRr conjuiieliv*. iiiRiH rrrsr^i^^S^fir^. DISEASES OF VOXJLXCriVA, COH.SEA, AXJ) SCLERA. 2r»» rr^ion; tlms.' of the l.mcr lid niv (M.nnoctcd ni.in- .lircetly with th.- Th- n.Tvr supply is from tl..- larryn.al aiul from the supratroch- lear aii.l infratr.x'hlrar hraiifhcs of the fifth. CoMenital AbnormaUties. Th.' most fr.'.,u.-nt coi.K.nital growths n.H with are .lerinoul tumors, which visually cxt.'U.I onto tlu- .•ornca; thev ar.' usually pair i» color, hut may Ih' pi-mciit.-.l: they arc. us a rule supplie,! witha numher of hairs, glands, ..tc. pn.s.M.tm>j the c har- aeteVistics of the skin. Small fattv mass<-s an- also m.-t with: these are situate.! appareiitlv Ix-neath the conjunctiva. .\n>:ioma, cavernoma. and telauKic'tatic ^^rowths. conpenitul in oriuiii, sometimes are found in the conjunctiva, \„ usseuus irrowth <.cca.sionally is found l.eneath the conjunctiva, situat.-d hetween th- out.T margin of the corn.-a an.l the .•ommissure. ■ Mules or pigmented patches .sometim.'s ar.« observed ..n the con- junctiva ; then, occur n,..st fre.,uentlymmdivi.h.al> who present 'similar spots on tlie skin. Kil.rous Lrrowths. sometimes ern.u.M.usly spoken of as lii.omata. ..ccur rarely just l.eiu-ath the n.eml.rane in the upix-r outer portion of the ocular conjunctiva. . rn i »„,i Hypersmia of the Conjunctiva (Dry Catarrh). The palpebral ..Sctiva is the part usually affected. The mucot.s nu-inhrane is n- 1 1 verv slightly roughened, hut is not apprc-iahly thickeno.1. Etiology. • The con.lition is .lue to irritat.on lr.,m inanv caus.-s- explrfto heat, bright light, glare from water, -''' - ;'^;;- ^I'^^f wii.l .old, St. rms of rain or snow, cnstant use .,f h. .■>.■> %Mth hci.M ■ iUuu.ination, eyestrain, in.ligestmn, alcoh..hsm. gou . i;"I„H.tor .listurl)ances, lacrymal .liseas.^ acute exan.hemat.ms fevers, and blepharitis marjruialis. . Symptoms. The lids iM stiff ami dry, an.l are m..ve.l with .l.fh- cuUnV burning sensati.-n is experi...-.! an.l then- is mcn-as.-.l c vn, tion. Ti;e su.H.rtW.ial epithdial '-";='"'';''*"?:.; nip^llv than in h.-alth, an.l are f..un.l "' ^;'"' .^''-^tteZ s ^ ,,;„l,i an.l s.,metimes at the margin of th.' I .Is. J '"'I"^ <" "^•' the eves with artihcial light an- ;. romi.am.Ml b% .listnss. Treatment. The caus.> <houl.l U- s..ught t..r and n-move.l. In a.lSrtt eves shouM b.' hathe.l twice .laily with a :5 p.-r cent. «>hiti<)ii ..f boric aci.l; ( t her measures atv unnecessar> . C^^^m^tl^l^^^^^^^^'^^- Tl'istormis applie.l .- a .mmber o .li^aS^f tl. coi^ictiva. all of which are acc.,mpam.j.i J- ujer..^d •nul alt.'re.l s..cn-tion. by .listivss.ng symptoms, an.l In transit nt uriH-rmamMitpathoh-gicalohiinges in th.- membrane. Classiilcation Sine- the disc..very of th.- g.>n..c..c(-vis ot .s.-isser. in is" h s° ecihc micro-.>rganisms of a numb.T ..f ..rms ot .•..njum^ i^- ti lave tl-eii .lescriln-.l, which makes it a.lvisab e to '"...h th I r ! iKr>li„i> >.f li-e.w- of thi.s nionihrane. .\11 of th.- forms .f ;;::j .S;S:';rit^^".le<lun;lort..hea.lings:a^ a spe,-iHc cause has not k^on detenmned. and (-') those forms in c?wi ••«£ WWE. "K »!&?..<¥: 'ii»«i£«.'TSKi&3 2tin Tllk' KYK. isf lii.<* 1m .'I. .!*'t<Tiirm<-.l. Tn til.- first cla^.* U'hnr. .i.upl.MM,! lui.clivitis iM.Tviual .■..njunrtivitis, h.-rprtUMMmjuiM-tivitiH, xvn lil nrnjuuHivitis, l.lli. =,lar ••.mjunclivitis trarlnMua, |h-,m,. np.>. l..rin;u..l-s .■onju.Htiv.M-, „.uty .-...i.-Mivms. T- ll.r s..ron.^ rhiss l,il„p: .,„,.. .-.nau...... nrnj-. -. -^i.lKU'ut.- .■nnju.u-tm Us, srunnrrl.u ,1 n.njnn.iiN nis. .lii.l.tl.criti.- .■o,,|.m.;..v,t... n.tus.s ..j-.t u- r,.,lis pl.lvctoi.ular or oi-zfiiiaH-us .•••njunctivitis, uiUTralosis, lupus, Non-specific Forms of Conjunctivitis. Simple Conjunctivitis (Catanhal Conjunctivitis, or Ophthalmia). Tl.is ,.:„uliti..i. is cl.aracl.Tiz.Ml hy i,.j..-ti.m an.l sM.t t h.ck.M.n,« „,■ tlu- (■n„j.m.-tiva (•..nfmo.l ali:...st .-ntin-ly t.. tl..- i.t.l|«l.rM' port inn. l.,ss..f transparciu-v.sliKl.t r<M.stu■..i^^^ a.i.l tl.-' prosoi.r.M.f a v.Ty littU> „n„.us, wl.icli fauscs tlir li.ls tu a.lh.-r>' tojiKluT u. tlu" monnng. Causes. Th.'sc arc i.uiucrnus an.l |H-nnit <.t (•lassihcati..ii: 1 Mk. MWi.M lrritati..n.)f the (•..njuiictiva. .luc to tlic cntranc-c „f partirlcs.'.f tn.-lai. .lust, p..tl(M», oxposun' t.) win.l. plar.M.t l.plU. •> Vhhoci \ iKi). .\ir.)nipanvinj; tlu- cxiinth.-uiatous fevers , rli<;u- luatisni, nasal cntarrli. I.n.iicliitis, ecwMua, facial .'rysi|K>las, iiupeliK.. c.intapiosa, in.iliuscuin cmtani '^uni. i Symptom \ric. Forms a.TMmpanyinn eyestrain, otr. Symptoms. S.iuk.tivk. l.ia^ li.-avy. hurninR s.-nsation;* m tlie oyo. irritation oi' niovi. i: the ey.'s, p!i.)t()pliol)ia, ann.iyanee in use of the e\vs. ,• . . .• ■ • . ,i . Ohif.tivk. Lacrvii.ation m..re profuse, slight sti.-knig t.-petlier of the li.ls in the nmrninf:, s!ij:ht thiekeiiin;; of the h.ls, liyp. nenna of the tarsal conjunetiva an.l .)f th.- r.-trotarsal fol.ls. Simple cnjunctivitis, as is apparent hy a ^lanee at the list ot pauses, is m.)st e..mmon in ehil.lr.Mi, tnit no sta<;e ..'. life is exempt. Prognosis. The .lurati..n .lepen.ls ..:> the eontmuation .)f the cause; wh.-n this is reni.iv.-.l (mechanical an.l sympt..matic f..rnw) .)r siib- si.l.-s (associate.1 f..rms), rec.)very occurs spontaneously. No lasting iniurv results. _ , i- r Treatment. In a.l.lition to removms the cause, much relief m:i> 1,,. ohtaiiuMl hv Dathinj; the eve two t.. four times .laily with a s.) u- ti„n ..f iM.ii.- aci.l, ;} per c.-nt. .\ mil.l astrin^'.'Ut solution may .also lM-empl.>ve.l-ziMc(fir. j t.>.',j) is.'xcellent. ... , , , Lacrymal Conjunctivitis. \ form ..f onjunctivitis dependent „n th<- i)resence of irritatiiif; secr.>tion fr..;n the c.n.lucttnir portion of the la.Tvnial apparatus. .\lm..st a'l of the cases mifiht projier y he eh.ssed witli the simpU- coajunctiviti.les, hut a few cases develop a mirulent tvp.' whidi tnav result in much .lamage to the eye. Diagnosis. The .^xu:\,trm. jHTulia: tn nhsfru.'tinn uf the lacrymal P'lssapes an.l, fre.|ueiitlv, a .lacryocystitis are present. Treatment. This consists in renderinjr th. lacrymal canals patul.)u.s ■uvl in c..rrecting the condition ..f th.- lacrymal conducting apparatus; rm hist:.ist:s of co.sji mtiva, corsea, .isn sclera. 2i;i ihc-"' lucuMin's innv !«• suppli-tiK'nt.-.l l.y clrtin-mK th.- cMnijitictn i with niii.. I)l:iii(l artfptic sulutioii lUi.l iIk- iis«- of a mil<l a-'tniip'nl. Litliiasis Conjunctivitis. A form of irrititiii.n of tli- <-oiijiihii' ,liic \" ill"' pre- iicc of <'alfar.M>us deposits in the (isHur of the | I„.|,r;,l coMJuMctiva: ilifv ocftir most cummonly it. th. tarsal c u- I,n,ctiva. hut are lu.'t ^^itll also i,, tlir paliM-l.rJ p-rtioi. of t .0 ivirotiMsil f-'l'l''. Til*' small ma,-:<<-s apiK'ar a^ vfllowisl.-wlii •• l,o.li<-r. alfinst imm.-.liat.'Iv lK-ii.-atl» tli.- cpitlHliiim. Thy ton.l t,, pctirtrat. tiu- cpitliclial lav.-r and to procure irritation .rf il„. cwl.all aii.l li<ls. Tin- conditicm i- m<'t \Mtl •■ommoiily m tb.M-'ol a.lvaiicMl v.-ar.. an.l is a.^suciat.".! usually with rhcumatisn. ur trout. Tli<- (IqK; • i-onsist principally of calcium carbonate an.l cliolotcrin. Treatment. Hcmoval. . , , if Herpes Conjunctiva. 1 ^^ condition is characterize.! l>y the lor- ,„ation ..f .lusters of v.-sicles on a hyiK-nemic base The vesicles col- laps.-. formiiiK a .suivrticial ulcr which heals rapully. leaving :iv.-ry .sliitht sui-erhcial cicatrix. The afTecIion accompanies herj»s orbitiilis, and -.vill he .lescrihe.l un.ler that head. Vnnal Conjunctivitis (Conjunctivitis CatarrhaUs «sUva; ^myc- tena PaUida ( HirschLergi : Spring Catarrh). A .lisease characteriz.-.! hv roudienini! and thickening of the p:ilpebral coni-inctiva. ac.-om- ,,a„H"d hv hvpertrophv of the conjunctiva at the marKin ..f th.worn.-a. Gauge. ■ \Vhil.> this iliseas.. is in all im.hahility .lue t.. a s,H.citic germ, tl enn is n..t known. The exac-rhHi-ns occur when the weather h .".nnes warm, wh: • .<-r th.> season; hu. .he ,m.cu lar apjM.irar.c.. ..f the tarsal c.mjunctiva is n..t -Mitireiy ahsem m th.- wmt-T months. •■ ■ ■ flftcm vears are aiiacke.1 mo.st fre- • : '- apiH'iirs in adults, often two ''hililren from the age of ti: piently, hut the condition .'•■ or more in a family an> :;tta' <|uality. In .dmost all cases Symptoms. Irritation, jis . on use of eyes, hurniiiR and which point.s to a contagi.-us ,. 1 e affected. ,iu'. iMxly. phot.»phohia. di.4re: ^ ,',ur(> is excessive lacrvteition. a scantv nuicoi.l (stringy) .lischarge, which is evidence.l m t,. ■ hv a v.'ll. .wish-white mass along th.' lashes an.l at the inner . in ..verting th.' upjx-r li.i. the tarsal cotijunctiva is foun.l "• t"'^ »^ > ,hi..kon,.d and th. 'surfac." is roughen,-.l hy the pres..nc..of t.um.^^^^^^^^^^^^ ,,„,, pMuillitonn elevations. The surfac' .f the pall«-hral '■"" ""<-^' ' hoth ah.,v,. aiul Ivlow presents a f:un.. i^'arly hu.>. as th'-^l; « U. .p ^ skinniUMl niilkhadlnH-n pass.Hlover; :. ;insapiH.arance..ohM^^^^^^^^^^^^^^^ th, ..arlv as well as in the later stages of the -hsease. .rh'"' ^^^^ : j m-tiva. except at the margin of the cor.,ea is hut ;l'.Pj» ' f •''l' .; at ti... hmhus th. epith..!ial layer becomes much <h'<-kene.l. This liuckening is usualU greatest in the horiz. 1 '':''l}'^'^''-.JX^Zh vatioiLs have a pearly, translucent apin^aranr ■-' the "P^;- ^ ;" is.-haraci..:-i.c' The hypertrophic! t>-^e - . enc oach- mUo the cornea .-t a distance of one ..r two milhn. res, and a narrow grayish zone separates the hyiK-rtrophied tissue from clear cornea. 262 THE EYE. ' »i i Pi In the later stages in severe eases Hattene.l fun^oi. elevati.jns apiK'ar on e alpel,n>l e.n.junetiva ..f the upiH-r and Unver h. s These o te re eni.le traeh..,Ma granul.-s. They n.a> Ik- l";.'"'"'" 'f'"';,, ., Pathology. Theehanp..sinthenmjun('tnae..ns,st.nseant> s n a 1- oell inhltnttion an.l the .level..,Hnent -f pap.! a., i.art.eularly .me up «: tarsal eonjunetiva. Thes<. papilla" eons.st ot a <:;;»-•='•'' v.!k,.N -.M.l s.,n.- n.nneetive-tissue stn.n.a eovere. w. h a la>er .< h rk n<' «^tratitie.l epitheliu.n. It is un.l.mhte.lly the tuekene.l eni hel iu n th t jjives he whitish shin.n.er to thesv.rtaee In severe elv^. S'i .1 ix'n-seenees fcnn, eonsisting of a tibrous pap.Ua eovere.l bv thiekened stratiHed epitheluun. ,...,;..bl,. n.'rio.l • Prognosis. The .li.«*ease reeurs every summer for a % ai lalle pi ri d (t"T> twenty years), when it subsi.les, usually leavmp but httle '''i;eatoent. I'roteetivn glasses, a bla...l wash (borie aei.l solution) and the use of an ointment of the yellow ox.de of mereury .1 to i wr cent ) usuallv give the best results so far as rem.-. I.e. an- .-o.,- ^erned ral mtr, in i.npalpable powder, .luste.l o..to th.' pal,H-bral crimetiv i,. vrv thin laver every see.,...l day ,s a.lvantageous ?Satie eJaliges .lo .....st g..o.l: the sufferer sh..nld go to a eo..l pliiinte duri.iit the h.)t .iDiiths. . ■ x ■ FoWar conjunctivitis (conjunctivitis folliculosis sunplex) .s ehSeriz..! by\he app.-ara..ee ..f small, I'-'-'^h ,»-''';';^'';' .^ . .lovations arra..g(Ml ..ffn in rows wh.ch oceupy th.- m.U . i rt .m „f the fornix ..f the low.-r li.l. oeeas....ui ly be.ng pr. sent at oufr an.l i.m..r porti..ns of th.- paliH-bral e...,ju..etiva of th.' "''cai8e"'Ther.. is .... know., speeific ea.ise. b,.t the .liseas.- ..eeurs n.o^t fre..u.'..tlv i.. ehildren wl... liv.- in m.hygi.'ni.; surr..u...h..gs. an.l Z ev-uU''...'.' is i.. fav..r of tilth as a cav.se. The .l.s.'us.- .s ...fe.-t.ous. '^'tZ^'^r. is oft.... e..nsi.lerable irritati.m: ,h.> li.ls ^ .lichtlv thiek.-n.'d. Th.T.' is so....' n.uc.i.l seor.'t..m .... th.' h.ls ... the n' oSp. l-se ..f the .'V.'s <.aus..s s.-nsations .>f l....-.....g a... s,nart..,g. The oeular e....jnnetiva a...l .•..r..."a are s<.l<l.m. ...volv.'d. ( M. .i.spe«'- .il!,, ,h,. palp.'l..-al e..njunetiva is fonn.l t.. be e....g.'st,..l. a.ul the folli.'le-s an> nroiiiine.it. , , ., Treatment' Th.' .'V.'s sho..l.l be bathe.l three ..r fo.,r t...>..s .la.ly with a .i p.'r .'.'..t. si.hitio.. of borie aei.l, a...l a sohit..... of me.rur..- ehl.iri.le lum to \:Mm. sh....l.l be .In.j.pe.l ...t.. the .......iimet.val s,. afte'r .'aeh batl.h.g. Aris.ol, i...lof..r..., bWn...tl.. a..d .■alo...el. ,.„ual parts, or eal.....el al.....' ...ay b.' en.ploye.l. In i.e.-s.stent eas..> X ,.ssio.. ,.f th.' eont,'..ts of th.. follieh's ...av be resort...! t..^ Km- -s of'n.f.-aeti..n sl,..ul.l be e..rr...'t.'.l. T.. I'r<-ve..t spn.a.l...g -.f t |e d.s- ,.as.., isolation sh..ul.l b.' res..rt...l t... esp-eially when .t oeeurs m '"xiachoma (Granular Conjunctivitis; Egyptian Ophthalmia; Mili- tary Ophthalmiat. This .lis..ase is el.araet<.nze,l by the presence <.f DISEASES OF COSJUNCTIVA, CORSEA, ASD SCLERA. 263 ,n„nrr..us small oval n.assrs in tho paliK-hral .•..njun.-tiva by n -U V ami l.v fjrav,- suhs,.MUont c-hauges in the cnjunctjva 1 .1. , ten n th.- RlolM.. It oc-curs most fr<-.,uently m ';l»l'l"'»- ^'^ ;;;;'. aff'.I-t in.liviauals at any ag. .'X.rpt ,..Tha,.s .lunng the hr^t •■'De^rii^n. Tradu.n.a .nay Ik- eonveniently .livi.le.l into three '' nr;i, the stage of Im^erirophy, «. whieh the P"-^""!;;; T 'l' -^S .„ 1 the -irc'i <.f the conjunctiva is as great or greater than m the ;;;:;.',;';. -;:, eieatrh-ial tiiue having fonne,l. This stag.- present. *';:; The'S"iui-"-e;up without .!iscon.fort to the patierU, veij lit le mm-.fus.HT.tion Ix'.ng pr..s.M.t-n.,t sutticu-nt to «-al the . Is • ^- tiw>ro i« •! ^lidit excess .)f acrvmati.Mi, and the U.ls '.;;,;:'.;:;'"i'SX u,x;:,i;'S"i. „„ r,Hi,„» ot ,>,. ,«-.,,» c™,. Sh- .-a Iv ^irt ..f this st.ge th.- c.rner. n.ay give .-vulence of thev l)econi.- visible only aftor the «w.>lling of the conjunctiva lias sub- sided. The pn-auricular glands an- en- iarg.-.l. Wh.-n .u-curring in residential schools, asylums, reformatories, an. n> famili.'s, the disease spn-ads rapidly, and, unl.'ss isolati.m is jmictised, many of the imnat.-s become aff.-cted. U-) This phase is f.)rtunat.-ly rare: it is the most stnere, usually aff.-ctmg vmnig and inid.ll.Mige.l adults. The onset is rapid. Hurnuig and scratch- ing of th.' lids are .-omplani.-.l of. Th.- lids b(-.-)me mo.ler: t(-ly s\v.)llen. Tlu-re is lacrvmation. and in a .lay ... ■ . ■ „„.>».i,t a ptinolent discharge. Hyp.rtro,^,y of the -"^V""^ ^ . ' .^-1 aft.r a few .lavs: at theen.L.f ten .lays or tw.. we.-ks ' ■•'. "^^^^^^^ is gn-atlv thick.-ned, the en, ire f.,rnix pres.-ntn>g a p - , u" > 'f tissue. Th.- ocular conjunctiva b...-.>n,es .U-ep v '"l^';; V " ^\;;,,j;4 unusual to observe evi.lence of corneal irntatu.n earl> m the course Fio. 132. ConJ>.nr.iv»of upper li.llu chronic Kn.ii- ul«r conjanctlTllii. (Arlt.i or two a nuiwpurul.-nt and 264 THE EYE. of tlio (lisoaso. The preauridilar lyinp*> glands are pwoIIpii, and in some cases the siibniaxillary glands are similarly affected. The first stage of trachotiia may last six weeks to a year: it grad- ually ijasses into the scmnd stmje, which may be termed the "toge «/ coalescrncc or bef/inniw/ itj cicotrizntum. This stage is common to the thre«> phases of onset, appearing later in the first phase than in cither of the others. The granules, which before were di.screte in the first Iwo pha.ses(,f onset, coalesce, and cicatricial tissue apjx-ars in the form of narrow bands throughout jMirtions of the paliM>bral conjunctiva. The area of the conjunctival surface diminishes, and the cul-de-sacs decrea.se in depth: with this change the tarsus tvcomes narrower and shorter and abnormally acutely curved. The rough surface of the lids rubs again.st the cornea and destroys its ejiithelium. \'ascular pannus forms, suix'-'ticial ulcerations of the cornea follow, and if {)athogenic gcruis fii'il entrance to the corneal tissue, dw]) ulcers, with more or less deatru -tion of 'he coniea, ensue. The margins of the lids l)ecome inveited fentro|)ion), and the la.shes rub again.st the cornea. The palp«'bral fissure is narrowed. Trachomatous tis,sue may appear on the ocular conjunctiva, the caruncle, or even on the cornea. Years may elaps(> befon- the second stage piv.'^ses into the third statje, which is known as the dwic of atrophy or cicatrization. The cornea now presents an opacjue ap|)earance. The conjunctiva is nmch reduced in area, and presents none of the appe.irances of the normal nnicous men\brane: the .surfaces are dry. except i)erhai)s fo-- the presence of a few islets of approximately norma! tissue. Vision is reduced to i)erception of light: the con- junctival surface as well .is the cornea is dry (xerosis cicatricialis) and pale in color. Trachoma -leed iiol neces-sarily pa.s.s through all of these stages, but may Ih" arrested, with the preservation of what normal tissue remains at any i)art of the first or second stage. The dis«>ase ceases spon- taneously in rare ca.ses, l>iit too fre(iuently p-rsists throughout the life of the patient if tr<-atment is not resorted to. Causes. While trachoma is not confined to the poor, it is much more freiiuently met with aii'ongthem, filth, overcrowding, vitiated .atinos- phere, and improiM-r aii('. insufficient food contributing to its produc- tion. It is pos-'ible that a cnntagium mu.st \w added to produce the .lisease. .Many researches have In-en undertaken to discover tiie siH'citic cause, and a micro-organism has IxM'n isolated which In'ars a close relation to the disease: this micro-organism, which is a small double coccus, has Imvu des(Tii)ed by Sattler and Michel. Mutler- milch has .Irscnlx'd a funsrus which he terms Microsporosa tr.ichoma- toruni. I'feifer and Hidley have described i)arasitic protozoa. .Mthxugh it is iM'lieved to Ih' a microphj'tic disea.se, sufhcient evi<lence is not yet at hand to establish the identity oi any known germ as the sjM'cific cause. It cannot be demonstrateil that any condition of the system pre- dis|>oses to traciioma. It is found in the robust a.* well a.s in the < a. 'Hi 5 it) i DISEASES OF COSJUSCTIVA, CORSEA, AXD SCLERA. 26.) ,,„„rlv nourisluMl. Lymphatic in.livi.luals do not appear to c.n- i-ict "the (liscasc more mulily than others. pltlology. The trachon.a folliele, wlm-h is suhstant.ally a nnn.a- ,un lvn.,!h Klan.l, is the essontit.l elen.ent; these folhelc-s consist of a ■ icate in.ietinite connective-tissue capsule cmtainniR a n.ass of V m oi. c«.lls. this collection of cells In-ing traverse, by very hne ne vcMissue tralK-cuhe. (Plate V.) ^>-' V'^tr t [l^!!;: i' „• co.ni.-ctivc-tissue stroma that surrounds the f., hcle an.lcap 1- "ri ' an nud in the mas« ..f cells that form the foUu-le. As the i^-as. passes into the second stage, the septa between mdn.dual f Hides lisappear an.l the lymphoid nuisses beco.ne <'.«'"t>m>""N / """ 1 , aqu,>s of various sizes, and the substantia propria o the c.njm.c- ,i\'a pnlduallv gives place to cicatricial tissue. The epithelium cover- imr the irraiuiles varies in thickness and IS irregular. , , u '"ioli Trachoma in its first stage may »- -^^fl^'^j^;;'^^ venvd c-itarrh tulwrculos s of the conjunctiva, and I arinaud s (Usease. VI "h i r "the case will suffice to distinguish it from the first, or if 1. hi^Jorv is not .suffici..nt, microscopical examination of a nodule i ufl ( n vernal catarrh the nodule is a fibroma. The m.cro- scniclal examination with the history of the ca^ will suffice t.. . ^- tiiS t fn.in tuberculosis, and in Parinaud's .hsease the excessive S e un^ cer^•ical an.l preauricular glandsw.th the aiTect.on ...nfincl to one side (as it usually occurs) wi \w sufficient. iro-^osis This is favorable when the .hsease is seen m the first or^nrh mrt of the secon.l stage. When the cornea has become lohl;i.'furlher da nage may be obviate.l: but the tissues .lestroye.l ••='i;;ati:r tSs is prophylactic medicinal, and -^^;^J- n-r k it; .'.ia ion ^vith indivi.lual tow<>ls sh.mld Ije .-nforced. M •m.-iNU ■ The evesshoul.l be thoroughly cleansed as often as s n..e . ■ V to keep then, free from .iischarge. by bathing with a solu- • ; n,!:;' liid or mercuric chloride (1 ^^^^L^^'^ „„.rc„ri,. chloride (I : o(KX. to 1 . :«KX ) formalin (1 . • KM) cl lor. e w.,.er ( ->() ner cent V. S. P.). or chlor.de of zinc (gr. J to .^O n.a\ iie ::;;;;;-;;;,';;;':!yMhn>e or fourtimes daily: thec^nju.^^ nnv he MM-n-e.! ,nce dailv with tannic acid and ghee in (gr \\x V o ^i ' IV -oglvceride CM) to .50 iK-r cent.) may b.- applied to V:J... onh.tniunctiva, and is of value in the bU. s age.w^ien tl«Te i- more or less xerosis. Io<lide of l)eiizosinal, i ptr unt. (. <a , k V I o ser^•iee. Je<,uirity bean in infusion and m powde lr:;I;;,iu;ed to "Idt^a counteUnHammation to cause absorption ..t '':;S'1;,//.,..... TI. ren.edy that finds ^^\;^^^^^'^ tra.'homa where t!ie discharge is not profuse is tlie crystal 2()<i THE EYE. "■"■'7 tsK;;'i.'^,s:a' ^JSSirttZ^f;'^ smooth irystal over vv amio ' \ ., | ,i„, ^n-k of luiti- FIO. 133. Knapp'i exprei«ion forcep*. i, „„on„,...,l \"l'f '-^^r^rjii XS ..y 1.^ cnp'oyoa/ Fig. w, cocL ;» y iJ -'■ T"" li'i' -■ '""^ """"'■ *'■ ""'""■ Fi«. i;M Wocks' scarlfiCRlnr. r • n,. ......nfiod -10(1 the shallow incisions (lirocto.l parallel suiio.hc.ally !*^"''7 • •'" "If,,,. f„,,,, „f o„„j..nctiva arc s<..z,m1 •^'•u^l"irS,S^ IK.^^ aSl or ;.onnal .ali,.o ;oh,tion. an.l In , 1 rtoM .np^^^^^^^ witho.,t ba,ulasi..K, or a l.a.ulapc ..my nli I o t Xfour Ixmrs; th.- intnuluclio.. ..f n,. o.nt- VISEAHES OF COyJUyCTIVA. COBSEA, ASD SCLERA. 267 ,l„.«o iulhcsions aro attacko.l. In ras^-s whore the pallH.l.ral ti«.ure Is nTrrmve-l a.ul the c.nH.a is sufforiuR fn.n, u.ulu,> prrssur. fr...n the li.U (•anth()J)lastv inav lie resorted ti). . Pariiaud'8 conjunrtivitis is a ...ueopurulent affectum of the ..onSva rharacterize.1 by the f<.nnation of rather larpe pranuies ' va ..ns on the eonjunctiva. whieh^.net.n.es "H" ,"■• u-ulat.. (Jiffonl) The condition is aceon.pame.l by ,.ron..uneed suelhng of ihr,,reaurieular. retrou.axillary, an.l cer^■ical glands, wh.ch son.e- ^' '^"1;!;"!;' l'annau.l-s .Usease, s., far as the eye is eoncenved is JX like that of acute trachoma. Lacrynuit.on .s fo ll.Aved ,n fort. - ^ito seventy-two hours by a n.ucopurulent --;•'"; -*--^'^ iii of the li.ls which in si-vere cases is pn.nounce.l. On evcrtinp £• nner i. on the third or fourth day, elevatmns are observed S^id'T^i-n 1 lo the granules in acute trachoma: these nodules gen- nllvl^^ ».L.n.ewhat l.xrger than in trachoma, and soon superficud uJers aro obscTved in the sulci between the small ""'l"'^^- 7"; i s'eem to In-ar some relation to the degree of mvolvement of he r lur cu • r an.l cer^•ical glan.ls: when the ulcen> are numerous the KnT-i ' no" severelv affecte,!. Ulceration of the cornea wh.ch f; u occ si d is also more apt to occur when the con- ;;;;ct!"l ui:^;';a;i..n'is nK>st .narked. Chills and fever accon.pany ""ca^'^'The .lisease is supposed to Ik- ,lue to an infection of animal ori'trit at tcks in.lividuall of all agc^s. is "u.nolateral . »md dr.s no ; .; to U> contagious. No specific nucrc-organism has l>een <Ils- ^llliidlalthoigh ihe nature of th^e disease ,K.ints strongly to a spec.hc ''Station. The .lisease nmy temnnate in three weeks or it .nay • H-S^t for six or eight months. Relapses are very apt to occur, but sarv. Fre.,uent clix..si..g with a sdut.on ^'':;^^Xt^^\ sufficient. A solutio., of mercuric chloride (1: .«KM) n a> 1h> in. tuu , v"rv four hours or calomel mav 1«> dusted onto th<- lids Gout of Sie Ooniunctiva. An intense .edematous swel uig .-f the .M^-^" 71. SSaiKl of the eyeball,, accupanie.! by pr.^use nSation, with little mucus, and ,>ccasion.ng grea ^^^^^^ ,,„ient, is sometimes met with m in. ivi. uals « »^ ,;"^" Vf,' " 1 Tl,w form .if oiiiunctival irritation cl.)sely n'sembles the nianiie. la ^ ;';^.u asa;::.S-e.l in thesw..lling of the great t-^^the .e.Ujnu, f lu. ankles .an.l .,ther .listal articulatu.ns ^PP^''; J' c le^ reaching its height in twenty-four to f'>'^y-''!S'^\ .*^?"^;; ,X h • T.n - i„ five to ten .lays. Thenu-sis may Ih' marke.l. is "J^j" '';; "!^^ na.ue.l bv gout: manifestations in ..ther parts ..f the sjstnn. ami tli.> occasional manifestation of a gtuity crisis. Treatment. Locallv. cleansing "♦ the conjunct val ^J^^^}^^^ "J four times daily with a solution of boric aci.l an.l the application of """wgjf -'Tr!tiriwr 'Biai . .i rr-sg t H Htet ji 1 ' ji h !i , v rwi^ ' 2(M niE KYE. u Hiii .....l loa.l-.M.l-o,mnn wash .■..n.,>n.ss.-s t., tlu- W^^, Intornally, troat- Horner. It i> ( liar.uu n« i • • ,, ,.„i.,r c.iiiunctiva, whi<-h fnnn on tlu- i-alin-hral an.l "«■"<:" ]^^^^^ ^ Ho.,r sliphtly pal,.r than th. surroun^mp nn.jjmHn j th m ^^^^^ Langinp to its hor.l.-rs: tho .l.-nu.l.Ml -"^f'"" ";: ^ '^', i,,, .u-nu-lo.! fornuMl .'pitliHiirn. an.l tho ,.roc.>ss is sho t > . t < • ' .urfaros !..•<•..,»• aRplutinat.-.l t^"I'i;:»^'"«.;','\t o.uh an.l pal- .:onn.ri..ian....u..Uof~>;^;^^ .....nphiRUs foliacc.is, an.l .Iq.omls on a (hscr.isia ..I attacks in.livi.luals at all ap-s Treatment. Tn'atnu«nt is of httle value. Forms of Coniunctivitis in which the Etiological Factor has been Determined. ,, „ ,™,ll l.»"ll-J<';'» ' - , J,^ ■;;; K..,.|, i„ IN«. a,„l ,r,.v,.,l his (Flat.' \ 1., I'ljr- II- n^^^' '": '" , .. ,x-.:..i... ;., \-,.v,.i..h<T. ISSH. to he th.' SusceptibUity. AH .'onjnnC this niicro-orsanisni. ""»"""tL, For thirtv-ix to fortv-oipht lumrs a l,„rning s-M.^.t.-m n. tho h.K .•'.;['•,,,,.,,, an.l th." iJ.'n.'ral Towar.l..v..nin,th..nu.e..,n.rul< t - « ';^'<; ^ „„. ,,,,,,,„ ,.as .hscmfort is n.on- n.ark.-.l. B> th >"""''' . ,5.,,,^ „f „„. ihsl^^o is t^sually roaoho.l ..n th.- ;'''••; ^ j^jt-' -on. >i."ai;v sfi.'.> lasts fniin throo t.. s.>von .lays, an. ina> d. a . "•- i:;:;r;;^;™;:iL,s';;'i:;'rr,;;™;i; fr-"^' „.enh. ,nior.,-..rganisn» by ^^.-ks in N..v.>.nU-r >M, ' \11 .-onjunctiva' aro suscoptihl.' t. th.' nitlu. n. - ' Olio **•■"'■ "' '*■" ''•'*•■•■"''■ ''<'*'^ '■ •"■'"'"" attack of tho .lisoaso .I.h-: alter ti ■ uicoption tho i'\<' is .•XI li.l^ FLATK V Ki l)-W<oUs Bncillu>. M. .1 ,,x-Ax.-lU.-l>l tJii'l>''''" '""" In h 1 DISEASES OF COSJISCTIVA, COHXKA, AS1> SCl.riiA. •JtSH tw-' Tlic f..i.irrr'ti..i. of tl..- .M-uhir (•onjunctiva in tin- acut.- Mat;.- Jivrs t .. ..v.. avivi.! r...l i.,.|H-aran.--. wl.irl. has .-aus...! tins f..nn ..f .f.tf.' slll.si.lcs. the s..<Trti..|. l,cc.mu-s Irss copuuis l.ut tluk.r. A |,;iht-vrllow mass of s,.m.tio„ is ,,r..s<.nt at ihr mn.T .■antl.us n. t ..• inurni..'^, a si^Mi ti.at is almost |.atlu.(ji,oni..n.r „f ll..- disoas.-. \M h ! !."•.■ of tlH. s,..T..tiu„ ana of tl... sw.llmK of tlH> h-is an.l .-on- ; , iva. II... ,.ainful svn,,.ton,s .iisap,H-ar: howv-r a M-ns^.twrn of ;;;.';„'!;; ;,f ,1..' .•onju..Hiva ,....-sists for w...-ks, ,,art.rularly notin-abl.. ,,„"vis<-of ll.ci'Vi's withartiti.'ial lijllit. Duration. If'si.n,-!.- .•Iranli.u'ss is ol-s.-fv..,!, tlu- .l.s<.asj. nsuall> ,,."" ..ours,, in two or ti.r..,. w.vks. all of tlu- syn>,.ton,s , .sa,.,..-a - Z It n.av last for six months if no tr.'at.nrnt is n.stitut...l. \ rxl.T snital.ic treatment the averape .luration is e.pht f; twelve .lays Con1»gio«. QuaUtie.. Mueopun.lent eonjunet.v.t.s ,s extremely nSS. Z .vsulential sehools. asylmns l.arraeks, penal u.st.tu- ' o n nunities. an.l fan.ilies. it fre.pu>ntly lH.,-.Mn..s epul..m.r ,av lM-on,e en.lemie. ('onmmnirat.on fr.m. one in.ln.. lal to ..theris prol.al.lv. hv means of towels. romn...n l.athn.K wat.r.etc. , el as V .lin-et' e..ntact. There is littl.- .l<.ul.t that the e..ntaK.o us ;.lemen; nluy L rarri.-l by .Irauphts of air an.l by the water .n pubhe '"'liiimoBiB In a tvpieal rase the .liapnosis is comparatively oa.sy. U^^T'iJ^ the ■i.n.lition ,nay be .nistaken for p.norrh.ea eon- „;3 s or even for dii.htheria in eases wh.-re a pseu-lona-mbrane ;;;,;:;,'^. Th, ;nicr,.scope is necessary to clear up the .hap.os.s m "'SnSa^ons. Phlyctenula-, ,«*eudome,nbrane, corneal v.lcer ''Stis^rX-l^^ianH^. oonsi.s in strict quarantine ""iLiii;^^ (3';;;;i;:Sr;ie ii..s ..r one .... at a tim.. tlmrf"!es .lailv .lu inp the acute stage. Fre.,u.-nt cleansmg w h ^e "hc d!i soluti. ' (3 ,..r cnt. ) shoul.l 1.- "-y-, ^;'- ,„^ j^ -p^SocS''isSc;i^sr^Acuto c.^ ,,, ,. the pres..nce "f th.- p..e.u;..occus r^ ^r^x a j^ ;;irr siinn.^.?';!::^ ::i r...;,- n ^^^^-^-;,:-z ConUgious Qualities. Pneun^ococcus '"''J^'L'- ' ' '^ ""^;'*;,' J^j , • •m.l adults an.l it mav become epi.lemic. It has l)een pr^^f"' ''> I.on.m;.;wrthe conjunctiva mu.t exist before the disease m.,uest,on MICROCOPY RESOIUTION TEST CHART iANSI and ISO TEST CHART No 2! 1.0 I.I i-IM f~ 136 1.25 IIIIII.4 m 2.2 ZO iJ= 1.6 ^ APPLIED IIVHGE Inc ^^ '^^i tJil M'lr :,lre** "^= i"e) *8^ C300 - Phorv 270 THE EYE. can hf produced. It is well known that tho Wcichsolhauni pnonnio- eoccus may exist in the normal conjunctival sac witlu ut protlucinp; intlammation. . . . . , Diagnosis. It is difficult to differentiate it from conjunctivitis due to the small bacillus. The microscope will serve to establish the diagnosis. Duration. Tiuie, three days to two wwks. Prognosis, (iood in all cases. Subacute Conjunctivitis (Diplobacillus Conjunctivitis^. This form of conjunctivitis is insidious in its onset, iiroducing redness and slight thickening of tht! conjunctiva, largely conhned to the con- junctiva of the lids and fcniices. There are slight increase in lacry- mation, a scantv secretion of mucus, with some i)us corjRisdes, irri- tation as of a fo'reign hodv in the eye, and burning sensations on use of the eves. The annoyance is relatively slight, but jiersistent. The eyelids liiav become somewhat congested, but they are not apjm-ciably thickened." In rare cases the cornea becomes involved, a superficial nnrginal keratitis being produced, followed by cloudiness of the affected area. This may advance and narrow the transparent area of the cornea to verv small limits. Cause. Morax, and later .\xenfeld, have described a bacillus as the cause of this disease, and their studies have been confirmed by (Jifford and others. Tne bacillus measures 2 to S ,« in length, and I to 1.5,« in brei;dth. (Plate VI., Fig. 2.) Duration. The disease may last for six weeks or as many months. ConUgiousness. \erv slight. Treatment. The eve should be clean.^^ed with a boric acid solution, and zinc chloride (gr. j to .^j) shouhl be instilled twice or three time-; a day. ... » ^ m Gonorrhoea! Conjunctivitis (Purulent Conjunctivitis; Acute Blen- norrhOBal. This disease is d(>scribed under two titles, namely, goiiorrlueal ophthalmia and ojjhthalmia neonatorum, the latter tenii l)eing ai)plied to the disease as it occurs in infants less than one year of age. Cause. This affection is due to the iiresence iii the conjunctival sac of the goiiococcus of Xeisser, descril)ed by him in 1S7!). (Plate VII.) The contagium is most fre.|uently conve.ved by the finger from an Mctive gonorilKcal urethritis or from a gleet ; towels, washing utensils, -oiled linen, etc., may be the means of carrying it. In all proba- bility the micro-orgaiiism is not carried by currents of air This micro-organism attacks all human conjunctiva' with which il comes in contact, regardless of the condition of the individual. Description of the Disease, Acute Stage. A ])erii)<l of twelve to thirty- six hours is reciiiired after the entrance of the contagium to j.roduce marked disturbances, then the lacrymation is increased, the conjunc- tiva soon becomes injected, and swelling rajiidly advances. Twenty- four hnnr^ inter the liils have become much swollen, the conjunc- tiva thickr'iied and deeply injected, and the secretion mucopurulent. PLATE VII Gonococcus. DISEASES OF COyJUyCTIVA, CORXEA, AND SCLERA. 271 MUiiPtiiiics sanguiiiolont an<l mixed with the lacrymal fluid. Buni- inp and jrrittv sensations are ex])erienred ; dull jjain in the eye is occasioned i)v pressure of the lids. In two or three (hiys the heifilU of the acute stape is reached. The swelling of the lids now is (jften enormous. The eyelids cannot be ojiened by the jiatient, and are oitened with difficulty by the surgeon. The ])alpebral conjunctiva is much thickened and velvety, due to a cellular infiltration : the ocular conjunctiva is swollen and often glistc-ning: small ecchyinotic spots are sonietunes present: chemo.sis is marked. The secretion, which is yellow, not verv thick, and almost entirely free from nuicin, flows from beneath the upper lid onto the dieek, matting the "ilia. The acute stage continues five to eight days, when it gradually pass(>s into the subacute stage. The tense sv.elling of the lids subsides and the venous stasis is relieved. The .secretion, which is copious, is creamy, the conjunctiva is thickened and thrown into folds and nodules, and the cheniosis is less marked. With diminution in the weight and tension of the lids the pain becomes less severe. This stage may last two or three weeks, and recovery then be established; or the disease may i)ass into a chronic stage, which may continue for weeks or even months. Severity. The description just given applies to the ordinary cases met with. Cases occur in which the affection is exceedingly light, the discharge scantv and not free from nuicus. Some ca.«es aie ex- tremely severe, and the swelling of the lids and conjunctiva great. The c(injunctiva is pale in hue, from the jjressure of the infiltration. I'seudoinembranes form on the surface of the palpebral conjunctiva, nften closely resembling diphtheria. The severe ca.ses occur most fre<|ucntlv in adults. Complications. The cornea is involved in about .33 per cent, ot the cases occurring in adults: the ultimate imi;airment of vision varies much ; complete destruction of vision may occur. I'lcer of the cornea .Iocs not occur ordinarily until the second week of the disease, (jonor- rlKcal iritis ami iridochoroiditis may complicate the attack, (ionor- ihoal rheumatism mav also result. This complin tion occurs only in the late stage of the disea.se. I'seudomembrane forms on the paliM-bial conjunctiva in perhaps 20 i)cr cent, of the cases that occur in adults. i i vu Diagnosis. Light forms of the disease may be confounded with acute contagious conjunctivitis: severe cases may be mistaken for diiihthciia. Microscoi)ical ex.'Uiiination of the secretion will serve to make the diagnosis clear ii- the -rr; atcr number of cases. In cases that have been under treat M.eiit for some time .and in the very mild cases it is difficult to tiud the gonococcus, but patient search is usuallv rewanlcd. Prophylaxis. One who has goiiorrluval urethritis .should be cau- tioned regarding the danger of infecting the conjunctiva. Alter a -..norili.eal conjunctivitis is established in one eye, care should be ■liM'rved not to convey the contagion to the other eye. In adult.- 272 TlIK EYE. it i« wiso to protect tho eve citlior by a carefully ai)i>lKMl aseijtic haii.laiie sealed at the nasal half with collodion, or, better, a Hiiller .hield inav be eiiiploved. This consists of a watch-plass which is .ecure.l over the ev."- i>v means of rubber adh<"siv.' plaster AH .h-essings that come from the eve should be destroyed, and the iin-itest care should be observed in the .lisinfection of api)liaiices used The nurse and others in attendance shouM Ix' nistructed re- frarding thr danger and the precautions necessary. The hands shoul' b(> washed 'ter touching the eye. Treatment. In cases that are seen in twenty-four or tliirty-six hours after the eve has b(-en infected, it is i)ossible to abort the disease, i„ a number of cases at least. This is done by thoroufihly cleansm- the eve freeing it from all secretion, thoroughly ai)plyin>I a s<.lutiou .,f nitrate ..f silver (1 to 1 per cent.) to the entire surlace of the conjunctiva twice in twentv-four hours, and makmg cold ai)plications to he lids, .\fter three applications the silver may be stopped. The use of boric aci.l for cleansing the conjunctiva should be mn- tinued for a f(>w davs, as shoul.l also the cold applications 1 he greater number of cases have i)r()gressed too far when seen l,y the surgeon to ix'rmit of abortive treatment. Careful vigorous treat- ment should be commenced at once. If the lids are much swollen, cold applications should Ix- made constantly. If the h.ls are not creatlv swollen, the applications may be made for three hours at a time an int(>rval of one hour permitted, and the cold applications resumeil This should be continued until the acute stage has i)asse(l. and the f-ciuencv and length of time gradually dmnmshed. Mkthod of M.vKixr. ("old Ai'I'I.u-.vtions. Pledgets of Imen one and uno-half bv two inches s.,uare, of thr(H> or four thicknesses, or s<iuares of t)atent"lint or absorbent cotton, shouhl be prepared, and, alter being moistiMied, jilaced on a cake of ice to the number of a dozen <)r ,„„re ( \ thin piece of linen mav l>e spread on the ice and the i)ads laid <'.n tile lin<>n.) The pledgets should be change.l from, ice to eye cverv one to two minutes, or sufficiently often to ke(>p cool the pledget that" rests on the eve. To carry out this treatment re.iuires the constant atten.lance" of two nurses-one for .lay and one for mgh ,h,tv It mav hapi)en that the eye is kept too cold and tiie cornea tissue lo.ses its vitalitv. This calamity may easily l)e avoided bv inspecting the coriiea from time to time. In such ca.ses the ,.;.rnea becomes uniformlv hazy, taking on the ai.p<-arance of grouiu trMss If the cornea shows the effect of cold, the applications should be made for a few liours at a time, and the intervals lengthened. Heat is not desirable until the gonococci have disappeared: m the later stage of the disease it may be of service. The eve shoul.l be k.>i.t as cU-an as possible by fre-iuent "it "'f.^^J*' ;, solution of boric acid Ci per cent.), nr mercuric .hloride, 1 : .).(MX) In ..leaning liie eve. the lids shc.uld be separate.} very g.-ntly an. the solution b.' p.>rimtted to enter th.^ eye by .Inppmg ironi a pl.dg.v of cotton, bv pouring from an undine, or by a gentle stream fr.nn DISEASES OF COSJIWCTIVA, COHXEA, AND SCLERA. 273 a i)i|)('tt('. For washiiip the oyc, boric acid, trikrosol, potassium jx-r- niaiifiaiiate, mercuric chloride or cyaiiitle, formaldehyile 1 : 1(),()(K) to 1 : ")()(K), or hydrogen dioxide (one-third, l'. S. P.) may 1)«> eini)loyed. Tiie ])eroxide of iiydropen m:iy he employed four or five times daily for this purpose, rotassium [KTmanpanate, 1 : 2000, to irrigate the coiijiiiictiva, is efficient. It has heen found advantageous to stutT the conjunctival .sac with boric acid ointment (5 (kt cent, of l)oric aci<l vaseline. Wilson) each time after bathing the eye. Applications of a solution of nitrate of silver 10.5 to 2 per cent.) mw Im' made once in twenty-four hours. Solutions stronger than five or ten grains to the ounce are .seldom necessarv. I'rotai-gol, 20 to 40 per cent., may be api)lied to the conjunctiva once or twice daily. The continued use of this drug ])roduces a thickening of the conjunctiva that is recovered from but slowly. It may be employed with advantage for a few days during and innne- (liateiv following the vt'ry acut" stage. When ulcer of the cornea is threatened, borated vaseline should be aiiplieil at least every two hours to the corneal surface after thor- ough cleansing of the "cornea and conjunctiva. To the va.seline, atmphie may be added in the proportion of one grain to the oimce, or atrophie ni solution. 1 per cent., may l)e instilled twice daily. If perforation is innninent. i)aracentesis may be (hme through the floor of the ulcer. If there is no evidence of congestion or inflammation of the iris, and the ulcer progres.ses, eserine (0.5 per cent.) may be in>lilled twice (hiily. The leucomata and staphylomata and the shiimkeu globes that follow in some cases should be treated as thought most expedient. Dkim.ktion. If the lids are greatly swollen and the cornea likely to suffer from iiressure, a fre(> caiithotomy may be ix-rformed, which af- fords depletion as well as rel<-ase of tension. Critchetfs oi)eration, which consists in splitting the upjx'r lid vertically through its entire thickness and stitching the fla])s to the iin.w, restoring the lid by a plasiic operation after the disease has subsided, may l)e resorted to. Scarilication of the chemotic tissue may be done in .some cases. ('i)\snTiTi()\Ai.. The general condition of the i)atient should be studied, and .■<uch measures as are re(|uin'd to maintain the normal vital processes in full vigor should be instituted. Ophthalmia Neonatorum. Liberally construed, this term may be made to include the purulent or mucoi)urulent inflammations ol the conjiinctivM that occur during the first year after birth. Ordinarily the'term is api)lied to those forms of conjunctivitis that ajij-ear before the end of tiie first month after birth. Cause. .Ml who hav ■ made careful bacteriological examinations of the secretion in cases of oi)hthalmia neonatorum -re convinced that the cases that occur before the end of the third day after birth are due :ilmost without excejition to the presence of the gonococcus. Cases that occur later may be due to the gonococcus, but not a few- is THE EYE. ..rr ,luo to tlu- Koch-Weeks haciHus.tlK- l.tieinnococous. the Klehs- Ln..iHcr Imcillus, or some other form of i-iith.-penic pern, or irritating '"Metiolof Infection. We are m^ .< luen.e.l witli the .-lass ..f eases that ..ceur h. the first few .lays after birth, an.l nee.l not n.ent.on the ,a.„les of infeeti.... that pro.kiee .'onjunetivitis later than this ,K>no.l. In almost all of the eases infeetion undouhte.lly oeeurs .hirinp th( passage of the ehil.l along the genital tract of the mother a.ul J.ist at h.' thiie of (leliverv, due to the entrance of th.> vaginal secretion i„t„ the conjunctival sacs. In rare cases infection takes place ante- r ,1. the disease being well a.lvancd at birth. In some cases is u iio of e cornea has already taken place. Infection !.>• the uri's han.' loan wa.shes, and soiled linen may occur after Inrth. Descriptic the Disease. A slight re.ln...ss of the conjunctiva is usually ob.s..n-e.l on the second day, an.l .m the thinl morimig the li,ls are glued together by a small .|uant,ty ot mucopus. The 1 ds iK^gin to swell, and soon the upper lids lK>come •'"">•""•»'* y^''''^: ened, .luskv re.l. and very tense. They overlap lie lo^-- '< . a in the earlVpart of the acut.- stage sen.nuic<.pus tinge. 1.. ten xu 11,. pignu-nt ..ozes from the palpebral fissure. Tlu- height ..f the acute stage is reache.l on the thinl ..r fourth .lay atfr the cminence- ne of ?he .lisease. Soon the character ..f the .lischarge changes t., a creamv pus, large quantities of which escap: the co.ijunctna be,'..nies gfeatlv thickene.1, the palpebral portu.n suffering n... e tlrui the ocular. The acute stage gra.lually pa.sses into a subacute con.lition, in wliich the swelling of the lids subsi.les: the conjunctn-a although rough, becomes pale an.l at..n.c, the .lischarge a ittle less creamy an.l less in c,uantity. This condition may continue^ fnr weeks '"^aiverity! The above is a description of a ease of mediur seventy. Ca.ses of much greater severity are occasionally observe- "t is more rapid, the secretion serosangumolent at hrsf .. ^ -i- brane forms on the palpebral conjunctiva, and the diseu. -oles .liphtheria of the conjunctiva. A numlier of cases are . ..reuieU mihl: the onset verv slow, an.l recovery rapid. Diagnosis. The age of the patient determines the term to be applied to the disease; but it is not always easy to determine the variety of inflammation without a microscopical examination of the secretion. Thi- will serve to relegate each ease to its projier category. CompUcations. Corneal ulcer, .lestniction of the cornea, pan- ophthalmitis, iritis, and gonorrheal rheumatism may complicate "Ctil^^'lfKaXen fully demonstrate.! that efficient meas- ures taken to prevent the .levelopment of ophthalmia neonatorum serve to reduce the percentage from between 9 and 10 F'" cent, to 5 per cent, or less. , , ?j u ■ Just before and during labor the genitals of the inother should bi- rendered as aseptic as possible by the use of suitable douches and of n- ,te ini to bi- nd PLATE VIII, I Hi 1 Diphihot la Baiilliis '«*:s v^ ^ <; V •Si - --^ « Dipluhi rjn Bncilliis. 'I IK I i ii PLA'l K IX Sliiphvlc" i>i<i.l> Pvo()>'iifs Auicl-l'- Si ri'|>ti >i< n<Hi-- Pyoqciu'S. DISEASES OF royjrscriy.i, initsEA. i v/' sci i:i:\ wiislics. Wry shortly iiftcr tlw hirtli "f frcrd from sccnMioii tiy wipiiij: willi :lll^■■l ,h«' cbild ilir liils slioilM 1«' ,1 nt cottMii: ilic fvo >lioulil till' ;icut»' -. <-ii. than iKnisly I for two .lild caM's, 1 liru mini ^< '■>•■■•■•■■.■•■ -I •■•'- . ; i llicii lie hathcil wit' i weak solution ot mircuri ciilorKlf, l)oric tu -I. ,,r i.oni.al salhic solution: thr li.ls part.'.!, mi..! mUc .Iroi. -.f a 2 i«t .•.■ut solution of nitrate of silver iiistill.Ml from the en.l oi a class ro.1 If more than one drop enter- the eye, the solution sliouid Ix' neutralized hv washin): with normal sali.i.' solution. It th.; ivae- tion is eonsideral.le, .-old al.l.li<'ati..ns should !«■ made to the hds lor an hour after the applieation. This is th<« method of ('rede mtro- dured l.v him at the Lyi-e in Hospital in I.eipzip in ISSO. Memine ehloiiile! 1 : 2(KH), may h uhstduted for the silver. Treatment, ("old aj.p •uons are most desirable m stap'. Thev should 1 niade more e. Mtimiously ••' in mild ea.se" , but need not in any ease he employed •,-• in adults. In some ea.-es applieations should i "hours at a time, with inter\als of one or tw<. hours. .,ne hour three tim.s daily will sutliee. Irripitioii .m»1i l^.'ie aeid Uiti-n should he .lone fre.|u.ntly. every hall-hour in an onlmary ..:.;,., to keep the eve free from secretion. Fotas^ium permanganate -olution, 1: 2(KH), or m.-irurie chloride. 1: V,m) may he substituted from tune to time for the borie .■id sohuion. As 7"' l';";'."^:^;:; brawn V condition of the lid has , ,itly si.bsi.le.l. applications oi sih . r „i„,,t. 0..^ to 1 l.er .rnt.. should be made once m twenty-four hou s^ . otai-ol, 20 IK.r cut., may be substitut.-d for t^je s.lv,.r: but the .01 p. ilse of protarpol Should be avoided. The a,;plwat ions o The nitnite ot silver ano the b.thiiiK with bone acid solution should be eontinued until the secretion ceases. wi 1, ;„ „nd Ihnt of Pathology. Tli<- pathology of pee.orrhn-al ophthalmia and t at ot oilthalnJ! neonatlmim are very similar. The t.ssiie <^ - j ^ - i, Hltrated by serum, plastic eM '•.tion. and ^"'a l*^'' "- J^^^^Z. tion is undoubtclly excite.l b. .maines prn-lucd « "^ '^I ment of the conococcr- in tli. 'ix'rfi.'ial layer of the ..njuiHtna iS";;i.il;:f'^he conju..ctiva «... nds '-•••-;'-'-^';; -;::;!;;;;?;; ; .,,,,1 a certain decree venous stasis is produced. 1 he "J""", j chronic cases, in which ne.lular masses remain ir the conjunctna ,1 tie p,■l,.illar^• body remains jK-rmaneiitly hypertropu . of conjunct notably the \ the staphvlococcus, which mo.hfy the acillus, often increasing the seventy of ,.ffrct of tlie K!t-bs-L'>effl the disease. (Plate? VIII. and IX.) •i7(i THE EYE. Description. The jxTioil (if iiiciiliatioii is I'rotii twelve t" tliirty-six hours. Intense swellinjr of tlie upper li<l, wliieli lieconies brawny, dusky red. and very tense, develops rajndly. the tinn condition heinjx due to a jjlastie exudation into the tissue of the lids, venous stasis from jircssure imparl inft the eyanotie ap])e:iranee. The seere- tioii from the lids is scant at hrst, heinjt compo.sed of laerynial fluid, serum, and hlood. Very little pus or mucus is seen earlier than the second day after the onset. Craduaily the secretion becomes flaky and mucop\irulent, containing blood and shreds of hbrin, which char- .•icter it assumes in the subacute stage, becoming purulent at the end of this stage. The tense .swelling of the lids lasts from two to five days, after which the lids become flai)by, but remain thickened for oiii' to three weeks. l{estorali to tiie normal condition progresses verv slowly. Pseudomembrane. At the end of twenty-four hours after tlie congestion of the conjunctiva begins the paljiebral conjunctiva is covered with a thin i)seudonieml)raiie, which rapidly increa.ses in thickness and extends to the ocular conjimctiva. The i)seudomein- brane persists until the subacute stage is well est.-iblished. It rarely attains the thickness of more than one millimetre, and when detached it often presents a perfect cast of the fornix. Severity. Diphtheritic conjimctivitis may exist without the intense thickening of th(> lids that has been described, but a i)seudomeinbrane forms and is persistent. The pseudomembrane may be scarcely notice;d)le and the affection extremely mild. Some cases may be termed ■fulminating." >o rapid is the onset, so intense the swelling, and so disastrous the result to the cornea. Pathology. ThedeveloiHuent of the micro-organism in the conjunc- tiva ajipears to cause destruction of the superficial epithelial cells, and so to affect the bloodvessels that a portion of the jilasma of th.e blood escapes into the tissue of the conjunctiva and lids, there coagulating, ;ind producing the tense, firm thickening. The ]ilasma of the blood also escapes onto t!ie conjimctival surl:ice, there coagulatimr and forin- inir the p~eudomenibrane. In mild cases where the lid <loes not become hard coagulation of i>lastic lymph in the tissues of the lids does not occur. While the formation of pseudoniembranr i-^ ii'it pathognomonic of diphtheria, it almost always occurs in iliphth' la of the <Minjunetiva. The greater mnnber of cases known - crou])ous conjunctivitis are in reality diiihtheria: they bear the siuiu^ relati(in to the more severe forms that membranous crou|. does to diphtheria of the nose ;md pharynx. Diagnosis. When di|)htheria of the conjunctiva is associated with diphtheria of the nose or pharynx, the diagnosis is easily made. How- ever, jirimarv diphtheria of the conjunctiva may occur, and the diag- nosis is then not so readily made. The condition may be confounded with ironorrhd'a of lh(> conjunctiva, or even with nmcopurulent con- junctivitis in rare ca.ses. liacteriological examination will serve to establish the diagnosis. DISEASES OF COXfrSCriVA, CUItM:A, AXD .SCLERA. Zi I Treatment. As soon as it is i<no\vii tiiat diphtlioria of tlic coii- jiuictiva exists, tlic i>aticiit should he given a liypoderniic injection of l.")(M) to l'(HK) units of (liplitheria antitoxin, inai<infi the injections either in the loose tissue in the sides of the abdomen or in the loose tissues of the hack. If the pseudoineinlirane does not hogin to soften at the end of twenty-four hours, a second injection of 1500 to 2'M) units of the antitoxin may he fiiven. If the circulation of the lid is not too nuich interfered with tiy the swellinjr, cold applications should he made, as in fjonorrhceal conjunc- tivitis, and as soon as the pseudomemhrane is removed nitrate of silver may he ap|)licd once daily in ihe streiiftth of 0.5 to 1 i«'t| cent. riie eye should he cleansed every hour with a saturated solution ()f hoiic iicid, a weak solution of ))otassium jiermanfranate, salicylic acid, or mercuric chloride. Peroxide of hydrogen is of service in the re- moval of the membrane, if for any reason this is thoiiglit advisable, it does no good to remove the pseudomemhrane forcibly, unless for the purpose of applying remedies directly to the surface of the con- junctiva (even then" it is of doubtful expediency), as the membrane ri'forms, and the traumatism occasioned opens up new avemies for the entrance of the micro-organisms. If sloughing of portions of the conjunctiva occur, the endeavor must be made to prevent adhesions Ix'fween op])osing surfaces. CompUcations. I'lcer of the cornea, total destruction of the cor- nea, i)ani'i)htlialniitis. and sloughing of parts of the conjunctiva and lids are the complications met with. Membranous Conjunctivitis. This is a class of cases in which at the beginning the lids are only slightly swollen and red; there are excessive l.'icrymation and some nuicopumlent .secretion: the con- junctiva is slightlv thickened. On everting the upper lid, a pseudo- membrane is fomid which extends into the fornix. It is usually not very thick. It mav be removed without much force, and on removal discloses a nnicous meml>rane that bleeds only very slightly, but is not deepiv injected, nor does it exhibit the characteristics of active inllammation. The p<eudomembrane promptly reforms after re- moval, and may continue to reform indefinitely, .\lthough commonly affecting both eves, it is sometimes confined to one eye. The indi- vidual sutTers hilt little pain: there is but slight photophobia. In UKxuv of the cases recovery occurs in from three to five weeks, but in somr cases the pseudomeuibrane persists for as many numths m sj.ite of treatment. Cause. In a number of cases the Klebs-Loeffler bacillus is lound. These cases res]ionil readilv to treatment. In a few cases the streji- lococcus is found, and the'affection is associated with dacryocystitis. ( H'ciMring as ;m accompaniment of measles, scarlet fever, and iiiHuenza (dc Schweinitz), the prognosis is not only imfavo-.able as to vision, but unlavorable to life. Membranous conjunclivitis may accompany iiiiiictign ;M(inixi. The sl;ip!iy!orncpus aiid 'he p.neumocnccus have ai>o been found in the secretion in the.se ca.ses. •'7.S TIIK EYE. Diagnosis. Wlioii pscMiiloincinlinmc occurs in tin- conjunctiva, it is not always possible to <|ctiTniinc tlic cause. The hacteriolojtical examination will suffice in a number of cases, ami tiie history of the case will (letermini' others. Treatment. Meinliranous conjunctivitis due to di.seases which have been discus.sed, viz.: diphtheria, gonorrlKea, mucoimrulent conjunc- tivitis, etc., also acconi|)anyinfr the eru])tive fevers, and that due to Imrns and injurv, (lisai)pea s when the local or constitutional disea.'^e is recovi-red from, or when the effect of the b-irn or injury has [tassed awav. Ill some of the indeterminate forms, which are rare, treatniont seems to have littl(> influence. However, cleansing solutions, such as saturated solution of boric acid, salicylic aci.l in saturated aciueous solution, mercuric chloride (1 : (KM) to 1 : lo,(K)0), pota.ssiuni pennan- jianate (1 : "JOtMl). and hydrogen j)eroxide, may be employed to kee]) the conjunctiva free from secretion. Cold ai)plications in the more acute stage may be u.sed intermittently with benefit. Neighboring disease proce.s.ses. as dacryocystitis, abscess of the lids, eczema, etc., should be properly treated, and the general system should be put in a healthy condition, Xerosis epithelialis (xerosia triangularis; xerosis infantilis) is characterized by a lustreless, grayisli-white, foamy, greasy deposit on.tiie conjunctiva, wtii. 1 i< not moistened by the tears and is very persistent. The disease aitacks all individuals except the very old. Cause. .\ six'cific bacillus in this disease was described first by Cohniatti,' and carefully studied by Leber' three years later, and termed by him the diplol)acillus of xerosis. The bacillus is short, and often apjiears in pairs joined end to end. One of the members is often broader at one end than the other fclubbed); the cheesy secretion cont;iins multitudes of the ba"illi almost in pure culture. Description and Symptoms. .\ recejitive conilition of the system a|ipears to be neces.sary to permit the development of the disease. When infants are attacked, it is always the marasmic infant: the robust never contract the disease. Children and adults always give a historv of malnutrition, most often because of scanty food, with scarcity (if fresh vegetal)les and fresh meats— those who are con- fined ill barracks, ])risons, or who work reni' •" from a base of plen- tiful food supplies, as in mines, or railroads on plantations. In infants the lids become slightly swollen, and a thin flaky secretion escapes: the infant is but little disturbcl by the condition present. On everting the lids, the conjunctiva in the fornices is more or less covered bv thi' characteristic secretion. The secretion may extend over the whole conjunctiva and cornea. Koth eyes are affected. In chililren more tlian one year of age the secretion may show itself first either on the palpebral or ocular conjunctiva: in adults ahnwst a!w:iys on t!i'- ■-■iiliir cMnjunctiva, the patch occupy- 1 Ci)u«. iMTl(Mii.iue inter. 'Ic (>i>liili, Atuiuxi's. Mtiy 'JH, lK,s(). ■ i.mefi'n Arch., Itn;!, llmul xxU., iv,. S. iH. i)isi:A^£ii OF coyjiwvrnA, cohska, asd sclera. 27!t iiijr the ( juiictiva in tlic liorizoiital nii-riiliaii nii Ixdh sides of thr (MinicM. iisimllv triaufiular in sliapc, the i)as<' ix-iiifi next to the iiiaririii "f tlic coriica. Tiic sensation to tlie adult is that of a(lry sui)stancc on tiic conjunctiva. One i)ati(Mit sjjokc of it as liis "dry patcii. " Slight irritation of the conjunctiva is notic('ai)I(' about the iiiarttin of tl:e patcli. In ciiil(h-en ami in adults a condition of henicraloi)ia obtains. The disease is not a local one. In a number iif autopsies that have been made, the bacillus was found ni the parenchvma of the liver, spleen, kidneys, and pimcreas. duration. In infants this disease la.sts until death. In adults the secretion jiersists for n.onths, and in many cases for years. CompUcations. In infants the cornea is <le])rived of mitrition and .sloufrhs. All infants under one year of age (He. In children and adults the cornea may become involved, the patches of exudation jiraduallv advancing from the margin of the cornea, or ai)pearinp m Muail islets slowlv encroaching on the pupillary area. Years may pass befon> the pupillarv area is completely covered. Fortunately, in the greater number of adults and cliildren the cornea iloes not iM'conie involved, jirovided suitable treatment is instituted. Diagnosis. The condition camiot be mistaken for anythmg else alter the clinical picture is recognized by the surgeon. Pathology. Aside from the presence of the bacilli, the superhcial epithelial lavers undergo fattv degeneration and death, and are-ca.st otf The oi'l globules in the cells are very minute. The secretion consists of these degenerated ei)ithelial cells, some leucocytes, and the bacilli. On examining the conjunctival tissue little change is found ex''ei)t a .slight increase in size of the blood ve.s.sels, some small- c, 11 infiltration, and the thickened and superficially degenerated epithelial laver. ,1,1 . Treatment. In infants it is of no avail. In adults the local treat- ment consists in the use of antiseirtie lotions and washes, and of ointments, such as bicliloride vaseline (1 : 50(K)), the u.se of powders -calomel, iodoform, aristol-the powders t ) be du.sted on theaffectec area after the secretion has been gently wiped off. I'nless the local treatment is supplemented bv a nutritious and varied diet, a cure cannot be exjx'cted. Suitable tonic remedies should supplement the diet. . X ^ • I Phlyctenular conjunctivitis (conjunctivitis eczematosa) is ciiar- acterized bv the ai)pearance on ihe 'hulbar conjunctiva of one or more small "nodular elevations, which are situated at the ajM'X 01 a triangular leash of vessels, the base of the leash being directed toward the fornix coiijunctiv;r. Cause. The writer has feU justified in including this affection among those that are cause.l by a specific micio-orgamsm, because of the res,>arches of others as w.-ll as of himself. If an mibroken lihlvctenule be carefullv rendered asei)tic externally and the con- tents of tile |,hlvctenule conveved to a tube of nuf>-tit agar, a culture of tlie stai)hvlococcus will invarial)ly be obtamed Ihe same 280 Tin: EYE. * I 1 ^iii i. tn... of the n...U.l.' "f <-<-^nim. Sin.ilur n..,lulos may ho im.dun'a hv i.itn«lucinfi th.' stai.''yI..c.KTi hcncatli the .-imh.-liuni m su.tahl.' sul.iccts. Pustular l.l.'i'I'aritis inarjiinalis an-l n...ist <><-zrMna are iv- nu.-ntlv a.Tu,ni.a..i..l l-v plilyclenular c.njunct.vit.s ..r k.-ratitis; th.-> an- und-uhtcUv s.iuroos ..f inlV.-tion. Phlyctenular '•"•"J""*:^';'^^ '^ ,n..st frciuont in ohihlron <.f th.- poorer classes who have n.hen • taints or are tubercular, or who suflV-r fron. n.alnutr.tu.n aee.mM.a. e.l I.v Ivn.pluul.-nitis, l.y moist eczema ..n son>e P'^^. "f ?•"■«"'>,•. f!'': j.irlv oil the hea.l. face, and ears; eczematous rhmitis,etc. (1 ig. 1.5.>.) Fiv.. 1S5. I'hlyctennlur conjiinctlvittB in a scroliilous subject. (Dalrympi.e.) V.lults are not exen.pt. hut they are rarely attacked. Occas.onallN : parentlv robust individual is affecte.l. but n. tlu^se cases bl.-phar- i iV anrinalis or a ,>atch of moist .■czenu. is pn;s...t or has pre,.eded ,. ;, H.k of phlvctenula. Acute c.njunct.v.t.s. the exanthen.at: , ,„,l ,le,,ilitatinfi illness of any kind predispose to eczematous con- ^"DeSion and Course. In the early stages small tnjnslucent nodule, ai.p ar t the limbus conjunctiva- or on the bulbar conjunctiva ; •!: ;.n., The bloodvessels of the conjunctiva ra.lmtn^ f rom 1 1 ,„„,„,,. ,„,,,„„, i,,i,.,.ted. The nodules n.av be smgle <"■ "■" ''o S.on the apex of the nodule softens and ''.sappears. a d Icon^ Wn\< of the vesicle take on a yellowish api-earance. The softemnR ■i.. a- .mi .. i^aiHi i^WL^iJ..- DIHEASJCS OF COyjUyCTIV.l, COliyEA, AMJ SVLEUA. 2H1 I >n ijrrcssos until th" ihmIuIc Iims iciicIkmI tin level (if tli'.- conjiHictivii, wiicii the ul'-cr hccdii cs clean: ei)itlieliiini is developed on its surface, ami recovery occurs without leaving a scar. l{ecurrences are the rule. Tii(> process from the first stajje, the stafje of efflorescence iFuclis), to coinjilete recovery retjuires eipht to fourteen days. When hut one or two nodule;^ a .■ present, the redness of the con- junctiva is hut partial, and is confineil to the vicinity of the nodule. 'Hiere is liut slijiht incre -^e in lacryniation and little irritation; no photojihohia. When niaii> nodules exist, the rediies-' may extend to the ])alpei)ral conjmictiva, the lacryniation and secretion may be nuich increased, and .some ]ihotoi)h()l)ia may be experienced. Fig. 13fi. I'hlyotenular conjunctlvUis. (Dalkymple.) Diagnosis, riilvcteinilar conjunct ivitis may be confounded with herpes of the coi'ijui.ctivii. i)iiiguecula. lymphanpectasis, and vernal catar.li, but the hWovy I'f the ca -e will serve to make the difTerential diiifrnosis. Pathology. The elevation or nodule is composed of an accumu- lation of small cells restinj; on the basement membrane and causin;, an elevation of the epithelium. The bloodvessel +he base of th( nodules are eiifrorRed and enlarged, and there i cant small-cell infil.ration in the surroimdins tissues. Treatment should be local and constitutional. I.(i( Ai.. A cleansing aseptic wjish should be used to bathe the eye three or fotw times dailv. An ointment of the yellow oxide of mercury 1 1 per cent.) should be" put. into the eye twice daily. After the nodule has been coiiverteil into an ulcer, calomel may be dusted over the afiected area once dailv, if the patient is not taking io.linc. 2H2 Ti/A' EYE. Intkunai.. Hiiitahlf tonic rciii(>( lies sliuiild l)c jlivcn. Small uihI f itly rci)i':it<'il (loser f caloiiicl (fir. .' to ,i„. tlircc times lailv) :;rri;':7m^rS;:-^^^^^ ^"^iel^XS'oi E^iunctiva may '^;.pH-ry or .-conaary: ■"i;:";;;;:X'i;:U';"::f^ho conjm.tiva. whi.;h is t.. n..^. •K-ut • £ the tuheicle bacilli ontrr the conjun -val tissue through ' uml t e conjunctiva, sonu-tin.es due to o,K.rat>ve procedure X^!^n^ to Valuile, tubercle bacilli canm.t penetrate the mtact ^'"cli'i^n^ptcs. Withina .eekorten,l.^^^ftc. tl.en trance of the bacilli the con uiict.va m the vicm ty of the plac. ot n ;;:;.^ l'con.es injecte.1, and numerous ^-^^^^^'^^^ tub.Tcles resembling trachoma granules, appear. This nui\ "C ."r ' " ouaro palpebral conjunctiva. The li.ls become shgh e • n a verv protracte.l cours,s an.l .nay mvolve the.ornea I;:i' n.s>;it in loss ot Vision. Son.e rise of temperature accompan.es the earlv stages of this for... of tubercular ..ifectio.i. Dainosis This for... of tuberculosis ...ay be ....stake., for acute trSu and for I'arh.aud's co,.ju..ctivitis. It.< '"<»"»;»>=^V<' >; " , ; ' . the ...arked i..volv.>...ent of the ly...phat,cs o,. the aff..cted , . \v e suffici.-t to exchule trachonia. Kxannnat.un of a sKti.;;. .'f theS.le will disclose the bacilli, .lifTere..t.at...g .t fro.,. '''Tl;^::^ni;"^A5de fro... earlv excision of the affecte.l tissue little , J beTne. Appropriate constit..ti<...al .treat...e,.t a..d attc.t.o.. to the <v..ilitoms as thev arise are all that .s pnss.ble T 1,. i Irv lorn, oj tuberculosis is ch.-o..ic fron. the onset. It .s th. 1 se for..-.Vrly kn.nv.. as lup,.s vulgaris, a..d .s "'-t freq.uj.. e to exte.isi,.., fro... the ..asal ...ueous ...e...brane by ^^a^ of th( crv . al, a' ages. It is characterise. 1 by the appea.-a.ue of .rregu ar Sr;,lcers .m the palpebral ..ro.a.lar co..junct.va < mon- fre-ju^^ n the .v.lnebral co.ijunctiva). with raised edges an.l g.-a> .sh. u... ^. .. H , r . 'te re enti, g gra.mlation tiss.ie. The s.jrroun. ...R conju..c- f vai u i"htlv i"ieei-J. the lids are slightly th.cke..ed, a.ul a .■ 11 an ,..t;i rather thi... flaky ...ucopus is p.vsent. there ,s l.ttle in a.". 1 ;Mlist,.rba..ce to the patie..t. except fro,., the p^^^^^^^^ In cus is slight. The p,'eauricular glands on the affecte.l s..le DISEASES or COXJIWCTIVA, COllSKA, AXD tiCLEllA. -JS-'l arc ciilarficil. I)iit tlicr*' is little tcniiciicy to siipimratiitti. An alTcctcd aiva iiiav cvfiitiiaiiy l>t' ncciipiiMl iti whole or in i>ait hy cicatricial tissue. Ill old cases the conjunctival sacs may he entirely obliterated hy the cicatricial process, the cornea may become involved, anil vision Ik- lost. Years may pass with but little chanpe. but the tendency is to slow and stea<ly progress. Diagnoivs. Tuberculosis of this form may be mistaken for ei)i- thelioma, or chalazia which ojM'n on the coi.junctival surface. Study of a section of the tis.sue with the microscope will suffice to make a diapiosis. Pathology. The change in the tissue in the first form is such as is found in miliary tuberculosis. In the second form the margins of the ilcers are made up of a small-cell infiltration of the conjunctival ti.ssue, with increa.se in vascularity. In the tissue of the wall of the ulcer the tubercle bacillus is found. Treatment. Excision of the diseased parts, thorough scrapmg of the ba.se, and freciueiit inspersion of iodoform will produce good results. The ulcerated areas may also be d -^troyed by means of the cautery. . • , ■ i Leprosy of the conjunctiva may occur as a pnmary infection, but it is secondare to leprosy in other part? <.i the boily in by far the greater muiil)"er of cases" Morrow' cites a case in which a lejjrous tubercli' appeared on the eve and was mistaken for .sarcoma. Cu- taneous tubercles followed. A sclerosed, aiuesthetic condition of the conjimctiva follows the api)earance of leprous nodules on the coii- imictiva. This i)rocess mav invade the cornea. Irregular pterygia are sometimes produced. Ai. infiltration of the cornea unattended bv pain is (.•served in the later stages of this aflection. A mih i>erslstent irritation of the conjunctiva, with slight redness and increased lacrvmation, has been observe.l by the wnter m cases of le])rosy. Fuciis mentions iritis and cyclitis as accomi)anying leprosy of theOcular conjunctiva and cornea. Syphilis of the cor.junctiva manifests itself in a numlM>r of forms corresponding with the s'age of the disease. Chancre, papillary syi)hilide, copper-colo.od si)ots, mucous jnitches, gummata, nodular svphilides. and svphilitic ulcer may ai)i)ear in the conjunctiva. ■ Chancre appears most frecjuentlv on the tar.-al conjunctiva, extend- ing to the margin of the lid, but may occur on the retrotarsal folds or ocular conjunctiva. It possesses an indurated base much reseml)ling ii piece of parchment. Considerable irritation is produced by the chancre and a rather jirofuse mucoiiuruleiit secretion accompanies it The elevated mass sometimes disappears without ulceration: but usuallv the apex of the chancre softens and disappears, and a shallow ulcer with indurated sides and base is present. The ].ai)illary syph- ilide is not common. It accompanies papillary syiihilides on tne face and lids. Cnpi)cr-col()red spots nre not of common occurrence. n of DlseiweB of the Skin, Dermatology, vol. ill. p. 5S7 2H4 TUK EYt:- A ,.„, i,.,v.- lu..-n ..h^orv.Ml to uc(....Mim..y tli- sanu- (•...uUti.-ns on tl.(^ l;™::™, '",;.;': .IS,; ;;"'■■;!, ;;:;;-t;r';;™;: iii^ flu. l.iillvir conuin'tiva near tlic liiunu!-. iiii\ .ii>i"ai ' . . ;;:lTXiiviii"r,,ivL,iK.un,i..,iyn "'^;^:;' 'i; ;:*sJ;:,si'!'ri,r.,«„». w,.,, .una,,,,. .^. curie chlorulo (1 ; 5(MX) in vasc'lni.') may be plaml m tlu o>o alter ,.Mch cleansing. «)r at least three times a day. /^vio d disease of the conjnn.tiva is a very rare aff..ct.on. It s Amyi0iaai8e» .,„,„..,rance of waxv. translucent, polypoul i^;:rS winliiv'slru., fron. th.:.l.nver forni. In.t n.y '^;ive 1 e entire conim.ctiva. converting .t ,n to large f<.Ms winch .n P .Mn-nc-, 'uu greatlv obstruct vision. The tissue is alnu.st ;E;l::r.' hi::;i^;:^ls and is ^ery fniible. A-IuUs onW are attacked. The diseas(> is apparentlv a purely local one. , , f ,..„, Pahoogy. The masses are found to l,e made iip largely of l,n- ,J.idcd? which in parts near the surface un.lerg.. a change, con- ic Ung them into a ho\nogeneous ma.ss. which, in the greater numlK^r f ,..wn« irivc the starch reaction to the iodine test. SS»S xci^on of the masses is necessary. Recurrences are the rT If thVbases are tn.Ued by superficial cautenzat...... return '^c£S'iini;^Ss (Chronic Ophthalnua). A t.uH.ened. iu j'.H.T'mdition of the conjunctiva sometnne.s follows an acu e c. - iunctivitis- accomiwuies blei>haritis margmahs in <.ld peojile par ih Id- ends' on partial or c.Muplete closure of the canahcuUe c'^. If the puncta, and trophic or hv,K^rtrophic rhuuU. Fr . rs of refraction and nu.scle anomalies serve to perpet ; >■ the oi Iti 1 l' old people a flabby, slightly congested, swollen con- io he conjuictila exists, associated with enlargement of the DISEASES OF COSJVSCTIVA, CORSEA, A.W SCLEJiA. 285 <-aniiicl(\ These cases are almost always accompanied by slight mucopurulent discharge. Treatment consists in correcting all conditions tliat staiul m a causative relation to the conjunctivitis. Thi> nasal and lacrynuU jiassiges should receive can'ful attention. The conjunctiva itself should Im' hrushed with a solution of nitrate of silver (1 to 2 j)or cent.) if secretion is present, and it should be kept free from secre- tion l)v bathing with a simple cleansing solution. Egyptian Ophthalmia. This term has Ix-cn ustvl indiscriminately t(. de.'^crilK' all forms of ophthalmia that affect large mnnbers of individuals, esjM'cially the forms that apjx'ar ei)idcmically. The term has been made to include acute contagious conjunctivitis, gonor- rlucal conjunctivitis, and trachoma. The la.st -named disease has been most generallv indicated when the term was employed. Atrophy of the Conjunctiva (Xerophthahnia). This comhtion, not accompanied by the presence of the xerous bacillus, occurs in a number of forms: ((() Cicatricial, as from trachoma: extensive burns of the conjunc- tiva, as from lime or from li(|uid ammonia. In cicatricial xerosis the duct's of the lacrvmal glands are obliterated and the gland itself atrophies. In addition, the character of the conjunctiva is entirely changed, so that no mucus or other lubricating fluid is secreted from it. The cornea becomes opatiue, and vision is reduced to perception of light. . . , ih) XiTosis from constant exposure to the air. as m ectropium and ui lagophthalmos. In cases of this kin.l the exposed conjunctiva and cornea take on a cutaneous appearance; the eiMthehum becomes thickeneil. corneous, and drv, a provision on the i)art ot nature to l)rotect the deeper lavers from desiccation. In this torm the remedy lies in the oi)erative j)rocedure necessary for the restoration of a proper protection to the exjiosed jiarts. Toxic Conjunctivitis. This term is aj.plied to the forms of con- iuiictival irritations th.at are caused by the chemical action of certain substances. ( )f these, mav be mentioned the mydriatics, the myotics, chrvsarobin, calomel, the dust from aniline dies, bites of insects, cater- l)il!;ir hairs, fumes from formalin, menthol etc., intense light, as 1.....1 the electric arc light, the reflection of sunlight from the snow. Mropinc produces two forms of disturbance: ir/) .\fter long use of a non-sterile solution the conjunctiva becomes hvpera'inic and follicles develop in the fornix and tarsal conjunctiva' There is a scaiitv mucopurulent discharge. The picture is one of mil. I trachoma iii the earlv stage. The cause of this form of con- junctivitis is probalily bacterial infection, the bacteria being carried into the conjunctival sac with the solution. {h\ Six to twelve hours after the instillation of a few drops of a ;-(>Kiti(>!> of atropine into the eve the lids become swollen and brawny an<l the conjunctiva injected. "There are excessive lacrymation, a sen- sation of heat, and much irritation. Hyoscyaminc, duboisine, and •jHti liuiiiatropiin" soiiK'liiiH'! Tin: i:yi: Tliv' •■fleet b ■lii' prtMliicr tliis (listiirlKiiicc also, hut in less ,1 tnlMMliic tn idiosyncrasy iicirrcc. 1 IK' •■111 Ti i> ■" IK »• '• ■ . ,.■ •■ • .1 ... Tlu. treatment of tl,.- f.rst fonn ..onsists m '''^<'"'''''''''"'^' .";; ' pin., orusii.^' st.-rilr solutions, clcansni^ ,1,,. ,.y,. lrn,..rntK with laturafil solution of l.ori.- aci.l, an.l usin^' su.tal.l- astnnp.-nts. < >f tlu- s,.con.l form, in ijiscontinuinfi th." use ol tli.- atropnu-. Escrinv solutions son.Hin...s .ausc irritation ot tlu- '•""J""''t>V:|. Vhn,snrM,u tis.-.! in tin- forn> ot an ou.tnu.nt on t'"' r";' " psoriasis, .nav pro.lu.'- intense irritation ot the eon.|un.•t.^a. ( alo u 1 ,lust,..l on- the eonjun,.tiva when the pat.ent .s takn.j: an .oil .1.-, .suits in loeal uleeration an.l n.ark..il irr.tat.on ot the eonjune . Zmm- when api-iie-l to ih .njunetiva proiluees at first a eontrac- ,i. he l,loo.l v.'ssels. hut as its efTeet wars away there ,s an en- Ijoiement of the vessels whi.-h stinn.lates an.l .rntates the e.-njune- tiva, i.r...lucinj: a n.il.l f..nn ol eonjunetivitis. ..nVetion The hiU-s „l insects eonnnonly oeeur ..n the luls. an.l tlu- atlut . n of tie eonjunotiva. whieh sometimes hee..m.-s greatly ...lematous. is due to extension of the irritation. ..■•.• i ; i„ ieatment. All of thes.- f..rms of eonjunet.va n-ntat.on suhsule in a .^h.vs if the eause is remov.l an.l si.uple .•l..an]n...ss ohserve. . Mnia So,losa This e..n.liti..n is .lue to the pr.-s..nee of eat - oill r hairs on th.' e.mjunetiva. The atfeet.on may .'Xten.! to h. e. ' m.l .■v.'n to the iris. The n.,.lul.>s are yelL.w.sh. senntra s- " ' l>ave l,e,.n .■on.,>are.l to tulH-rcles. O.t exo.sn.K lu- Jllldules an.l .■xan.inin« then, un.ler the microscope, Papenstach.-r fonn.l the hairs of eater])illai's. • .i .. Abscess of the conjukctiva is .,f rare occurnmce. It forms m the suhconjunctival tissue an.l is alnu.st always traumatic. Treatment should he that as ..f ahscesses m ..ther ,.arts of the ... "chymosis of the conjunctiva is .hu- to the escape ..f hi... 1 h. ''ufirhe c.njunctiva fr.Mi. whatever cause. It pr... luces hrifrht- r ,!• rk re.l patches, an.l mav affect all hut the tarsal con.iunc.va. ireaUent. Thehl..^ ahs..rhe.l sL.wly. Hath.nir w.th hot soluti..ns hastens ahs..r].t...i.. . • i u,. „-,.llinp. nn.l Chemosis. This is a c..n,.ition charactenz.-.l hy swelling an. thKng-f 1«> "eular c.njunctiva: the swTlln.p: at the c.n.ea !:;;;,„, fon..ins a raise.l wall, pn^ducing a shallow circular p.t, of which the c.irnea fori.is the Hon.. Pathology. rheni..sis is n.oro than sin.ple mlema m many cases. iZtSv is this s.. when the chen.osis is the result o a slow u.flam- u.S of the coniea, iris, ciliary ho.ly. an.l cl...ro,.l. Sec ...ns of ; ie, oti tis ue in acule cases show litth hut a .listent.<,n of he con- ,e hal tissue hv s..r..us or sen.plastic i.ifiltrat.on: hut .n the suh- ao or chr<.,.ic forn.s there are a dense infiltrat.oti of small cells ami ""'l^erease in eo.u.ective-tissue ele.uents and m the size an.l numher ''imphyiini^the conjunctiva is characterized hy puffiness of thrZjmXt. with little injection, and usually w.th the appearance oi.sEAsKs tir co.\jr.\vTiy.\, /.-.vam, amj scleha. 2«7 .if »iii;ill ciifulMr pale |i(>iiits jti>i lifiicath the cniijuiirfivii, which iiidi- <"iti' thf iircsciict' "I air in thf ti>.>'uc. On iircisinj; tlic cnnjutictiN-i, ihiic is a faint crcpitatiiiii, and the circular I'nints chanp' their pusi- tiiiii 'l"hr condition is due to the entrance of air info 'le >ul)con- jnncliNal li-sne as a result of traniuatisni, the injury tliat most fri-- c|Uently ])roduc('s it heinn fracture (if tlie l.icryinal Ixine. On lilow- \i\fi tlie nose violently, air soinetinies fin its way into the orl)it,i! and suiieonjunctival tissues, causinj: them to putT up. Treatment. Tlie air in the tissues dis.ip|M'ars by al)sor))tion in :i few days. Injuries to the Oonjonctiva. It freijuently happens that foreign liodies enter the conjunctival sacs. These impinge first upon the irlolie, and are then brushed downward by the ujnier lid. They may remain in the lower conjunctival pouch, but often are caupht on llie tarsal conjunctiva of the upper liil, from which they may Im' re- moved on everting the lid. When lodged on the conjunctiva of the upper lid, they are foimd most commoidy in the shallow groove which lies innnediately alM)ve the inner angle of th(- margin of the lid (sulcus marginalis or sulcus tarsalis). Rarely the foreign Unly lodges in the ictroiarsal fold. Slight i)ressure backward on the glebe after the lid i- everted will ser\-e to expo.se this fold, when the foreign.body maybe ninovfil. Hits of .steel are sometimes imbedded in the conjunctiva: they may be removed by the onlinary .surgical jiroceduros. (irains of iiowdiT th.Mt are deeply inibe ' led need not be distuHx'd, as they produce no irritation after the wound made bv their entrance has healed. Wdiinds. These may 1h' a.ssnciated with extensive injuri(s to orbit .ind lids, or may be simjile lacerations. I'nder favorable circuni- -t.Mices they may be riean.sed and the margins of the wounds a|)- proximated by sutures. Hiinis are occasiimed by the entrance of flame, glowing wooil or metal, powder, ashes, steam, hot water, niclten metal, acids, alkalies, nitrate of silver, and other substances. Treatment. When th(> burn is iccasioned by thermal agencies alone, the treatment should be by n.. ans of bland oils or vaseline, to Iw placed in the conjunctival sac e ery two or three hours. If molten metal hiis entered the eye, all of the particles should bo removed as early as possible, and treatment instituted as above outlined. Burns from acids, if recent, should be treated by means of a weak alkaline solution (bicarbonate of sodium, sodium hydroxide, or verv dilute ammonia): subso(|uently the conjunctiva may be well washed with water, and the oils then employe<l. Hums frotn lime and anunonia should bo treated by first removing all particles of lime or mortar by means of forceps or cotton pledgets, then by washing thoroughly with oil, and subsequently dropping in simple synip made from cane sugar, .is thi.=. forms an insoluble com- bination with lime, (lil or vaseline, medicated with boric acid (') per cent.), may then be used until healing takes place. in i-n,.r 17;:, »;;t:;;s:r;x;':i,: ':;::: ::li:-'^;:-l;;: Argyna '~Kyro8») """J'*" , ,i^,,,i,,r.,,i,,,, „f tin- mukm.us ,.f silver n„ tl..- .-nnjunHna r u . . i 1 ,,^ all.u.ninat.. .,f .siiv..r i.. .1... tissM.. nt t ..• "'J ''•.*;• Z*^^,;,. .,,;w i,r..w,. !:J: SK; t," :;nS ..f l • U h.'wa„ ■• ..as ........ su.,..st...l for ''iZ^. in .nan, >..aivi,.;..s ;v,... '-J-.-;-;, ^ „,, ,„sal sul- nt "'':.!""";\';;;,„,,.„,, ,,,,vati..n ....•asuri..K two nr tl.rc.' niillii.K'ti-es in (liai.H'tcr. Tins tii.nor is at ti.-st niovabl'- •'.. tlic sclera. It foiisists in a tliickc.i- iiifl (•)■ the (•(.njvnictiva. particularly ■„, a,i increase of the elastic film's, an.l the deposition of .luii.erous ',„•• 'te livaliiu' pai-tides. The yel- lo, elastic tissue and the hyaii.ie Ix.dies (livp it the yellow color. II the tumor causes annoyance by its api)earanc<' or hy becoii.'.n}! m- tlaiiied, it may he n'luoved t)\ in- cision. . Pterygium, rtevyjiia may be classed as "esvilar and irrefjular. Tlie ivfrulai' form of iitei-yfriuni con- sists ii ■ triaTiffular fold of mucoes memhn.P. oc.urrin}i oi. the ocular nie iia>;ii ^"" ill the horizontal meridian. Pterviiiiim. A w.mi.l. >-. is rarrii-l U'lumih thui^ia.' "I- tl.c l.UTy''.c». P The. .loitiM line -h.iws th.. vvay in wbieli Uie section is :,mclo ill removim; tlie i.U>r>Kiuni. C. Car- :,m,U. ill removini! the l.U.r>Kiu.„. (j lar- .■»■;■ . l.irizoMtal IIIC- nnrle The ml ia, enl l.li-'a semilunaris li«« COIIJUI'.C ' ' Va 111 the l.orlZO.nai 111. . ...u.. ..,.., i... 1,.,™ of tlie • 1- :, 1 l...;iwr ..t tlu. (•.•HIT ins. till, le. • "^ .»-.,,.- . - i- ,1 l«*ll lialtelR.1l .-lit by Ihe len^i^e loioe of the lileryniiiiii, ni"l is hence iiivi>il>le. /'. I PPt'f piinctum Ittcrymule. iFicHS.) riilian, 'I - base heiiin at the canthus, its apex at the marpin of or on the cornea. (Imk. 1:{7.) The I.I00.I- ,.,. ...„i. <,n„.v .,t the base, diminish in size, and conyrrp<> at the apex i>terv.num occurs h. indivithials of m.d.lle mula.tvanced life, nu-sl r untlv.level..pinKon the nasal side of the cornea: it may also M. r the temporal si.le. Pterygia n.ay bo either progressive or ' WPPIPP /j/.sA.iA£'A "F coxji'ycrn.i, coii.\tA, a.\d x /.a;/m 2x{> «i;iti(iiiary. In pniftn'ssivi ptfrypiiiin the folil of mucous iii<'inl)raiif Iki> a lli'>iiy a|ilK?araiu'»' and .l> vessels arc prMiiuunci'd. Tlic a|M'\ of ilif Krow'ii is pri'ccdt'tl liy a urayisi. zone, one to one and one-half iiiilliinetres wide, wliicli is very slijjlitly raised at the margin of the a|«'\ of the jrrowth. In non-proj;ressive pieryuiuni the fjrowih is pali- and Hat, and the grayish zone is narrow, and is flat or slightly shrunken, appearinj: like a cicatrix. rteryciuin may advance until it passes the pu)..;: it may stop at any point on the cornea short of this. irregular or pseudopteryniuni is the result of hums or ulcers of the cornea. They have the same jreneral shape as the re>tulari)tcryf:ia, liut the ajM'x is often very irregular in contour, takinjj on the sha|M' oi the mar>;iti of the ulcer farthi'st removed from the limhus of the coujunctiv;i. The conjunctiva at the margin of thi- cornea corre- >pondiMH t'> <!"' nicer Itecomes swollen, and a fold of chcmotic con- junctiva hecomes agplutinated to the floor of the ulcer. As the ulcer clox's and cicatricial tissue forms, the mucous memhrane is drawii onto the cornea, at the .same time l)ecoming hy|)ertroplii('d. Tl ■ plrryfjiiim ni'ver propresses beyond the cicatricial floor of the Hi'Kular pterygia are undoulitedly due to irritation of tlic ■.■- junctiva in its most exposed part, corresjMmdinK with the pa., - iiral fissure, hy particles of dust ai-.. various minute bodies that impinne on the ocular coiijtmctiva. This irritation results first in the formation of pinguecula : extending, it |)roduces the ptervfrinui. I'terypum is prone to Iwcome indamed because of the lodgement of noxious germs or irritating particles in the folds of the nuicous iiiembrane. These iiifianunations may lead to ulcer of the conjuiu-- tiva, ulcer of the cornea, and serious damage to vision. Diagnosis. I'ierygiuui cannot well be mistaken for anything el.s<'. Treatment. Tlu- cautery may be used to destn y the head of the growth, or to cut ofT its -.utrition by making one or two deep gnxivps across the neck of the ,■• rygium. The operative procedures resorted to most frecpiently are exci.sion, transplantation, and strangulation. MxcisKiN. The neck of the pterygium is grasped by the fixation forceps and jiierced close to the limbus by a shar]i cataract knife, ihc knife iia.-*sing just below the tis.«ue of the pterygium and parallel , h its surface, the edge of the knife beiig directed toward the cor- nea. Hv .-I to-and-fro motion the knife is made to pass iM'iieath the iiead of the ))tervgium. dissecting it from the cornea. Instead of this iTocednre, a thin strabismus hook may be pa.-'sed through the in- ii-ioM made Iwneath the neck of the pterygiu!n ( Triiu-e's nietiiod), and the head of the pterygium torn from the cornea. The body .'f llie pterygium is nowdis-sected from the underlying ti.-isues for a distance of three to .six millimetres, and a diamond-shii' i ; ' ■c- exci.seu. 'he imier apex lying at the canmcle. The con.', -ic',, a ■ now loosened from the underlying tissues above and belo . i;; i th edg brought tugeth' ■ by sutures, covering the defect as n.r ;)s Tne ivt ■J!M) THE EYE. fll 11 iiiarjriii of the (uiiica. Tlic cdnical ilotVct l)Ocniii('s covered witli epitlieliuiii ill a few days and liealiiifi profiresses satisfactorily, leaviii;: soiiii' opacity. Thanspi.antation (Kiiapi)). Instead of excisiiift tin- i)terypiiiii after liaviii}; dissected tiie ftniwtii toward tlie caruncle, tlie corneal tissue may lie removed from its head and a suture passed tlirough the ai)ex of the pterygium. .\ straifrlit incision may now he made in the lower hulhar conjunctiva, extendin;; from the margin of the wound about four millimetres from the cornea, downward, and .slightly outward, toward the fornix, suthciently long to accommodate the free part of the pterygium. The suture tlin.ugh the ajx-x of the ptervgium is now pas.secl through the conjunctiva at the apex of the last "incision, and the hea<l of the i)terygiuni drawn into the space and there fixed. This directs the ti.ssue of the pterygium into the lower fornix. .\11 defects other than the corneal are now covered by suturing the edges of the conjunctiva. Instead of transplanting ail of the i)terygiinn below, the body of the i)terygiinn may be split —one-half may •>•' trans])lanted below, one-half above. SriiANCi i.ATioN. The neck of the pterygunn is grasjie.l by the fixation forcejjs and slightly raised. .\ suture with a needle near both ends is employed, one needle passing ujiward beneath the neck of the pterygimn at the corneal margin, the other needle pa.ssing upward beneath the neck of the pterygium three millimetres from the corneal i argin. The ends of the suttire are not dr.awn through, but the loop holding each needle is cut, liberating the needles and forming three sutures. The suture at the corneal margin is tied tightlv over the neck of the pi' rygium, as is al.so tb.e suture nearest tcrthe caruncle. The middle suture encircles the base of that i)or- tion of the pterygium lying between the two end sutures. The middle suture is now tied, |)roducing strangulation of a section of the pterygium. The sutures are |)ermilted to retnain until they come awav spontaneously. Deprived of nutrition, the head of the l)terygium atroi)hies and ilisa|)i)ears, leaving only an ojiacity. Eecurrences. These are not infrecjuent after removal by excision, but are very infrei|uent after transplantation and strangulation. Ljrmphangiectasis consists in dilatation of some (tf the lym])h channels of the ocular conjimctiva. It ajipears as slightly elevated, transpanMit vesicles, usuallv associated in chaiiK, very superticially situated in the outer or inner half of the bulbar conjtmctiva. The vesicles , ire irregular in shape and vary in size, seldom exceeding a dia ter of three millimetres. The vesicles may be readily moved over the underlying tissue. They produce no irritation and are not a source of ])ain. The vesicles are due to interference with the lymph stream by ol>struction. Klderly individuals are more fre(|uently atTected. Treatment. The vesicles may be excised, or they may be very satisfactorily destroyed by means of the fine galvanocautery point. Removal is necessarv only for cosmetic purposes. DISEASES OF COSJUSCTIVA, CORyEA, ASIJ SCLEllA. 291 Vascular growths in the conjunctiva arc seldom primary, hut arc (■(inimoiily extensions from tiie tissues of the lids. Tiiey apjM'ar as arterial prowtlis, when they are of a bright-red color, slif;litly ele- \;ite(l; as venous jirowths (cavernous anjiioma), lncate(l (jeej) in the conjunctiva, dark purple in color: or as telangiectatic growths — hright-re(l patches in the conjunctiva. All these conditions may he |)resent in the same growtli. \'ascular growths are congenital. They tend to increase in size. Ivirly removal is advisable. (See Removal of \ascular Ti.ssues of the Lids.) Polypi. The occurrence of polypi on the conjunctiva is prohal)ly always asiaciated with ulcerative iirocesses of a more or less chronic nature in the conjunctiva. Wounds of the conjunctiva that <lo not pro|)erly close, sy])hilitic or tubercular ulcers, simises from chalazia ojM'ning onto the conjunctival stirface, sinuses from areas of orbital necrosis, all give rise to the development of polypi. The irritation from wearing an artificial eye may result in the development of jjolypi. Pathology. Polypi of the conjunctiva are composed of myxf)matous tissue with more or less .small -cell infiltration, according to the degree of irritation. Treatment. Removal and correction of the conditions favoring their formation. Benign Tumors. Those that develoj) ])riinarily in the conjnnc- ii\a are adenoma, fibroma, gramiloma. lipoma, myxoma, osteoma, l):ipilloma. simple cystic tumors, and those due to cysticerci and ccliinococci. Ailcninna occurs rarely as an extension from the tarsus or as a ilcvclopment from lacrymal glandular tissue, or from the caruncle. /■'ihriiiiHild are usually the result of chronic conjunctivitis, par- ticularly of vernal catarrli. <inniiiloiii(i develoi)s from the base of an ulcer and from wounds. l.ipiniKi occurs in the fornix in tlie shape of a soft yellowish mass. Mtjxnwn. The most common form is ])olypus. O.-li'iima is of extremely rare occurrence. (See Congenital Con- ditions.) I'npillnmn. Ttiinors of this nature exist as small multiple pajHlhc, fonuing soft, pale-jiink, villous mas.ses. They may develop from any part of the ocular or palpebral conjunctiva, but are seen most <'iinimonly on or near the caruncle. Papilloma is not iiifn^juently mistaken for gramibtion tissue. To avoid recurrence, removal should lie thorough. Simple cystic tumors appear in the [lalpebral conjuncti\a after chronic conjunctivitis, after plastic operations on the conjiuictiva, anil after oi)erations on the ocular muscles. They usually form as a result of the invagination of epithelium. The treatment is excision. Cysts dtie to entozoa are very rare. Cysticercus cysts are large. ii tiie wails are thhi, the head is visible as a white spot at some part "I the cyst. They are easily removed by splitting the conjunctiva 2i>2 riii: EYE ;„-;.,,„...,, ™M «.. v..i,„i„U,n,,,,„*o.«.. .-iv.. tissii.' "lit of tlif wound. .Icvcloi) ^'lowlv, tuul ma\ oxt.-..a int.. tlu- orl.it an. pn. '-'^1; ' , ^.,,„,,,,^, „f „,, .yst. ,ysts an.l hnuklots n.ay >«■ /T ;;.'•' ,. sarconu. arc th.- n.ost :rri5u:r°s.-Hiis^ a = ->-'• ^--^ - ^^'-^— soc.on.larv. that is, an <-xt.-nsu.n • !^ '^^ J- ^,„^i ,.^,,,,,is onto It . srurs wh(-r.> pipn.-.tt is <'»*•»'"':, „ ,\,, ,„„iunctiva of the vhore it is n.on. ^^^^^^^ ^y^;.Z^. San-ma of th.- ;-,.- "^S.t.eat. Complote excision is the only treatn.ent that . of vaUie. , „ ;. .,«vct^ the ponjunetiva. appears Lupus erythematosus, wl.; ^f/, ' ,\.ish nuisses of exudatu.n as snmll in-ep.lar pla.,.u-s ''"^ i" ^ h punctat.- ..xeoriati.ms. ,„d superficial ^^^^^^xiJi^^^^'^^ conjunctival .dTe.- Lupus.TytluMnat..sus..f th( la< <« ^^,,on,,,anie.l by shfjht tin!. The .lisease pn,sresses M(vU>- -"" ivritation an.l increase.! '•^•^^J;";;^^"^,,,,, ,,is.-ase of th.- face accon.- Etiology is not xvU "!"l''\^^.;" i^,. i! ;„.,sis is rea.lily nuide. ..aniesthat ..f th.- cnjunctna tli. .l.a.n Treatment is ..1 no aviuL ,.,„„r,tion soinetinu-s acconipanu's ^'^^ f *'« ^T"?r Th to.;;; 'liu....tiva usually is afTecte.l. ' AfiectionsoftheCarunceandSenuluna^^^F^^^^ ^^^^ ^^^^_^,^ ^^^ ^,„ , ,,,uncl.- n.ay be .lu.- to " !\ ,,^,.,.,, tIu- ahsc.-ss n.ay ,,„,,„,,,. res..lti,.^ in the f''"''; ' / 1 „.onta,.e..nsly. when ^^ '«;:'"-'-l- r ;l "^Se liai;" nil: .'ivunele nlay hecon.e a source ..f vviil n-a.lily hea . 1 1>« "'"'■.„„,•,,,,, i^ the n-n..''lv. , -;1^'; <^;:s::i;»r ;;i;;:;;'.;;:;s:-'i".«- ^ "^r»,'^..i- i™rs^i;;ru:;S=--!"r'"f DISEASES OF COSJVSCTIVA, CORXEA, ASD SCLERA. 2^ Cuslic viilnrqemnit is soiiu-tiinos ..hsorvo.l. rholhj ih'po.ih may „m.r in the'fila"'''^ "f '•»'■ <"'>-uncl<', ouusinK' cnlamen.cnt. Advmmn nu.v <U>vcl(.i.. Wlict. the onlarK.-in.-nt is du.' to . level.. pincnt ot sar- coma or opithelioma, f. c term cucontlms mnhijna is applicl. Treatmeit in all cases of enlargement from the development of iiew-OTowths should 1m> excision. ,,,..1111. Symblepharon. Cicatricial imion of the palpebral to the hull.ar conjunctiva is terme.l syn.hl.-phan.n. It occurs a ter burns mjunes, an, son.e operative procedures, an.l as the result ..f P""''!'"' ?;!"- iunctivitis, pen>phipus, and trachon.a. The bands of c.catnc al 'sue ma- extelul to the cornea. ShouUl the union between the lids and El<.l.<- be complete, the condition is termed symhlephnron M If the union extends from the bottom of the fornix, partially uniting the li.l to the fjl"l>f. '^ '^ ♦''""f''' symblepharon posteruix ZZxhl union of the lid to the eyeball is such that the cuatncial Land .Iocs n<.t extend to the bottom of the fornix, the condition i.^ termed symblepharon antcrius ■ , t i i„.,V,orr«n The treatment of svmblepharon is surgical. In syrnble haron a„ ius, carefuUv dis.sect the lid from the eyeball am if the mlhcsion is not extensive; the surfaces may be separate.l . a. y ""/.l ccatri- .ati..n has taken place: a ple.lget of cotton f ^^e.l with ol ve o n,av 1... interpose.1 between the raw surfaces an.l penn.tt. .1 .. re na n unt'il healing occurs. The bri.lge of tissue may be hgate.l and the liuature all.)we.l to slough through. , ,. , . ..v, i n „, ^In ext<"nsive anterior symbl.'pharon, the defect in the bulbar coniunctiva may be c.vere.l by dissecting the <-""J""^\7,^,,^*.3^ honhT ..f the .lefect from the underlying tissue, making sliding flaps ,-,„,„ both si.les an.l m.iting the margins of ^^c «'njunct.va ov.-r t^^^^^ ,lef.rt in the ocular conjunctiva. With an epithelial ^^"'"f ^^7/ ^"^^^^^ to th.> .lefect in the c.njunctiva of the lid the .lefect m the lul nmH ci.'atrize without adherei-o. to the glolie. Plastic operati..ns of x-. >us ki.uls have been advocated .r cor- .■...■ting svmblepharon posterius an.l fetalis: but none of the n is pe - fectlv satisfac orv. After the li.ls have been <lissect...l from the .,l„l,e a flap .>f .onjunctiva from a rabbit's eye may be cnvey.. , with antiseptic precautions, to the defect an.l nuule to cover , l„.i„g stit,.he.l into place. A Thi.-rs.-n graft may be ma.le o com ,1... d..f..ct, or a thin skin flap (WolfTe's flap) "'f /^.''"'jt " ^imi ar n„. fla.. is in position a shell of glass, lea.l, celluloi.l. or ^<'!'\'' ^" ;''. .„hstal.ce shoul.l be so placed a-s to hold the flap m position until healing has taken place. CORNEA. Anatomy. Tlie cornea forms the anterior part of the f^^^^'^^^'f .,f the eve. It is in f.)rm a horizontal ellipse, measunng 11 tnnv in iis vertical an.l 12 mm. in its horizontal men.hans. At ! »\P^' Pj?';'^> It,,' c.rnea is 1 mm. in thickness, but at the centre it is slightly 2!t4 THE i:yi:. tliiiiiicr. Tlic r:i<liusnl' (Mirvatiircof the aiitcriiir surface of the conica is variously estimated at 7..") nun. to N nun. Sinee tlie radios of curvature of tlie scleral portion of the <rloi>e is Vl nun., it will he readilv seen that the cornea is more sharjily curved tiiaii tim sclera. A slifiht ariiuilar depression is found at the anterior niarpin of liie sclera— the union of the cornea witli the sch'ra— known as the mdnm KIO. lis. Sectional view of cornea. (Sohawer.! jsWcrT. .Mthough ova! in form anteriorly. |)osteriorly the cornea is circular. The sclera overlajjs the corneal tissue externally, the over- lap|)infi beinp }ir<'iitest above and below. The cornea is composed of five l.'iyers (l''ii!:. lUS): 1. The ei)ithelial layi-r. which is stratified; the sui)erticial laypr of colls is comi)o.sed of tessellated or pavement epithelium. The ceii.s i>isi:.i.st:s or co.y.irxcTiVA, corska, aso scleua. 2ft.-, Ill ilic niidtllc liiyt T arc incfiularly culxiidal in fdiiii, and arc sui)])li('d willi ruiMicrous fine j)r(>('csscs (" prickle cells") wliicli interlace witli liic luncesscs of the adjouiin}; cell>. The cells of tlie deep or liase- Mient layer are cohinuiar or cylindrical in sha|)e, are somewhat irrejiiilar in length, and aii' placed on a basement nieinhraiie. All of the cells of the cornea are supplit d with nuclei. i»ef;cneration of cells takes place from all the layers. '1. The .second layer is a thin niemhrani', anil is known as Howman's niemhrane. (Fij;. V.Vi.) .'{. The third layer is the thickest layer of the five, and is known as the yiilistiuiliii propriii. It consists of numerous bundles of con- nect ive-ti.'<sue Hbres associated in thin layers— lamelke. The lam"lhe are arrang.'d parallel to the surface ot the cornea. They are joined hy connect ive-ti.ssue fihres which pa.ss from one lamella to another. The connecting; fihres are so numerous in the anterior part of the substantia propria that they are given tiic name of librw arciinta. Fig. 139. Anterior epithelial layer of cornea. (QfiiN.) I.yin<r between the Innidles and lamella- are small .spaces known as l.nuiia', and, imitiiifi these, numerous small canals known as canaliculi. These lacuna' and canaliculi together form the canalicular lymph ^vstem of Hecklinghausen. In each lacuna a branching cell is found whose ))rotof)lasmic ])roce.s.sps extend along the canaliculi, anasto- mosing with those of adjacent cells. These cells are known as the lixed cells of the cornea, in contr.adistinction to the leucocytes, which, iiy amo'bic movements, penetrate to every part of the cornea, and ;\yr known as the migratory cells of tlie cornea. t. Tlie fourth layer of the cornea is a thin homogeneous mem- brane, known as Desremefs membrane, which po.ssesses chemical projierties that serve to distinguish it from liownian's moml)ranc. Uaiivier is of the opinion that this corneal membrane is the product ■ il the endothelial cells of the cornea which rest upon it. The mem- Inane of Descemet breaks up into numerous fibres at the periphery I'f the coni(>a. forming the ligamentum jK-ctinatum. ■"). This layer consists of a single layer of polygonal ceils of the ■ •ndothelial variety which lose their (tecuiiarities at the ligamentum .:>6 Tiii: i:yt: ^ t 1 i ,„,,tinatu,n, passing ovor int.. .•-lis that an- ...uch thinner a.ul -nat •■'N^r;^''!.;:':^;':^! Irian ,1... ^... ..l-xus fo„n.l hy tlu. ,0.^ 3' short riliary n.-rvos. . Fi,. 14.).. ^rh-y pass tl.-uj^. t - Jr., on th<- outer ^i.le of Schlc.nn,-s canal an.l l..nn a n.-t«..rk. t^^Z^l .n.„l.,r.. in th. vicinity of tlu- -^^:^;:;^l Fro, , tl,is pl.-xus two sets of t.Mjis arc pv.'., off. one set !>''- ' P lu. l^onjunctiva. wi,,.,.- tl,cy join the conjunct,val nn-v.. an.l fon u olcxns Fro,,, tl,is l-l.-xus a nu.nl.cr ..f ncrv .ninlvs a., sn V whi..h enter the c.rnea .m-l supply -he a., enor JX--^^ ^^ structun- Th.- se<..n.l set of tw.^s pa>> .hr.rtly t.. the ^ubhtantia pn.pria cornea-, cnterinR it near I)esc.-n,ct s ,ne.nl.i-ano. Fio. 140. Obllq..e section of the hunum cornea, rt,o«i"g ranuflcatlon of the nerves, (De Weckee., Ra.iial fibres which leave t'.e nerv.> trunks at the no.les of Rain r pa" t Hown.ans ,nen,hra,.e. which they inerce an. f..nn a pUxu , flu' . uhepith.'lial plexus, from whicl, tennu.al hhnlla' are .lenve.l, Ii;!, ;.,!,1 ,,, the epith..lial layer in .,erve plates, peculiar c.nvolu- ti<.ii< hulbs, h.i.>ks, an.l frw en.ls. r i , lo, <.s;.ls .lo n..t ..ccur in the cornea, .-xcept at he Im.hus, ,vh' n the episcleral hl..o.lvessels en.l in a circle of h.ope.l capillaries. Diseases of the Cornea. Diseases .,f th.- cornea are inclu.l.'.l un.ler the gen.-ral term keratitis. Th..y may he consi.lere.l un.ler tw., iiea.lings-.suppurative an.l non '"Clodcal Considerations. Regeneration ol Corneal Tissue. It is ^ resX c:,nce,le.l that th.- n-Renerati.,,! of «>rn7 tissue proce^ J fro , cells that mifrrate into the corneal tissue and form the nuxe.I DIHEAHES OF COy.IUSCTlVA, CORSEA, AM) SCLERA. 2!»7 ci'lls of llw cornea. WIicii rejtri-ssion of a corneal nicer has com- Mienced, formative elements are found at the edfte of the nicer which jiradually develop into connective-tissue fibres; this process con- tinues until the defect in the cornea is filled uj) by the new tissue. The new fibres are not arranged in lamelbe, nor are they dispo.sed parallel to the surface of the cornea. This irregularity of the dis- position of the hbres causes a lo.ss in transpan-ncy; the tis.sue so formed is opacjue. In the liealinR of an ulcer the surface Iwcomes covered with epithelium before the defect has been filled up by the ilepositlon of the new fibres. The development of new-formed tissue continues until eventually the epithelial layer is raised to its normal heifiht. In a certain projjortion of ca.ses complete filling of the defect iloes not take place. The area involved in the ulcerative process in these ^a.ses is often flat, forming what are known a^ jncctK. How- man's membraiii' is never regenerated. Accompanying ulceration <if the cornea, if the process is at all widespread, and in some ca.ses where the ti.ssue affected is not extensive (the invasion not dfH'p), irritation of the iris is produced sufficient to bring about an exuda- tion of lymphoid cells and of the coagulable portions of the blood into the ante/ior chamber. This exudate constitutes what is known as hyjwpyon. Suppurative Forms of Keratitis. Eczematous Keratitis (Phlyctenular Keratitis; Scrofulous Kera- titis; Lymphatic Keratitis). The etiology and pathologv-, except in regard to the affection of the tis.sues of the cornea, are the same as ill eczematous conjunctivitis. The disease is met with most fre- Hieiitly in children between the ages of two and twelve years, but may appear in individuals up to the age of forty years. In many 'it' the patients with eczematous (phlyctenular) keratitis obstructive liiinitis and adenoid tissue in the vault of the pharynx are found. S3rmptom8. S<>vere irritation, as of a foreign body in the eye; jiain of a neuralgic type, often extending to the orbit and temjile; profuse lacrymation: photophobia, which is often intense, causing ilonic blepharospasm in the milder cases and tonic blepharo.spasm ill .'^evere ca.ses. In some cases the photophobia is so intense that liic ]iatient cannot be induced to oikmi the eyes, even in a moder- ately lighted room, but avoids the light in ever\' j)ossible way. The intense photophobia is due to irritation of the terminal sen.sory nerve filaments, which are so richly supplied, to the corneal epithelium. I'ig. Itl.) On forcibly separating the liils, there is often a gush nf ' iciymal fluid mixed with flakes of mucus. There is iiypera'inia •I the ocular conjunctiva, particularly in the vicinity of the phlyc- I'liule. The vesicles may ho single or nmltiple. They may fonn t the margin of the cornea onl\ , Tsiny be dif^tributoil (npr the surface •I the cornea, or may produce peculiar figures. The phlyctenule '"veloiis as in the conjunctiva, the apex softens and disappears. •J!IH 771 y; i:yi:- ,„.l .,„ ulcT results. Tl..- nlcT in mMi.y cmsos it.volv..s tlu; sii|M-r- .luc t.. the l..vs.'n.r ..f a thii. lay.T ul .Mcatncial t.ssu. Fio. 141. ,,.,,..,,1, ec7.cmat««. The •i<'<l»''=. "''ii'h c.uUts of cells, Uei Emor.-soence nn the .onua ... "'"J" ''';'' ""'^.'^T „.hich latter Is th„» mis«l so as to form a U.twee,, ll.mma..'» ...e...hrane. «,«...! the ep he .m^A^^^^^^^^^ ,,r,„„inenee. 1.. the e,.i.helin.n we '"»""«>"^ ''f^^' *,;;', !\ . ,,,;,ere,l .H^twee.. the epithelial !»^r;>' '-;'-::;.:r::^,r;""i t;::':":':^: ^™,ii::; t:..^ the ,«,...chy.na of the oomea, : j:::;;^;h;^:;;u.a.';;:.th,;:;,';;:-anii. ain.t.y i., aa.!,... of a ,..,» .„i«i« s i.s illBtinKiii'ihed by its more rtelicate fibril- Eczeraatous efflorescence in the l..>b,.a. ^J-o »cUm .S^'^^'^^^^ H. The no.iule i» lationao.. its bl<x«lve»els from t!.e "'"^« h.^o^mmu, n™ va^c ^^^^^^^^ ^^, „.,^ „,.„ ,ituated Ht a pMtit ^"r'^-'P»"'''"^'° ''^,''.^„"„"'"J,,^;^cked roun.l cell,, bet«..*n which the the sclera than over the eor.tea. It <=™*'f " °\^f''^'^;J_l^„,o„,,, ,trta;. In the vicinity of the blo.«]ve^ls are recognizable ..n<ier the form "'"«'''" ™^^"^,^ere<l bv extravasated lenc* „cKi„le the ve^ls of the conJuneUva. ■•, ^""^ !^^^7f;,';,'„'^ ^X. nolole, and at the apex of cyles. The epithelin.n, E. of the <■"""""■"* f„"hermn" cells int.. the epithelial layer itself, rrrr:;':rt;^:a-^:::r'';^:;'ru:nd the connective ti«ne. ««,.««. (12X1. (FlTHS.) Siufctiva by a It-ash i.f vcs.sols ^vluel^ Ik- in the track of the disease-. HJHEAfihS itF VOXJlWcTIV.i. C'lJiM I, .IA7> >/7,7,7M. 2'M The pn. cess I lit (I I extend.- far onto llie cornea, and tornis a cwrved tract. On .-nh.-idiii);, an (i|)a(|iie stripe i.- left, which has heen termed tlie scnijiiliniK IkiikI. Complications. A phlycli'inihir idcer may extend, rapidly produce lierforation of the corneji. and result in much damage to tiie eye. Diagnosis. Ilczeniatous keratitis may l)e confounded with lieriK-s of the corne.'i. luit the history of the :'ii.sc will suHice to difTerenliatc between them. Prognosis. Is favoral)le in nearly all cases. Treatment. Local and constitutional treatment should bcemijloyod. It is often difliciilt to ins|M'cl the cornea on account of tlie photo- phohia and l>lepharospasm. If a drop of a solution of cocaine he instilled, the photopliohia and blepharospasm will In- much relieved. With many children it is neces.sary to i)lace the head between the jihy.sician's knees before attemptiuf; to expo.se the cornea; a lid retractor is off. m re(|iiired. The cornea is sometimes hidden under llie ui)per lid, , il it is neces.sary to wait, with the lid retracted, for it to come jim tally into view. In severe cases a little ether or chloroform may be fjiven. Tlu' eye should be bathed or douched three or four times :\ day with .1 .solution of boric aci<l. Atropine may be in.stilled sufficiently olten to keep the |)Ui)il dilated. If the ])hlycteiuile has broken down. I'.ilomel may be dusted onto the corneji once daily. .\n ointment of the yellow oxide of mercury (1 per cent, in vaselinei may be put into the eye twice daily. Kissure of the outer cotnmissure often exists in the.se cases. The blepharospasm may be relieved to some ext<'iit l)y touching the fi.ssure with a stick of nitrate of silver or with .1 crystal of the sulphate of cop])er (Koller). Obstructive rhinitis and postnasal <irowths should receive ap]iropriate trciittnent. Systemic treatment should be instituted as for eczema of tiie <'oiijunctiva. In fascicular k(>ratitis the cure can be hastened by cutting tiie liMsh of ves.sels at the scleroconieal margin by means of a siiarp -pud. Ulcers of the Cornea. I'lcers of the cornea are variously clas.si- lied. In regard to their development, they are primary, beginning in the cornea itself, or secondary, by exten.sion of the process from the conjunctiva or from contiguous ti.ssues. In regard to [)osition, they are marginal or central. .\s to involvement of tissue, they are su[)erficial or deep. .Vs to shai«'. *'"'.^' '•^^*' cin'ular, crescentic, punctate, dendritifomi, iilamentous, and irregular. In character they are simple or infected. To the latter belong '\\i- so-called mycotic forms. In regard to the stage fif development, thej' are progressive or :• ;:n's.<ive. ricers of the cornea present certain symptoms in common. (F'ig. MM) TIIK KYE. „f the c.rn.'a at .»• Mf; <-» ' » ' ,■, , " .....rnivtir f.-rin. In.pair- ='■^'1';; •■ :■';::;. -rin ;;.':: *:; srih.. ..upinary an. i^ involvcl. 1 ; ' .'^'' ; " / -,.,.' iris, ciliarv Ixxlv, an.!, m nir." .•as..> r:r.;it;:^.':;:r inv...v...lin ,,. inliannnat..ry ..n.-ss. an.l sh..ul,l n.n-iv apprupnat.- =';";";|;;;'; ,,,„„ „.,< ,,„.i ,„ ^ulvanr.-. '■'■■« ''''1' mn..,!(. uln-r i- usuallv traumatic : »n.t the tor... is also .,°rr-t. tlS tins ..f in.V.:t.l ul..r in whicl. tl. pr..„vs. .s speedily arrested. ,„,rlvii)s the use of a hone JTSSL i:f:£tT,:ti'^^ .. : >"..». ^^ »" that is re(iuired. Corneal nicer. (S*»mi«h.) Inkcled Vlar The term infeeted ulcer is ap,)lied to ulcers which lov after soluti(.n -f .-.mtimuty ..f the corneal tissue, due to the ' .'^ly a ;;:Unic .nicro-or,anisn., such as thcj^tap^iy kj^^JU^ vumues •uireus, streptococcus, pneun.ococcus, etc. Ail '"" ^ K n> a^.riated Jith an intiltratic.n of the corneal t-s-K. -^ ' V n Tu \ BTviU-v or less .legree from the margins of the ulcer. tie' •uiompanips eczema of the .njunct.va. sUaoh has b.vn ''f-^ '''^" no e'headinft of Eczematous Keratitis. Another n of 'gna keratitis is the form that appears m the shape ot a long ■^^ m DJsJi.isJiS OF coyji-ytriVA, couyK.i, .\si> s<Lt:it.\. ;i(»i crescent involving frmii (iiir-til'tli tn two-tliinls of tlic circunifcrciu't' fif the cdiiica.sdiiictiiiics the entire circuiiiferi'iice(»f tlu'coniea, and to wliieli tlieterni " crescentic ulcer "sdinetinieK \*< applied. Tliis variety presents itwif as an interrupted line of jirayisli intiltratiim ininiediately lieni'atli tlie epitlieliuni, occurrinu just heyoml the free margin of the liinliiis. To the iinaidr-d ey<', this seems to he a continuous line; iiut examined with the lens it is seen to Ik' made up primarily of minute pustules uliich rapidly coalesce. Within twenty-four to thirty-six hours the e|(ithelimii covering these pustules disappears, and a su|)<T- licial ulci'r results. This process tends to adv.'ince toward the centre of the cornea ri'gularly, the line of demarcation lieing ((uite clearly cut. Witii the advance of the .su|ierficial infiltration the epithelial cells disap|M'ar, hut the dee]) layers of the cornea, save for a scantv inliltration of small cells, seldom are invaded. The afTection, par- ticularly in poorly nourished individuals, may advance until a large Fio. 144. cicatrix or corneal nicer. (Saehisch.) part of the epithelium of the cornea has disappeared. The super- fnial lamella' of the cornea are also sometimes affected to such an ■ ■\tent that when tlie ulcer has healed a delicate cicatrix, indicated !i\ the presence of a thin oji.icity, remains. (Fig. 141.) This form nt keratitis is usually iuoikk ar. Cause. It is highly prohiilile that a condition of the corneal tissue which renders it less ca|)al)le of resisting the inroads of micro- ti traiiisms is an essential «>lemeiit in the develo|)ment of this condition. \lii'i()-organisms that have heen ohserved in this form of ulcer are -inphylococcus pyogenes aureus, Klehs-LoefHer bacillus, and the I'liciimococcus. Duration and Symptoms. This form of marginal keratitis seldom is iH'l with in children, hut is most fre(|uent in adults of advance<l ' I ars. It progresses slowly, is attended with pronounced symptoms I irritation, and is accompanied by more or less secretion from the "njuiictiva. Injection of the palj)el)ral as well as of the ocular "HJunctiva is present. Tlie process may terminate in a few days. lit in some cases three months may elapse l)efoie recovery takes :ln.> Tilt: K> A" t Ix'ar ,,la,T. (Vrtitin Inrms nl niaininal -r < rrscnitic k.Tatm> ,.l„s,- n-sniihlaiKT td.lriMliiiil'-.nii k.-ratitis. DiagnosU. Tl... .lia,n.-sis .,1 .■n.^.-ntir ..I.mt p.rs..„t> mu .hllu-ult...> sin.M. tl..' l..cati..n an>l I'.-nn atv ilw .'ssrnlial Iratnr.s In a.iaitinii til tlif 1"<"'I lii'aliiinit. Ilif p-nrral III the liamtic ,1„. lH..t, I.Hlnfunii. arist..l, or n„snplicn may !«• \n>\x-r^'^ J , itvufrasrs. Ii..w..v,.r. tlir us. uf a .•l....nu.al .,,■ tliHiiial rsr laintu- : u'rvinavi;. appli.'.l -linrtly U. tl... ul.'.T W ..■.. t',. ...,!,..> : n . nv...l ..v..n I art uf tl,- .lis,.as,.,l M.ria.v slu-ul-l «■ t.uirl.r. . A ^. i. api.llatin„a.,ann.MluM.anU.,H.rf...^ pure carlMilic ac'ul. Othrr forms uf marfimal k.Matitis srcoiHlary to ,,,h,r,.s an. oLscrvr,!. Tin-., aic .luc to mlcHion nt , ,„,„lv pr-Hl,,.- .■vf.nsiv.. ,l..strurtiun ot tlu; rorn.-a, lla- t, .at- ;;:r;^ljs<. uln.. •. .imilar to tl.at for .1,.. .a.opatl>... tnarpnal or .•r(.sn.iitic (ilc<'r, wliich l.as Ixri. ,|..scnl)c.l. ..ir,.ular or at. i.T..«i.lar shap.-, Tl..,v .nay n-sult m .l.-struH.-n ol Fir, U'>. operative |iro- tlie woiiiiil. ami mav ass\im(' a ., .mall or a larg.' portion of tl.o corneal tiss„.>. or in .1.-st ruction of -ntin- cornea Tl.c fonn of uIo.t to which the tern, circular isa plie 1 occurs most frc.ucntly in the shape of a cone whose a k-x s n'th<. stnuna of the cornea. The walb ot the ulcer presen a L vish appearance, an,i iniiliration of th- c rn..a extoiuls q.nio regularlv nto the ailjacent tissues. In some cases hernui o th^ nt Sr cl.a.nlH-r n.sul s. . Fi^. 145.) I , some cases perforatH.u takes i>isi:a.si:.s ttr cnyjiyrriVA, cou.sE.i, ami scihji.i. ;jn.| I'liHT, aixl ill iillicrs plastic Iyiii|ili t'driii^ at llic Ixittinii ol' tlic anterior ihaiiilMr, whfti a conilitinii kimwn as liy|Mi|iyoii is jinx luce, I. Tlic (•irriilar iilcir i> usually a ri'lativt-ly licnipi roriii, ami rcKri'ssiini sets in Ixlwrt' [icrloratioii occiii-i. The ulcer wlieii first iiotited presents as a sii|M'rficial loss of epitlielimn with a >;rayisli-yel|o\\ centre. This jrrayish-yelldw centre represents a mass (if superficial ni'cn.lic tissue, which li.|iie(ies and extemls slifrhtly until wiliiin twenty-tour or seventy-tw(» hours a relatively drep loss of tissue results. This form of ulcer may occur ;it any period of life, hut is most frei|uent in adults. Its duration is usually from five to ten days. In severe cases |MTforation. fistula, and partial staphyloma may result. Treatment. The measures previously spoken of. omiprised hv the terms cleanliness and ase|)sis. should !«■ employed. In many cases the ins|M'rsion of calomel once daily, with the introduction Of the ointment of mercuric chloride four times a day, will sufhce to hrinji alxHit recovery: hut in all casi's of circular ulcer either the .M-tiial cautery or pure carbolic acid may he employed with very excellent results, and recovery hrounht aliout much more rapidly than hy the u.se of simple medication. The condition of the system -lioiiid alw.ays 1m' inquirecl into, and siiitahh' measures instituted ,o correct irrejiularities. /////«)/)(/«/( Kcnitilis. In all pronounce<l cases of corneal ulcer the :uit<'rior segment of the vascular coat of the eye (iris and ciliary lio(ly) is mon' or less irritated. As a result, exudation from the vessels ensues. The jKiueous humor Ix-conies more alhumiuous, and lilirin forms. Kihrin is deposited on the |)osterior surf.ice of the cornea, and often on the other surfaces that are in contact with the ,ii|ueous humor. If the irritation is sufficient, leucocytes esca|K' from tne vessels of the iris and ciliary hody, and reach the anterior iIiiiimImm- and jiravitate to the bottom. If sufiicient fibrin is present, ilie leucocytes become imbedded, forming a pulta"eous mass which Anc< not change its position when the position of the head is changed. In the absence of sullicieiit fibrin the collection remains fluid and rli.inges its jHisition as the position of the head is ch.-ingi-d. The Hiass is yellow in color, and resembles pus. It contains no i)athogenic -iinis and is itmocuous. Its |)resence constitutes what is known as 'lypopyon. Tiie suiwrior border of the hypopyon is often slightlv coti- \('\. ( )n looking ()bli(|uely into the anterior chamlK-r, it will bl' set n hat the pus is chiefly depo.sited on the jxisterior surface of the corn.'a, iie surface of the iris In-ing free to a considerable distance below the :|iper m.'irgin of the deposit. The researches of LcImt make if evident lit the iirespuce of the leucocytes and fibrin is an attempt en the irt of nature to aiil in preventing destruction of the cornrid ti.ssue. ^'■iny of the leucocytes penetrate into the corneal tis.sue b.- way of 'Htana's spaces and jjroceed to the vicinity of the ulcer. The less remain in the anterior chamber, and there form the collection -I described. Older ob.servers, noting the convex upper border of !■ niass of exuilation in the anterior chamber, and the fact that .•!()4 THE EYE. • the iris \v:is free, siijiposcd tiial tlic (•(illcctioii of pus was hctwci'ii ihc laiuciia' of tlic coriica, and, ix'caiisc of tlic rcsciuhlanoc to tlic Imiuia of the fiiificr-iiail. tcniuMl it iinijiiis or ..n/x (nail). Tlic presence of liyi»o|)yon in itself calls for no particular treatment. With suhsiilenci- of the disease which calls it into existence it <lisap- pears 1)V al)S()r])tion, sometimes slowly, sonu'times rapidly. It may disappear and reappear, and vary in amoimt from day to (hty. Andc SIoHiihiiKj Vlnr iScrfwiit liar, Saemisch). Tiiis form of ulcer affects ailults almost exclusively. It may occur in children del)ilitated hy exhaustinf; disease. Infection through a wound, usuallv superficial, is the cause, the pathofienic micro-orRanism hcinfi introduced either at th(> time of the traumatism, or subsequently, from tiie contents of the conjunctival sac. This affection has heeii ohserved fre<|uently in farmers ilurinj; the harvest season, and has been termed "harvesters' keratitis." Stonemasons are par- ticularly liable. .\ similar form of corneal ulcer has been observed in those enjrasred in oiieninji oysters, and has been termed "oyster shuekers' keratitis" ( Rudoljjh)." Tiie micro-orfranisms chiefly engaged ill the production of acute sloufihiiiK keratitis are the |)neumococcus ( rraenkel, Weichselbamii, Sattler, (iasiiaiiini, I'earls, Ba.sso, riithoff, and .\xenfeld), streptococcus. Staphylococcus pyoS<'"<'>' aureus, gono- coccus. Klebs-I.oefHer bacillus, etc." The term serpent ulcer is not descriptive of the disease, and should be abandoned. ,\cconlin<; to Fuchs, the characteristic clinical picture of the disease is present only in the eaHy sla<!;i'. It then ap|)e;irs as a disk-like opacity near the centre of the cornea, the centre of the disk beinj; not so dense as the marfiin. The surface, which at first is slightly raised, soon becomes slightly depressed. Iritis, cyditis, and hypo])ynn develoj) earlv. The ulcer advances irregularly: an arrest may occur in one portion, and the epithelimn may advance over the edge of the defect. .\t anothi'r part the gray inhltration advances, and loss of corneal tissue continues. Hernia of the anterior chaml)er. followed shortly by perforation, is the usual course. The entire cornea may become involved and slough. .\s comi>lications, there may be loss of the crystalline lens, escape of vitreous Innnor, detaciuneiit of the retina. intra-oc\iIar hemorrhage, panophthalmitis, etc. Treatment. This should be energetic from the start. If the ulcer is small and in the e.arly stage, meiMcinal treatment may be employed, providid the patient is imder close ol)servation and can devot(> the time to licatmeiit. This consists in hot bathing, which should be eontiiuious during the waking hours. .Atropine, in 1 to ',\ y ■■ cent, solution, should be instilleij suflicii'iitly often to keep the jun Elated. Labarraipie's solution. 1 : 10 to 1 : S, maybe instilled every t\ - hours, lodot'orm may lie inspersed and a compress bandage api)lied. It tri'ated as an "out" ]iatient, operative procedures should be resorted to at once. In the eiiriy stage, if .a large area is not involved and little hvpopyon is present, cauteri/.ai ion should be rcMirted to, ]>ref rrably with the actual cautery, .\tropiiie should have twen instilled ■■H wmm wmmm JJIHICASICS OF COXWyCTIVA, COJiNEA, AM) SCLERA. :U}-} |iivvioiisly. After cmitiTiziiig. iodoform may be dusted into the wound iiiid a eompress handiifte applied: or the eoiijimctival sae may U' tilled with hiehloride vaseline 1 : otMK), and the eye hanihiRcd. The eye should he inspected, the remedies used, and the handape reaj)plied from one to three times in twenty-four hours. In ulcers i;ii' .'ire larjiewith larjre hypopyon the Saemisch incision should Ix" peril. ;-)i.! This is done by piercing the clear cornea at the margin I'i the u'f •, carrying the point of the knife into the anterior chamber li( neaih he ulcer, and making the counter-puncture in clear cornea. I h • inc.sion is comjdeted by cutting through the floor of the ulcer. The a., leous humor is permitted to escape slowly. The lips of the wound are separated, and the pultaceous mass forming the hypopyon IS washed out or lifted out with a spatula. This operation permits of incarceration of the iris, but prolapse .seldom occurs if the operation is performed with ordinary caution. The margins of the wound close rapidly. It is advisable to open the wound once everv day for n few hours. Bandaging and the usual medicinal treatment" should lollow the oiK'ration. ilccr in Variola. In jjatients suffering from smallpox the cornea may 1k' the site of one or more pustules. The.se do not, as a rule. lead to destruction of the eyeball, but they are followed by more or less opacity of the cornea, which greatly impairs vision. In France :]n per cent.— and after the introduction of vaccination 7 per cent.— of all the blind lost their vision from smallpox. In the Inited States, wliere vaccination is so general, blindness due to MiiallfMix is seldom seen. If the eyes are insi)ecte(l daily during the illness, and cleansing by means of mild anti.septic .solutions and bland ;iiitiseptic oils or ointments is employed, something in the way of prevention may be accomplished. In addition to the formation of variolous pustules the cornea may be the site of a destructive kera- 'itis, due to infection from other germs, as occurs in those who are lint infected witli variola. The results, on account of the (iepress<Ml iiindition of the individual, may be very serious .«o far as vision is <oiicern(>d. .W/.vroN o/ thf Conira. .\ process terni(>d :inmilar abscess of the 'I'nira sometimes occurs after perforating wounds and after opera- iiMiis on the cornea which result in infection of the coniea. In these '■■ises a yellowish anmilar ring forms in the central jjortion of the '■ornea. The centre of the cornea and the zone next the limbus are 'Kizy, but less densely so. Tlie yellow ring extends, involving the lit ire corne.-i. The corneal tissue sloughs. Destruction of the cornea II these cases is complete in three or four days. Destruction of the \<' is sure to result. Fuchs advises enucleation at an early stage. Fi.^liila of the rorneu ai)|)(>ars as a small black point at or near 'le ceiitiv of the cornea. If perforation, the result of ulceration. ■ui-s in file coTifre nf the cnrnra, it may nr.t h<- povf-red by tin- iris. id recovery must take place by the development of new connective >ue from the margins of the ulcer. Recovery under these con- .'}()« Till-: EYE. ! ditiiiiis is slow, and it .sdiiictiiiics liiijipcns tluit with closure of tlic pcifonitioii the iiitra-ocular tension issiiHiciont to rui>tiin' tluMlclicatc ii('\v-t'onii(Ml tissue, and tlie anterior (•lianil)er is evaciialed and a fistula is formed. If the fistula remains open, tlie eyehall firadually atro|)liies or infection occvn's, and panoplitlialniitis follows. Tlie fistula may close, and on restoration of the intra-ocular tension may ajrain he o]iened. This may he repeated a mnnlur of times. Infection usuallv occurs sooner or later, and lo.<s of the eye results. Treatment. In recent cases an attempt may 1)0 made to secun- closure by applying a comi)re.ss liandage, and myotics may 1k' em- ployed to keep the intra-ocular tension reduced. If the anterior chamber becomes restored, an iridectomy may be ])erformed for the same purpose. Cauterization of the walls of the fistula is resorted to .sometimes for the production of a firm scar; but it should be em|il()y(Hl with care, to avoid woundinfr the lens. I']xcision of the walls of the fistula may be resorted to, and the opennifi may be closed by a suture. Filanicntiins Kc'n'ilis. This disease may be classified as idio- |)athic or traumatic. (/. Iiliojxttliiv jllitwcntoiix kcr(ttiti>i is characterized by the forma- tion in the corneal i'i)ithelium of epithelial fjlobules, measuring; usu- ally 1 mm. to Ij mm. in diameter, which are pushed jibove the level of the epithelium, and finally become pendent from the epithelial surface and coimected by small pedicles (Xuel, Mess). The globule consists of epithelial cells, of the tessellated variety, which are uiideifioing mucoid degeneration. In the centre a hyaline body u ually is ()hs(>rve(l, resembling coceidiuin. The ])edicle consists of a central core, composed of epithelial cells which have become elon- gated until they assume the appearance of fibrilhe. These an' twisted into a small thread. The masses rise and fall, accompanying the movements of the lids. The filaments last from thre(> to four days. A fresh grouj) of the gloliules may appear. The number of globules may be but two or thre(>, or they may be n\niierous ;ui(l cover almost the entire cornea. This disease is peculiar to advanced adult life, and is observed more frecjuently in eyes that have been the scat of an inflammatory process affecting the anterior segment. Shnilar globules may form from the floors of ulcers that are in the |)rocess of healing. h. Trdiimatic lilamr»li>iis krrdlilis is probably due to the adher- ence of ])artly detached threads of e]>ithelium rather than to fila- ments derive,! from the eruption of globules as above described. Symptoms. The development of filamentous keratitis is accompanied by symptoms of irritation, slight injection of the ocular conjunc- tiva, a sensation ;is of a foreign body in the eye, and the |)resence of scanty mucoid or mucop\nulent secretion, ))ortions of whi?h adhere to the coriie.al surface, Slight f(>brile reaction sometimes is ol)servc<l. Treatment. Treatment should be constitutional as well as local. Local treatment consists in keej)ing the cornea cleansed, using mild DUiEASES OF VOSJISCTIVA, COIiSEA, AM) SVLEUA. 3(»7 .■ii]tisc|)tic sdliitidiis -solution of horic jiciil f.S per cent ) or pota-^- simn pcnnaiipiimtc (().L> to I p<"r cent.) niav l)c cniplovcd. In addi- tion, niiich I'onifort is };ivcu tli." patient if a lubricant in the form of horated (.") per cent.) or hicliloride vaseline ( 1 .oOOOi is intro- duceil into the eye tlir ir four times daily. The systemic treatment consists in the' eiiijjlovniciif of general Ionic remedies. Tiider this form of treatment we mav hope for a suhsidence of the affection in from tliree to five davs." Hecurreiice may take place. Ikndrilic Kmitili.-- {Furrow Kenililis ; Mi,r„tic Kmililis ■ Kcra- hti. Arh„r,sn„s). Th<> term is applied to' a superficial form of keratitis supposed to 1><- due to the presence of a specific micro- orKiiiiism. The process usually begins at the peripherv of the cornea l.iit may al.so begin in the centre of the cornea. It is characti'rized by the appearance of a narrow gravish line of infiltration in the corneal tissue near the surfac( . accomiianierl hv an elevation of the ^•pithelium. 'I he ejuthelium covering this line of infiltration breaks down, and a shallow groove f furrow") is formed. Preceding or tollowmg the destruction of the epithelium, offshoots from the original Ime ot infiltration are observed. The offshoot fre(|uentlv terminates 111 a minute grayi.sh enlargement (colonvi. These offshoots imiltii)Iy, 'iiitil eventually a tree-like ("arborescent") formation is presented! I he infiltration is not confined to the grooves and lines, but advances into the surrounding ti.-^sue for a short distance as the process con- tinues. The advance of the process differs in different cases. As a rule, the advance of the disease is relatively slow, a minilxT of days, perhaps weeks, elajjsing before f"ll <levelopmeiit is reached. fh(> -uperticial nature of the process • be continued throughout its 'oiirse. Involvement of the deep, i.s.sues mav supervene, and in 'xception.a! ca.ses perforation of the cornea may take place. When the deeper tissues are involved, it is the result' of a mixed infection ot the cornea. Symptoms. The symptoms of this affection are frequently verv 'hstressing: the i)atient comi)lains of a sen.sation as of a foreigii body m the eye: i)holophobia to a very annoving degree (leveloi)s. Xeu- !.i gic pains. ;ifTecting the distribution of thesui)ra-orbifal and iiifra- -iliital branches of the fifth nerve are experienced. Those svmptimis iiiay suddenly ceji.se and Im' absent for a dav or two, and then sud- eiiiy recur. The intensity of the svanptoms deiieiuls directiv upon 'he activity of the jj-ocess. Cause. A cause h;is not as yet been determined. The apijcar- iiices indicate the presenc(> of a micro-organism. Diyurolioii Kmititi.y {K<ratitisr Lofiophthalnm). When the cor- 'Ma is ,.x,,osed for any length of time without suitable lubrication, le epitlieli:,! cells iH'come dry and irregular and the cornea l)eeoui08 liL'lnlvo.,a.|ue. Kxp..sure leads to one of two things; the corneal >Mie either takes on a cutaneous cf.ndition, or the corneal sub- '•■'iice is lost, and ulcer occurs. Keratitis from desiccation occurs Il)l •MH THE EVE. ill cases (tf cxtrciiic cxuplitlialiniis, ri'tractiiiii of tlu' Irvalor (ial|)fl)ra' sii|HTiiiris. cxlninc cctniiiidii. paralysis ut' tlic i)rl)i<Milans palpc- liramni iircvcntin;: closiirf (if tlic cm's: in licltilitatiiifi diseases, as tvplidiil f<'\('i'. siiiallpnx. ami in the later stajies of disease eiidiiip in tlie deatii of tiie patient, wiiere, from in.aiiility to close the eyes, the corne.a is exjiosed. In all cases of desiccation keratitis the por- tion of cornea first afl'ecte<i is the exposed |ionion. Desiccation keratitis is prohihly most fre((uently observed in laf;oi)litli;ilmos. The ulcer • rofiress and destroy nion- or le.ss of the cornea. Symptoms. The symptoii.s are, as a rule, not severe, Ahire or loss pain referable to the eye is complained of, and in cases of in- volvement of the iris and ciliary body, .symptoms peculiar to di.sea.se of these structures develo]). Treatment. The treatment consists in jiroviding protection for the exjiosed cornea. This, in the cases of hifiophthalmos and exoph- thalmos is accomplished by the ai)])lication of protective bandages and the u.se of lubricatiiif; ointments. In cases not admitting of relief bv spontaneous recovery, tarsorrhai)hy to an extent sufficient for the |)roi ■ciion of the cornea may Im' performed, .\fter cicatricial ectro- pion plastic operations for restoring: the lids should be resorted to. Kcriitiiiiuilitciit. Keratomalacia accompaiiies xerosis epitheiialis, atTectin^ infants, and occurs in the hiter staf;es of exhausting diseases, such as typlioid fever, scorbutus, etc. It is characterized by a prayish discoloration of the cornea, increase in thickness (if the corneal tissue, accomjianied by softeniiif; .and coin|)leto loss by sloufihing. Keratomalacia is .seldom seen in adults. The condition beloiifis almost entirely to X(>ro.sis affecting infants, as has been stated in the descii|)tioii of x(>rosis (see Conjunctiva), and needs no further reference here. A lethal result almost invariably takes place in those alTectcd. Treatment manifestly is of no avail. Xciiroixtrdhilir Kcr(ilili.'<. Diseases of the fifth n(>rve occurrinp (>ither in the trunk of the nerve, in th" (las.serian fraiijilioii, or at the i\ucleus of the nerve, produces insensibility of the cornea, and at the same time removes the source of stimulation for the lacrymal <:land, c.ausinir a dimimition in the secretion of the jilaiid. With loss of the sensibility of the cornea and conjunctiva the individual fails to appreciate the presence of foreijin sulistances, .and is not m.ade •aware of atmospheric influences on the surface of the cornea, which uiider^rocs desiccation. W'inkiii}; is not performed sufficiently fre- (|uentlv to maintain the proper moisture of the (-(irnea or to remove foreign substances from its surface. This co> :'iition leads to jiartial loss of ejiithelium and permits of the entrance of destructive bacteria, briiifririK about a keratitis which at fifM is superficial and general, but later may develop into deep ulceration with loss of substance, perfor.ation, and, in the sevrer cases, complete loss of vision. It is held by sonip writers that this process is not entirely 'lue to exposure. DISJ-SA^ICS OF CoyjiWCTIVA, VOIiyKA, AM) SCLEHA. .•!(»!) l)iit tliat linpliic ilisHirl):iiiccs occur consciiticiit on tiic ilcstnictioii of the ncivc. Since, liowcvcr, it is not proved that tropliic nerves, so-called, exist, we are not warranted in assuiniiij; tlu.l tliey d() exist, and we must attribute the clianfies that occur in the cornea to insensil !ity of the cornea, to exfiosure, and to the entrance of noxious jjerins. Cases are cited by :■ number of writers in which, after protection to the cornea has been fiunished, the process has not aliated. but has contimied, and destruction of the cornea has resulted. These observations, lujwever, were made jirior to a perfect understanding ol asepsis, and it is possible that destructive micro-organisms were jiresent. and that tlie continuation of the diseased jtrocess was due to theui. Treatment. It is found that protection of tlie coriipa eitlior by means of a |)rotective bandage, tarsorrhai)hy. or bv the use of oint- ments sulliciently fre(|iiently applied to keep the cornea covered, will l)rin<j: about a restoration of the corneal tissue, and will prevent lurther dev(>lopinent of the keratitis. Non-suppurative Forms of Keratitis. Pannus. This is a form of sujierticial vascular keratitis, and is the result of an attempt on the i)art of nature to i)rotect the cornea Irom irritatin-i influences. It is observed most fre(|uently in tra- choma, and occurs in that stage of trachoma in which the I'levations Mil the surface of the conjunctiva are hard and dense, and are cai)al)le nl producing dis|)laceinent of the e|)itheliuni of the cornea with which they come in contact. The vascularity may affect the whole or a part, usually the u])per portion, of the cornea. In ca.ses of trachoma in' which the lower lid is but slightly involved, the pannus of the cornea may be lini'te.! exclusively to the ui)|ier half. It sometimes occurs Ih.'it the irritation of the corneal tissue affects cnly the lower half uf the cornea, in which case the pannus is limited to this part. \"as- <ular i)aniiiis may be extr(>mely slight {/xiiutiis tenuis), or the vas- 'ularity may be very proiioimced (jxinnus niscularis); it may be so intense that the cornea is converted into a condition resembling a tieshy mass (iHiiniKs rrn.-<!<uy or nirnosny). The vascularitv remains ■1-- long as the irritation is present, and then gradually" sub.sidps, •'tteii leaving bui few traces. In sev(>re ca.ses complete opacification ■t the cornea may result. In the later stages, when few bloodvessels lie present, the condition is known as pannus siccus. Pathology. The blood' essels in paiuuis, in the earlier stages and mhter forms, are found immediately beneath the epithelial layer. Iliey lie in a scant stroma of new-formed connective ti.s.sue or forina- i\e cells, and are accomi)anied by a more or less plentiful small-cell 'ifiltriitiun In p:uuius tenui.-^ Bowukui's membrane reniain.s almo.st, I iii.t ((uite, mtact. In the severer forms of pannus the superficial lUiella- of the substantia propria are involveil and Bowruan's mem- :i\t) Tin: i:yj:. I)r;iiic is };rc;itly (•Ii:iiij"m1, l().>in>r its cliar.-ictcr ciilircly. It is never restiireil. Treatment. Tliis consists in feniuvirif; tlie ("iiise. Herpes Corneae. This disetise. which reseniMes eczema cornea' in some respects, is to lie dit't'erentiateil liom it. It occurs as an accom- paniment of herpes lelirilis most l're(|iiently, liut also accompanies lierjies Irontalis. It is characterized hy the appearance in the cornea of two or more vesicles, wliicli at first are transparent, but soon become cloudy and of a yellowish color. The ejiithelimn then gives way. Mud there is ;i su|)erficial ulcer with shreds of epitlielium hanj;infi from it. The floor of the ulcer is ana'stlietic. hut the surroundinjr cornea is not. Tin a|)pe.arance of the vesicles is preceded by sliariJ. prickiii"; pain, by lacrymation, and, at times, by nuic(>])uru!ent .secretion. The jiniy inhltration at the base of the vesicle may not extend, liut tine lines of inhltration extendin<; into the surrouiidinji cornea may be present. Crops of vesicles are a|)t to occur. This form of keratitis attacks adults of luiildle life most fre<|uently. Vounj;er individuals may lie attacked. Accomjianyinj; herpes of the cornea there may be herpetic vesicles on the lips, iio.se, face, and eyelids. llorner. who described this atTection in ISTl, oli.served it followiiifr pertussis, intermittent and typhus fever. .Vccordin;; to llaab, the outer layers of the cornea, Howman's membrane, .and the epithelial layer may i)e elevated by the process. In cases that are suit;d)lv treated, recovery occurs as a rule in a week or ten days. In neglected cases sec<indary infection may occur, accompanieil by more or less destruction of the cornea, hypopyon, and iritis. Treatment should be local and constitutional. ( 'le.ansiiiji the eve with a '-i per cent, solution of boric acid three or four times daily, and the introduction of bichloride vaseline ( I:.")()()0» after each balli- iiij:, will be sutlicient. ('oiislitutional treatment should be directed to improvement of the general .system. Keratitis punctata superficialis begins uitii symptoms of acute conjunctivitis: it is related to herpes febrilis cornea', but does not form \-esicIes. Small gray spots form in the superficial layer of the cornea, occupying the central portion: the.se may be very numerous, or may be limited to six or eight. The corneal surface is rendered uneven by the elevation <if the epithelium lying over the spots of infillrali<iii. Bullous Keratitis. This condition consists in the formation of a large vesicle or vesli'les on the cornea, usually occujjying the lower portion of the cornea. It occurs in eyes that are affected by a chronic iridocyclitis, after sujierficial traumatism, and in those whicli ;u-e subject to increase <if tension. The presence of the bleb or !>u!i;t is ;u'con:paliird !iy syUiptotiis .if l;>il;tlioii. There art' ('XC<';ssivr lacrymation, iihotojihobia, and mucopurulent sec.etioii. The affec- tion is jieculiar to adult life. i:_ i>i.si:asj:.s of co.v./r.vcv/r.i, c»iiM:.i, .i.vy> sclicua. .hi Duration. 'I'lw l,|,.|, usually persists for ;i lew ilavs. tlwn niptiircs the tliivjKls of cpitlicliimi liMiijiiiifr fn.in the iiiar<;iiis: il,,. ,l(.nu,|,,i surlacT IS rapidly rccdVcriMl hy ciiitlicliiiin. In soinc case- tli.. Mrh nf«'ns spuMtaiK.msly al th." siiprrior part aii.l tlir hid, wall l.ccnincs nattaclKMl to the cnriK-a. l{(Tnrr..nc.'s aiv lr(>(|ii.'iit, tin- nriirrnicc takiiif; place iii some cases within a tVw davs. aiul in some cases months or years atterv.anl. Pathology. 'I'lie outer wall of the hleo consists of the entire epi- lii.'lial layer of the cornea, which h,i.> heeome raise.l by the tr.aiisu- I ation of fluid through Howman's nienihrane. lirufrjrer' helieves that the first step is an infiltration of the .substantia propria of the <Y'".ea with fluid which could not escape bv the liinims: iiev; tissue- '•nnenis lorm beneath the epithelium of Bowman's membrane and the ei.ilhehal layer eventually becomes detached and is pushed torward. ' Treatment. It is sometimes sufficient to puncture the vesicle and .•ipply a compress bandage. It becomes neces.sarv in sonn> case- to remove the anterior wall of the vesicle, ami to "treat the denuded suriace by an api,lication of a solution of nitrate of silver 5 i.er cent, to 1 per cent., or by superficial caut.Tization. In some ca«es removal ol the superficial parts of the cornea has been resorted to It IS. ..t course, desirabli' to cure the condition which makes the lorniation of the bleb p,,ssible. The ultimate result in the vast iii;i,iority ot ca.ses is favorable for retention of the eve .aiid the pre- servation of some defrree of vi-^ion. In rare cases" removal of the irldbe becomes necess;irv. Parenchymatous Keratitis (Int^stitial Keratitis; Diffuse Kera- titis!. l';ireiiehymatous keratiti/mav develop from the peripherv ■■I the cornea or first manifest/self by thi- apjuNiraiice of oj,aeitie"s "n or near tiic centre of tlir^ cornea. A\heii developing: from the |i''npliery. its free border is irrejrular an<l is usuallv less dense than ■Il the marjrin of the cornea. If .-an-fully c-xamined. the infiltration will b.' I.,und to be uneven in den.sity, fre(|ueiiflv beinjr made u]) of :. number of loci. Thickening of fhe conjunctiva "at the sclerocorneal .iunction accompanies the process, the limbus apparentlv advancing :i sh.irt distance onto fhe cornea. The limbus here is"deei)ly con- i;i;st('(l and pre.-^ents a bright-red border. The extension of the ve.s.sels "t the conjunctiva onto the cornea is limited bv a sharp line of demarcation, and sel.lom exceeds I mm. or H nim. Soon vessels ni.ike their appearance in the i)arenclivma of the cornea and ■Mend into the infiltrated .area. The inf'iltratic.n .advances toward 'l|'' centre, and may eventually involve the whole of the cornea. I lie op;icitication may become limited, afTecting onlv a small portion •I the cornea. It .seldom occurs that infiltratioii of the cornea Hlvanemg from the margin involves the entire margin of the cornea !^il.,nn!y. In the majority of cases infiltration begins in the lower II SI I (luadraiii. ' .Mou. f Aug, Ueilk.. 1886, vol. x.xiv. p. 500. .$12 Tin: lAi:. The scconil iiiikIc nt utisct is that in wliicti tlic oparity fifst iiiaiii- tVsts itself ill tlic ('('litre uf the ('(iriiea. In tliesc cases thi' iiitihratidii iiccurs ill miiiieniiis foci in tiie centre iif tiic cdrnea, ^fachially spread- ing until the greater part of tiie CDrnea is involveil. (Fig. 14(i.) The vessels of the liinlms throughout the whole pi'riph ry of the cornea are soineuiiat inject<'(l, hut the |iriiici|)al vascuiai ty occurs in the deep tissues of the cornea, advancing from ihi" periphery. In hotii forms of onset the -urface of tiie cornea becomes soP'ewhat irregular, thit" to numerous iiiimite elevations, \ision is impaired in propor- tion to the density of the intiltratioii. The intiltration of the cornea advances rapidly, in s<ime cases involving the entire corneal tissue ill from two to four weeks. In some cases the advance is much less ia|)id, the height of the atTection heing readied only after two or Fill. 1411 . ■' ''' ■ .v.„%j5j;' i.^*"*-" ■-*•»»," ; ti-JE-% Section ol" interstitial keratitis. (Wkdl.) three months. In the average case the corneal tissue recovers its transparency almost entirely, but on close examination with briglil illumination o|)a(|ue tissue may be detecteil, and a fine network of lines representing the site of the vessels may be made out. In many ca.ses the tissue of the cornea does not appear to have been greatly affected by the jiroccss, but in the severer ca.ses sclerosis of the tissue results, the cornea becoming thinned, and its diameter increased by stretching due to the mtra-ocular pressure. In some ca.ses only a ]>ortioii of the cornea becomes scleroseil and (>ctatic. Duration. In the average c.'t.se the disease runs its course in from five to ten months — selilom less th.'in five months even in the mild cases: In tiie severer cases the clearing up of the cornea does not reach the ma.ximum in les.s than two or three years. DISEASES or coyjryvTiVA, cnjtsj,.i, a.\j, svlui. 31.} tlic eye- iris, ciliary l)u,|y, aihl" (•|,„n)i,|. Symptoms. More or less irritation increased lacryinatioii, photo- , 1, 1 • • ■•..■..,,, nil n-.i^rii acrviiiaiion Dlioto- : ;':,;:: ''TT" '" ""■ ';''"'"^>' "^ -iva,u.e.i.nt o ti r 'c.n ^vni in:'";;' "'"■"""•' ^t' "■ ''"«^«- -""•*""- -luit.. Cause P , ."•■•' r"' "•' .''"■ ••■"'I''"' ="■'■ '•XFKTic.ur.l. Cause. 1 an.nfl.y.natous k.'rat.tis is -luc in ti.c va.st niajoritv of ;-.iM> to syph.l.s. .Mth.-r inlH.rit.Ml or ac.uin.d. InlH..it,Mi s • L is s ,y ar th.. most l,v,u..Mt <aus,., m...un mtisn. an<i p.u l?. '^ . aps m very t.w ..asos, an.l in,l,.finit,. ,|ys.rasia Ly also .'aid '" l"".lucr ii very small proportion ui the cases. As' liid result of Fig. H7 _^§^fili^ IVmmrieiit Incisors of inherited syphllli). Rachitic teeth. i"li"il"l «.vr.l,ilis. it ,„„,- „(I„1 i,„livi,l„.-,fc l,o(,v,,.„ ll„. «,„ „f ,i,,. ::; t':::s:;;«c;,[:. "-"" " ' "■ '-—" .i:'.;» Accompanying parcnchytnatoiis keratitis ,lue to inherite.i svi.l.ilis ;| <• .-.Ttain pecul.anties in the conformation of tlu' ,!^1 ^^ ? . ^■;.p-:t..Smt;;:;fr^;:;;;^--;;L;in:^^^^ ;n;.<n.,. principally the n^^tL^'^.^. ^^^ ^tt^ no H r/,; t ,e fn 'llr; e'r Tr-'""r'' '^^'; ir«-ha,,ed, and present '""h ni tm ine border. This form of de.itition was described :il4 I III: iivi:. I hisi l>v lliitcliiiisi.n ;i> iiccuiiiicmyiiif; lln> Ml'lVctimi, mid is known as Ihacliinxm Icc'ili. ( Tij;. ItT.i ll -limilil not lie (•(.nluun.U-il witli lliul in wliicli ti nainci is (Ictcctivc at tiic a|ic\ of the trctli, (11- in whicii 1)V a |iria<'i''l aniicarancc of the i-naincl ililTrnMu |)li:i.s«'s ii, its ilfvclui MU arc tvinvscnlcl. 'IVcih nf iliis cliaiartcr arc usually llic rcMilt «>! rickets ami ol' oilier forms of nialniilrition ni the iiii'ant. (I'ifl. UN.) N"' infrequently the heariiif; in infants with iiarcnchyinatoiis keratitis is defective, due to involvement of the auditory nerve In pareiichviiiatous keratitis the result of ac(|iiircd >yi)lulis involvement of the cornea occurs from six months to as many years after the ajipearance of the primary sore Treatment. The treatmeiit should Iw local and constitutional. In puretichymatous keratitis .lue to inherited syphilis the treatment is not the same as that employed in the cases due to acipiired. syphilis. In the lirst form the local treatment consi.sts in the use of atropine for the purpose of maintainiiif; ililatatioii of the pupil; the use, ordmarilv, <> tl le cornea: if stinmlatinn ap|ilications to induce vascularization c'f iiid inoditication of the lij;ht by dark plasses, suitable shades, or by keeping the patient ui a da :irk room. In manv cases )f this disease stimul.ition is m t necessary in the early stafie, but stimulation, altlioujih not necessary m many ca.ses, is never harn fill, and. ill the opinion i if the writer, is desirable even in those cas II which the onset is relatively ra| Stimulation i IS effected bv means of the introduction of suitaiiie ointments, either ointment ol yellow o i 1 ■.■)()(l()l \ide of iiiercurv il to !..') |ier cent.) or mercuric ( •hloiic )r the iiistill.-ition of stimiilatiii>; druiis the wine of Ilium, or by hot a|>plicatioiis t<i tin eve, usually liv means of ;iioist heat ihot batlini!;! acid three or four timi ither with salt water or a hot solution of boric .1 da\. lifteen to thirty minutes each time). Powders may be dusted into the eye. the best beiiiji calomel. Caloni when employei 1. shoulil be introduced i nice a da\ Internal treatment consists in the WMieral tonic treatment of the iniliyiiliial iiid the administration of a iiK-reurial with, po.ssibly, have apparently a lietter effect than potassium iodide. Mercuri: the iodide ; tlii' mercurial m.iy ninisti red satisfactorily in tin form of calomel, 0.1 firain four times daily, ("hildren bear n 'dicii tion of this kinil even better than ailult I'arenchvinatous keratitis due to ac(|uire<l .syphilis ordinarily doe: not recjuire stimulation. In other respects th similar tre;it:iii'!it is ll treatment i^ to that eiii])loyed in the inherited form. The constitution (■ as that ordinarily employed in acquin tl le s;ili sviihilis. It should be rijrorously inishei Sclerosing Keratitis (\oii (Iraefe riiis form of keratitis accoin- Danvinsi scU ■litis is, in fact, an extension of the pn •ocess into the cornea. The opacity is of a layers ot ' >ill tl le cornea. avish-while color and liivotve> the deeper It advances slowly, seldom reaching the pupillary area. The oiiaciflcation ol the cornea ( does not extend II'" opacity Ml tlu- n.aruin n.ay l„.,.u„.,. ,1 ,11^1,4 ,1,. " i, ,,,, ,„ -"'■'..a tissu,. ,s a, na tin.,, thi.-k,-....,!: as tl., ..panfi ,1 „ 1 s- I-<ars tl... n.UH.al tissue inav l.,r..„„. n.lur.Ml i, (I k '' ^ l.-n.,n..s .nvjiuar, an,l s,„n,. ,|,.f,.,.ts in it n.av .Krur Symptoms. I „■ syn.ptu.ns arc thus,. r,.f,.,,,i.|,. f. th,. scN.ritis an.i uill I),. ,l,.s(.ni),.,i under that hcailinj; ' '"" lHv.ti:,.nt .^th,. pnniary ath.,.ti..n-th,. s,.l,.ritis Stnated Opacities of the Cornea. .\ft,.r „p,.rati,.ns n,.c.,.s.i,a,in.r "■'"' ' ^''" '•"■•"-' <'-""■ - . n.sult ,.t'ti«ht handa^in." a r ' ;:"■ ••'"■^ ^" •"I^.nyn.R ulceration „f th,. ,;.rn,.a, !,.n^ rurn w ^ MVish s,r,,,,.s are ,.hs,.rv,..| uhi,.h trav,.rs,. th,. ,.,.rn..a h "• , ^ '"'■.•tn.ns. !hey ar,. .•.ppar..ntly una..,-oM,pani,.,l l.v inflann • i n !- >"in. n,..,s,ons ..t ,h,. ..„n...a. th,. strifls ...wnnvn..,. a n v at tlie nMr.m, .,. the n.c.s,,,,, an,| ,.xt,.n,l in ra.hatinjr hn..s', • ;. -- .l.'.j..anc,. iron. th.. .„un.l. s,,nK.tin„.s tra^;rsin, th,.';.,; n. '"„,,. Il.ex app,.ar in Ir.wi, turnty-lour to t„rtv-,.ijrht hours ..fier I- n,,.,s,on ^ n,a,ie, and disapp,.ar v,.ry «raduallv. . !s -^ 7",."'-''''-l '•;, ^vlwl. th,. ^r,,,vish hn,.s r,.n.ain,..l p,.rn,a..,. ty "'!■ '""■•"■ "l'.a'ahcation n.ay W so slight as not to i't,., er . i{h Mon ,n any w..y. an.l ,nay h,. sulfi,.ientiy ,|,.nsc. to .-aus,. a e<^ h^ """...ion .n vision. In striat,.d opacitv of th,. ,.,.rn,.a r.' u iiVJ ■;: . ' 1; '\ "'" :'«"'*^' ;'"' '";-'"='>• '•••- --i' -ti.-- i" aii .nn.." i ^ ..- nsimlly most n.ark,.d near th, ,.,.ntn. of the ..oriu-a. In ; '""I oi.a,.|h..at,on a.-conipanyinf, ,„,,n.al uic,.r. the stria- radia ,! ,""' th,. n.a,-«ins ot ti„. uh-,.,-. Knies, Fuehs. an.i oth,.rs at! i e •ml':' ,^:;;;';-"' "'-•"'-":- ♦" -nnklingof I,osc..n.,.fs ni,!^ "an, that occurnnK att,.r M.c.sion of the cornea l.eing due to n. I at tro,., ban, ajre pivssur,. to a r,.,iuction in lie tension of ' doh,. or fiatt,.n,M« ,.( th,. ,.orn,.a. H,vk,.r an,l von Heck! ,1- "iM.n .ien.onstrat,..! th,. fa-t th:,t the !vn,ph ..hannrls in i -- aiv son...tiin,.s .iis,..n.i..,l an.l th,.ir .-ontlnts til Th ^ >ti.ufrht In.es. It has l„...„ thought that the channels thn.ugh .'U6 Till-: /•.»■/.• whul. tl..' ...TV tnn.k.H pass iMMMmu- lillr,! will, t.ul.hl tl.i.a a...l ....... ^'c;^:;'T;;;.;:'r lit,... ....... .,r .his .i,i.... u.;......- „C.s pla.v i.. .!..■ ...ajo.ily ..f ..as,.s, a...l .!..• t.-a..spar.-,.rv ol th. "StiXn Of the Cornea Originating from the Posterior Surface l,"Ts vvl>.n. a.. ..x..aa..on. a I....S .lisl.K.at...! ...to th. a ..-■..n ,' ,;„,, „, ,, ,vsl Mi th.' i.is h..s af:ai..s. .!.• <-nr....a, a., npac'v ...a> r w!.H.h ...ay ...v..iv.. ,h.. ...>ti.v .hi.-k.K.ss ... t .•;-...;.• •;; ,...n..>a ai.i>.-a.-s t.. !.«• ...ac.af.l a. th. p.....t .,f ......ta.'t. th.- >..... uZi- slilrhtlv .■i.-vat...l ai...v.- that ..f th- ^nnnnud^nii .•-.r ..'a. I- •- '"Deep'vascular Keratitis. This ,lis,.as.- ..f th.- .;..n,.-a .l.-v.-loi.s 1,V tra.lvann-....-..t ..f ...i....t.- v.-sm-Is In..,, th.- ...a.p" ...to th.- .l.-j-l. HV . , — pa.v.,.-hv.Ma ..f th.- .•...-...•a. It a,.,..'a.s a. a ............ pal.- ,f th.- .•...-...-a: it K.a.h.allv l.r-.a.l.-i.s a.i.l .•xt.-...U ..... thy .......a ts r ^Zn passu.« l>.-y..n.l th.- p..pillary ...a.^i... a...l ....t ^u.^^^ ... ,ha.. ....l-.p.a.t.-.- ..!■ th.- .•i.Tm..lVn-...- .. th.- <;";>-=^- "^ -,' VUT..W .,.a.gi.. ..f i..tiltrati.... p.v.-.-.i.-s th.- vas.-ular pat.-h. Th.- i I " ![,.,-s.!st at th.. ...a.t;i.. of th.. .•or.u.a. (tra.lually h............. n .,„..-. until it C(.as('s ahii.l.tiv at its fr...' li..nl..r. " SyJi^ms. Th.- aiM-as- is a,..-o„>pa.,i...l i.y sy,np..,...s ....•.- XhT<Lh^ .nstu.-ha.,.-.-s..f visi...i,a..a phof.phol-.a. 1 u- ...-uia. .. ..- S;;;;;:,iva is '-......-stc-l l.. tlu- vi,-i..ity ..r .l.- vas.-,.lanzat,o,. o, ,h.- '■"cause l)...-pvas..ula.-i/ati....of th.- .-onn-a is.h..- 1.....!..-.' i..h.-ri..;a o.- .riuir...! s'pi.iiis. It .s p.-ol.ahly ...... with .-.".v •-■.■.....■..'ly ". -r;i:''^'T.;;;;:s;ix^^^^^^ f..,vTwi.h l.v t.v,tnu.,.t ...ay last fro... th.-.-.- to >,x m.....hs Ph' !:;;,;«.., l..-.-o,..c.s ..•a,.spa.v..t wi.l. ,1... .•x-.-p..o.. o. a v.-.y sl.,h. clou.h....ss. lv-.ati..-tasia...ay..v....t.iallytollow. Treatment. Tn.:miu...t shoi.l.l Ih. local a.-. 1 syst.-,.,ic_ Loi-a I .at- „.^"^:^ists i„ s,„n.,lati.., .h.. ,.• ..vss hy hathm^ w,th ho s. J. uh.s soiutio.. ..f l...ii<- a.-.a, :{ p.-.- .-.■..t., l..-...f; usually .-i.plo>.-ai, th.. >< <r . , t.. pn-v,-..t postU..r sy...-.-hia- in .•as.M.f .nv..lv......-..t ..^^^^1^ : 1... fn.M......t i..t.-oau..tio.. ..f s...,H- .....t.......t. as th.. y.lK-Nv ;;Sa".f.u......■^^l-• '•'■■>'••''■• ''^''-■•''''^t^li^^ iuiK-val <ac Th.. svst........ t.-.-at....-..t shoul.l Ih- the o..lu.a..% " <; ,ili...- ..■oat.,..-..-t, .-nploy.-a vgon.usly h.r th.- h.st f"- ^v-k>• , ;„'„,,.„,,„„, ,„ , „..,.i.-.-at.- ^vay f".:-".;.n""ths subs... ._. Iv. Ribbon Keratitis (Trophic Keratitis; Bandolet Keratitis:. ^ . '""""'f. .. , _. ..f ,,,.„„,,,,r..,„.n uf th.- a.it.Tior lavci^ ..f the coru.-a. It (.(•(•urs ... ey. that have Ix-c. l«>st thi-.)ugh glauc.).. affpctca l>y iiittai..i..atioii m.iro .)r less d.-p-.i.-ratio. ith if tin- antcrioi- s(-fi.i.«'.it of thi- jclol..-. w of the cor.K-a. The .^pithcliu... "f that />/.S/;.l.N/..v „t CKSJI SvltVA, CUliSEA, AM, SCLtJU. .-{17 P">'i'"i "I III.' <-nrti... n,m.~pun,linK I" tin- n|„,,in« ,,f U... |,:,l,H.hnl ■ w lias >pa,v lH...n„u.s .■lou.l.v. Mini wln.i.s|, ,.la,,u,.s ms<.,„hlin« a y-v j.nl.i ty,H.. \,s,o„ is int..rf,.r,.,l ui,h Lrau.. „f ,h ., .. ! Ii"ii <.l the n,,;M,u.- strip ..v<.r the pupillarv area Treatment. A.ulr Inm. tl... (..nnati.,,, ..f an artificial p„,,il f.,r \isual ])urpust>. trcatiMciit is ol n,, avail. Non-inflanunatory Conditions. Arcus Senilis Corneas (Oerontoxom. This „cnirs as a nam.w ^'rMy..i,-wlMt,. |,,,M,| wlnrh appears at tl... nu.rKi,. n( the o-rriea The I'aiHl IS scparal... tn.n. the lii„l,„s l.y a narniw strip „( uvrivctW .•-ar .•..„,.,•>: t „■ Im,. of tnmsiti,,,, is sharply cut; tmvl.nl tl... n.„tr;. ;;, I'" .■.„•„,., th,. ^rray 1,...„.| ta.l,.s Kra.h.aily into transparent .•unira ll.i> pay han.l ,s .hu- t., th,. pr..s,.n..,. „f tninuf.. kI..1,u1.-s „f fat' hyanu- in,iss,.s. af.j snn,Hi„„.s ,.alfar,.„us granules in the snp..rfi,.iai la.v.Ts ul the eoi ., Th,. ehanft.., which is ,K.c„liar to a.iuit. 'Uvrinl. ..,1 s<.mi. ; , atrophy of th(. wsm-Is at the litnl.us Treatment is not ..i- sarv. Ectasias. The cla.s>ifi..ation adopted l.y Fuchs is a v.-rv ..xcellent -!"■. Me .hvules ectasia- into those of inf!a.nn>at..rv .,riKin, which include ..,,/,,y/.„„, and k;rnt,ctasia : and those of non-inHa.nn.atorv 'Tijrn. which include Lrmtoco„w< and krmloqlohiis Staphyloma in.-.y he either partial, total, or multiple. Staphvlon.a 1- a protuherant cicatrix, the result of a perforating' ulcer of th.. <-rn..a with mvoh,.m,.nt of tl... iris. Th.- iris mav Im- simply incar- ■•■ rated Hit It IS usually primarily pr..laps..,l. Aff-r a i...rfoiatinK uNcr ol the ..oriu.a the cicatrix that forms mjiv hulf,'.. as h..alinK I'lofrre.s.-, m which cas-. it is termed prinmri/ sl„f,/n/l,„„n ■ or th.- '^'•■■iinx in,.,y 1„. Hat an.i l.uljre sul)s..,|uentlv. t.-rm..,! in this .-as,- ""'."'";■"■;'"/'''■'""""■ Th.. shai f th.. stapln-l.,ma is usually c<..ii..al !'-"ti..ularly m the partial staphylomala : in f.tal staphv l-.x it may -■■ -ph..ncal. ._|tt..n th.. e.l^n.s aiv al.rupt, and they nmy eV.-n oy.-rhanp "• ••oni.-a. 111,. d.-j;re.- of th.- protrusi..ii yari.'s jireatly. In certain .j'hylomabi cic-atricial han.ls .levelop across th.. surfa..... .-xten.linK various . irections, pro.luci.ifr a lol.ul;it..<l ..onditi.m kn.iwn a- •■" iiiiii'v sidphiiliniiii. >i.iphyl.,ma may d<.v.-l.,p ..ith.-r heciuis.- of the protrusion of the ■■■' nx due t., th.. normal t..iision of the ghilK-, th.. tissue being to.. ' ak to withstand the pn-ssur.-. or, as is m.)st fmiuentlv th.- .-as,-, "• -tapliylonm .l.-vel.)ps Ix-caus.- .,f an incr.-ase .)f intra-..pular tensi.).. I .•o.whti.m of s,.condary irl..u,CMma. In p.'t-t- when- ihc entire ii'illary margin of th<- iris is involv.-d in the ci.-atrix. the oniniuni- ' ''''♦^ve.-n the ant.-nor and p...steri..r chamlwrs is shut oti' and an ■ i''.i-«- m t..nsi..n naturally f.-llows, Ix-caas.- .)f a cl.)surp of the nat- :]18 Tin-: i:yi:. iiral wavs U<r tlic csciipc of seen Th tiiiii t'rniii tlic interior of the eye increase ni tension usually conu on extrenu Iv si owlv. Il I rare however, tlie inerease in tension is rapid, and may lie attended 1)V inliainniatory sytuptoius and by pan Consequences. In tiie early stajii s of tiie formation of .stapiiyioma vision is interfered with in proportion to tlie extent of opaeihcatiou I the involvement of the free mar>rin ol the ii;is if the fornea am im- I'nless .secondary fjlaucoina supervenes. perce|)tioii of lifjlit is mam » .: I 1 o,. ,",i' .■■.t..i,f i,.M i.f the integrity of the ih-eper tissue: tained because of retention o! o: enlarsje, f tiie Klobe. W ith increase in tensii u the stajihyloma c.intiiuies to the retina, choroid, and ciliary body become atropine. In inanv cases the traiisi)areMcy ot the len- IS lost, the lens lUlllK and in soim ■ases is transformecl into a thin opaque ( hsk. li ■itaphylomata tiie apex is or take times re aneous coiuhtion. freiHieiitly exposed, and iiecomes ulcerated Kctropion of the lower lid some- <ults. The anatomical conditions present are a; >ll< The ins alwavs lines the posterior surface of the protrudinji portion: suiierimi i()se( on the laver of ins is a of the coniea that have not beei layer of cicatricial tissue, plus the eleinent.s destroved i)y the ulcerative process: covennj; an< this is a laver of epithelium. The ('[litlielial layer is thickened less of the cicatrix varies in different parts. found, but at the 1 irrefiular. The tliicki ,\t the aiiex of the staplivloma no c(iriieal tissue is sides corneal tissue is ]>! -en variety it fre(iueiitl mation of the pnn be extremeh rtl cornea. o ir\- mav t. In tot.al staphyli'ina of the spherical lis that no corneal tissue enters into the for- ..}); portion The walls of the staphyloma may |ierhai)s one-third of the thickness of the iionnal be thick and dense and contain calcareous deposits. Accoiiii)aiiyii.« tiie protnision ( if the cicatrix of the coniea we may also have a freneral eiilarfiement of the jjlolx Treatment Much mav be done to prevent the foniiation of staphy- loma 111 nartial anterior svnechia'. followiiift ulceration of tin' con lea. DiiriiiK the proce; a compress banilap lornie< there tl Tl le eve f healiiifi of perforatinj; ulcer of the cornea sjiould be retained until a tinn, flat cicatrix is d if liould be examined from time to time, a ('Villi nee of mcreasei I tens r evidence of bulsins of le cicatnx, a broad i loma has fonued, if it is partial an M'come eiinn ridectomy should be made. After a stapliy- tlie anterior chamber has not 1 Iv ()l)literate<l, excision of a small crescent-shaped piec O! f thestaiiliyloiiia y be practised in connection with the iridectomy. TlK' eve mav , then be b;iiida>ied. and the baiidafje retained until a trix has fonii<''l. It may be necessary to remove the lens tills manner, .\blation of the apex firm cica in some of the cases treated in if the staiihyloma may be practi loinata, tiie lens pn mav be c 1)1 removed at the same t d in partial and in total staphy line T le pip thus duce.1 HKiy be prrmilted to close under iiress baiidaire, or il losed by sutures. In extensive plan is to close the opening by means o taphvloiiia a verv excelleni '1 f the COIIIUIK tiva, with or lJISlAi;i.S OF COSJi-SCT/VA, COJiSEA A.W aCLEUA. 319 l><-uclij suture „r l.v in ,.rn .f, ' " ''.""""""u^ U.-bacco '»u<-l. pain. l^Tf,.rulin„ artlH- . Kx f ' ''"S^';'^'"'" occasioning tan.'.,usly: following this ,. ,oi' 1 '^ h!!' ?' fl '"''•r ■"^f^"'" ..^s..„t at th. ajK.x of the pn.trusion. Keratecta!;.; i^h^o:; t:^ This ron.iition shoul.l not bo confoun.l,.,] with l<oratoronus k.-nto I fjrayish aroa-thc nifiltrate.l n.amns of the uleor !'../.,♦ , -nay follow k,.ratocole, l.ein, the n^iit'ofU..! .,,;,„ ^ ^S : ?n^ h i/"' "Tl^ ""•a.reration or prolapse of the iris f o - Res^l „f ^ 1' ■"* fonnation of a.!h,T<-nt leueo.na. Results of Keratectasia. Vision is .listurhe.i not onlv on aeeount :::£;;j;f f^^^^^^^^ .--^ ."." tolSt!: ""'"■'"" •" '™^'"" '^^ ^^^"" - ^- visual Uposci ^"IJnNilf ' '*'°'^ M^ ^r**' Staphyloma PeUucida). (Fig. 14!..) >^ <- ulit.on r,.se,„|,|,.s kerateetasia; it, however, is unasiiate '' "'"'"»'>'at...n. an.| does no, present opaciHcat on f h Ipex :?2() rilE EYE. until tlic cLiiilition lias muhctl an advanced stapc. It is due to thinniiiii of the cornea and loss of power to withstand the intra- ocular tension. It hcRins hetw(H-ii the ajjes of twelve to twenty years and affects females more fnuiuently than males. The condition ;ieveli)i)s ill those who sutler from malnutrition, in those debilitated i)y illness, and occasionally in those who use the I'yes excessively for close work. •■ •. r . Symptoms. Keratoconus is not accom])anied \>y jjaiii in its earliest stages. Its development is hrou^dit to the notice of the patient by the etTect on vision. With the bulging of the cornea myopia and astig- matism are produced. The patient seeks relief, and is supplied with glasses which s i nvpiire change. With advance in the conchtion vision becomes much imi)aired, and because of the conical shape of the cornea relief cannot be obtained by glas.ses. as suitable glasses cannot be made to correct the jjcculiar curvatures imiduced. The change ill the .shape advances in many cases until the conical coii(htion is roiiii'Bl o>rnea. (Pai.kymi'LK.) very marked. The ajM-x of the cone becomes opaipie and the process limited. Spontaneous perforation and resolution do not occur in these cases. . , Diagnosis. In the very early stage ot keratoconus gnosis i> not easv, but careful examination liy me;ms of the . . ■oineter and liyVlacido's keratoscope makes the diagnosis po. : i. Treatment. The use of gias.s's in th.' <'arly sta . dvi.sable. In the later stage improvement in vision may be ( . d l)y the use of the stetiopd'ic slit; IJaehlman's hyiM-rbolic lenses are of service in -^nme cases. In advanced ca.ses improvement in vision may b<' obt.dned bv methods calculateil to i>roduce cicatricial contraction of the cornea. This may lie bnnighl Mbout by puncture at the apex, by excision of a portion of the tissue at ijie apex, or by use ol the cautery ai)l)lied to the apex of the cone, {{emoval of a small eiicular piirtiuii at the apex of tin- ct.rnea by the trephine h!t« also been resorteil to. Operative measures aflVctiiig the ajM-x of the cornea increa.se the opacification, whicii is in almost every case OISKASKS OF roxn-SCTIVA, roRSKA, AXV SCLERA. 321 -li'vctb- i" the pupillary area. As a c.ms,.,,u(.nco it beecnies neces- Ti.^ ^ff Jt^"" 'Hy*^»PJ»tJ>*l°?o'»; Keratoglobus; Megalo Cornea). lin> atr,.cfn„ consists ,n a unifonn oi.largon.ent ,.f the d„b,. I ^.Pl-ars at or shortly after birth, and is suppose.l t„ be due 'e... ^len.tal Klaue.,„ja. The e.,„.iiti.,n usually aff.>ets both eye^ I - ^Messes,.xtre,Melyslowly. In buphtha'n.os the .ii-mu-ter,^ the oo m , a. iKr us ailj .ieeper. I he lens fre,,uently UTonu-s disloeated, . n . t le .hseas,. advanees v.s.on ,s slowly nxluee.! and son.etirne l^lhHi.ln) m otlH-rs ,t beeon.es eh.u.ly. the condition then beine Treatment is of little avail. The general condition of the patient su.uld be nnprovjMl as ,nud. as ,K.ssible. Shoul.l the tension^o he ^'lobe be. mcrease,!, piloearpn.,. or eserine may Ik- e.nployed. A e best the prognosis IS unfavorable. ^i me Injuries of the Cornea. Injuries of the cornea of all .iegrees of ...v..r,ty occur W ,th abrasion of the cornea the patie t lv^ffc>r intense pan. at hrst o n sn.arting, burning character, and a fee i^g a. -t a foHMgn bo.ly „, th> eye. Photophobia is also experienced T- .nt<.nse d,s turlKU.ce produ.-ed by abrasion of the cornea i iueto le miu.,- ,o he sen.s,ry nerve filan.ents that tenninate in th^ yer he s> np on.s ,K..^.st fro.n twenty-four to fortv-eight hours as t i.' '■I.ithehu.n IS regenerated they disapiK^ar. In im-i.se.i wo „, S ;;' the cornea the pan. is relatively slight' \\-ounds ,,f tl ,■ c S -■lune treat.ne..t to prevent h.fection. c.nsisting of careful cle s! u., w.,h anOseptH- .solutions. Where the wound is an '^tensive e lliMiiargnis n,ay be approximated by n.eans ..fsutuie Foreign Bodies in the Cornea. The pro,ni,K-nt position of the - n-a .■xpo.ses ,t to the contact of foreign bo.lies of all kinds. hen a tn,v.g, body stnkes th,. cornea, if the sen.sitiveness of the c r e '< normal, ,he ey..hds clo.se involuntarily, and if the fon>ig bo h i n . (.xed n, th,. rorneal tissue it will ,|,..scend into the low.-r cul-de-sac " ••■'■'•nie hxed on the cmjunctiva of the upiH-r li.l. If ,he f, re en '""l.y .emanis attache.1 to the cornea or imlKMl.led in it.s is.ues'^a - J.c „.g s,.nsat.on n. the lids, u.sually the up,K>r lid, .s ex,v>rie,^;.. n 1 tin.s ,.s re,K.ated whenevr th,> eye is opened ..r closed The "-.■-gn body may 1h. snnply adherent to the epithelial laver it may . u n. e 1... ep,thehu,n and project fron. the iurface, it ,na;be,"me . 1 > nnbedde.l m the cornea, or it may pierce the corneal ti.ssue nd pi.je,.t mto the anterior chamber. Particles that enter the y nea do not as a rule, produce .liscoloration of the corneal tissue; . a hot cin.l,.r pro,luces an eschar which, after the cinder is ■nimed, .'ippears iu* a circular ring of brown fi.ssi.e I no pr,.,s,.|.,.e of a fon>ign body on the crnea is accompanie,- " i'li"topliobia, lacrvmati • - ■ ■■■(.aiuM icna n, and often by pain that docs not entireli rt (.ven when the lids ar<' kept (luiet, aiid l)V 21 pain n.f(.ral)le to the fi2-2 THE EYE. ^ i-ycball tiiul to tlic corrcspondiiiK sido of tlic lioail. Soon injcctioii of the c.fular conjunctiva ilt-velops; this injection may he very iniUl, or il may \w marked, varying according to the degree of irritation produced. If the foreign l)ody is iKTinitted to remain in the cornea, it may iM'come loosent!tl in a few liours or days and We removed from tlie cornea by the ineclianical action of tlie lids. It may liave earrieil micro-(jrganisms into the tis-sues of tiie cornea, producing ulcer; the defect in the cornea may l)ecunie invaded by germs from the co'i- junctiva, whicii, gaining entrance into the tissues of tlie cornea, niu^ themselves set up a destructive inHammation. Treatment. After instilling a dro]) (4 to 10 per cent, solution) ot cocaine the removal of the foreign body should be attemi)ted. For- eign bodies, if superficially imbedded, may often be removed by means of a small probang of absorbent cotton wound around the end of an applicator.' If tlie foreign b>dy is firmly imbedded, it should be lifted from the corneal tissue by means of a spud or sharp-pointeil foreign- body needle. In certain" cases it is necessary to cut the corneal tissue about the margin of the foreign body to get iM-ncath it to ,iit it out. In ca.ses where the foreign body lias penetrated the cornea and projects into the anterior chamber, it is at times neces,su-y to support it from behind while the tissues are cut away suthcieiitly to enable the surgeon to grasp it with a small forcejjs. .Vfter removal of the foreign body the defect in the cornea occasions the individual some annoyance until the epithelium has extended oyer the afl'ected area. During this time the eye should be cleansed with an antiseptic solution from time to time (boric acid, 3 per cent.): and if infection is feared, more energetic antist>ptic mea.sures should be emploveil. Blood-Staining- of the cornea sometimes fr)llows injuries to the eye which result in hemorrhage into the anterior and posterior chambers. The pigmentation of the cornea is due primarily to the entrance of luemoglobin in s(.lutiim into the corneal tissue by way of F(mtana s spaces, the luemoglobin being the result of disintegration of red blood corpuscles. It permeates ilie lymph canalicular .system of the cornea, .iiid there undergoe- a change into luemosiderin, an iiisol"ble product which is (h-posited in the corneal tissue in the shape of minute, irregular, octahedral crystals. These crystals occupy not only the sjjaces between the lamelhe. but also the spaces iH'tween the connective bundl(>s and fibres of the cornea. The color of the corne.a at an early stage is olive, with a tendency to red. This soon becoiiH's a deep brown. The staining of the cornea occupies the central jiortion. reaching almost to the limbus in marked ca.ses. At the liml)us an annular ring of transi)arent cornea is found, measur- ing one-half to one and one-half millimetres in width. The traiis- paiviit ring of the conica i'^ due to the n-mova! of the hLemoglr)l)iii from the corneal tissue: also to the fact that the alkalinity of the cornea is maintained at the |M'ripliery through ilie iiiHuence of blood in the capillaries of the limbus conjunctiva-, preventing the change imKiai:^ of joxj i:\ctiva, corxea, a.\d svleua. ,32.3 int.. ha«ni<)wi,lerin. The staining of tlic cornea (icvcl.m.s rciativelv .-lowly alter llio Hrst api^-arann- is notice,!. It may take from one to lour weeks for it to reach its heiKJit. In some cas.'s the stainini: nnnams with little cliange for months, but in many absorption goes on shjwiy, and eventually the cornea may regain its transpar.'ncv Actonipanymg this condition we may have secondary glaucoma ()ss ot vision, and pain, depending not on the condition o'f the cornea' hut on the condition of the eye itself. ' Treatment. There is no 'treatment aside from stimulation by means ol moist heat, that is of value in this condition. Fr.Hiuently the condition ot the eye is such tiiat enucleation becomes neces.sary Bums of the Cornea, liurns of the cornea are not verv infre,,uent 1 hey are due to the entrance of molten metal, cinders, steam, acids, alkalies, burning gunpowder, etc. Molten metal hnpinging upon the cornea seUlom does much harm 1 lie sui-hice epithelium may be destroyed. The metal usually escapes Ironi the eye at once or falls into the conjunctival .sac, where tlic j;reater damage is done. Glowing embers aligliting on the cornea may ix>come adherent and destroy the corneal tissue to .some depth; ordinarilv tlie burn is -uiM'i-ficial. (Slowing cind.Ts that fiy into the eyt; sometimes become imbedded 111 the cornea, rendering necrotic the tis.sue that comes in direct con- tact with the cinder. Before recovery takes place, this necrotic laver ot tissue must be cast oft'. Steam entering the eye may destroy th(> epithelial layer in tiie poition of cornea expos<'d, u.^ually a narrow strip Iving in the hori- zontal meridian corresponding to the paljx'bral lis.sure. The treat- ment consists in cleaiLsing the eye and instilling an anti.septic or aseptic oily preparati(m sufficiently oftt'ii to protect the affected •lira, usually three to four times daily. Olive oil. with 5 per cent. lit Ixjric acid oi vaseline, may be ii.sed. Burns of tlie cornea from acid usually affect the entire .surface of ilie cornea, turning it a grayish hue, destroying tlie epithelium, tlie Miperficial layers of which .-^oon Ix-conie detached. With burns of this iliaiacter tiiere are some .s(-cretion from the conjunctiva, increased l.urymation, and .sw<>lling of the lids, the a-.pearance presented I'l'lK-iting a grave lesion. Ilxcept in rare ca.ses. burns from acids are recover.-d Ironi with little if any loss of tissue or ix-riKanent in- jury to the eye. The treatment consi.sts in thoroughly cleansing the I ye, using weak alkaline solutions (bicarbonate of sodium or very weak ammonia), and. as in iiurns due to thermal agencies, the instil- l:itioii of an oily substance, Huins of the eorne.a due to an alkali are most frecjueiitiy occa- -iiiiinj i)y the entrance of nuicklimc into the eye. The fine I'ticle.s ()f lime U'coine iml)e<lded in the corneal t'ssue, and the '- iar,>tic action is continued for some time. When first seen, 'li' aHected area presents a grayish discoloration, frequently not 324 TUK EYE. very <U'n.-(". The up var.i-uc o Mi. cornea after e(iiiil)usti(.ii I'n.in limv, as first pr.'seiitetl. i..,im11v induees a more favorable prognosis than is warrantable The iticatu > in almost all eases inereases in intensity as the liealni}; p.o'-,..s a.lvanees. Treatment m these eases is to free the eornea as rapidly as possible from partieles of hine bv washing with olive oil, which is probably the most suitable for this purpose. Af'-'r the particl(>s of lime have been removed, the eye sliould Im' filied with syrup of cane-supar, as sugar forms an insoluble compound with lime, preventing extension of the destructive process. The sub.se(iuent treatment of burns from lime is like that of burns with acids and thermal agencies. ..... Tumors of the Cornea. Tumors of the cornea originatmg m tlie cornea an- extremely rare. Cysts sometimes develop, but tliey are the result of inflammatory processes, are usually extremely small, ani seldom rc(iuire treatment. Tumors of the cornea usually cxtenii onto the conjunctiva; they are dermoid, papillomu, fibroma, epithe- lioma, and sarcoma. These have all l)oen treated of in the chapter on dist>ases of the conjunctiva, and need no further mention. SCLE&A. The sclera, together with the cornea, forms the fibrous coat of the eye. It is the segment of a sphere, the rsvlius of curvature of which is about 12 mm. At its junction with the cornea a depression is found, which is known as the sulcus sdene. The sclera is thickest at its posterior part, where it measures alxmt 1 mm. in thickne^ss; thinnest near the e(|Uator, becoming slightly increas<>d in thickness in its anterior portion, where it receives the insertion of the r(>cti muscles. The anterior portion ;)f the sclera is pierced by a number of minute openings through which pa.ss tli(> anterior ciliary arteries and v(>ins. Some small iierv(> tw.f;s also pass through the sclera a short distance back from the corneal margin. At the e(|uator of the globe the sclera is pierced by four, .sometimes five, relatively large openings, which give passage to the large vetue vorticosir. Pos- teriorly a number of openings are found which give passage to the short ciliary arteries ami ciliary nerves, and a large opening to |)ennit the passage of the optic nerv(> fibres. This oiM'iiing. which measures about \.T^ mm. in diameter, is traversed by connective-tissue V)undles, which are continuous with the sclera proper, forming what is known as the cribriform plate. The sclera is made up of connective-ti.s,sue fibres, which are not disposed in regular lainelhe as are those of the cornea, and which run in various directions. Between these bundles of connective-tissu(> fibres sjjaces are found resembling the lacuna' of the curnca. In the ^cli-ni about the optic nerve entrance and in its anterior portion branching pigment cells are found. These are most plentiful near the inner sm-face of the .sclera. In certain individuals the i)penings for the passage )f the anterior ciliary veins I)JtiJ-:.i^J-:s OF COX/UXCTIVA. VOJtXKA, ASV SfLElt.X. ;i25 Mv pifriiicnt...l giving tlio appoarimce „f a mimLcr ..f black points '•n ll.c scrni. In m-tain iiulivi.Iuais, particularly tii..sc „f the colored ran', the piKinentation of the sclera, aiileriorlv, is v.-ry in'irkeil At Its aiitenor margin the tissue of th.' sclera is 'continuous with that of he cornea. Near the anterior margin of the cornea an<l separate.! from its mner surface by a thin laver of connective-tissue Imn.i.es, is the venous smus known as Schlemm's canal Kxternallv the sclera is c.jvere.l by tlu" visc-ral layer of Tetx.rrs cai.sule. Inter- nal y It attonls at its anterior part attachment for the ciliary b.M y by means ot th.- Iigam..ntum annularis. P.,steri..rlv the inner surta.'e of the s<-lera is cover.'.! by the lamina fus<-a of tl.e ch.)roi<l th.' .sclera being s,.parate.l fr.)m the choroi,! proper by the supra- .•h..roi.lal lymph space. Hut few bloo. I vessels are f.)un.! in the sub- >tan.'.' ot tlu' sclera. The episcU'ral tissue, h..wever. is richly supplied with bloo,lvesscls. particularly in its anteri.)r portion. The nerve suj.ply of the sclera is extremely scanty. P.)steriorlv the tissue of llii^ sclera is c.)ntmu.)us with the sheath of the optic nerve Scientis. Inflammations of the sclera are of relatively rare occur- reii.'.', an.! may be .livi.le.! clinically int.) two f.)rms;' cpi.scleritis I'/) tugaeious an.l (h) persistent, and deep .sderitis. Fuiiacioiis Episcleritis. A transient inflammation of the epi- scleral tissue sometimes occurs, the attack b<Mng cliaracterized by the appearance of an injccte.l area with .slight el.-vation ..f the con- junctiva, the t!i.s."a.se usually occupying from 1 fi to 1 5 of the surface "I th.' .sclera in ts anterior segm.'iit. Th.- ajipcarance of the inflamed ai-.'u is acc.nnpanie.1 by symptoms of irritation, manifeste.i by an nicn'a.se of lacrymation, jxThaps very slight mucoid secretion -li^'ht paiii in the eyeball ra.liating to the temple and forehead, and photoph.ibia. Tlu> irritation is increa.se.l by u.se .)f the eyes for' near work. This inflammati(5n .)f the episcleraf tissue reaches its height III troin three to four days, and then gra.luallv subsides, every trace • lisippcariiig at the end .)f a week or ten days. Till' affection is met with in in.livi.luals' at the age .)f puberty ind 111 .-arly adult life, an.l is prone t.) recur when the svstem is in ■I nin-down coiiditi.m. Cause. i:pisc!eritis .)f this nature is met with most fre<iuently :n thos.' wh.) pr.'s<'iit a rh.'umatic or uric-aci.l .liatliesis. I'ndue u.se "I 111.' cy.'s, .'v.'strain c.)n.se«nient .)n imperfectly corrected errors 'I icIiactKiii and imbalanc-e of the ocular muscles, exjMJsurc to inclem- 'Ht w.'ath.'r. use of the eyes in a bright light, .listurbance of dige.s- "'"I. . I may ontribute to bring on an attack. Treatment, Treatment consists in correcting any err.)r of refraction lilt may .-xist, in correcting the ondition .)f the syst.-ni which 1 ■I'lisiM.ses to attacks, and in prot.'cting the eves from "the influence ■1 l'^^'ht light when this is a fact.)r in the pro.luctl.m of the .Us- ui ii.tiice. l:iHKrl,ritis is characterized by inflamed nodules which occur near I'" margin of the cornea. The area of inflammation is often firgle. :!i'ti Tin: i:ye. ! 'riic tissue at tlif |M. lilts alTccli Ic, I is slinlitiy raised, and is of a deep- red ur purpiisli iiue. I'he l)lu..dvess<-ls ..I llir eoiijuiictiva (iverlyiiifi llie iutlaiiied ana aiv enlarged and iiijeele' Tlie itiHatiiiiiatioii advances slowly, and is atteiideil liy syiuptoiii.-. oi irritation tliat are niueh more sevei"' in some cases than in otiiers, and rather deep neuraij;i<- pain wiiii photo|)hol>ia is also ex]M'rieiiced. Both eyc-s usually aiv attackeil. and fresh areas may Iw involved before subsi- dence of the process in the part (irst affected. Duration. The affection jtersists from four to eijjht weeks, but may continue for a lonn<T period. Uecurreiices are the rule, and another attack may occur immediately after the subsidence ot one attack, or may not occur until veais have elapsed. As a ivsult'of the iiitlammatory process, there is usually a slight bluish-colored patdi in the sclera, but recovery may lake place with- out leaving a trace. Tliis diseasi- usually attacks adults, but may occur at the period of adolescence. Cause. Kheumatism and gout are common causes. In some cases the cau.se is ol)scurc. It is probable, however, that digestive disturbances are accountable for the greater iiuiuIkm- oi cases. Prognosis. The prognosis is favorable, as a rule. In rare cases ectasia and inflammation of the deeper structures may result. Treatment. Ueuss advocates the u.se of the constant current. 8<'ariticatioii has been advised in cases where pain is severe, and ointments of various kinds are indicated. The process is most favorably inlhienccd by internal meilication. consisting of the sah- cylates, 'iodide of potassium, ami the mercurials in small continued The deep form of sclerltis cannot readily be distinguished in its onset from the superficial form, except in degree of severity. Pain ace 'iipanying deep scleritis is usually more severe. The afTected \\\' is of "a deei)-purple hue. The elevation is somewhat more pro- n. uiced. The affected area is larger, and may extend around the iiitire cornea. .\ccompanying deep scleritis we freciueiitly have mtlammation of the cornea in the vicinity of the affected area, and the deeper structure of the eve iris, ciliary body, and .'interior |)ortiuns ot the choroid -also are afi'ected. the process attacks both eyes and i)rogresses extremely slowly. The change that "takes place leads to attenuation of the tissue of the sclera, reduces it in thickness, and lessens its jjower of resistance, so that it cannot withstand the normal intra-ocular jm-.ssure, and iH'comes ectatic. The bulging of the sclera is usually irregular; it sel<lom ext.'iids around the entire cornea, but in the few eases^in which this does occur the entitv cornea is imshed forward. The ectasia usually occurs after subsidence of the inffammation. When the s<-leritis subsides the afTected area presents a dark-blue a|)pear- ance on account of thinning, which permits the pigment of the uveal tract to show through, .\ccompaiiying ♦he formation ol />/AAM.s» OF CoyjlMTJVA, C()tl.\J-:A, AM) SCLEHA. ;J27 ilicsc stiipliyloinatdus j)r()triisi(nis (lisDrnaiiization of the interior of llic fjlohc is ohscrvcd. )isioii is ordinarily very iiiucli iiiipain'd. Sclero-kerato-iritis (Scrofulous Scleritis; Anterior Uveitis). This coiidilioii is one closely allied to dcn-p scleritis. but differs from it ill that the whole anterior segment of the jtloU- is affected. The iiitlaiiiiiiatory piocess usually hepiiis at or near tiie sclerocorneal junction, and progresses as adeep.-cleritis involving the cornea (which i.ikes on a condition of sclero.sis), the iris, the ciliary hody, and the anterior portion of the choroid. In addition to the appearances and .syniptoins tiiat accompany scleritis and .sclerosing keratitis, symptoms jx'culiar to involvement of the anterior jjortion of th(' uvea' tract are present. The iris JM'comes congest«"(l, loses its trans- parency, takes on a du.sky hue, and is thickened. The acjueous hiiiiior l>ec 's turhid as a result of transudation of plastic lymj)!! Irom the bloodvessels of the iris and ciliary Ixxiy. There is pai:i refer- able fteiierally to the temple and forehead." The anterior jMirtion of the vitreous body l)econies hiled with flocculi consisting of hbrin. Tlie (lisea.se pri>gres.ses very slowly, both eyes IxMng commonly affected. Individuals in early childliood and at the age of pulxTty are nir).st tiiMiueiitly attacked. They are individuals with inherited .sypliilis ,111(1 those whos<' condition may 1k' described by the term .scrofulous. .\s a result of .sclero-kerato-iritis, sclerosis of the anterior portion of liie sclera and of the cornea occurs, followed in many cases by sclero- I'ctasia'. Tile ordinary results of .severe iritis are also preseilt. The choroiditis is followed by atrophic changes in that membrane. The ciliary body In'ounes atrophic and niucli elongated by the stretch- ing that accompanies the ecta'i'- process. The coriu'a is thinned throughout the area involved in the sclero.sis and becomes more or ess opaipie. The effect on vision is pronounced, the diminution dejH'nding on the degree of opacity of tiie cornea and the interference with the tiaiispaicncy of the media of the eye. As a result of this ])rocess the ciystalline lens not infre(iuently Ix'comes opa(|ue. shrunken, :iiiil till' .site of calcareous depo.sits. In cons<"(|ueiice of the dianges .itlccting the filtration angle, increase in tlx- tension of the eyeball ilrvciops, secondary glaucoma results, and total los.s of vi.sion n.ay lollow. The increase in tension may also lead to .spontaneous rup- ture of the glo])e, the rupture occurring at some pohit in the ectatic purtion. Treatment. Treatment directed to tiie correction of any dyscrasia cj liie system that may exist should iie instituted. If "tlie condi- tion ;tccompaiiies liereditary syphilis, anti.syphiiitic n-medies should be employed If a uric-acid diatliesis is present, it should i)e cor- iic1c(|. Local treatment consists in the endeavor to prevent tiie tdnn.ition of posterior synechia'. Hot liathing with a solution of iMiru' •■ti'ii! ;i!i(! tlie introthiPtion of a lucn-unal locally are of .-ser- vice. Ointments of the yellow o.xide and mercuric chloride apjM'ar Id be iM'st suited. As a matter of fact, local treatment .seems to .■{•_>M THE EYE. \ have little ctTci-t in arresting tlie progress of tliis condition. In eyes atTceteil l)y tiiis iliseas*- more or less serious daniage is wrouglit. Scleral ectasisB (staphyloma of the sclera) an- elassitied a.H antenor, eii-iatorial, and posterior. Anterior eeta.sia- may l»e single or multiple. Tliey may Ix- annular, extending entirely around the jM'riphery of the eornea. At the e(|uator the eetasia' may present the same' conditions present in the anterior sj'gment. l'o.sterior ectasia' are usually single, and fre(|Uently include the optic nerve .'iitrance. Scleral ectasia' present a bluish ap|M'arance. iK'caase of the pigmented uvea, which shows through the thinned scK'ra. CauBe. Staphylomata are produced either In't'ause of a reduction in the power of the sclera to withstand the nonnal intra-ocular pressure or tension, weakness of the scleral coat Ix'ing either inherent or the result of di.s«'ti.se; or it is due to an increa.se in the intra-ocular tension alH)ve the normal and above the iM)wer of »he sclera to withstand. Scleral ectasia- are most friMiuently due to scleritis. When intra- ocular pressure only is the cause, eiiuatorial staphyloma usually results. If the weakness is structural and congenital, the staphyloma usually occurs at the posterior pole. Staphyloma not infre(|uently accompanies neoplasms of the interior of the eye. In certain cases ectasia of the sclera reaches enornjous dimensions, as in the case of scleral cyst accompanying microphthalmos. Treatment. After ectasia- of the .sclera have developed, treatment is of no avail. .\s a prophylactic nwa-siire in inflammatory comlitions which have resulted in the formation of posterior synechia', iridec- tomy may be useful, and in ca.ses of glaucoma, either primary or secondary, the same procedure may prev(-nt de\ 'I.)pment of ectasia- by reducing the intra-ocular tension. Syphilis of the Sclera. Syphilitic involvement of the scleni is seldom observed. When it does occur, it manifests itself in the form of gunnna, usually iift'ecting the anterior segment of the sclera. Cases have been observed in which th(> ])osterior jjortion of the sclera has been the seat of a gummatous ma.ss. When gumma of the sclera occurs ill a visible portion, it presents itself first as a small nodule sinuilating a large phlyctemile. It incn-a.-^es in .siz«- (piite rapidly, the elevation becoming pronounced, th(- base of tlie elevation iM-ingdeep red in color, and the congestion extending for some distance into the surrounding tissue. The apex of the elevation is of a yellowish hue. The growth is circular at its b.'isc. It may reach a diameter of I cm. to 1 cm. If treatment is not instituted, ulceration takes place at the apex, due to breaking down of the tissue, and destruction of the eye may ensue. The tumor is rather firm in consistence, and Vf elastic. It may be mistaken for sarcoma. \ microscopical examina- tion of excised parts may disclo.se the presence of cells which dosf-ly tt i(i>e tif s;trcoMia(ous li.ssue. Sarcoiha of the .M-iera as a ])rimary disease is extremely rare, and the presence of a growth such as has just Ix-c-n descriln-d should always awaken suspicion of i>/sh:.\sf:s OF rns.irscTivA, <oi{m:a, am* svlfma. :\2\\ a sypl.ilitic ..riRin, The liistory „f tin- ca-s.' is not always tu Ik> IV if.l upnii t„ suhstaiitiatc tlic <lia«M.)sis. Cminiia of I lie" sclera is .-.•Idoiii met Willi III cliildrcii, hut is an omisionai nianilcstalion of lirtiaiy syphilis in a.lults. The writer has never seen a pn.eess of this kiii.l (.(ruiTiiiK as a result of inlieriteil syphilis. In these cuses the tissue of the sclera is inva.le.l h\ a sniall-eell infiltration. I-il'ires III the sclera are |)re.s.se,l aj)art, and some .lisap|M'ar ah.solutelv \s Ihe |)roee.sssul)si,|es, if .scleral ti.- mc has Ihm-ii (lesf<.ye,l. it is replac.Ml l>y cicatricial tissue. Treatment. Inder vinnrous antisyphilitic treatment of the usual kind jtuinina ot the .sclera suhsidcs with marwilous rapidity and il lh<' deejM'r tissues of the kIoIm> are not involved, no trace" iif the liuiior is lelt. Tumors of the sclera other than that just nieiitioncl do not occur as primary fjrowths. Injuries to the Sclera. Tli<. sclera is sul.ject to injuries of various kinds: iierlorating wounds, inci.sed wounds, lacerating; wouJids and iu|ituic ot the sclera. Perforating wounds of the sclen;, if made'with Miaipand noii-infected instruments, are usually of little importance provided the p.-rtoration he small and occur hack of the ciliary lejjion. II, however, tli<' wound is large, i^'riiiittiiiK i>r()lapse of a portion ol the ciliary hody, the effect on vision may Ik' disastrous Noii-infected woumls heal rapidly. It occurs from ti'me to time that pertoratinK wounds of the sclera result in total detachment of the retina without suppuration .nid without iiiHamniatorv reaction of .my appreciahle .lepce. A cas,. in point is that of a'wonian wiio, ^^llell shakiiif; a carpet, felt a twing.. in the ev<-, ami found tliat a larpct tack had pierce.l the sclera ahout 7 mm. from the .sclero- |-..rneal margin. Sh<- removed the tack hy traction aii.l |)res<-nte<i lieiself at the hospital within twenty-four hours. At that time a -niMJI opciiiiifr could he d-.t<.cted in the sclera, into which a he.-id of vitivoiis projected. There was hut slight injection of the .sclera and '•"njiiiicnva, and the opening in the sclera had already hecoine clo.sed l>v plastic lymph. K.xaminatioii with the (iphthalmo.scope disclosed the point of entrance of the tack. There w.-is no h.'iiuirrha".' in the vitreous and very little hlood surrounded the oiieiiing. The eye was li^iiidajie.l and the jiatient removed to her home. No intiammatioii loulted. In the cour.s<" of four weeks complete (let ichment uf the iitiiia developed. I'eit'orating wounds of the .sclent may re.suit in infection of the ■■.vehali and loss ot the gloln- hv panophthalmitis. Lacerating Wounds. Lacerating incised wounds of the sclera, if occur iiosterior to the ciliary region and are not of gre.it extent. he closed either hy a scleral or conjunctival suture, and recovery '■•ly occur with little or no loss of yision. Clean incise! tliry •VAX clera, even th(>s«> which involve the cilian' 'imds of region, may al.so ai. if properly clo.iod, without lo.s.s of y wound in the sclera the prolap.se of vitreous and i)rolapso"of Xh ision. In the latter f orm .•!.!i» I in: LYf- U rili;iiv l.(,.lv. It tlK'V ..mir, -huuM l-c v\v\>-'\ 'ni.. ^011^^1 n,;.v then I.C ilip>f.| liv >rlcrill III- <-n|ijUll(!iv:il suture, 1 .vratiiKJWuun.Uatffctiiij; tlif nil ^ ImmIv rrsiill >ii ;ilini>-i > ry ,.,^^. i„ l„ss of ll V.-. IJ.'inoViil of the .->■.•, fivqiH utiy, is i.^ >i oiirc iu'(fssarv: Inil .i^ tlif scar coiiinicts panifui sym|.ioiii> .li\ aii.l, in s(,iuf<"-iis.'s, symptoms of syini.alh.-tu iiMurhaiic. .t the li'-r i'vc liccoinc ppiiomicnl Mini rcii.iri .•iiucl<itioii in'ccssar\ . ■ Ml ,. ,s,.s of uuuii.l to the scliTa sl-uM !»■ tivatr.l 011 strictly :intl- s,.|.ti.' hriiicijili's. IVolMpMiiK iissu> -t.ouM !«■ .•\ns<-(l il an attempt is to Ih ma.l. to sav.- tlic >:IoIk-. ! :.r onhuary ciiTUinstatuvs tl,.' palirnt wh.-thcr siitT.Tinfi Ini 1 porl-natui^ wouii.l, iin iiu-i«.'.l .r ., lac-iaiih); woun.l "f tlic uloi.. -^lioul.l !«■ -n to IhkI, an.! .M.mpivss ■•■iiiil:i"cs applii'.l until recover' is \v( !1 uil\ iiu rii Rnpture of the Sclera. l{oi -ureof the sclera oecur- m tli. t.ajorit ,,1 caM within the /...ne in. ,!.•,! ui a strip I ••in. ••vule in. ;i U. m-ir Ml .1 the conu^a. A l>lov. on trie eve from vliat.- r source niax npHhin -uch a lui.ture. Tl, ruptiu tak.'s place , ve most tro- ,1. ■ ah It ..••■urs in the sh.,|H' ot :,,-, irr.>:iilar line cxt. imIiii^ h-.m ue,' tiie Kirpn of the cornea .li,--.'oiially hackwar.l, ai: . mea.sures i„ the majority of cases ah- it 'l em in lenRth The iluiry U v ami th. anterior portion of ti • choroul are usually push. 11. wont, i an.l I n-s«-nt n~ a .1 >- hnc following the wound: crvsialline l.Mis ir v ' •■ for, .1 out of 111.' eye an.l he h -■'.: in'" conjunctiva. Sui..-.. .ian<''iva! iK^niorrhacc cciirs, ■.vhich ihIs soiile aistai.ce from the womd. soni. tim. ^ .vteiir mk h. 'h 1 entire ocular conjmn't Th- antei r aial ire. - ehamlHi- a ,„..i-e ..r l.'ss lill.Ml '."..1. Sucii oun.ls ire<|u. "ccur ^\n- oiit rui 'uf. of till- f..i.,uu'tiva. ■ , . Kupl, • .>f the -.l.'iM - not llecessa-ily ..nlilie.l ' tli. eiHM .ejjmenl . thetiloh. In laie cases it .iccui M thei...sien..i lent of the -ll.''.-. It i- '"'ll 111 nilVst hy a ^';. uT -i »'.•- .Icj; e\-iph!halmos .hie 'l"' I'l'-'^" ■■■'' "•' '''"" ("a.se- 111 which the uptur. is very slifjlit with.' It lo-s of vi-i.iii and witlioii' a paiiifu rare In til. ariv stajic ot rii| Mire ..I u .■i<'ni may l)e relatively sliftht. aid, to ili. \\" ' favorable recovery may app.ar hrr II • .litioiis above .lescrilx'd alino-t n -ial , i|-i lie r.'-. irt.'il to. Foreign Bodies in the Sclera i ;:ii -eld.itn pr. .-elit witlioul p-rfont, chanibe: of tl;.- eyi, ih" ri'.sult \" <! iiplv \\\v til'- !■ ''V has fen -lu.ul.l be ret.. >e,l, its ivnioval bein;. leetedby the nieaus onliiian employed !.■ -einove uwinii bo.iies . .10 oil,. V -sues of the bv..) in tin 'll al t!.s.-iues liv re^^ult 11. recover} ,>Im', Im t such are vcr> ■■■ y H'K. '• pahi j)ros|H' if a lly -011- nu tioii tl ■ Ulii .'lltr;. sclera be. •lera :,.t' post, lallv a •' ..'.I imbe.l.i' 111 'he sclera. < HA PTKR VII, niHinol.OfJY OF HK IK; ANOMALIKS, DISKASKS. AM' INJriill > OV THE IHIS. (lUAHV MoDY, ( IIOHOII). AM) VITUKOl S. '»Y 1 \ \ ! RDKMA-W, MD. EMBRYOLOGY OF THE EYE. Gmi'-a.i Development. Th .■ U-giux its (Icv.h.j.nKmt a., a hm,^ in>.. M'rii(-....i,.riiiic!in<lccl ic layers of tlucmhrvo. .■ullcl the ""' )'<"• 'fit', c-onm-ct. h the brain l»y the "optic iH-dicio Mfrior Ctrttra/ l^uck ^y s^Oplic Vesicle ilM ^^Ine nf SfcHatf -^ite t . 4 -M/dd/e Cerebri ' t'fiKle fbiferiorCereii'. mcM Aut/'forjf Budi Spinil Cari Entire embryo of a fh)(! (After Fick.) 'r >ta!k whiHs «uh^'qi:(>nt!v lu-nuiu-s tlic nptir nonr. (Fig. 150.) .'" '''■vt'loimu'iit of th»> ^oderini.- portion is so slow in the majority '1 «iMt)ryo> that the vesid,. is not fully covered l)y this structure, ( 331 ) ^ 3:12 THE EYE. ami tiius rciiiains in iiitiiiiatc (■(iiiiicctioii witli the (■clddcnii. Im-Iiij; at first. Iiistoldjficallv, vci\ iimcli like the l>rain vesicle, i I'late The priiiiarj' ojitic vesicle then ix-coines thicker, becoming invafii- iiateil, t'lirininf? the primary optic cup (I'late X., H); the eetuderni lyinj; over the eyehud becomes thickeneil, and at the .same tin e sinks into the subjacent inva}iinate(l optic vesicle, forniin>i; a de])i'es- sion known as the lens pit or secondary optic cu|). i Plate X., ('. i The mesoderm does not cover this place, but the ecto(lerni thickens, ultimately forininf; the lens. .Vt this time the eye has .somewhat the form of a pair of sci.s-sors, the points projectiiift upward, i Plate .\., !).) These points soon coalesce, coveriuf; the secondary cup, dosing; over the lens, and developinf; the cornea. (Plati' X., K.) .\s development goes on, the iiivajjinatioiis profiress with uni- form rapidity until the lens sac reaches completion, when the expansion of the inner wall of the latter no lonj^er keeps pace with the pushing in of the optic vesicle, and thu.s forms a s|)aee, the primi- tive vitreous chamber. (I'late X., !•'. ) The portion of the wall invagi- nateilby the j)rocess of involution undergoes |)roliferation, forming the retinal layer. The outer l;iyer of the o|)tic vesicle increases, but becomes so attenuated that by the time the retinal layer comes into contact with it, it is so thin that it forms ultimately but a single layer of cells, the retinal epithelium. (Plate XL, .\, F, (!.) The inner wall thickens and forms the ess<'ntial nerve elements of the retina. The lower [Kirtiou of this double-layered vesicle is not coiii- plete(l, but forms a hiatus, the f(rtal ocular or choroidal cleft, which soon narrows and finally closes, but. before doing this, allows the entrance of mesod(>rniie tissue, which constitutes the primary vitreous stroma. The impri.soned mesodermic ti.ssue in the optic stalk is represented later by the central vessels of the retina a!id the as.'^ociated comiective tissue of the optic nerve. The optic stalk becomes the optic nerve chiasn., and tract. Lens. .Ml of the lens, (>\cept tlir capsuie, is of ectodermic oiigin. i-larly in develo|)ment the optic cup closes ( Plate X., ]•]), the inner w all becoming thicker than the outer. The thickening progresses, so that by the time the lens sac has become completely isolated from its attachment to the surface ectoderm its walls consist of two or three layers of e|)ithelial cells, limited externally by a delicate nienibnuie. the lens capsule. Tin obliteration of the cavity of tlu' lens .sac and the conversion of the organ into a solid mass are effected by a phe- nomenal growth ;ind elongation of the e])ithelial elen;ents composing its jjosterior or internal wall, which rapidly increa.ses in length, Ix'Ciiriiiag converted into the primitive len.s-libres. (Plate XI., .\.) From the unusual demands made by the young, rapidly growing, .and non-vascular lens on the surrotmding ti.ssue for nutrition, a special temporary structure develojis, the tunica vasculosa lentis (Pig. I'lU^ which 1 compietj'ly surrounds the young lens Irom (lie seci )nd month toward the end of gestation, at which period it usually lK'er)me: PI-ATE X A. AVcf/oH through Cmbrijonic froy Head. C, Duck. ti. Fruif. CetoJwm Muttritr l(Wi/» of ^ittnar^ 0»t , Cup Corner i,d fK/piiliff MrfnO'inf Le/t} vtuc/t P'gmtm tp.ti,tfnm k. Ouck f. Cat Development of the Eye. ( Fick. -sBrrr" PLATE XI Devol<i|>im-i I c >f the Evi Fick. EMBRYOLOIiY OF THE KYE. 333 •i>|)liicil and (lisiipiM'ats: when jxTsistont, it is called jxTsisting pillaiy inenii)rane. (I'late XIII., V\g. 12.) at I I'"l . - . y ; --;• " - — ' Vitreous. The vitreous body is eoni|)()sed of connective-tissue elenii'Mts I'oniied from tiie mesoderm. In the pro.(.>is of development a I'ud of mesoderm is pushed into the eye through <he clioroidal cleft, which soon grows and ac(|uires hloodve.s.sels. Through these vessels leucocytes aid round and spindle cells are produced: the foriner have amcelioid movements, and the latter are fixed cells. These actively pioliferate, tilling the space JK'tween the primitive lens and the retinal layer of the optic cup, forming the substance of the \ ilreous. Bloodvessels. The bloodvessels of the eye are developed from ingrowths of inesodermic tissue. (Coincidental with tlie growth of the primitive vitreous ;in .•irt<'ry and vein develop in the optic nerve, Arttnesof Pvpit.Memti. Veins LtfiS Ca.pitl»ffZen^ If'trrai/s 'rttritHfilMtl Crcutvs ArtfrlQS'JS ^cessrs of Aneriti oftht Vw.. ir.l.— BliKirtvessels of the embrynnic eye. PIk embryo. M»(fnlfle<l l\i diameters. (After Srnn.T/f-;.) Ki.. 1 ij -The impillary mcinbraiiu and bloodvessels nf the lrlf<. I'lg embryo. The arteriea ^l.nm!lnJ; Irom the I'irculii- artcriowiin iif the pupillary membrane are lint visibk' In the pupil. MItT S4MVI.T/K ■ whicii lati r become the arteria centralis retina- and vems; an artery develops in tile vitreous (the hyaloid), going to the jMJSterior \m\v "I the lens. Then the vitreous becomes abundantly supplied with rapillaiies ( I'late XL, A), which new bltHxl sui)ply permits of increa.sed nutrition, resulting in rapid proliferation of the niesodermic vitreous ind growth of the lens. During the last weeks of ftetal life the blood- ■>se!s of the vitreous and the lens di.sap{K'ar, lejiving a pa.s,s!ige, the \( H.\;iloid canal. If the hyaloid artery does not fully atrophy, vestiges 'iKiy lie .seen later in life by the ophthalmoscojx>. Retina, The retina is formed from the eye cup by early (lifTcren- :.:n<iti of the outer and iniiei' ?ayers. Hy the time tlie infolded [jor- iion ot the vesi(>l(. has iM'come closely attached to the outer .segment t has increased many times in thickness (Plate XI., D. F, G); the 334 77//; i:yi:. : lalttT tliiiis, liut early iitTUiiiiilatcs pifimt'iit cells, first at llie anterior liulc, wliieli jir.iiliially exteiul t<i llie pusteridr pole, iiltinia'.ely Ihtoiii- ing tlie pifiiiieiited retinal e|)itlielitini. ( I'late XL, A.) The prolifera- tion ol the iinier layer ri-sults in the formation of two varieties of tissue, the nervous Jind the sustentacular tissue. The nervous hiyer ilitTereiitiates into the nerve cells, their outfirowths, and the epitli eliuni. The latter eventually forms the outer midear layer and the rods and cones, thes(> two coiistif utitij; the vision cells. ( Fiji. I'lo.) The sustentacular tissue extends ihroujih the thickness of the retina and ft'vcs support to the nervous elements forminf: the radial tihres of Miiller. besides this, there are outfjrowths of true connective tis.sue coining from the surrounding me.^^oderm, which accompany the ramifications of the retinal arterii's: all tiiis portion forins the pars optic." retina-. Thi' anterior marginal zone of the optic cup becomes a thin, deeply pigmented layer of epithelium, covering the MmtMnHtat ^mtrt{/ittit/f mil <i tmirmitmrUfr !*,'«#*? tvflilt CH/M Ucveloi.mt'iil ol the reiiiia. Uuiiimi embryo. 3 n mm. long. (After Falchi.) ciliary body, pars ciliaris retiiuv, and the posterior surface of the- iris, j)ars iridica retina-. The anterior edges of the c\ip form into ridges, l)ecoming the ora serrata. Optic Nerve and Tracts. The anterior portion of tlio optic stalk becomes the optic nerve, the middle portions of either side unito to form the chiasm, and the posterior portions become the of)tic tract.s, .\t hrst the optic stalk is a sliort tube between the primary optic vesicle and the mid-brain. (I'late X., A, H, (', D.) The invagination affecting the lower wall of the optic vesicle forming the choroidal tis.sure affects the optic .stalk at tlie ocular end, allowing the entrance of vascular me.so<lerm, from which arise tlie retinal bloodvessels. As the lower wall of the stalk folds in, its lumen becomes obliterated by apposition of its walls and thickening due to active proliferation, the young optic nerve becoming .solid, the imprisoned mesoilerni EMUKYOLOUY tJt iUt: i.Yh. •5;{.> producing the accoiiipaiiyiiiK bloo.lvcs.scls ami th" n. .r.fctivc ti -iic surruuiwlmf; tliciii. Tlu- lu-m' tilm-.s arc .|..v.-l(.p<.(l Iroi.i ncun.lh.t^ pa.<siii« tidiu tiic retina toward tlic hraiii and ..tluTs .rr.,«ii,! loni till' l.raui toward the retina. The sheaths of the optic nerve iu^ the septa are produced by continuation of the niesoilcnii, which I'orin-^ the cerehral dura, arachnoid, and ])ia. Uveal Tract (Choroid, Iris, and CiUarv Body). The larjte amount ol vas;'ular tissue m the iris, r-iiiary an.l choroid show, that the tunica vasculosa oculi or uveal has 1 n develope.! from the mesoderm. In the early (hftVr, .. . n of the eve structures the lens sac becomes separated from t>. overlving ecioderm bv a thm stroma ot mesodermic tissue, which iKronies cleft in develop- ment (I'late XL, D), un<" j)art remaining' over the outer surface of the lens, and the other adhering to the inner surface of the <rtoderm Ihe former constitutes the pupillary membrane and the latter the substantia propria of the cornea, tlu- space between forming the aiiterior chamber. The forward growth of the thin double-lavered hp ol the optic cup beyond the edge of the lens and over its anterior Mirtace lorms the ciliary body and the iris; extending backward II h)rins the primitive choroidal stroma which accomi>ani"s the retinal tissue in its growth forwanl. Almost th<- whole of the an- terior surface of the lens becomes covered, witii the exception of a central area corresponding to the pupil, which is closed Hrst bv the vascular pupillary membrane. (Figs. 151 an.l 152.) Further altenu- Mlion ol the epithelial cells on the edge of the lips of the optic cup I'-nns the colunuiar and cuboidal elements of the pars ciliaris and pars iri.hca retina-. The pigmentation of the cells increa.ses until the anterior portion of both layers forms the consjucuous pigment ot the posterior surface of the iris and the ciliarv bodv. .\bou; 111'' thml month of f.rtal life the epithelial cells surrounding the '■quator of the lens form into a series of radial folds, into which i.'lu-ate processes of me.sodermic tissue extend, developing into the xascular structures of the ciliary processes. The outer stroma of 'he |)ars ciharis becomes pigmented, the inn;'r layer remaining un- coil ired. • '^ Cornea and Sclera. With the exception of the corneal epithelium, 'iK' ('".s and tlu- nervous tunic with its cerebral attachments ail "I which are derivinl from the ectoderm, the other parts of the eye- liall are develo])ed from the mesoderm surrounding the jjrimarv optic vesich;. At the same time that the many changes hitherto described "< cur in the optic vesicle the surroun<ling mesotlerm exhibit.s marked l'i"lih'ration and condensation, resulting in the production of a dLs- tiiut envelope of embrj-onic connective tissue. The posterior .segment "1 tins mesodermic cai)sule difTerentiates late in f.i«tal lif.> into an outer ,|,.n.se tumc, which becomes the .sclerotic coat; the anterior- l'"iiion becomes earlier differentiated into the sub.stantia proiuia of ' "• ••"••■lea b,.mg dev(.|oped from a homogeneous nia.ss which fills nie small cleft between the anterior pole of the lens and the ectoderm lut A)/;. Fia. IM. whicli forms tin" (•..meal cpitlicliuiii. Hctwcf-ii tin- anterior surface of tlie lens and this mass, niesodennie eells ^o in and form the endo- tiieliuni of tiie cornea. ( I'iate XI., V, (ij The.se ceJls tiirow out projections piercinjr tlie ma.ss and forming; the corneal corpasdes; the pi/sterior layer of the hoinojieneous mass remains, forming the lamina elastica posterior, and the anterior portion forms the lamina elastica anterior. Precorneal hloodves.sels develop later, but disap- jM'ar iM'fore hirth. (I'late XI., .\.i Ocular Appendages (Eyelids, Conjunctiva, MuscJas, Glands, and Orbital Tissues). The eyelids develop early a.s an ujiper and a lower fold of the ectoderm, which ftrow over the corneal surface until thev meet and fu.se, this takinj; place early in the third mcmth of fiital life in man. contunjing until sl.ortly before birth, when the iwrmanent w'paration is effected by cleavage along the line of juncture. (I'late XI., A.) The hairs, the irlands, lym|)haties, tarsal and bulbar conjunctiva-, and the anterior epithelium of the cornea, are developed from the ei wxlerm. The lacrynial jKi.-sages appear early as a fi.ssure (about the thirtieth day), Ix'ing develo|X'd, as are the tear glands and tear sacs, by infoldings of the ectoderm. (Fig. 154.) The ocular mus- cles, together with Tenon's capsule, the comiec- tive tissue, and various structures within the orbit, with the excep- tion of the nerves, are derived from the mesoderm Itetmtt / Human embryo (if thirty one days. Magnified 5 dl ameters. (After His.) ANAT0M7 AND PHTSIOLOOT OF THE UVEA. If the outer coat of the eyeball, wiiich is composed of the cornea and sclera, Ix' removed, a grape-like bodv is exposed, which is the uvea or middle coat of the eyeball. The anterior portion is coiu- jjosed of the iris, which is a diaf)hragm in front of the lens witli a central opening forming the pupil; it extends to the junction of the cornea and sclera, where it is continued as the ciliary body: this being seen on cross-section is triangular in shape, and i.« "a circul;.' organ about 2 mm. wide, which is continued posteriorly as the clioroid to the opening in the .sclera wliich admits the optic nerve. The whole uv.-a is .soft and friable, the chorcjidii) portion iMMiig composed mainly of cot -ti\e tissue and bloodve.s.sels, whose ;he e.s.seritial parts of the eye. The tat, and has, in additi(m, mascular (•■impo.se(l of nervous, vascular, and , . . t<» <1<> with secretion, excretion, and the luiictiun of accommodation. Iris. Macroscopic Anatomy. 1 he iris is a membranous and mus- cular diaphragm containing a central opening, the pupil. It extend.-^ function is to cover and iiouj anterior portion or iris is ;i ph(. elements: the ciliary body is muscular elements which hav: rsTiSRrTJarr .^-.JU>L .UJ wmm- M.ATK XII <-.'<•/•> IV- r :s^M.\ ftutttttt rndofhthum I'^'t-V lay,-' iUoam Pumm Cells Ktifulof stroma layer layer 2 t^m Difujiaminnlii' Sections of Choroid. A Mict..~c.iiiic Sictii'tl of Ivisiii Iritis. II. Mitrosi"i>ic S>ilion .)f Nuvlilal lii-. C. »ll)itrficial t rivers of the ll:it I'ortiiiii .,f a Ciliary I'roiess in McriMianal Scliun I) Mtri>liaiial Stctimi uf rurtiml olCiliar\- I'niccss near Apex. K. All.inolic K>e . no I'iRnnut in IMKint-nt Cells, 1-. Tes- sellated 1 nil. In-. I'inintnt Confine.l to Stroma. C. Negroid Hun.lus : Ueciily I'iRnienteil in Iwth Retinal .lycr nnd Stroma. A Arteries. V. Veins. P. Perivascular I.yiniili Spaces. A AVI TOM y I M, I'll YsittLoa Y Of TIIK I ' yfA jp frn-n tl„. .■..,t,.ri„r surlac.. of tl„. miliary Ik,.Iv ..vcr tl„. |,.„s its ,.,.,„ral or pupillary l«.r.,.r li,. an.l kII.!,. up..., tl... a..t..ri..r , ps |.. * -s l.us ol,annn« a finn support. Tl... ..iiiary hor.li! ;;,',.; ." ir. ,s ,nu,v p,.st..n..r, .„, a.Tm.nt nf tl,.- simp.- ul t!.r l.-n. mu thus t „. ms t,.rms a sl.all..«- trunrat,.! ,.u,u-: ts rilia v ^1.1. an.l . xt..n,ls u. a plaiu-. I-.t n„nnal appcarancT .,f tl.. ins, x.o BJlcroscopic Anatomy. ()„ s,rti,.n tlH> iris is .«,.,.„ |„ 1„. ,.o,„„hs,.,1 of s.-v,.ra! .I.s„„,.t layrrs fl'lato Xll.. .Al: 1. .Vntoriur .....iutl i , •nor huutrntt layor. ... Pipn.nt lay.-r, ,.,„npn.s,.,i ..f',,,, tl,,. ., ,t t layer „t pi-iiu.„f,| p„lyiroiial cells. P<>st.,,.,r Kio. .■cerior ,H,er» of .h. iri. o. an a,bi„o,„. „„„.„ eye, .Minified 30„ u,„^ , „„. K,c>,m The stronia „f the iris ct.sists „f nurneroas l)I(K,dvessels enclose,! to le pup, lary „.arsu,s. ...n-l are surroun.l.nl by a lo...se „.esl." k of 'ranchcl and |)iKn,ente(l cells There is •. H.,t l....„i '' '" , .--.ular h,,n.s iL, .,,... ,. „.e pl-slc^ii.^ ^u/Jt' ' ,;'irr;; | '«■: 'h.' pupillary inargin, which composes the .sphincter ,„iscl,r cuns,r,<,or pupilhe. On .he ante.ior sirface is a T, e "v "o tl the an er,or en.lothehuin. and nex, to this a honioK,.ne.n,. 1. ' ' both o» win, I, have crypts or openinir lea-lini^ into The in ,.ri J^'f he ms ti.s.su,- thus placing its spa,., in fre,.' co.nmu i,- ti , vi he cavity of the anterior chainlxT and allowing of rlid ch ng^i oluine. The p,)sterior surface is covTcl by the ,K..ster o ■ I mi ing nembrane and the pign,ent layer. The fornu-r contains vev even 1 se fibres cxteiuling n a radial direction from the ciliary 'to he pupillary margin, an.l is reg,„,l,.,l as a dilator pupilhe- as no „, us! cular hbres have been demonstrated here, its ksiue probaHv acts 22 Ill am Tilt: t.YK. !)>• clasiic iniriinii. 'l'||,. |,ij;iiiciii iiiyci-.ovcriiiK the |)o.-t«Ti..r .-^lirlafc fxtfiids tu the impillaty •ii.ii«iii, ami turns luuml t«> apix-ar a liMlc on the aiit.Tior surface, iMroiiiinft easily visihle where (he hi - is cataraetiius. (Fi^s. (>. loo, and l.'>«),) Till- (-..lor of the iris is .let.'riiiined liy \\^,^ anionnl of pinnunt, '-.' k.ids of which exist, the one lyiiiK in the hranch. d cells oi -he strotn.i, and (he other (ilhnu u|. the e|)iiheliii| ,ells uf the posteri r pigment layer, p;.rs iridii^a retinav W iih the I'xception of jdhitmiic eyes ({'iu. I.mI, the retinal layer always ahounds in |.iKnient. while that of the stroma varies, so th.it Nvhen the latter contains little iiijrtnent that of the epithelial cells shows throu>;h. the thin iris appearing hhii'. If the ,-troni.i Ik' deficient in jiijiment hut thick, the iris appears gray: and if there Ik- a K^eat atnoiini of pigment in the strom.i, lirown, the depth of color varyinj; with the amount. Isolated patches of pij;nieiit are found iu the struma a- na'vi or .s|)ots on a lirown, ^rav, or hhie iris. The pigment may Ik- dee|)er in one part than anothei Thi' color of the iris changes iu the early years of life, at lirst the stroma containuiR hut little pi>;inent anil hemj,' very thin. Witii increa.sinK ap- the stroma iH'cotnes thicker, and if th«' pi^imentation does not iiii'rease, the iris becomes light blue or gray; if it incrc;, -s, the color becomes brown. Cibary Body. Macroscopic Anatomy. The ciliary body is the middle .segment of the uyea. ext(>nding from the .scleroc-irnVal junc- ture in front to the ora serrata lM'liin<l. It is a circular organ, but when the eye is bisected the region appears as a triangle, the dinger and outer side lying next to the sclera, the short anterior .side against the jxTtinate ligament, anil the inner margin in apjiositioi! with the pars cili;«ris retina-. It has three distinct subdivisions: i. - ciliary ring, the processes, and the mosclo. Th- muscular portioi, larger in hyperopic tli'in m emmetropic eyes, i.iid is smaller in myopic eyes. Microscopic Anatomy. I'roceeding from without n\\\ ml. we find the ciliary muscle, which consists .ii an external portio i containing t!ie longitudinal or meridianal fibn-s which arise from tl xterrial tunic of the eye at the boundary iH-twcen the (.rnea and .sclera, and run straight backward until they are lost in the external layers of the choroid: the fibres here radiate and are transposed into'cir- cul;ii filires. (Fig. i.jt;.) The ciliary jirocesses (Plate XII., (', I)) are stroma containing a large iiumlK-r of bloodvessels t)r;tiiched Digiiient cells placed upon the ciliary muscle. The a connective-tisMii and bninched layer next t(. the vitreous is a single stratum of'iion-pigmented cylindrical cells. I'nder this is a layer of pigmented ells, the pig- mented epithelium: these two form the pars ciliaris retina'. VuCv these is a homogeneous membrane, the hvaline lamella of the ciliarv body. The iris and ciliary body are attached to the .sclera a little back •.=f the eorne.wfjrrai liUirdn bv eon.-ic.-tive li.ssue. which i.> caiied tiie lig;imeiitu!n pectinatum. (Fig. 1,")7.) This forms 111 angle with the iris and cornea, forming the sinus of the anterior chamber, aiul where .I.V.I7o.l/r .i.\/* I'llYsHl.ooY OF TIIK IVi:.[ :J39 a.t..|lMMl t.. th- M.|,.ra .l,..n. i> .,„ un.lar lyn,|,l. s,.a,t. f..n,.a.g the caiwl ol >d,|,.ihih: tins ,M,rfi..n i, ulr. U,,. dliary ring. Kl., * Merl.llan.l «^tlon through .nterior r«rt of the eye. ,h.,wl„g .b.- cllUry hodv .nd Irt, with n...«,„n„« .r„c„m., (• ,„r„ea. .v. s,-...™. ,. ^hleinn, .«„.,. i Limb™ «„, m'c.Tv" M.h friTTornL t. 'j-^r'^""""/"""""""- -^ '■^•'"" '" '•'-""» "''"oMrr ;:: 5r : r ,'■-> "f=" -"■''«. ■=■■ «''..s=:'.,=".T» >ir.Hia. ,h. ( hon,l.l. r. Flbpw of r^niiU- ,.f ZInn. r,. Krif ,«,rllon of lonuU / Cn.! nf i-Pti? .' Ua.. *. Nuclei of len.. M.gnliicl 14 tlm« (Arter K,.,i,." "' """'•■ ' «•"*' »' '""■ • • ;■ •<Ti.,r chainlHT of the pyo is formed in front bv the cornea '"1,1 , '"■ ins, in the region of til.. ..npil by the anterior capsuit' Fio. v.-. Su.-f view of te !iL-an;i-::!-.!m jvt.- tinsS'im. 'i'l His an,! at its margins by the ligamentum i)ectinatum. behind " '' '"• '1" <'aMai of Sehlemm and tiie anterior region of tiio ciliary ;mo rUE EYE. body. Tlic il('|)tli 111' tiic aiitcriur cliaiiilxT is infiucnt'cd l)y accoiu- iiiodatidii, \»m^ .sliallowcr <luriii); tlio act fmiii |)r(itrusi()ii of tin* anterior .surface of the lens; it i.s greatest in younj? persons ami siudlower in 'ild aj;e: niyo|)ic ejcs iiave a deep anterior clianiher, iiyperopic ey( s a siiailow one. Where tiie tension of tiie i-ye is increased, the anterior ciianilM'r U'conies shallower. The posterior cliand)er is an annular s])aci' at the edge of the lens, heiiiff jiroduced by the iris coming in contact oidy at its pupillary inarj;in with the anterior capsule of the len.s. It is bounded in front by the iris, to the outer .side by the ciliary body, its inner and ])o.s- terior wall bei.ig formed by the lens and the zonuli- of Zinii, th( latter approachiii}!; from the inner space between the lens and the ciliary body. The two chanil.-ers coniinunicate only by means of the pupil, and both are tilled with the aqueou.s humor. Choroid. Macroscopic Anatomy. On o|H'nin^ the eyeball and removing the vitreous and retina, the inner .surface of the uvea is e.\])ose(l; *'.ie choroid extends fr mi the ora .s;'rrata to the ojitic nerve, appearinji as a smooth brown ineiiibrane. On removing this from the underlying .sclera, it is found to be attached more firmly at .some .s|)ots than others, more ])articularly at the optic nerve, at the en- trance of the ciliary arteries and nerves, and at the ecjuutor in the region of its hirge veins, the vena- vortico.sa". Thus the outer ])ortioii appears to Ik? .shaggy, on account of adiierent shreds of membrane. BCcroscopic Anatomy. The thickness of the choroid varies from O.OS mm. at the optic apertmc to 0.05 mm. at the ora .serrata. It has five outer layers ( I'lat(!XII., 1', F, (.i), being from without inward: (I) the sui)rachoroid, which i.s a richly pigmented layer of fibrous tissue; (2) the layer of large ves.sels, which are mainly veins, the intervasculai s|)aces being richly supplied with pigment cells; (;<) the layer of medium-sized ves.seU, which is but slightiy pigmented; (4) the laj-er of capillaries, which is non-pigmented. Tlie.se caj)!!- laries have a very wide bore and are packed closely together, with their interspaces narrower than the capillaries themselves: (5) the lamina vitrea, which is a homogeneous membrane lining the inner surface of the choroid. I'pon tliis lies a .single layer of cells which lunc l)een de\-eloped from the retinal mesoderm, whicii are deeply pigmented ami belong to the retina, the pigmented t pithelium of the retina. The choroidal stroma consists of a ground substance of loosely interwoven connective-ti.ssue lamella' containing bloodves.sels, white fibres, and elastic tissue with stellat( pigmente>l cells. Ophthalmo3copic Appearance of the Choroid. This membrane gives the chiiracli'ristic color to the fundus, and the amount of pigment therein is responsible for inu<'li of the variations f()un<l in normal and diseased conditions. The pigment is contained: (1) in the pigment epithelium of the retina ( l"ig. loS): (2) in the stroma of the choroid (Fig. I")i»\ If the pigment be wanting in both of these structures, we have the albinotic fundus (Plate XII., K), which is .i.v.iroj/1- AM) piirswLOdv of the vvea. .'J41 li>:lil red. tlic oiitirc liirpor circulatioii of tlic retina and choroid being visil.le: on account of the overlyinR capillary vascular layer of the choroid the intervascular spaces between 'the larger bloodvessels show as pink. Where the pigment is wanting entirely, or there is but little in the pigmented eiuthelial cells of the retinad'late ,\II., V), while that of the choroidal stroma is more or less normal in amount^ the tessellated fundus is observed, in which the inter^-ascular spaces appear as dark pla(iues. Where the pigment epilheiium and the stroma are heavily stained (Plate XII., G) the choroidal circulation is not visible, an<l the fundus is of a dark hue. This tyf)*" of fundus exists in the dark races, varjing from a dark brown in the China- nian. Indian, and .Malay, to a .slaty hue in the negro. Occasional bizarre effects are seen, as in the fundus flavus. The o))hthalnio- scopic appearance of the normal average fundus lies between these Fig. IM. Fi<!. V«. m ® @ Fio. 1'*.— HexDKoiial iilumeiit cells ipf the retina. Flo. l.'>9,— Pigment ctnima cells of the choroid. ixtriMiies. Ill the blonde more of the choroiihd circulation is obsorv- aiile than in the Iirui-ette, and in the latter the intervascular spaces arc seen more iistinctly. Bloodvessels of the Eye. The liloodvessels of tin- eye belong for the most part t(. the uvea, which is made up for the greater part of vascular ti.-;sue, and. hence, is very liable to become inflametl. Fuchs ilcscribes the ocular va.scular system as follows: Three .'systems of bliMMlvtwels exi.st in the eye: that of the conjunctiva, that of the retina, and that of the uvea (ciliary system of ves.><els). The arteries 111 this system are: I. The posterior ciliary arteries : these ari.se from ilie oiihthalmic artery and enter the interior of the eve through the MJcra in the region of the posterior pole. Tlit majority of them |i:iss !it once into the choroid (.short posterior ( ''Mry arteries). (Fig. Hill, r, c) Two of them, however (the long posterior ciliary arteries) I iK. It'iO, (/), run, one on the outer side, the other on the inner side, l"iween the choroid and .sch'ra anil as far forward as the ciliarj' ""-•'■ Hire each divides into two branches, which nm in a direc- iiiii 342 THE EYE. tion concentric with the margin of the cornea, and unite with the brandies of the artery of the opposite siile to form an arterial circle, the circulus arteriosus iridis major. (Fin. liiO. h, and Fig. 150, a.) This giv.'s off the arteries for the iris, which extend radially from its ciliary to its pupillary margin. (Fig. KiO, i.) Shortly before they FIH. 160. lllo<xlv«.self ..f Die eve; hohenmlle. The reliiml system of vcMels In rtcrtvcd from the central ttrt«r>- a. «■'-! O"^ "nt™! vein <■„ "f the ,>i.tie nerve, wbi.h Rive oil the rotin,.l «rlerie« h, hu.1 the retinal vein. h,. Th.*e el.J ..t th.- ..r« serrala '/r The system of <ili«ry vessels is fed by Ihe ,«,slenor shert ciliary arteries r f , the ,K*l.rior 1o„k ciliary arteri.s ,(. aii.i .he amerior ciliary arteries f From these arise t,i" v.iscnlar nelivork of the ehoroDal e>ipill..ries/, an.i of Ihe .•lllary l««lv <h and the cireulus arl.rMsus .riiiis major h. From the last s^riiiK th. »rl.-,le, oJ the iri. ., which »l the smaller (inneri eir.oinr.reiiee of the latter form the eireulus iri^lis minor k. The vei I the ins ,„ of the ciliary hortv a^d ..f ilie choroid are collecie<l Inio the venffi vorticisie I: those veins. h,.«- th»t come t"ro„i the ciU.irv muscle m, leave the eye as anterior ciliary veins ., With Ihe canal « forms aiiashnnoses. The system of cmijoiicllval vessels consists of ihe Thc-c commi.iicate wilh those bniii<lii-s of Ihe anleiior ever, latter. Schlcmm's c i«sterior conjunctival veswls o and ■ , , ■ , Is which run to meet '.liem-Ihat is. with Ih'- anterior conjunctival vcwels ;,-iind form /; ll|>lic nerve s lis sheath. .Kc. S<'lera. .4. I'ho- R Internal rectus /(.Conjunctiva i .Xfler l.KBER. fnun ciliiiry vessi wilh these Ihemalijinal lc«n>sof the cornea t;. rohl -V. Ke-ina. L. I.eus. //. lornea. Fl'ciis I reach ihe latter they form by ana.s^toiiiosis a second, siuailer vasciilai- circle, the cifiiius arteriosus iritlis minor, or the small circle (>f the iris. I'ig. IfiO, ^.) -'■ 'l"l><' anteriov ciliary artei'es conie frtiin in front, arising from the arteries of the four recti muscles. (Fig. IfiO, c.i They' perforate the sclna near the margin of the cornea, and a.ssist AXATOMY ASD PHYSIOLOGY OF THE UVEA. •M:\ in forming tiio circulus artrriosus iridis major. The siiort oosterior ciliiiry arteries are theref(,re det^ignod inaiily for the choroid, the loiifl posterior ciliary arteries and the anterior ciliary arteries for th? ciliary body and iris. The arrangement of the veins is essentially different from that of the arteries. In the choroid the capillary network of the chorio- capillaris (Fig. 160, /) is fed by the arteries. The blood from this Hows off through a gn-at number of veins that unite to form larger and larger trunks. A nund)er of these trunks simultaneously con- verge to a common centre, where, con.sequently, a sort of whorl or \ortex is produced by veins coming together from ail sides. These vortices, the numlier of which amounts to four at least, usually more, lie somewhat behind the ecjuator of the eye; from them are given off the vena' vorticosa-, which, perforating the sclera in a very obli'iue direction, carry the blood to the outside. (Fig. 160, /.) In the ciliary processes the arteries break up into a greater number of twigs, which pass over into thin-walled veins. (Fig. 160, g.) These cniistilute the greater part of the ciliary process, which, accord- ingly, consists mainly of vessels. The larger veins, which are fonned by the union of these vessels, and also most of the veins of the ciliary nuisde, pass backward to the vena' vorticosa". The veins that come from the iris (Fig. 160, /,) likewis" pass to the vena' vor- ticoste. Hence, almost all the venous blood of the uvea empties into the latter. A portion of the veins coming from the ciliary iniiscle (Fig. 160, ?«), however, take another course, as they pas.s out directly through the sclera, and thus come into view Ix'neath the (■iiiijuiictiva near the margin of the cornea (ante-ior ciliary veins, I'ig. ItK), c,). In their course these correspond to the anterior ciliary arteries: they constitute princi|)ally the violet-colored ves.sels which are setn running backward beneath the conjunctiva in ciliary injec- lion or in sta.sis within the ey<'ball (glaucoma). The anterior ciliary veins aiiiistomose with the coiijunctiv.'d veins and also with Schlemms canal The latter is a venous sinus running alonjr tli.' sclerocorneal juni'tioii. (Fig. 160, n. and Fig. l.')6, a.) Nerves of the Uvea. The nerAcs of the iris are derived from the ciliary plexus. They are at first me(hillated and (|uickly reiniite within till' <iiiary zone to form the iridian plexus, which becomes denser i~ it ai)proaches the sphincter. Three kinds of fibres arise from this I'li'xns: (li non-medullated fibres Ix'longing t<i the .sympathetic pa.ss I'i'IsuanI toward the dilatator iridis; (2) me<lullated fibres. a)«imr- 'Nily sensitive, pass to the anterior .surf.'ice; (.3) mediiiiaie.i lihns I'a-s ii> the sphincter and give if tnotor influence. Certain va.'^omotor tiiiic- pass tu the coats of the vessels. There are no ganglion cells ni the iris. Its tactile sensibility is not great, and ojM'iations are '"■' very jiainfnl if tr.action im' avoided. Inflammation, however, is iIIiihIciI with great pain. \\\<- nliarij mrrcK supply the ciliary muscle and processes. The !"!ij: nerves are .sensitive, being derived from the na.sil branch of ;i44 Tilt: KYi:. tlic ophthiilinic: tli(> latter aiv from tlic ciliary piiiplinii. and are doubtless of a mixed cliaraeter. The eiliaiy nerves penetrate the selera near the tiptie disk, runninji; forward in the su|iraehoroidal spaee, enter the eiliary niusele, and unite to form the ciliary i)lexus, which contains a few" nerve cells. Fibres are fiiven olT from this plexus which pass to the cornea, iri and ciliarv muscle. Tliese nerves end foHows: (') vasomotor endinps in the wa is wf the ciliary ves.sels; (2) motor endiufts in the ciliary mascle; (."i) extremely tine reticu- lations of grarmlar nerve fil)res, which jjrobably minister to ordinary sensation: (4) terminal arborcscences. which are believed to lr;ve to do with the nmscular sense which is particularly develoi)ed in the •le. The sensorv nerves of the ciliary body are abundant, ciliarv nius( d 1 iHamniation of tliis structure is attended with pain. and lience u _. The larrvs of the clmroid are derived from twigs given off from th(> long and short ciliary nerves as tliey pa.ss iM'tweeu the fibres and v:iscular tunic.-^ in their course to the ciliary Ijody. The si)ocial Inanches destined f'>r the ehoroiil form a wide-meshed plexus of both medullated anil non-medullated fibres within the lamina sui)racho- roidea. (ianglion ceils, isolated or in limited groups, are found in this plexus and al.so along the ves.-<eis; the nervous supply of the choroid is distributed especially to the muscular tissue of the bUxul- vessels. and belongs to the vasoii.otor sy.stem. The choroid C(mtains no sensory nerves, and inflammation oi thi? membrane runs its course without |)ain. L3rmph Passages. There arc no true lymph ves.sels in the eye, except in the conjunctiva: there are, however, large lymph channels and spaces (Fuchs): 1. Anterior l.iimph Posmges. The lymfih of the anterior section of the eve is collected into two large lymph spaces, namely, the anterior and posterior chambers, which communicate by means of the ]iupil. The outHow of lymph from these spaces takes place by its discharge from the jxislcrisir chamber through the pupil into the anterior chamber: tlicnce it filters throiigli the meshwork of the liga- ni(>ntum pectinatiim into the subjacent Schlemms canal (Fig. 1(»1, .>•■), and from there g<'ls into the anterior ciliary veins (r), with which Sclilemm's canal is in dirr-ct communication. •2. I'dslcrior Lijinph I'nssiif/cs The.se ari' iis follows: (a) The hyaloid canal, or central can.il of tiie vitreous i I'ig. Kil, /(), whicli extends from the point of entrance of llw optic ik rve f..rwar<l as far as the posterior pole of the lens. During the developiiunt of the eye this cinal lodges the hyaloid artery, which in the fully formed eye dis- ajipears, while the canal remains. It has its outlet in the lynij)!! j^paces of the optic nerve. /') The perichoroidal spaee i Fig. Kil. /i) is the space between the choroid and sclera. It is continued ;ilong the ves- .sels which pass through the .sclera, especially the ven;e vorticosa' (Fig. Ifil, >■), and thus coimnunicates with the anterior ciliary veins (I'ig. Kil, c). Tenon's .space (Fig. Kil, /. /), which lies between the .sclera and Tenons capsule. The outflow of lymph from all these AXArOMY .I.VX» PHYSIOLOGY OF THE UVEA. 345 spaces takes place into the lynipli j)assages wliich sjiread out along tlic optic nerve. Tliese latter are (/;) the intervafjinal spice, which IS found iK'tween the sheaths of the optic ner\'e ( Fi^. 1(11 , i), and I A') the supravaginal space (Fift. Ifil, ,s), whicli surrounds the sheaths of the optic nerve. H\- far the greatest amount of lymph leaves the eye through the antf^rior lymph passages. The.se, therefore, are the more imi)ortant. Thiir imj)ermeal)ility leads to serious changes in the eye (glaucoma), while up to the present time nothing certain is know"n in regard to disturhances of the function of the i)osterior lymph passages. Fia. 161. 1„ 1 Z , ?7?H ?'!' ""'"™""' "■ Schlo,«ms™i..l. .. Anterior cill.r,- vein-. A. Hya- Ion L^, r' T?' """" '"">""""""- by mean, or ,he ven,P vortico.* ,•. «m, -'.a »I«>"tl>cl..„,|„,„„r,„o.HMlariDU«-lM,Utemllnv.gln„li„n. Hfter Fuchs.) Nutrition of the Eye. The nf>urishment of the e-ve comes mainlv ' uni.^ri, ,i„, „v,,,l vessels; the secretion of th.. flui.ls of the eve i's il^o nuhrectiy elicited l.y the uvea. Th.- a<iueous humor is the ■■niv secvhon of th.- evehall pro|KT. It is a limpid li.p.id containing ■' ^iiKill aUMMinf of all.uiiiin. secreted mainlv l)v the ciliarv proces.ses i""if: poured first into the posterior ehamher. thence pa.s.s'ing through I'" I '"I'll '"to the anterior ehamher, leaving i he eve through Schlemm's '"■'1 ;"id tne hgamei-Mim |.ectinatum. It is secreted and e.xcreted :yu rui: EYE. rapidly in health, and is n'stored quickly after evacuation of the ante- rior chanilxT by operation, sooner in youtli than in old age. The flui<l that accumulates in the anterior chaniln'r after evacuation of the aqueous contains more albumin than the normal a<iueous. The cornea is nourished by the marginal loops of bloodvessels at the limbus, and somewhat by the aijueous humor which diffuses into its tissue. The lens and the vitreous obtain nourishment mainly from the ciliary body and the anterior .section of the ciioroid; hence, in disciuses of these structures the lens and vitreous l)ecome clouded, and may undergo degeneration. The internal layers of the n'tma are nourishe<l by the retinal vessels, the outer layers being deix'ndent ui)on the choroiil; the regeneration of the visual purple is accom- l)li.shed through nourLshment from the choriocapillaris. The intra-ocular |)ressure is dependent upon the relation of the capacity of the ocular envelojx's to the contents. It Ls discussed in the chapter on tJlaucoma. For the participation of tlie uvea in the visual act, see page 65; the reaction of the pupil to light and acconnnodation, see i)age ."«): HMiction of the pupil to jioi.sous, mydriatics, and myotics, see page 112; reaction of the ciliary body to cycloplegics, see page 112. DISEASES or THE lEIS AMD CILIAItT BODY. CONGENITAL ANOMALIES. II > M I Variations in the Color of the Iris. Then> may be irregularities in the amount and distributi(m of the iris ])igment, which may Iw mas.sed into little heaps in the stroma, giving rise to a numlK-r of brown or black spots upon a lighter colored iris or patch upon its surface. (Plate XI 11.) Sometimes one iris differs in color from the other; this is ealleil ht'lrrochromia. When one eye is decidedly brown and the other a uniform blue or gray, indicating al)s<>nce of pignient, the latter may have been the site of previous tlisea.se, or it is liable to Im" affected later by cataract, while the dark eve may remani normal. In inflam- matory conditions the color of the iris always is changed. In albinism the iris usually has a pink appearance, which is due to the shining of the fundus reflex through the iris stroma. Membrana Pupillaris Perseverans. As has been noted in the chapter on tiie d<'velo])incnt of the eye, a va.scular membrane fills the pupillary area which nourishes tiie lens. It is of comparatively frei|ueiit oecurrence in newborn infants, but, as a rule, is resorlK'<l, entirely before birth or shortly afterward. In a few cases complete resorption iI(K's not take place, and a gray or brown tissue lies upon the anterior capsule of the lens, arising from the circulus minor iridis; in the centre it is attached to a small round white capsular opacity. When of such a degree as shown mi I'late XI II., Fig. 12, it inter- feres seriously with visual acuity. Many cases, however, display only PLATE Xlll. Anomalies nn d Diseases Affecting Uie Ifis and Pupil. Z)/AA-1>AVV OF TUE IKIH ASD CILIMIY liUOY. Ml ..lie or two tilaiiicKts Iroiu one portion of tin- pupillary nvAT^m lo lh<- opiiciiy, or from the iris to the capsule of tin- lens, or in other fas(> only a Uw l)ro\v!i dots n-niain u|)on the lens capsule. If tlie |)Ui>il Im> .lilate.i liy atropine, it oih'Ii.- fully, a.n the filires are .-ery exteii- >il)le. It is'otheiwise the c!,se in postt'rior synechia', for here the characteri.stic clover-leaf formation of the pupil is observed as it becomes enlarged. (Plate XIII., Tig. 9.) DESCRIPTION OF I'L.VTK XIII. Kiii. 1.— Myimlsfrojiesu Ine; direct lllnminatton. showlnK the full eitetit of the maikinirtof the Inn ; Mie puiiilUrj' iwrtioii ^l^l IcbeJ ty cimtmctioii ul the circular Hbr>.-« ; the pupil Ik ntvcr prr- fcctiy r'l'im} aiiJ is usually situated 'lowiiward uud InuHnl. Kiii 2-V,-tlrwfs ir. in Hlropluu ; ophthalmonopic illiimlnatloii : fullent exranrioii of thepopi! I,y comnictjoii oi ihe null.il li'jiwi; the dlsilncllve iniirkiiiKS ou tb« Irinare nearly obli'cr.ted; the Ifii- klur shows Indistinctly. Ho o -Corcctopia. dl»pla.cmem of Ihe pupil ; direct lllumluaUon. In thU condition ibe pupil is usually sotnewhat Irrvitular, snuU. and displaced u> one rtde of Ihe Iris, mually downward and Itiwanl- In congenital forms bcinc somttlmes a».«oriaud with co'.ohoma of the choroid. V\v.. 4.-(ilaucoma, ths irlf structure being 111 delincd fr.,ra swelllnit ; the pupil irregular. dllaUH), and having a greenisn reflex. , , _ K... .'.-Iridectomy for glaneoma: oph-halm. wopic mumlr.atloii. Ihe edge, of the coloboma ..,vu and the whole pupil tpelng tlie shape of an inverted ke> hole ; the urp<"r edge of the leiw and the cillarv prooemies are seen. ,^, , Fiu. R. llmiwrfwt hdlcg In Iridectomy f.>r gla.icoina ; anterior synechia cau.e.1 by incan-erailon of one edge o' the coloboma in the corneal wound : direct lltuniinallon Fio 7-Ot,iUal iridei'tomy for Icucnma of the cornea; di.cct illumination. The coloboma is usually made downward and inwaid on the bact of the clearest i«.rti»n ..f the cornea ; small iriilecloniv which d<«» not reach to llie root of the Iris Fi„ s -I ouKeuitul colol)oma of the cornea : direct Illumination. Wlicn the eolol«raa rcachea to Ihc f(«t of the iris it is usually accompanli-d by cohitama of the ihon.ld. , ,, . , ¥v. .J -irHis with iH>»t"ior synechu. ; ophthalmoscopic illuuiiuution. The markings of the Iris «r.> not well dcHned ■ the synechia show dark, forming Ibe characterlsilc cloverlcaf pupil. Kl. 1.1 -Exclusion of the pupil or total ixelerlor syuechiu from chronic Iritis ; ophthalmoscopic ill.unination' The »h..lc e<l^e of the iris and snmetlmei the entire p..stcrh,r surface of the Iris arc Ismnd down by adhesions to the atilerlor cai*ule of the lens; this cmdilion and the f..Ilow- iiiL'iFiu 11 1 arc imiie to ;,'lTe rise to secondary glaucom.i. K,„ 11 -Occlusion of the pupil from lrldo,yclitls ; o'-lique illuminailon. The pupillary area is lillc.! ttltb orguulzed exudation ; the pupillary margin of 11- Lis Inking l«>und down to the anterior ,u|wilc..f the Icus, the centre" ..f the Iris being bulged forwarl, causing the condition known as Klc ■ • -eerslsliug pupillary memhniuc : diicct Illumination. A few strands mich fr<mi oyer the , .Ige of The pupillary margin to the centra of the lens. This condiliou is frequently associated « iili IsrsisUtiK hyaloid artery-. , . , .1. liu. n-lridodialysis (ophthaliui«coplc illumlnatlmi), lonning two pupils and asKielatw' with .l.iuble vl-ion This coudltion and that of the next are of traumatic .Tigln. l-i.. H --Cohcoria; ophthalm<»e<.pic illumination. In this i«licnt there were three pupils and triple vision ; the clge of the lens au.l ciliary i.nKvssis could lie distinctly 8.*n. Kio 1.-, - Foaigu bo<lv 111 iris and lens, binding the iris down h. the lens ; this l*lng a.sepllc was „„i asMKiated with Inllamimuon- ch.mgw, and w„s retaiucsl in the eye ten .lays before extnuMi.m by '..■mUEucti hutsl.ghlopacityof thBlenscap«Ml. r..;io«Ld. Direct Illumination. Ki.. Id -Traumatic hcmorriiagic Iritis with hvph.Trai:. siuinlaiiiig iiyiH)pyon. IHrect lllumlimtlon. li.i IT. -Anterior synechia with hernia .if the iris from in- ircerutlon In corneal woun.l. Direct liluininatiou. 1 10. is— Sarcoma of the Iris; oblique illiiminnthn. This was attended by IritLs and i>»u;rli.r viicchia. Vt,. Y) —Syphilitic irllla ; direct Illumination. Gumma of the iris. V\n. JO -Acute .■hor.>iditis, direct illumlnaliou In .his comlilion the exudation in the vitreous -■ ves rise to a yellowlsb-ureen reflex lr»ni the pupil. h% fTr.?r«««^.£*x*sis. (if vision ; iuit if iliviiinl l>y tlK- :UH niKEYE. Treatment. As m rule, tlx'tv ,- lull.- .li.tuil.aiuT tlu iMCMl.ranr U- v-iy tl.irk. th- sIra.i.U ...ay 1. Ooloboina Iridis. ('....Knutal r,.l..lH.i>.a of th.- ins is al^va^^ Mt- !'..'.,...., ,n..L'.- nti,.uuusly ..a,-n.vv..r. t ..■ .,.1..,.,... hi...., t ho „„,,jin uf th- pu,,.! ;u. :.!.<.. the .■ul..lM,...a as far as .;- .\>vs. . 1 tat • V n FiL' s ' 1" the ...ajority -f rasrs a s...aii n... ol .r.s ...ay Ik :1s 'nV,! a. .!..• In-ttn... of th.- ,.„i..l,.m.a It .^ t.. 1..- .hst.nmi.sh.-.l ... ,h H. ...a,lr i.v i...l.T......y: i.. th.. btt.T tl... s,,h....-t..r .s . .,.« i.. 11..- .•oh.i.o,,,:,. a...i it ...ay iH- ..M t.. 0...I -' •' f ;'n' - P; „ ,1,0 .livi.h..K li..o lH't«-..'n th.- l.ui..i a.Hl tho ,-..lul,.... a. (I at. \ni l-itr- -) 7.) li th.' o..l..l.<.i..a 1..- ac.n.„pai..o.l l.ya shjjht ;hl.-t' „f tho Vhor..!.!. thoro ...ay iii<owiso oxist a .l.-tioio;.oy ...tho .'iliarv IhmIv; sn,„oti...os onl.,lH....a or ....loi.tat.o.. ... tho o-ifrr ..t tho l,.„s aooo..;,.a..i.'>. Th.T.- an- .... >I.ooial sy...l.to..,s a...l .... tnat....... Aniridia vel Irideramia. Th.- iris ...ay !«■ .-..t.n-ly al.s..,.t ..r hut , small rosi.hia! ,.or,io,. .-.■...ai.. ; this.i.-lVot .s a,T.....i.an.o.! Ko...-rally 1 V ..L'o..ital o,.ao,.ios i., tho lo..s a...l con.oa a...l nthor ah..on..al.t.cs. K... th. ;,.oial ......l.tio... .lark ^lassos ..r tho sto....|..o.o l.olo i..ay be ""Kpla PupiUa vel Corectopia. Nonnailv .ho puj-il is ....t pro- ,•," V m .ho o...tr.-. h..t is usually a littl.- 1h-1... a.u f. ho s..lo. I h.s I s ao.-...o„t is so,n.-ti...os so p.oat that .t .s not.ooa -lo <-s,K-o.ally ,„: (IMato XIII.. Ki«. 1.) It ...ay ov,.„ ho s.tuato.l oc-c-o n- i,..llv ... th.- .>.-inhlM.rh....l ..f tho o...-.,oal ...a.-p.n (I'iato MIL, .' ,; • . „.l is so,„.Mi....-s oo,.,plioato,l with .r.slo,.at.o.. of tho l.-..s. PoUcoria ..r ...ultiph- pupils havo Ih-o.. .losorih.-.! as <>';;'""-"'ff <';;"- jr,.,.itally, l.ut as a nilo such ciuUtions aro .luo to ti-auu.at.s.n. (i late '""lilflaliiSato^' Diseases. IuHanu..ati...i ..f th.- his is h.ti...atoly ,, ". o™ vith il.a, ..f tho .-itiary ho,ly as hoth an- s..pp l.o.l by tho : ; W uivossols, a...l tho iris spri.,,s .lin-.tly fro,., tho o.l.ary bo. y^ f . i„g ;. .•o...i..uous ti.ssuo. It sh....Kl hkow.s.- Ih- n-..,o...bon-.l that ;! 5-oi.l is a i.ortio,. of th.- uv,-a, a...l is us.ially ...oro or loss afToo .-.I : fl .n.aa.inas of tho a,.tori..r portio..s. pa.-t.oularly whoro ho Hi- rv b...iv is .,.v..lvo,l. Thus, vvl.iio wo sp.-ak o, au .nt.s, a oyol t.s. . -horoiaitis, a,. i..Ha.,....atio,. of th.-so tis-uos .s u.on- pn-porlv a ;. , Th.- aisoaso ...av. l.ow.-vor, bo so pn ,l.,......a..t ... t ho ,ns o . 1 . V l,o,lv .hat tho atTootio.. ...ay bo .•lass.-.l .-.s .r.t.s or .•yol.t.s, an.l f, ; ,';a!....'a^ purposes tho sy,..i.to...s of tho pn..lo......a„t ios,o..s .uay '"■^;;;;^i:i;f Xiris. (-.....osti.... is th.- .irst sta.o ..f i,^a.n.na- U^!^.nA onhor ...ay , t.. rosolut.o.. or to lato,- -^ ^f- "^ 'f ; ,„.„io„ i:vo,-v iritis is pn-o.-.l.-a by hyp.-ra-„.,a, but .-..sos an ... t •i, hat .lo not pn,n-.-l fur.ho. tsan this stage. It =..ay also 1k- IIm with ,.r bo a sy„ , 'om ,;• i..(ia>..,..ation -] ^^^^^ „f tlu- uveal t.-act or th.- ..oi^rhl^nuig ooular tissues; thu> .t iucum 1)Isi-:a.si:s or iiii-: mis ami cilimiy iioity. •Mt |i!inii'« iiiHiiiiitiiiitory cliiiiip's in fhi' riliary ImmIv and iiculf, «'Vrri! I'iiiii'iiiilitis, also ulcer of tlif cornea and .iclcrilis. Iiy|H'rainia of the iris is cliaractcrizcd l)y clianfje in its color, so liiat a liliu' or Rray iris iM'ciinifs greenish and a hrown iris yellowish red ; in dark eyes the discoloration is not s<» marked as in lilonde eyes. < ine of the lirst symptoms is ix-ricorneai congestion, a characteristic (if affections of the uvea and cornea, coiisistiii); of erdiirKcmenl of the line vessels situated in the episcleral tissue railiatinjt from the corneal margin. (I'ijr. UV2.) The pupil is sluKgish and d(K's not respond freely or (|uickly to lifiht, accommodation, or mydriatics: as there is III" exudate, posterior synechia' <lo not form. In acute cases coin- plele resolution takes place as IIh' cause ceasi's. In ciiroiiic hy))<'ra'miji the iris Iwcoines di.scoloreil from chaiifres in the pigment cells, anil the pigment at the pupillary border disapiM-ars, the edjie U'cominn raided and notched. S<'nile changes in the iris caus<' hieacliing of a similar nature. Hyperemia of the Giliary Body. Simple hy])era'mia of the ciliary ImmIv is accompanieil usually hy changes in the choroid of a conp»'stive nr inll.inrmatory ty|M'. The ciliary region hecoines easily congested liy u>e of the eyes or by irritation, and there is ciliary pain following close Work. Etiology. IlyjM-ra'inia being tlu> first stage of iidlanunation. the cuise of congestion of the iris or cilrary body may be looked for in eyestrain, injuries and inflainma- liipiis of the cornea, sclera, choroid. ;nid in disturbances of general nutrition. Treatment. Rest, dark glas.ses, instillation of atropine, removal of the general or local cau.s<' of the congestion, regulation of eyework, ,ind correction of refractive errors. Iritis. In addition to the sym|)- lonis of hyjiera-mia, true iritis is attended by exuilatiou into the -tionia of the iris and the anierior iiid posteiior chamUTs. 1. K.rii(hili(m i)ito the strnmn of !hc iris is attended by infiltration with roinid cells w'lich ihi'-keiis.iiid -wells the membr.ine. (Plate XII. |.!oiiouMced than in h\ iM-raniia, the distinctness of the markings on iie anterior .surface iSecoming obscured: the rigid and swollen iris ivacts but little to light and accommodation, the i)U))il being greatly •MMifacted. fFig. lt)2.) 1. E.rii(hition into the nnterinr chamher is manifested by turbidity ■f the ai|Ui'ous from susjjcnsion therein of cells: the jniiiil looks gray iiMead of black: the exudate floating in the aiiueous sinks into Fin. ir.-.'. Iritis. Tilt' pupil In lrreK"l"»"ly t'onirnoteil. and eircumcornatl congentlon l« iiiarke<l. H.) The di.spoloration is more MICROCOPY RESOIUTION TEST CHART (ANSI and ISO TEST CHART No, 2l 1.0 i^ 1^ 12.2 I.I t 1^ — 11 1.8 1.25 1.4 III '•' ^ >^PPLIEa IM ^G E Inc ^Pl bbi £a?t Wo- S!rM( 7.^ ''ocnesttf, Ne* 'ori. U609 uSA '-^ t?i6) *82 - 050O - f^hote 350 TUE EYE. the bottom of the chamber, producing hypopyon With Rreat hyper- Lmia exudation of blood may take place, winch ^nks to the bottom onli: anterior duunber-hyplnenna (Plate XIII, 'S- ^•) Jhere is considerable exudate upon the surfaces ot the iris (Plate XII., B) nd u ^n the walls of the anterior ch:unber; hence the cor.iea and lens aupear cloudy on accunt of the deposit of numerous round cells upon th'ir endothdiu>n. These may even coalesce and 1m> dep..s.t^d .n sjK, s, hut this conditi<.n is more con.mon where tlie cmary body is mvoh . If these exudates become organized, a membrane is formed, connected with the pupillary margin, which closes the pupil, causing the condi- lioi. cane!l IcdaXm of the pupil (Plate XIII., Fig. H) I this results m great impairment of vision. i:„„„fi„ :i Exudation into the posterior chamber cannot be seen directly on account of the iris being closely applied to the capsule ot the lens it gums down the iris, forming adhesions at the pupil ary ■na-gin or ,in«r.s7«cc/u,r. (PlateXIII., Figs. 9, 10.) t is the layer of retina L,nent that becomes adh..rent, ami as this <lepos.t is formed when S iritis is at its height ami the pupil contracted when he pupil tends to resume its normal size, or if atropme be instilled, it is founc Uiat the iris retracts strongly at its unattached portions, forming clo^er- leaf a.lhesions. The tags jutting into the pupil appear dark brown or black, and there a«' isolated spots on the lens capsule, .aovMng where the retinal pigment has been attached and torn away. Dilata- tion of the pupil by atropine at this time may release some or all of the adh.-sions, but the pigment remains permanently, giving eyulenee during the whole lifetime of t' patient that iritis once existe.l If adhesion of the iris to the capsule of the ens exist around the ^vhole extent of the pupillary margin, it is called annular poM Tchia; this results in shutting off the anterior from the posterio chamber exclusion of the pupil (Plate XIII., Fig 10) which does not i self n..cessarily affect the sight if the pupil be free from membrane, but subseciuentlv causes increase of tension and glaucoma, resultmg iu blindneis. This condition fretjuently is associated vvith occlus on of the pupil, and as the latter rarely occurs without closure of the anterior and posteri<.r chambers, it is subject to the same dangers. Cyclitis. Most writers describe cyclitis under the name of serous iriti;.- Inflammation of the ciliary body i^^^ittende.l alwav^ ^s^h Lypera.mia or with inflammation in the ins. Simple cycht.s, with but i tie inflammation of or even with but slight hypera>mia m the n^ ay oc<-ur in a chronic form, the inflammatory symptoms being S.t. the pupils generally .somewhat dilated, the f^^ -^^^^^ of obscuration of vision being due to the presence of deposits on the , ..ior .urfa..e of the cornea (Fig. l(14),an< opacities m he y.treou. ' S^-vere cvclitis mav occur without mark.-d syn.i)toms being set up i„ the ri.iic tissue, which only becomes hypera-mic. hxudat.on into te an e ior chami,er is not usually pronounced,, ami while the ins n' acls slowly lo light, accommodation, an,l mydriatics, synechia, do not tend to form. DISEASES OF THE 'RIS ASD CILIARY BODY. 351 Exudation from the ciliary body takes place into the anterior and liostcrior chambers and into the vitreous. 1. Exudation into the (interior chamber passes either directly from the aiiterior portion of the ciliary body throufjh the ligamentum ix>ctina- tuiii at the sinus of the anterior chamber, or, beirg deposited directly in the posterior chamber, is carried with the aqueous through the |)Upil into the anterior chamber. In con.secjuence of this, e.>*pecially in the chronic fonns of inflammation, conglomerations of cells aggluti- FlQ. 163. Deposit upon posterior lurface of cornea In cyclills. The endothelium la Intact except where the deposit Is thickest. (Afler Fuchs.) iKited into masses by fibrinous exudate (Fig. 163) are thrown against the jjosterior surface of the cornea by the centrifugal force of the eye movements, and adhere in a triangular shape to the endothelium, the larger exudates being at the bottom, while the smaller are at the upper portion of the triangle. (Fig. 164, A and B.) These deposits are light gray or brownish, varying from a very small size to that of a pin's head, and formerly were supposed to be located in Descemets layer (descemitis), but are readily distinguishable from macular deposits Flo. 164. A B T>epcsits on posterior surface of cornea In cycUtls. ^4. Larger deposits. £. Smaller. in the cornea (keratitis punctata) by oblique illumination, by their 'liar outline and brownish color, and by the fact that they are ill <iii the same plane on the posterior surface, and not in different •'ipllis of the cornea. If the cornea be incised and the acjueous iinwed to escape, some of the deposits are carried away. Pigment M'posit on the .surface of the lens as well as the posterior surface of lie cornea has been seen following or during the course of cyclitis. : till" exudate from the ciliary bo('y into the anterior chamber l)e ly great, it may be deposited in the form of hypopyon; but if this 352 Till: EYE. occurs, Rrayish sp-.n^n- masses will be foun.l projecting around the niicrlc^ of the aiiteritir ('liaiiil)er. , . . • ^u T T le S-. ter n.assof exu.late in cyclitis i. .le,.os,te.l ,n the /.> - U^iorcLnhrr, and if extensive lea.ls to a.lhes.on of the whole poste or Sice the iris to the capsule of the hu.-total ,>osterwr s„mrhm. a"h ^.;Lk; thisexudatio^ draws tl.e iris everywhere to the a,Ueno surface of the l.-ns, so that the posterior chamlH-r ,s obliterate an he 1ite4.r chainber becoineM.roportionately deeper espenal yd t e rii.herv where the iris is .lisplaced fartluT backward. (H|:. 1(^.!tos occasions the sa.no danger of glaucoma a. spoken ot ui exclusion of the pupil. i • i :f ,.f Urcm siyc '.i. ExudntUm into the rilreou. causes opacity winch if "f '^^p m/- an.l ia the antc>rior portion causes g'-eat chminution of vision. If thi Fia. 165. Iridocyclitis after perforating injury. MagnlLcJ 50 time.. (After Fuchs.) „,e.liabe sufficiently clear, they may be seen im.ler lateral illumna- tio.i as a srav mass behiii.l the lens, causing the con.htion km.v n a p^nidoglioma^. (Plate XV., C, aiul Fig. U.S.) The sight ,s lost and •itniDliv of the eyeball occurs. , • r^ ;„ iff L-.s/.n of the eve, which in iritis usually is unchange.1, oft-n - elevate.! in the beginning of cyclitis, so much that ^^'■'■"V;^^^; in and blindn.'ss speedilv be pro.hiced. In the later stage cjchtis Im account of the shrinking of the exudates, tliminution of the ocular nre«>;iire is more conimon. . , f ,„ ^TCsnlnectire s.nnpt.nn. of both iritis an.l cyclitis are those .>f .sev re inflammation, consisting of lacrymation, phoi..phobm, and .w^ pl'ii. The pain and tend.-rness are situate.l not only m the eyeball, but 1*'.- OF THE IRIS AND CILIARY liODY. 353 also in the surn-iiidinfi parts, especially the region of tiie eyebrows. In tlie acute ' ^es the pain is intense, while chronic cases occur in which inflammatory symptoms are almost entirely wanting. In severe iriilocyditisthe pain is intolerable, particularly at night, and is accom- panied by hy[)erpyrexia and sometimes vomiting. \'isioii is always more or less diminished. On account of the inereaseil refractive index of the a(|ueous in iritis, a p.seudomyopia i- Icveloped in the Cdur.se of the disease, which disappears after reso. j.ion takes place. Tiie following signs show jmsitive eridince of inrnhevuat of the ciliurji hiidy: 1. When the inflammatory symptoi.is are very severe, especially if associated with ttvlema of the upiK>r lid. 2. AViien the ciliary region is painful. 3. When deposits occur on the cornea. 4. When the anterior chamber becomes very deei) from gumming down of the ciliary margin of the iris. 5. \\'hen the visual pcuity is greatly lowered, which is due to involvetnent of the vitieous. 6. When the tension either is lowered or elevatetl. Course and Sequelae of Iritis and Gyclitis. Course Acute ca.^es associated with marketl inflammation run a severe course, the average case of iritis lasting from one to two months, the first signs of improve- ment being decrease of the congestion and pain and i)ronipt action of atro[)ine. Chronic cases show l)ut slight .symptoms of inflanmiation: an iridocyclitis or iridochoroiditis may last a number of years. [{lapses of inflanmiation in the iris and ciliary body are common, licing due to renewal of the exciting cause rather than to the mechani- cal effect of the adhesions wliich may have formed. Formerly it was supposed that posterior synechia' were particularly dangerous, and many o|)('rat ions were devised for cutting the iris loo.seat its periphery. I'nlcss the adhesions have cau.sed exclusion or occlusion of the pupil, tlK'V should be left alone. ('iiiii|)let(> resolution may take place in mild cases, if seen sufficiently rally and the pupil kept dilated by atropine. Even if posterior ■i.lliesion of the iris has taken place, the pupil may fully dilate, leaving, linwever, pigment spots upon the anterior capsule of the lens, which ■ !'i nut l)(>come absorbed and may later i)e .seen during the entire life- linic of the j)atient by obli(|ue illumination or the ophthalmoscope; • hi y are likewise sulijectively evident as floating specks before the ■\ ts. IIy])opyon, hypha'inia, exudates into the anterior cha 'iber, and -lijriit opacities f>f the vitreous may disappear completely by resorption. Sequelae. In most ca.ses |j<'rmanent se(|upla' remain after iritis •!i;d cycliiis; 1. The most conunon se(iuela' of iritks are posterior "irliia : these are evident by circumscribed adhesions of the iridic !• riiieiit r.t tiie pupillary margin to thi' anterior capsule of the lens, " ' !(U|)il being irregularand responding to mydriatics incompletely in ■'over-leaf form. (Plate XIII., Fig. 9.) Complete adhesion of "the liillary margin causes exclu.sion of the pupil, the body of the iris ' irpiishcil forward, producing the condition known as irisbomhf !i- .Mil., Figs. 10, 11): the pupil being represented us a crater; iris being greatly stretched becomes atrophic, elevation of intra- 23 :{54 THE '■:ye. ocular proswurc occurs, ami the !<yniptonis of gocoiulary plaucoina set in. On account of the increase of tension, the sclera may give way in j)laces, forininj; ectasia-. 2. Atropht/ of the irix, especially of its pigment, appears as the result of rei)eate(l recurrences or chronic inflammation; the delicate markings of the anterior surface disap- pear, the pui)illary margin is thiimed down, and dilated vessels may often i)e distinguished. The iris pigment, particularly of the retinal layer. In-comes ahsorl)ed and a black ring at the edge of the pupil is no longer seen, the edge of the iris Icjoking frayed and its tissue lighter in color. The atrophic iris is very friable and makes perform- ance of iridectomy very diiticult. 'S. Ocduxio pupilhr u c.iused by organization of the exutlate forming a pupillary membrane which diminishes the vision in proportion to its thickness. 4. Exudates be- hind the iris : total posterior synechia' has been described. In severe cases the fil)rous mass completely envelops the lens, and, as resolution goes on, has a tendency to shrink, causing the anterior chamber to become deeper from shrinking of the vitreous, and direct contraction causing detachment of the vitreous and retina. 5. Atrophy of tlie e^c6«// follows, which, on account of the diminished tension from the effect of the extra-ocular nmscles j)ulling upon the ball, becomes of a quadrangular .shape, being grooved at the insertion of the recti. The cornea becomes smaller, opacjue, and flattened, at times remaining transparent, and becoming abnormally protuberant or thrown into folds. The lens and remaining vitreous become ojiaque and the eye blind. The eye Ijccomes sensitive to touch, and secondary attacks of pain occur, especially if the eye harbors a foreign body, or deposits of bone or calcareous tissue develop. The atroi)hy pursues a course of months or years, and pain usually dis- ap])ears when complete shrinkage occurs; the condition then is kn(nvn as phthisis bnlbi. 6. Opacity of the lens occurs on account of disturbed nutrition, particularly in cyclitis, as the iris and ciliary body become attached by exudates to the lens. Such a cataract is known by the name cntanida accreta. In atrophic eyeballs the lens is alw; s ojjaque and shrunken. Etiolog: of Iritis and Cyclitis. Iritis and cyclitis may arise as a primary j'rocess, the original site of the inflanunation being in the iris or cil.ary body. It is caused in the majority of cases by dys- crasia- and (jcneral diseases. In such cases both eyes usually arc affected, altjiough not always at the same time. The inflammation may likewise arise as a local affection, under which heading we put traumatism and those idiopathic cases in which we can discover m> delinab'e cause; here the disease usually affects but one eye. Tr ♦his subdivision belongs also sympathetic inflammation. Iritis aii': cyclitis may likewise arise as secondary affections from inflammati<m transmitted from the neighboring structures. In classifying inflain mations of the iris and ciliary body according to the above schenir we call the, II iritis or cyclitis or iridocyclitis accorihng to the struc; ure principally involved. /j'AAViA£vs OF TH£ mia Asj) CILIA ny body. .{;-,-, Primary Iritis and OycUtis. Syphilitic hiti.. Svihilisis n. spon- sible tor at least oiie-liaif (,f the cases f,f iritis. It is an early secoiularv symptom, appearmg shortly after t!.e first macular eruj)tioii, uiui occurs u. 5 jHT cent, of ti.e ca.s,.s of syphilis. The inflammation has acharacteiistic apj)earance in that no.hiles of a yellowish-red color "t tlie size ot a pui's head or l.-.rger, form either on the ciliary or I.upillary mar-ui of the iris, W. never between. In the majority of cases thes(« notlules disappc:;r, .caving broad and solid svnechia- and atrophy ot the uxs tissue. In some cases no distinct "no.lules are "n.ied, but the pupillary margin is swollen ui places, and un.i.^uallv broad .synechia- torm which do not vield to atropine Irit s niav occur in the later stages of .syphilis without the formation of nt.dules but fiummata (iritis gummatosa) (Plate XIII., Fig. 19) may develop m tlie iiLs and ci lary body, and, attaining great dimensions, nreak tlirough the envelojx's of the eye, bringing about its destruction Iritis likewise occurs in hereditary xyphilix, although not so fre- ■ lueiit.y, be:ng usually associated with interstitial keratitis, occurring early in childhood, while actjuired .syphilis -isually is ob.ser\-ed in adults. Inflammation of the choroid i.s as.sociated with mor- than half of the cas.s ot .syphilitic iritis and cyditis; the retina ami optic ner^■e are liv.,ucntly involved. There i.s a tendencv to recurrence The actual diagiiosis can be e abli.shed only by demonstration of the pre.«-nce ot .sypliili.s or the favorable action of antisvphilitic remedies /,v//,v Scrofulosu. Iritis scrofulosa bears a resemblance to the iritis ot liereditary .syphilis, occurs in ana-nic and sen fulous chil.lren aiul youths, and often is characterized by lardaceous-lor.king dei>osits wliich appear to come from the angle of the anterior chamber lr,lis Tuhcrcido.a. Tubercular ( h'po.sits mav occur primarily in the ins and ciliary bf.dy from wound infection, or, secondarily "in con- nection with general di.sea.se. They may take tlie form of miliary siiowtlis, with con.s(>(,uent inflammation, or may form laige tumors' ' lif;s. 1,S7 and ISS.) Irllls Rheiiwnlicn. Iritis rheumatica appears in persons of the I I'tiniatic. arthritic, or uric-acid diathesis, is characterized by in- llammation with little exudation, and has a marked tendencv to recur r>t,s Conorrhmca. Iritis gonorrhn-ica develops where general' liit.rtinii has arisen from gonorrlura. It is a.s.sociated usually with 'iuiioiTlu,,il rheumatism, arising after the outbreak in the larger'iouits II ''Mnhits recurrences fre(,uently associated with renewal of the 'intiir;,! (hscharge or of the joint-affection. liitis has been seen in relapsing fever and variola. Iritis occurs 'II >li<ihi'tirs. a.ssociated with hypopyon. /n//.v hiiopathica. Idiopathic iritis is the form in which the cau.se '•'Hams obscure, being usually attriimt^-d to col,l. The acute form is -'■neially unilateral; the chronic form generally appears with svnuv ■"•s ot ,.y,. htis and choroiditis, with light iiiflanuiiatorv .sympionis ■'■'I niiis a long cour.se. This has already been described under the 3.">(j TllK KYK. hcadiiiK (Vclitis. It lias Ik'cii railed iritis sorosa. Winn it occurs in iH-rsons of advanced ajic tlic cause seems to he dei'ectixc nutrition, and it slowly i)ro;:resses until blindness sets in. hill's Tnnotiiitlai. The causes of traumatism of all kin<ls, espe- cially perforation of the eyeball, traumatic iritis, and iridocyclitis, are described under their respective iieadings. Iridiiri/rlilis SijiiiiMilhi'liai. Sympathetic inflammation is discussed on i)age ;j'JU. Secondary Iritis and Iridocyclitis. Inflammation of the iris and the ciliary body may develop by transmission from neifthborinp struct- ures, more es}K'c'ally suppurativ;- keratitis and the deeper forms of scleritis; more rarely it is caused by severe conjunctivitis. Inflam- mations sometimes pass forwani from the j)osterior section of the eye, from choroiditis, intra-ocular tumors, cysticercus, and swelling of the lens. Cysticercus and filaria have been observed in the anterior chamber and iris by Continental writers, and have been successfully removed. Treatment of Iritis and Cyclitis. Most cases of iritis and cyclitis demand both local and general treatment. Lor.vi, MK.vsrKKs. 1. The nuidc of life nqnires m<tdij\c(ili<m ; physical exertion should be avoided, and, in severe cases, resi in ImscI is iin|M'rative. B<'cause light excites the \ni\)\\ to contraction, and on account of photophobia, both ci/cx Klniuld he praleeted by the patient being made to wear dark glasses and an eye-shade, and, as a rule, being kept in a moderately darkened room. (This is one of the few eye diseases in which a dark room is demanded. Confinement of eye patients to the necessarily poorly ventilated darkened room fre(|uently does more harm, as regards recuiwration, than the good tbat may be obtained from the ab.^ence of irritation from light; thus the dark room, except for the treatment for iritis and .some cases '' foi junctivitis, has almost disappeared from modern ophthalmic ;■ ' "I The luallhi/ eye should not he strained by reading, and, , it should be put in a splint by the use of atropine, as the' .^"'|ic action of the pupils to light and accommodation is dele- tiTlOUS. 2. With the exception of traumatic cases (when during the first twenty-four hours iced applications may be used), hot compresxinq is indicated in all ciises of iritis and cyclitis. The moist heat gives relief from pain and favors metabolism, thus hastening recovery. Moist heat may be a]ii)l!ed by cloths wrung out of hot water, over which Hannel may be laid to conserve the heat, the compresses being changeil every two mimitcs. Several ingenious forms of applying heat by siphon or electric ajjparatus, vnnler which moist cloths are kept, may be used. .'i Extensive hlood-leltiiu) by the Ileurteloup artificial leech (Fig. iriii) api)re(I to the temple once f)r twice, and repeated later, if necessary, may greatly diminish the inflammatory symptoms Frefpiently after such a j)rocedure the pupi! yields or the first time DISEASES OF THE IRIS AND CILIARY BODY. 3.-)7 Fio I6«. to tlif action of atroj)ino. Natural leechea may be used, of which six or eight may be applic<l, hut they are o.'ten unobtainable, are difficult of application, and are disgusting to the patient. Mkdicinai, Tkkatmknt. Atropine is the most nnjiortant remedy in iritis, as it dilates the pupil, diminishes the amount of blood n the vessels, and counteracts the hyi«'ra'mia; by paralyzing the sphincter it |)Uts the inflamed organ at rest; by enlarging the pui)il it ruptures recent posterior synechia-, as when the iris is ful y contracted its edge is not against the lens, and it prevents the formation of adhesions. Tiic amount of atrojnne ufc d should be carefully n>gulated according to the intensity of the inflammation. As during the period of ncrease of inflammation, sp;usm of the .sphincter exists, it is usually difficult to dilate the pupil, and atropine should be used in strong solutions (I percent, to 5 per cent, every three or four hours; or, if the pupil does not dilate, place a granule of atropine in the conjunctival sac, taking care to close the lacrymai puncta for a few minutes by stretching the .skin over them with the finger-tip). By the simultane- ous employment of cocaine (3 per cent.) or holocaine (1 per cent.), the action of atroj)ine may be heightened. On account of sys- temic symptoms, strong solutions cannot Ix* used more than a few times in succession, and may have to be combated by the administraiion of morphine inter- nally. Atn)i)ine catarrh, from the continuous instillation of the ilrug, may occur ; and if so, the mydriatic should be changed to .scojjo- laniine (0.1 per cent, to 0.5 jxt cent.) or duboisine (1 per cent.). If the inHamination be very severe, instillation of 1 : KXK) adrenalin dilnride tends to reduce the congestion, not onlv in the external Micmhranes of the eye, but also in the iris and ciliarv bodv. Dionin, in 10 per cent, solution, instilled .several times a day, isof marked \:ilue as a lasting local aniesthetic in cases of iritis as" well as corneal ulcer. In cases of iridncyclitir in which the impHcation of the ciliary '""ly is particularly prominent, and also in pure cyclitis, atropine is t well borne. If pain is cau.sed by its instillation, or there is ' vation of tension atropine should be stopped, and dionin and I'lfualin chloride alone u.sed. < iKNEiiAL .Mkasirks. 1. In all cases it is important to keep the ali- '''■ntaiy tract in order by regulation of fk liet, which should be iiiited to simple nourishing food, and conxtipation combated, prefer- Iv by saline cathartics, -'. The etiological factors should be considered, the majority of ■ < demanding general medical treatment. Syphilitic iritis offers Ueurteloup artjfiiial leech. .•{.■).S THE KYE. the most fiivorahl*' proKno-i-', as it gciHTally n'spond.s to ciHTRctic Iri'atiiiiMit. As the rt-iiicii^ slicmld act promptly, mercury is nivcu ill the lorm of imiiK'lion \ nm. of hint- oiiitiiiciil or of tin- olcalc ruMx'il into tlic arms ami tliij^iis twice a <lay, or tiie s'lme ([uantity smeared on the soles of the feet), and is continued until the diseased eve is no longer inHamed, or until symptoms of i)tyalism occur, and then iodide of potassium or sodium is administered in ;;radually increasin)!; dos(>s ( 1 to lO^m., three time- daily). The other aiteratives. especially arsenic and K"'*'. either siufjly or in comhiiuitioa willi ir. n-nry, are of henefit (auri, arseni. et hydrargyri bromidi, aa t).()01 to 002 gm., three times (hiiiy). The general treatment after the iritis has passed away is tliat laid down for syi)liilis in general. In hrreifilnrj) sifiiliilis the treatmi'nt should he tonic as well as siK-citic: syrup of the iodide of iron (1 to 2 c.c, three times daily), together with cod-liver oil (4 to Ifi c.c, ihree times daily), .syrup of hydriodic acid (2 to 4 c.c, three times daily). If guinmata form and are not relieved by six'citic remedi(>s, perforation of tlu; eye may take |)lace, and enucleation may have to be done. Other operations in the height of specific iritis are usu:illy contraindieated. In (V(7(.-i rhfiimaticn and ipnorrbaicn, sodium salicylate (1 to 2 gni.. three times daily) or the oil of gaultheria (0.3 to 0.6 c.c.) are indi- cated, and give relief in about the same proportion of cases as in other rheumatic lesions. In irititi (linbdicn, arsenic sihmiis to be of .service. I iu/()»/// subjects the causes of t(ie defective uric-acid elimination and such lesions as iritis are fre(|uently a.ssisted to disappear by cystogen or urotropin (O.-"? to 0.5 gm., three times daily iM-tween meals), to- gether with ai)i)ro])riate diet and lithia waters. Treatment of the Sequelae of Iritis and Iridocyclitis. Narrow and isolated pn^tcrior syncrhiw may often be rui)t'n-ed l)y the employment of atroi)ine (1 to 5 ])er cent.) by itself, or in combinat'on \vi h holo- caine (1 iier cent.) or coc;une (5 |K>r cent.). As a ver\' <'nergetic action is desired, it is secured most certainly by placing the pure drug direct in the conjunctival sac: the alternate use of myotics and mydriatics, the i)upil being first contracted with <>serine (0.2 per cent.), and then energetici'ly <riated ' th atropine, is even more elTective, but such jirocedures should not be made until some time after the iritis has been sulxlued. Hroad synechiir cannot be divided by such means, and were formerly operatecl upon (corelysis). a.; it wa.- bl'lieved that the acticm of the iris in the opening and closing of the pupil caused ir itation which set uj) recurrence of ilie iritis; but it is now recognized that in such cases the original caus;d factor again acteil. and. hence, ^ ch operations are now seldom jiractised. Aiunilar p(>!<trriit, sinicrhin. villi cjrliisio piipilla in addition, lemands iridectomv in order to restore comiiumication between the haiti';i-rs, for, if allowrd to re!r,air!, sec<.n< larv (lemands ant(Tior and posterior glaucoma surely sets in. The operation is often difhcult, on account of the shallowness of the chambers, due to protrusion of the iris DISKASES OF THE IHI.S A.\'D CILIARY BODY. .'WO (iris homhv, riatc Mil., Figs. H), 11), and ii\sn ( n aroount ot atrophy of tlic tissue. Tims a pood-lookiiiR cololMima i,> seldom the n'siilt in siicli cases, and we must he eontented if a [HTmanent o|)eniiiu' n-- maiiis, for the anterior eliamher, in conseiiuenee of restoration of the coiuiectioh hetweeii the two ehainliiTs, rejiains its normal dej)th, and a secondary operation may he performed later. Tdldl iHixlfTior ■•<!)iitrliifi i\U<) re(|uires iridectomy, wiiich is fre<|uenlly unsuccessful, as. on account of the ;i(lhesion of the iris hy its whole posterior surface to the lens it is fre<|ueiitly impossihie fo excise a suthciently larjfe sej;merii. In such cases the lens may he removed, toi^etliiT with more or less of the iris, or, if ubnent", iridotomy is indicated. Neoplasmata of the Iris and Ciliary Body. Haiinv Tumnrs. a. ( y.v/.x ()/ Me ,'nx. Sirous ny.v/.s- may de .up within the stro?na of the ■iris after penetrating wounds of the exehall, growing gradually until they reach the posterior surface of the cornea, and fill all or a portion of the anterior chamber. Their walls are formed hy thiiuied iris tis.sue. They produce elevation of tension, and from this glaucoma re.sults. Ii. Dcnmiid liiwiirs have been reported (Fig. Hi"), being caused by lienetrating injuries by which epithdial cells are carried within, starting u{) tumor growth. The.se may even grow one or two hairs, as is the case with dermoids elsewhere. Treatment. As such tumors are not benign when arising within the eye. they should be removed early by ojjeration, by incising the cornea at a point corresponding with the growth, entering the for- cej)s, withdrawing, and cutting out the tumor with the adjoining iris. Mchniotnnla are rare forms of real benign gi "ths arising fro--' proliiirationof »' piirmeiit sironut cells i." wing into the iiterior cliaml They :u-Hy ''ome of I -e(|ur'ncc ,iiid di-iwijiuished fn rn sai jrrowths by theii -lc\ -rn.'iil size, :in<l ;d)M '!• rii:itory syni[)toiTis. Tl ti'flecti<in upon the ,ii pupil may [)ro'ifirate ;. iiecoine se)i;tr,-ite(l from lerior chamber, but tliey > ■linl are of very sKjw growl Miilinmnit Tutiiorx. Sai-r, tion with the ciliary b.nlx :n- trniw very slowly at first. :in!(lly iilliiig the anterior cb 'ml Klo. 167. ,, l:.r atous iur.se, fhUH- rnient i fiermoid tumor of the lri«. 'Is of the retinal layer at its • e of the iris at the edge of the into the pupil; they gone ines ■ iry margin, dropping into • an- vcome larger than a grain o' heat, I of the iris mav arise alone or in con- f'lat X'TTI.. Fig IS.) Those of the "ariuf. IS j)ignientc'd brown tumors, hey I L gri \\ ' ack into the ciliary 3(M) riih: /.If.-. rpftion and fill t'lc interior of tho eye, hn'akir.R thrituRli the orular wivcloiM's, ami cxIfiiiiiiiK their Kntwtli externally. Sareoniata i<\ llii- ciliary Inxly, like those of the iri!4 and choroid, at (irst jfive ri.'e t«> but little inconvenience, hut, finally, from ai-ir size, cause jm-ssure syni|)toins, following the siune course in; those of the iris and choroid. These .-irc nore particularly doMcrilx'd in the ch.ipter on Neoplan- inata of the Choroid. Treatment. .Malifjnant Rrowths of the iris when very small may jierhaps l)e excised, but it is .safer for the lite of ♦•»> patient where they an* of any size, and in those involving l" cili-iry body, to remove the eyeball as .soon as the diagnosis is .. .e TulKicular tumor.- usually occur in children :d young adults. They generally Ix-gin us a tuU'rcular iritis, bu. when the nmlules rill. 18" ria. i«. Flo. 168.— Tnberculnsii of rilisry body BDd Iris cauntng cyclitls, fho v[i,f iici-lu> .1 .>f pupil with retraction i)f iris and deep anterior chamber. Tnlal iKBtmnrnyni-ohla. .'hoii .;r»ph fnmi speoimeii ) Fill. 169 —Tuherctilar tumor <if iris, anterior i-hamhershailnw from Iv <iil-..)i>«t tilled by neoplasm, winch tills lower [lart o( posterior chambe'. (Photograph from ipec'!-!.-! i enlarge and form tumors, their com. i .s much the t-ame as that of nialignant growths, and they are amenable to the same treatment— i. p., enucleation. Gummata of the iris and ciliary body form as yellowish tumors of somewhat rapid growth, occurring during the course of actiuiretl 01^ inherited syphilis as one of the later manifestations. (Plate Xlli., Fig. 1!».) They .seem to be nipidly reuorfx'd on exhibition of mer- curial inunctions and large do.ses of iodide of pota.ssium. Very rare forms of iridic tumors, such as vasculomata, myomata, and myo.-arroniata fniin tlic cili.uy luusclc, carcinoma from the pars ciliaris retina', and lepra nodules, have been reporteil. orsKASKS OF TUB //lis Ay/j CiUARY no/n. ;),ji Injuries of the Iri. and Ciliary Body. Wound, avd Fnreufn Bodi.. I autmt,,,,, ir„uu,s „j /„■ ,r,s .• re cnM,,,!!,,.!..! l.y w..un.'l. „f ,1..: .■..rn.-a aii.l u.s,..all> .v.tli tl.at .,f tl..- lens ai.! ■ iliarv I- .Iv If tli,. .■ihary l»Hly U- ,„jur,..l, the .-..njunciva, th.- .scl,.ra.Vhnr..i,i rHii-, aii.l vitrc.us. as wWI as tlir iris, are usually iffected. If tli.' „. t-atmu ,n, iy ,.. clean i..f,.cti.... .Lh-s ,u,t take ,.lac... there is usuallj 'It IM le ,1,. ..Ims. .,..1 l.eahng n-suits, with .iarna^re .le,K.,Hl,.nt u.k. n tu; ,.xt.-nt ., tne injury. If a vv„un.l of the iris Ik- a.r..,np«nie<l hy "iKrtinn, infla.nmat;(.h n-sulls which nmy exten.l to the ciliary ImhIv .injl . l,or.M.I. u-.th resultant intis an.l iri.l..eh.,r..i.|itis. Synmatln tic "Phthaltmt.s may ans,- fr,„n infecteil iris injuries, but is UHually • liie to tliose of the ciliary region. ror,l,,n Ii,HU,s in llu' his. Non-infectious foreign iMHJies niav Jinan, in the anterior chanilM-r, or 1k> enca,,.sulate.l in the ti.ssue oV the iris lor a long tune without giving ri.se to inflammation. They may Ik. removed In corneal incision an.l the iris .orcens, with ..r williout .se.ti.,n iMiiig made .)f the iris. (I'hite XIII Fig 15 1 The extniction of ,,„r.-s .,f ste<.| „r iron fn.ni the anteri..r chamh- .bv th.. «■ V<'tn.maj;n,.t otT.Ts the m.,st promising pn.giujsis f..r the ..i.Tation ( I.S.. _;u .ject.H are n.or.. s,H.eifiea. y .lescrilx'.! in the chajifr on Miiipatli.'tic Infiammntion.) ' Traumatic Changes in the Iris. iMceratiom of the iris usually start Iron, the j.upil an.l may exten.l t.. the ciliary margin, s., that iH' imp.l ap,,..ars t<. !«> jx-ar-shap...!. As a rul.-, th.- pupillary niarg IS torn hut httl.. an,l t.u gaping can only Ik- .li.scvemi by car.>ful .■vmiumtion. .V.ich lac.'rati.,ns are the ni...Ht frcpi.-nt cau.se of ,lila- t.ition ol the pupil, ..ccurring after contusions, as they caus.. weik- -nrng .,r paralysis .,f the sphincter, due t.. laceration .,f its film>s l.ey fie.|U..ntly accompany simple cataract extraction (with.,ut i>i>l..tom^ ), an.l are caused by tearing ,.f the iris in the efTorts to -■'■"M.V.. tii,> cataractous lens through an unyiel.ling pupil. The' iri.s ■'M.l ...iiary mu.scle inay also Ix- paralyze.1 by contusion, so that .KToinniodation is affecte.l. ■'J . "" mai lrif{,Hliali,si,. Sep;,rati.>n of the iris from the ciliary bo.lv is usually ■"/•<'nsi.l..rablo extent, involving even as much as .,ne-half of the '"""•y margin; it is usually single, but sometimes multiple In the ;nner w.. hnd two pupil.s in th.- latter -.yeral. (Plate XIII., Fig!!. •. .) The portion of the natural pupil towar.l the .lialysis is flat- . ,;. ,f 7 ' "•"';•' ''•■''y-'"f we mn;. ^r-e the e<lge of the lens, the ^ mule of Zmn, and the e.lges of tl„ .iliarv processes As a rule '• sig t Ls but little affect.>,|, alti,- ..f. if V^ diaS s.fg'eS ; ;. ,r, 1 •\^''''Y'^- Monocular .liplopia maj ..ccur, .,n acc.unt of nS; '"'"'.« i""'"^'' thr..ugh th.. .several openings upon the reiina. /' m >nu, Traurnahcn. If the iri.Uxlialysis be of such .^xtent that H > l,ecom,.s torn in its full extent from it« ciliary attachment, I > l.ill down in the bottom of the anterior chamber, an.l lat<T "1^ to an iiicoi:.spicuous gray mass. If rupture of the sclera in the 362 TUJ-J KYE. tiini', tlic iris iimv cxtrudo ciliary rcfiioii he iinHlucod at tiic saiiic i.r !)(• expelled t'roiii the eye. , , i Inrcmoii of the »•(.- consists in its Ikmiir pushed and turned biicK s() as to lie upon the surface of the ciliary body, and it looks as if it wore absent; partial dislocation is more fn><iuenlly observed, ami here the iris seems to be wanting, a coloboma appearing to exist. Total inversion is very rare. UjIplinwKi or hcmorrhniiv into the anterior chomhcr is duo to and Konerally accompanies wounds of the iris. (Plate XIII., Fip. U>.) It is particularly marki'd in ci)ntusions of the eyeball and m operations on irides tha"t have been previously inflamed. The blood sinks to tlie bottom of the anterior chamber, and disapi)ears by rescjrption within a few days, when we may determine the extent of the injury. It is sometimes impossible to And a solution of continuity of the iris structure. The subjective symptoms of hypha'inia depend uiion its extent. If excessive, .so that the tension is raised, considerable pain is complained of, and glaucoma may follow. Causes of Traumatic Changes in the Iris. These are most frequently non-peiietratiufr blows upon the eye in which two factors cause the iniurv: 1. The liattening of the cornea from the contusion, by which its circumference and al.so the insertion of the iris become larger. If this enlargement takes place suddenly, th<' iris doe.s not adapt itself, and tears away in places from its insertion, so that iridodialysis is i)r'oduced. 2. The coriuui being flattened, pushes the aciueous backward against the posterior wall of the anterior chamber, which ill the area of the pupil is formed by the Ions, and in the rest of its ("Xtent by the iris. The latter, when pushed backward, finds its support in the le-.s, except in the marginal portion of the iris, where the posterior chamber is deepest; therefore, the iierijihery forms the most yielding spot, and is the first to give way belore pressure. This bulgi's the iris back as far as the zonula, or even into tlie vitreous. Thus, a blow upon the eye may produce: (n) marked stretching of the vitreous in a radial direction; (b) dilatation ot the pui)il: ic) in (>xtreme cases, rupture of tli(^ zonula. The first aff(>c- tion mav cause iridodialysis; the second, radiating lacerations of the v|.hincte"r, and, conse(iuontly, i)aralysis of the juiiiil: the third afTection sublux lion or luxation of the lens, iridonesis, or tremulous iris. II the eiljie of the iris slij) back over the lens, it may imuluce inversion of the ''iris, and the lens may be li.xati'd into the anterior chamber. Lacerations of ihe pupillary "edge may be jji-oduced during the simple oi)eratioii for cataract— i. e., without iridectomy where the sphincter pupilia' is risiid and does not i)ermit of ea.sy jias.sage. Iridodialysis may also be proiluced in opeiatictns upon the iris: if the eye makes a violent movement or the iris be roughly grasped with the forceps, the iris has been known to have been entirely torn out iluring such an openition. In iridectomy done for occ'usion of the jnipil, the iris may be torn loose at its periphery if the adhesion at the pupillary arcii docs not g.vc way; hence the iris ought always first to Ijc DI^KiSES OF THE IJilS AND CILIARY BODY. 3(J3 released from the pupilliiry memhranp befnro it is drawn out of the wound. Iridodialy.sis may also be eaused by tumors of the ciliary body pushing the iris away from its insertion. Treatment. Tn-atment of the above-described hijuries to the iris (except penetrating wounds of the eye) (le|)ends largely upon the extent of the bleeding (hypluemia) within the eye. If trivial, the injured eye may be bandaged for a few days and the patient kept 1-1 bed to ensui-e absolute (|uiet, so that further bleeding does not take place and the deleterious effect of the contusion may not be assisted l)y further detachment of the retina occasioned by ordinary movements of the body. If the hypha-mia be excessive, causing tension and pain, naracen- . • f ., . • , Fig. 170. tesis oi the anterior cham- ber may be necessary. Hot comj)resses applied at iiit(>rvals, as in the case of iritis, assist in absorp- tion of the exuded blood. If an iridodialysis can be made out, atropine should be instilled, so that the contracting sphincter does not draw the iris farther away from its attachment. It is contraindicated in radiating lacerations, as a mydriatic would make the Wound gape more. Iritis does not usually follow iion-penetrating injuries. The internal administration of alkaline jjurges and one or two jjilocarpine (0.(K).") to H.O! gni.) sweats during the lir-t f<irty-eight htmrs .seem inatcrially to assist resorp- tion of blood in the severe '■■iscs; iodide of pota.ssium iiiay he given later. Operations upon the Iris. i'ornicHy a number of ope- 1 1 ions were done upon the 'is. but in modern practice Illy three forms are resorted to: 1. The removal of a segment of the •IS for enlargement of the jjupil. 2. Removal of a section of the iris '«! iritic membrane wliere the pupil has been closed bvintlamnsatio!). Incision into the iris or iritic membrane, in order toniake a perma- iil opening or pupil. These oix;rat ons involve incisions in the cornea, Portion of niwrator's lunds In flirt otage of Irldecloniy. (rz»iiM«K.) 364 TUf: i:ye. Fio. 171. Von oraefe Hnair knife (side). Fio. 172. Von Gmcfe linear knife (back). r J. 173. Struight keratome. FIO. 174. livnt keratume. Fio. 175. Probe and spatula. Fl<i. 176. Sharp iris limik. Fio. 177. Blunt Irta hook. Fio. 17«. Short fori-ep*. Fio. 179. Long, bent forcepn. i>/.SA'.KS/AV OF THE IRIS AXJ> CILIAHY BODY. Fig. ISO. 365 Fio. 181. De Wecket's Iridoiomy iicisaora (front). Fio. 183. I)e Weclter's Iridotomjr scinon (side) in.trnrat.m., used In .,r*ratlo,„ on the Iris (slightly reduced). ,ther inrtniment. rnmired are .m.l ppnotratuiR wounds of tho eyeball, which, if aseptic, Iieal without inlla.imiation; hut if septic are attended hy all the dangers of septic l-nrtratniK wounds of the eye. As sepsis occurs in the hands of '■■nefu oijerators in but 0.5 per cent, of cases involving opening the <'.\ii)all, tlie danger is comparatively small. Operations for Enlargement of the Pupil. Ihi decto.mv is t he renlo^•al -I .1 segment of the ins for the purpo.se of enlarging the pupil The "K'thod of performing the operation is as follows: The patient's I ■ Md, lace, and eyes are jirepared for the oinration as if for cataract ■ xtraction. In eyes with considerable tension, particuiarlv in ' iMinmatory g'aucoma, general ana'sthesia is advisable, as local ;i:istlietics in these ca.«es are not sufficientlv penetrating to affect Ills; in other cases local ana'sthesia is obtained by 1 per cent ■'"•ame solution or 10 per c(-nt. cocaine solution, dropped .several ^ 's uiM.ii the cornea. The instruiiu-nts necessary are a .speculum IVsmarres retractor, to keep the eyelids apart ]\ iWni' M the ( «iiig de.scripti(m of the ojK-rat ye, and other special inst ai)art, a h\;iti()n forcep.s riiments mentioned in the tion. (Figs. 171-183.) •JGG Till-: i:yt-- .pisderal tissue with hxatu.n forceps, f , / J,', j, ' , rcun.f.-renee linl.usan.l the pr.>,.ose,l meisi...., ..r at tl". '"'■["" ,'>^,.. ,, f,. Uuu-e knife ..r l.v the ^''^'^'^■^l'f::J^^Z^,,,,^vyA .hat f.,nuer, in the same numner as "''^ •^•\: /;7 „/ ,i ,s pussihle, the cut should be .na.le ^'>, > "j'^ " "' 1 '''' .; . ' ,,,,L,, the ,,,„l, hence, mostly m seleral tissue. 1 n > tn ^^^^^^ ^.^^^ knife is entered perpen. jcu.arly ""*''/•.". ;,, ,, h,, parallel ,,,anl,er; then the handle -;'<:f-^;^;,;t war until the wound Via. 1«. (CZKRMAK) • 1 f «i,lP SO that the ends of the linear ineisi-n on the inner tk ■ on e c'tu^fve made slightly lar,..-, ano so that the UMueous u .d into the anf-rior dunnher anu l^u^he. onto •■»'.'' DISKAHJ-JH OF rUE IRIS ASV CILlAll Y JlOl) Y. 367 small section is (losircd, the forceps heii.R Renorally better in glau- con.a o|,eratioiis, an,| tl... iris hook in cataract or optical iri.iecton.v. liie ends of the woun.i are freed from tlie iris, and tiie spatul;, hei.iK introduced int., tiie wound puts hack into the anterior chanilMT any ins tissue and riears away the blood and debris. At the com- p.'tion ()t the opera! ion the ,)upil and the coloboma have the sbnw ol a keyhole. ' The eye op,.rated upon, and usually its fellow should be light Iv baiK aged, the dressings behig a semilunar jHece of adhesiv.. pla-^«tT on the upp, r eye id, to act as a splint, sterilised vas<.|ine to lashes .() prevent them from gumming together, small patch of lintine or clu-.-se-cloth to protect the eye from tiie dry ab.sorbf nt cotton, which IS p aced over tl... eye and orbit, and over all a wire mask nuule to It the face, or a light roller-bandage. The first dressing need not "■ made for forty-eight hours, when the evelids are washed wnh ...lie aci.l solution and a light roller-bandage applied t<. the e ? that has been ofierated upon, the other being protected by a reading PlO. 186. Iridectomy, a, PeripUcml haision, as la glancm.. 6. Wide Iridectomy, c. Narrow or opUcal Iridectomy. (Czbiimak.) ^liM.le. Atropine solution is usually dn.ppe.l in at this and the sub- ■'■'','';;.'.' ^T 'r, ■'"■?: •'•■''■■^•^"p. which are made a. twentv-four-hour I .1 M.ils t., dilate he pupil against the po.ssible occurrence of trau- matic intis. (As there is excellent filtration ami hvperten.sion is n..t l-sMl... t.,r a week or more after the corneal incision, or until the ^^"un.l has fully heahnl, atropine is not contraindicat.cl, <-ven aft.T ilau,.oma operati.d.s.) Dark gla.s.ses ..hould be w..rn f.,r .s..veral "•'■l.s, a 1.1 at the third or fourth .Ires.sing absorbent cott..n mav ■'• P"i«;<' "V'T the eye operate.l up.m, and the dark ghus.ses placed v-T tins. Incismn for glaucoma is made in scl.Tal ti.ssue as ch.se to -_>■'... .,t the iris as j.ossible; it should embrace ..t least <.n<-fifth ne hmbus. Incismn for optical iri.lectomv usuallv is ma.l.> in ""ill tissue. Ihe section for glauc.ma and cataract extraction '■Hl.y IS ma. le upward; that for optical purpo.ses .lownwanl and ;""• «.i; m the region nf least opacity. (Pl.-ite XIII.. Figs. .', (] 7 J 'yhrnl,ons /or IridecUmnj. 1. The most important iiui.cati..n iM.lectomy is mcrease of tension in primary glaucoma an.l in s.-c- mm MH THE EYE. ondary jtlaucoiiia resulting from txclusio pupilla', ectasia of the cornea, or scierochoroiditis or iridoclioroiditis. The earlier the ofx-ration is |)erfornuMl, the better the suceei.s. Vet in some eases, in order to reliev;" pain and t'urtlier degeneratic/ii, in ectasis of the eyeball in wlii, ii |)ereeption of light has In-en abolished, the operation may be done. In iridectomy made after increase of tension the section sliould be made long, situated as far back as possible in th(> sclera, and the coloboma slu-uid be broad, and extend to the ciliary margin of the iris, for the reason that the results of iridectomy for the reduc- tion of tension are achieved through the establishment of filtr.-ition through the scar tissue ius well as by the removal of a portion of the actual contents of the eye in the portion of iris that is excised. The coloboma is mtide upward, so a.s to be covereil partially by the upper lid, and the confusion due to dazzling thus les.seiied. 2. ()))eration on account of (iiilicnl ohslruclidiis. Tlie formation of an artificial pupil by iridectomy may be done in ca-fcs where opacities of the refractive media occupy the area of the pupil ; among these arc opacities of the cornea, membrane in the i)upil, oi)acities of the lens lliat are non-progressive, in shrunken cataracts, which ilo not extend far toward the peri])hery. and in subluxation of the lens, where tiie ])U])il may be made in front of the |)art that contains no lens. To obtain results, the following conditions nmst be ])resent: (o) the retina and optic nerve should be capable of functionating; (^)) the opacity should be stationary; (c) the ojKicity should be so dense that it prevents the formation of distinct images u])on the retina. These conditions are to be ascertained by proper obser- vation and examination. Ci)ntrai»nlicati(ms to iridectomy for optical purposes are: (a') iotal abst'nce of perce[)tion of light; (i/) stra- l)ismus of the eye affected by the opacit . when the ey(> is not ])ut in alignment; (c') flattening of the cornea, which is an evi- dence of iridocyclitis and membranous exudates upon the iris; (d') incarceration of the iris in a cicatrix, where the iris is i)rimarily attached to the posterior surface of the cornea. Iridectomy for ojjtical coloboma is made preferably downward and inward, if the media are everywhere e(|ually transparent, as in t!ie case of central cicatr x of the cornea, pupillary membrane, o: perinuclear cataract, as the visual axis cuts the cornea a little to the inner sidi of the apex. In other cases the coloboma should be made at the place where the media ar<» most transparent. Where only the most exterior marginal portion of the cornea remains transparent, the iridectotny may be made iiuite peripheral, involving the root of the iris; but. as a rule, it is made as n.arrow as possible, and only the sphincterial area of the iris is excised. (Plate XIII., Fig. 7.) :{. In ectatic cicatrix of the cornea, iridectomy is made to cause flattening. 4. In recurrent iritis, iridectrmiy made durinsr :ui interval in whic!: there is no inflammation sometimes ])revents recurrences. i). In fistula of the cornea, in ca.ses where some trace of the anterioi DIHiAiiEii OF THE IHLS ASD CILIA Ji K HOU V. y^j, 0. In the CMS.- of foreign |„„|i,.s ai„| .s„uill tumors of tl... iri. « l,i i ,..';,»";::;;™,.,irS„™;:;':T::^';;,'^;;!r^ ;^ -'i. """■■■ .'IIU olll Klo. IK7, Fio. 188 oi nio wound to the sclerocornea mare n; the flan thii< out ;= ";-"•" out by gra..„ing it with tho iri^ f^rcoL o sha" /hooi ^' ^i. P 1 vidlTVh^"-'" •^r''"'" Mkmbr.>ck. [n<^tomv consists " I'lN, <ii\ (iing thp iris without excising a piece Th^ ineisinn ' . '"fl^inSa^l^^t' "t ^"^ ^^"^'^ '''- - Sucift';^'^ instance, as an after-operation for cataract cases in which 24 370 THE FA'K. le pupil has bocoinc closed by substniueiit iriciocyclitis. The opcra- on is (Itiiic by passiiij; the (Jraefe knife iM'riK>mlicuhirly throujrli le cornea, rotatiiiR it 90 degrees, making a liorizontal incision irough the iris. (Fig. ISO.) Tlie edges of the ojx'ning retract, leav- FlO. 1N9. Iridotomy. a. eorneal inclaluu. e. Iris iuciilun. iri Wicker.) 3. St.\phyi.oto.my for oi)ening a closed pupil, caused by incarcera- tion of the iris in a corneal cicatrix, is done by a sweep of the Graefe knife through the anterior chanilier. (Fig. 190.) Sphinctkkolysis antkhior (Fig. 191) is done by transfixing the ect!i.«iia by oneCJraefe knife, another being pa-ssed into the eyeand swept around, dividing the iris, and producing a more or less irregular pupil Fia. 190. Fia. 1»1. Ptapbylotomy. (AsikDii.) Spblncterolysis anterior. (Schvlek.) Formerly other operations were practised, such as iridcsis which con.sisted in moving the pup'.l to one side by allowing the iris to b(>c()me incarcerated in a corneal incision, and nirclj/sis or division of ])osterior synechiie: but, as tiieir results aio dangerous, or the operations are uimecessary. they have fallen into disrepute. .•Xs operations done for oi)ening occluded pupils are, as a rule, made through pathological products or diseased irides, their results arc often only temporarj-, the artificial openings closing later from recurrence of inflammation. Operative procedures may have to be repeated, and often are made in vain. The after-treatment of the foregoing operations is similar to that fo!lt)vving iridectomy. PLATE XIV. Anoinalieb^ >>l' Iho Clit>roi(l. A. The Alliiii.lK I-unilu-. 'Tvi)C 1.. -ve Plate MI., K' II. The Tes^ellaleil Himilu- ; iType II.. >.ee Phite .\II.. Hi. C. The Ne(jroi<l Fiiiuliis ; (Type III,, see Plait \II., <i'. D. The Yellow l-iindu-^ . I h'nndit-* l-"Iavus. Oelleri, K Sarcoma I' horoide*; V -^7--.. (Heniianopic Hield. see IM)!. I9TI. H CnliilKinia Chornirte;e Cenlralis ; (Oeller) ICenlrnl Siotoma} DISEAUBS OF THE CHOROII). 371 -'•id tyjK- I'late lie ijm> })ur ■< ot wit! ' ' 'i-( i i led DISIA818 or THl OHOaom. CONOINITALA DBIALIIS. yariatloM in the Color of the randu. A.si.le f, „ the three tyiK-s of funjlas .lue f. variati.,„s i„ the pign„.„t ,.,.||.s r ,„ ,e II llat. .\n.. A. ()„ aeecunt .,» the l,.s..«.ned contrast , .tweeii the < .'t .• .„ ne a„,l .„h..r part. „f the fu.uh... the nerve h. "m nin, ol a -lark re,l.|,.sh-gray e„l,.r; „..t only the retinal, hut »1 tin- a^ ess,.|s nf the ehor.„d are n.ulily s^.-n. Such pc-r.,, ns have v h.w f- M..- flaxen ha.r white ey.bn,w.s a„,| lush!;, and their' "e. are l'l"'t..ph..l,u., vLsual acity Ls re-ducHl. an.l nv.sf,,«n.us is c„.:ltan Iv |.res,.„t. and. as a rule, there are stral.is.nus ...n-,| ,■ v,.pi„, Sn ' 2 affords a deeidt d contrast fron. that of < .\I\ ., C.) Treatment. Correction of the refractioi iiiass.'s, to protect the eye from brilliant assistance, such patients are usually un Vocations. AccordiiiR to the dispositi(.n of the chor. takes on more or less color, as in the sevei I'late .\I\-., A. H. C. D. The result of in •III nicreas<' m and depo.sit of the choroi. tnmi this, great changes in the aptx'ai MTved. Coloboma of the Choroid. This anon, r .1 cn-cuniscribed defect in the choroid ns, "t the f(etal cleft, usually in the retina, p "ptic disk. If unaccompanied bv cololh .^ , "I the ins. It may be of .-m ovaj shaiM- i ui ii'gii.n and of the iris, it is that of a Av v toward the papilla. .Such eyes have ,rge > visual field m the up|.er (x.rtion. an. he cci usually less than normal, (l-'ig. HW. (\AuUn .i>s..ciated usually with other anomalies of ,|cv with microphthalmos and coloboma of the iri^c . ■ ire hyperopic. A somewhat rare form of coloboma is .-i dcfe.i tlie region of the macula lutea (I'late XI\-.. F,. a„ ,„„ -„,. „, IS generallv, elect of the retina at this ,,oint, and eo..; en .e ',,1 -toma All su,.h cases that I have seen have Ikh-I, ."w-c optic n,.rve atrophy and evi.lence of prenatal choroiditi.- "l„ I lent, itt- fun, ..H if \y]H-» fW"! -d in latior- i,-. Jrequerfth igniei ill sfMite, iiitt^ .f lM;i!. villi ''^ are i4)- ■ ' I- due to ' oi rfc.sing ' liriou the ''■ nnd .ary u! cted ft the y is id is lonly I eyes ■imroid at 'his tlicre with I;;;... f.;rms of coiobom.aa the .i;;rar;;,i;;; u- •;;.;• ;:nd ... iK'tily bonlered by pigment. Th.. bloo.lves.sels purs,,., a very rreeu lap course, the retinal yes.sels usually avoidiig the eoSm^b limning along its edges. Lt>it;.;oma m Treatment There is, of cour.se, no treatment for these defects I 'lit eirors of refraction may be neutralized to advantage. m' ,SHf i 1 1 I i 1 i 372 77/ A A,rii'. Inflammatory Diieases. H ilium imti of iln choritnl it* i >it in itself rrciiniiiziihlc ;is :i lisjoii <(r a >yiiipt()rii : a.-* it in tiic fiivr .wtajjf ol' iiitlaiiiinatinii. it iiiiliiiilittMllv i.n an accoinpaiiiini-nt ul' tmist clioriiiii.il atTcctiiins. Ciinruiiliti;^ iiia> Iw rxudativc or Mi|ipiitativ«'. Choriililitin I'lxuilittirit. Acute cxutlativf clioroiditi.s is cliarac- tcrizfd by isnlatcil fori of inliatnniation st-attcn-d ov»'r the fundus, apiwariiiK upon opiiflialnioscopic fxaniination as iiidist iictly out- liiM'd yi'Miiwjsli s|»>is lyinj; iM-ncatli the rrlinal vrsscls in tin- red fundus. I i'lalc \\'., A.I Tiii'sc aif due to intiitration of tin- cho- roidal sulistaniT with exudation, hiding the ciioroida! vessels: the overlyinj; retina usually is involved, and, l»einK clouded, co\ers the choroiilal mass with a faint grayish veil, l>olated heniorrhajjes may appear in the <-horoidal stron;a or under the retina. The exudates may pa.ss not only into the retina, hut also into the vitreous: thus opacities of the vitreous are ;ilinost always constant accompaniments of choroiilitis, and the di.-:ease is really a compound atTecti(Ui, Deposits u|Min the posterior surface (descemitisj of the cornea in a larjje niimlwr of cases of apparently simple exudative choroiditis show that the disease; is a trui' uveitis, and is not liiiiited to the choroid projier. Symptoms. Suhjectivelv, the patient complains of loss of visuu! acuity anil of floating spots, which are due to complete or |)artial s<'otomala from implication of the retina and vitreous, ;ind of flashes of lijih , and photopholiia, due to irritation of the retina. .Vs there are no sensory nerves in the choroid, then- is no |)ain in uncompli- cated cases. The limitation of vision both as rejfards visual acuity and the visual lield is not .i prominent symptom: itid.'ed, severe inflamma- tion may lie present without these visual factors heinj; apprec'ahly alTected, until the chronic stage or that of atrophy, w' tc degenera- tive spots and increa.se of pigment api)ears, and the r< ; la and optic nerve become involvi'd; then th<' visual acuitv and field suffer. (Fi«. KM.) Course. W'hil" the course of choroiditis is es.sentiallv chronic, it may be subdivided into an acute stage, marked by inllanunatioii and exudation, which last for s<'veral weeks or months, and the chronic sttifji', or that of atrophy, whici "ists for months or years. The chronic stage, or that :jf atro])hy, pri'sents a radically different jiicture: .\s the e\uilat<'s ix'come resorbe<|, the spots become more |iromineiit and lighter in color, ;.nd gradually a white spot is forme(l as the choroid.'il stroma atrophies, which is due to the white scleni showing through. In some cases tlie remains of the vessels and the pigment may be recognized in the white cicatrix. The jjigment generally ])roliferat(>s aiound the edges of these scars, so that the clioroiditic iilai|ues ajipear lined with >lack, or covered with black sjiots. (Plate X\"., li.) The visual acuity and the field suffer gn .itlv. PLATE XV Types or Choroitlnl Diseases V.lin.i , 'i' rif], ■ ' t.na, s rge. RM>g bcotoma. no ,HTCep.io„ „f colors. «, K„ ,„„ J R^m u™ ■^ ■r*?'. w....tr. PLATE XVI. B ■■^^£S--SSV2^ ■'; I, Aft Of At 4 of Opi- 0>l Artt Of \ Chonaid . \ NOBMJL OPTiC NERVE ENTRANCE. A. 0.. B. D,. POSTERIOR CHORIOIDAL STAPHYLOMA WITH SICKLE-SHAPED CONUS. C. 0|.hllMli.v».opi, .le* RING CONUS The 0|)ti< Nerve Entfaiioe ii URGE SEMILUNAR CONUS 1 its Relation lo the Choroid. DJS£ASJCS OF THE CHOROID. 373 Etiology. Exudative choroiditis is a frcqupnt disease, and is seen at all ages. Its eauses are local irritations and disturbances of the nutrition of the eye, due to eyestrain, errors of refraction, irritation due to ex|)osure to bright light, and to general disturbances of imtri- tion, such as ana-niia and chlorosis. Thus it is accompanied by general diseases, particularly .sy|)hilis and scrofula. .Myopia of high degree is accompanied also bv changes in the choroid Icxs of inflammatory character than of atroi>hic: these are caused by stretching and tearing of the choroid at the optic nerve entrance. (Plate X\I.j In mode-rate degrws of myopia, from —5 D. to — « I)., as a rule, only one side of the oj)tic nerve entrance is affected, forming a coims (Plate Xyi., V): in severe degrees the jiosterior section of the ,ye- bail i)ulging backward, the choroid retracting considerably with the sclera, forms not only conus, but also posterior stajihylonia. (Plate X\'I., (". D, K, and Plate X\"., K.) Such cases are accompanied bv localized choroiditis at the edges of the coloboma, with increase iii the choro'dal pigment ring: changes likewi.se occur at the macula, and the pigment granules of the retina are more or less absorbed! allowing the intravascular pigment of the choroidal stroma to show! An eye atfect"d by choroiditis of any degree of severitv always lo.ses more or less of its function, as may be determined bv careful" exami- nation (»f the visual acuity and of the field. Treatment. The treatment of choroiditis is that of its cause. Eyestrain shouhl be relieved by proper ieiises and unhygienic habits corrected: ))articularly is this the case in myopia, where full correc- tion of the error should be given for distance, and the ciliarv muscle favored l)y weaker lenses for the near. In most cases the glare of light should be mitigated by the wearing of smoked glasses. In acut<> ca.«es atropine .solution of sufficient strength and often enough to suspend accommodation should be in.stilled into the eye. Hot compres,ses favor resorption of exudates, and m:iy be u.sed three or four times a day for half an hour at a time. Injection of salt solution under the conjunctiva is used for the same rea.-*on. In acute choroiditis, extraction of blood by the natural or artificial leech, applied on the mastoid process over Hie emis.sary vein of Santorini, wiiich comes from the cavernous sinus, into which the ophthalmic veins pour tli(>ir contents, is useful. In the chronic .stage, mas.sige of the eye with t' .• '-nger-tijis once or twice a dav for hve minutes at a time stimulate> meialtolism. The general treatment .should be directed against the exciting cau.se. disturbance of nutrition from ana'mia, should be met by exhibition of iron and arsenic. pro|>er diet, and regimen. Wlien the disea.se is accomjianied by the rheumatic • ir uric acid diathesis, administration of sodium .saJicylate (()..")() to 0.1 gm. three times daily), or oil of wintergreen (().;«) "to ()..')() c.c.) is indic'Ued. (V«togpn or urntro})in ;().:50 gm. three (ime.s daiiv) rapidly relieves the .sy.stem of uric acid. When the patient is scrofulous, alteratives, tonics— j. c, mercury, gold, arsenic, and iodide of iroii 374 THE r.YE with cod-liver nil — should Im- cxhibitod. If t!ic local lesion !«■ a symptom of sy])hilis in the acute stage, luercurial iiiunctitms will often produce a ((uick effect; the salts of mercury, Rold, and arsenic stem to be s{)ecifics for this affection; iodide of potassium is ])ar- tieularly serviceabh," in rcsorhing exudates in the retina and vitreous. Diaphoresis by vapor baths and pilocarpine are of use when properly carricil out. Fig. 192. Fio. 198. Fig. 192." Central absolute arnl relative scutomft due to hemnrrhage in syphilitic chorioretini'.is irlateXIV., E) ; also trpical dI' ehorolditii^ centralis senilis iIMa'e XIV., <'!, {Visus ^ objects in periphery of field ; nt) fentrai vision.) Flo. 193.— Seetunil eoiitnietion due to choroidal cololtonm. a:id enlarged blintl sjKit IVoin iM»<teri'ir siaphylcuuii. iVisn.s - »> x.xiv.) Fill. 194. Fiu. 195. V/7 Fit!. 194.— I'ttracentral and [lericentral scutftniata in chnroiditis disseminata chronica (PliUt XIV., Hi. (Vi.-u.- -i;i.\.i F:o. 19.').— Ahsolutc and relative riuK scotomata in chorioretinill^ dilTiisa syphilitica. (Flate XIV. III. (Visus = 6i..\.) VISEAHES OF THE CUOIWID. ^^- '*• fta 197. 375 *,-»• Klii. KlG. I'Jti.— Great con'ractlon in ihorinretinitis plgui.^iuosa. (VigiM = 6'xn.) liir.-Stttnml contraction simulating vertical hemlanopla in sarc'iina of chomld in first iVisns -= ti xxxvi.) Vdrictie.t of Exudntire Chmiidilis. Aside from tho distiiictioii of ivcciit and old clioroiilids, certain well-defined forms are to be dif- ferentiated: 1. Choroiditis centralis is characterized by changes occurring in the icfrion f)f the macula lutea, causing disturbance of central vision from central scotoma, with resultant diminished visual acuity. (Fig. 192.) The most common ftjrm is that occurring in old jjeople Mtrecti'ig both eyes about e(iually, and is referable to .senile changes due to sclerosis of the central ve.s.sels. In young j)eople srlerosis of the vessels is not .seen. In some cases there is considerable deposit "1 i-iginent as well as atrophy of the choroid. (Plate X\., C.) 2. Clioroiditis Areolaris. The; fiist foci develops in the vicinity of the fovea, while sub.seciuent ones make Uunr a[)j)earance at con- stantly mcreasing distances from the latter. The most recent spots •lie entirely black, and afterward slowlv enlarge, at the same time iMcniiimg decolorized in the centre, at la.st iM'coiiiing almost entirely uliite. One or two isolated .spots may be seen in other portions til tiie fundus. This is ])e'-haps a variety of the dis.seminated form. Myopia ()f high degree is accomi)anied usually bv changes in the hivea. The acute form of macular choroiditis "is found most often HI syi)hilis: this subsefpiently degenerates into atrophy, with increase "i pigment dei)osit. Injuries, such as contusions, entrv of fore'gn l"'dy into the vitreous, burning of the i-iacula from direct exposure I" the sun s rays, as iti obser\nng an eclipse and electric light flashes, 'i<' liable to develop macular disease. The macular region of the iiiiiia and of the choroid is a vulnerable spot, and is affected readily •y :('ea! or general di.sea.ses. Injurv to it has a most deleterious '■"'"•t upon the visual act, causing central scotoma and -i.at lo.ss ' visual acuity. (Figs. 192, 194, and 195.) .376 THE EYE. :i. Chnroulitis disseviinntn is characterized l)y numerous round or irregular spots scattered over the fundus, composed of isohited iu- Hanimatorv foci wiiich at first loolv whitish, Ix'ing accomimnied by disease of" the o%eriyinf: retina. (IMate X\'., A.) Home of these sjiots progress to atropliy, witii incrciise of tiie retinal and choroithd pigment, whih' fresh ones appear, so that ultimately the eyeground appears studded over with the placjues, and in old cases a large portion of the fundus looks whitish. In the iM'ginning tlio o|)tic nerve and retina usually are involved in the hypera-mia, and the nerve looks reddish; ultimately atrophy of both the nerve and retina takes place. (Plate -W'., B.I " Wlien many of the spots In-come confluent, the whole background of the eye may ai)pear mottled and present a peculiar picture, resembling choroiditis diffusa. In the acute stage the visual acuity and the visual field suffer but little, so that nearly normal vision" exist.*, the patient comijlahiing mostly of dazzling ami flashing of light, and asthenopia. As this is an essen- tially dironic disea.-^e, it ultimately progresses to amblyopia. From the "changes taking place in the "retina and optic nerve, there are usually scotoma and contractions of the visual field, with reduction of the visual acuity. (Fig. 194.^ 4. Choroiditis anterior is characterized by exudation at the [m-- riphery of the choroid, the fundus being here studded with r nlish ink-black opacities. It is found in myojjes of high degree ano .some- times as an accompaniment of sy])hilis. In old pe;)i)le pigmentary changes are fre(|Uently found in the anterior jiortioii of the choroid. It is sometimes a complication of retinitis pigmentosa. 5. Choroiditis Dijfiiso. In recent cases the retina and vitreous appear cloudy, and circumscribed exudates are present in the retina and choroid, occupying mainly the region of the macula. Later on. thi'se appear as dirty light-gray irregular patches, and in the last stages the general cloudiness of the media disapjjears, being replaced by atrophy in the retina and choroid, into which migration of pig- nient takes i)lac(>. (Plate X\'., I).) This is a disease characteristic of syphilis, and has been described under the name of choroiditis syphilitica. The visual acuity and field suffer greatly, color vision part'culariy being affected. (Fig. 19.5.) (>. Tuhcrndor deposits rarely occur in the choroid: they present the jiicture of yellowish-white plai|ues, over which the retina appears grayish and infiltrated. (Plate .W II., A.) These ultimately degen- erate into atro])hy. pursuing nuich the same course as the di.ssem- inated form. 7. Chomn's in the choroid hi nijiopia consist («) in retraction of the choroid and atro])hy at the bonier of the o])tic disk. This first appears as a crescentic i>atch at the outer border of the papilla, being caused by the heail of the nerve being pulled, toward the temporal side. Later on, the scleral canal enclosing tiie nerve is so pulled and gets such a slant that upon ophthalmoscopic examination it comes into view through the transparent tissue of the papilla, ap- PLATE XVII. ''•»-»«« Diseases of the Choroid alfectiiig ihe Retiiin nnd Viireous. A Clu.roiiliiw TulienuloMi Milimii- B HyHlilis ,-1 (,-h,,rimlili^ Sii|ipiiriiti vn i P-.eil. lo.i 1 1. mlai C Cl)uru>- i-eiMi iti^ Ariiut .li ' -i fsm iJlSKAisKli OF THE CIlOROllK 377 |K'ariiij{ a.s a \vliit«' cTcsecnt cIom' to tin- ttiniioral lM)nl('r (Plate \\'., I'., and riatc -\VI., F); this is caiUnl conus. At thi.s time a rcHcx may 1m' seen in «)n(e cases at several disk diameters temporally from ilie nerve head, which is a characteristic symptom of progressive iiiy(i|)ia, the curvilinear line of Weiss. As the myopia progresses till' ntraction extends around the nerve, forming a i)and of white ii>su(— ring conus. (I'late X\I., E.) If the retraction extends lurllier, intiammatory changes, with con.>ie(|uent atrophy, take place, resulting in l)ulging back of the ball or postf-rior" staphyloma. I'late X\l.. V.) [b) High myopia is likewise accfinipanied by intiammatory changes about the macula, such as have Iwen described UMiliT the heading of Choroiditis Areolaris. CompUcationa. In mild ca.-<es of choroiilitis, the retina and optic nerve may U'come hy|H'rainic. When the atTection is due to eye- -irain, tlie cau.se may (|uickly Ix' relieved by correction of the refrac- tiiiii, and thus the retina and o])tic nerve ac(|uire no pronounced defects; but if choroidal disea.se exists for any length of time, or is -ivere, incidental inflammation and sub.se<juent atrophy of the oi)tic iicive and retina occur, with subse<|uent diminution of vision. Thus it is that most cases of choroiditis are a chorioretinitis. (Plate -W'll., C) The clioroid likewi.se is generally involved in cyclitis and iritis, which are accompanied by hyjiera'inia or ulirnal*' degenerative changes in the choroid. Iridochoroiditis has thus l>een de.scrilH'il as ,1 speci.il disease. The vitre()us is generally involved in exudative rhoriiidiiis. and the results of choroidal inflanunation and exudation ,iic to be seen therein in ojiacities of tlie vitreous. Choroiditis Suppurativa. Suppurative choroiditis may originate ill tlie clioniid. being evident at first by a local exudation containing iiutiicmus celis and j)us germ.-. The inflammation extends to the Kiiiia .-ind vitreous, and at this stage may be .seen through the pupil .1- :i yellowish mass in the fundus, or later as a yellowish reflex. I'hite .WII.. H.) The inflammation becomes violent, implicating tlie cili.iry body and iris, and, finally, all the structures of the eje, cMiisiiig panophthalmitis. Symptoms. There are but few mild ca.ses, but in tliese or in the li'L'itiiiing of supi)urative choroiditis, although the inflammation !iin|icr is confined to the uvea it.self, the media become clomled, and tuiidiis examination is limited to the perception of a yellowish glim- iii' 1. Tlie vision is greatly diminished, there is pain. and. on account "I :lie iritis, congestion is present. There may be slight rise of I'liipeiMture. In the graver ca.ses the inflanmiatory symptoms !.i..irr,.<s t,, s,.v,,p,> iinplioation of the ocular structures, violent pain '- I'lisint. ;iii(l .sight is completely lost: hyperpyrexia likewise occurs. Course. In the lieginning there is hypertension, owing to exu- ''•iii"ii: llie eyeball softens late 'ind finally atrophies. In severe ■ '-^-^ tlie riitijunctiva and eyelids . -oiih' (edematous, and the con- iiictna often so chemosed "that it projects iK'tween the lids, which ^^''^'' difficulty forced open. In violent cases the eveball 111 be 378 TIIK E\H. .K-nirs tl..- int.. •\'-' ''' ''f ,,,, i„,,„..,.s,. until tl»' puniU'i.t .-xu- choroid IroiM pyop'i.ic luattcr; . .^.^^^^^ 1. '^r^;'-;;;'K;;;;S'i^ ..'.'( i:!::;'.";' ^p..nuiv.. pn- the ..utsulf. CI Iduti.nmj, n fn'.iu.-iit "■'.'r :,;:■•;•;'.* ,'r;r.: »: .:a,!;;;l'.;;i «, .,.»,.>. :*;u: '.,wr ,i .1,.. t>...™ xLi;-'»!;:,i;i" :^;^, i;;;, ::;;;::; l^^tt''''- / ,• ,„.,i.-<- rr7i Tlir()ii"li ciiibulisiii I'niiii (it tllC llin.imi"-"i"" " ,. •.. ..i.:i.l .,■„ .m. , IS lllirilislicd (llll lllf in'iii"f^> •'• I- • . • 1 1 .,™ai r,„™. -r .«.. :;..■ .■.»* ";;|«™-;:;;;1 -:;,:^«Z:!;;:il ,,V ,l„.ir ,,,m|,anuiv.;ly ";*'"""';". ■',:„, ,|,.. i„ll,„„a,a- is j<>(ipMr.liz.>'l , „f suiMuinitivc Treatment. No iiicdii-alioii (.vn i'-'"-' "' ,,.,,■ „,,'^ siifTcriii<' ,,.„,„i,,i,is. 1, is .-onti,,..,! to an...hora,m, '1''' I^^'""!.^ ^f l™- If th.' .'as.- piosr."ss,.s to panophlhahn.t.s. tu'.. :uiil narcotic^ incision of tin Un.inishcs the tension hy allowing ,,,.... i„ its anterior r«.m^^^ ' "' " u sh„!t When tlu' eye beconu-s shrunken. ;;;.su;ily ren.ains ..uieseent ; hut in ^^^^^ ^:!T^y such as calcareous deposits, occurs, causui^ iirit.ition oi nerves ami synipath..tic irritatiot, in the oth,-r eye. evacuation o ivss of the ilir-ease are <■! »f^ ^ ■PHI DisKAn^a OF rut: ciiunum. ;i7i> Kii^. I9M. U liilf an artilicial tyc inijjlit Ik- worn nvcr the resultant stump, >till the irritation causi'il :»y llit- .shell may give riw to wrundary >yni|itonis. Altlinujfh it ha- Ix'tn customaiy to do prostlicsis over a :.|irunk('n stump, tiic ilangcr iVom sym|)atln-tic irritation should Ik- considcnd. and cnucifation should Ik- prai-liscd. i:nuii('atiiin in the ht'ijtht of panophthalmiti.s .should not usually Ih' done, cxcfpi in ca.scs where phh'ftnion of the orhit is likewise developed and where it is neeessary to oliiain thorough drainajje. Su|i|)urative meninjtitis hius Ix-en reported as oeeurrinff after enu- cle.ilion for panophthalmitis, hut also several cases have Ix-en reported 111 lalal nieninjiilis sueeeedinj; a pano|ihthalmitis in wl.ieli emielejition was not practised. The jreneral treatment should !«■ that adopted fnr sejiiicaMnia or pyaniia: (|uinine. alcohol, and strychnine are to U" e\hil>ited, anil the excretory functicitis kept in normal condition. Sequelc. The result of .severe plastic or purulent inllatnmation <tf ihe uvea is shrinking of the eyehjiJI, due to ahsorption of its contents and their replacement hy coiinoetive ti.ssuo. I uo forms are ohserved : I. Ali-ojilii) I |'i>;. lOSi. where the .shrinkage lakes place slowly; the diminution is usually ninderate, I «'in)i caused hy the contractinn exu- ilali'. The li.ssues of Ihe eye remain iiidivid- ii.illy distinct. The shrinking of the exudate ijraws tlh' inlra-ocular conl<'nls together, caus- iiiir repeated .•iilacksof inflamm.'ition. and, at limes, syinii.athetic irritation in the fellow eye. riir cause of atrophy of the cyehall lies chiefly in pl.i>iic iridocyclitis. The atrophy goes on Inr nioiillisor vears, and niav result in phthisis l.iilhi. ■2. i'hll,isi> liiilhi Mere the shnnk.age fol- I'lwiiijr perfor.'itiiig panoiihthalmitis is rapid. .■i> a rule, tliccye becoming very small, shrinking i'Vi'n to the size of a hazelnut. The ocular '•"Mlents .are cxtnidi'd through the rujitureor ■itc r.'ipiilly ahsnrlied: hence such eyes are -I Mom |iaiiifui, and do not give rise to sym- I'Mihetie irrigation in themselves, hut the orig- i.ii.ii inflammation through which they pas.sed, in many cases gives ri.se to sympathetic inflam- 'iiaiion. ly-snilial l'l,ll,;si.'< liidhi (ophthalmom.-dacia). I (lis is a rare affection, suppo.sed to !)<■ due to a • -ion of the sympathetic. The eyeball becomes soft, and in mildca.ses ^! aciiics of the media occur. The conilition may hi't for .several i ,v- or weeks, and fin.nlly disa])i)ear without leaving traces. In ' \ire cases the tension i)ecomcs lowered and the eyeball perma- i^'ntly diminished in size. Atrophy of the eyelmll. Tin* I'vuball is simtlliT and of • I'liKlraD^iilur sha|x--. from pitlliMK of the recti mnsfles, Hiirl Rf^iovwl at llicir lnM.T- lion ; tile cornea is irrcKOlar. the retina detarhed from tlie I'horoid. anil much exuda- tion in the remains of the vitreous behind tlie leiH : tlie choroid remains attaelieil at tlie iMtfterior |iortion of the Klobe. t»einK detaehed only as far as the ora scrrata : be- tween the clioroid f*r \ ttie retina is a space filled with an albuminous fluid ; ttie optic nerve is thinner and atntpbio. (h.iiicnliu,, ../ //-. rhi>rn.,l ami n«Milar f..iitcnts is foiin.l :i..t iiifn-- u,„.||llv il. -lllMhk.M .'V.'S nf I..I.K stMM.Iihj:: U lllih sll.'ll n| l„mr Is f...m.l in ilic"|.-'-"'iinr i-urliuM. in whirl, then- is a li.ilr Inr il.f upiir nnvr. <'alcar.'uiis ,lcv.'.'nrraliuii nf ih cuiilr.ils lii<cwis.. may ..••ciir. I In- stniii|. is uifii painful I.. Iniic:.. ami may «ivc n..' m sym|':itli.'tir "Treatment. Almpliic .•ycballs .-..iita.iMiMH luivinn lM..lirs ..r l.avini; „„,|..rnnhr ..sM-uns ur .•alra.v.,..s .Irp.n.Taliun. a.ul all imtal.l.- ami ,,,mlul stnmi- sIh.uM Uv .■nMrlralr,|. In hut IVw rasi-s n «l.irl. tl,..,v an- small nnn-irrital.l.' stumps. sl.ouM attitic.al .ys I..- titt.'.l witlinut cnui'iratiiin. , .• ■ i . . Neoplasmata of the Choroid. Nc\v-L'r.>wil.s ut the u%-.al fact ■nv rrhtivrlv unn.m.mm. urcuninfi in (MU7.-. U> (UMMi p.T (■.•nt. ..t ,,v i<,.s (»!' Ilifsc. sarruma is tvlativrly .•..nniioii, and is s.-<'ii m..-t uflrn in tin- .•l.c,r..i.l. It usually is pijinK'ntci. an.l its cnirs.- i< Midi iliai fnur aistinct sta^.'s may !).• nhs.Tvnl. II .KTurrmit 11.. 1''.' F„i ,...j -sarcoma of. :l.nr,ml.nn.t stage. .fh,.t,*rn..lu.,l fr,m, H.Tim.n , K,": V,-S«rr„nm,.f .■lu.roul; h.o. .,1 Mage : .....r,ml a«,-.t..l c.„u..;nm-.U->et«n. ■ „,,, ,,,,„,„i.,. i„ ,l„. first stap- 111. tmm.r is >,nall "'V ';«;'• ' , , ,• „,,,,,-ii.« awav from tl,.' macular ivpon, .Iocs m-t a tus : ., ,h.. visi.a a.-uiiy. but «ivcs rise ... .idcct in t u; vi.u:.^ fu . 1 ,,„„, ..ircumM-rihcl d-'lachmciit ..t llu' rctma, digs. 1!».>-1<><.\ "' ," r,' lallv n'adilv ma.lc by the ..phthalmoscupc, alt im.,h ;^" V .V upon lirst examination, as it is to be d.tlcrcutiatc.l tron, ,p tachmeut of the retina. .\s the tutnor ,n.vs the retma ,; :;,,...sn.ore and n,ore detached fn.nniie choroid the space^.^^^^^ . , ,,„, ,.,,„,,,i.i ,.,,ntainin-a thickened. ,|..lly-like mas.^ uihl i.iImI ;,, .,ive-,i<sue elen..n,s and an,n.boid cells Jmt not Y iV,„e. The tun>or itself is Usually circumsmbed. the ^l;;;'--;^ - ,,i nin.r in contact with the sclera in its lull extent. lAte.nal 1. :.;.".: still appears normal. (Plate .\I\ .. l-' On turther growth. ,h,. ev becoin.'s blind and ophthahnoscopic exammatio,. is m.l-os- ..ilili. ;,„ account of the .listurbance «i th.« media. . ,-, , „ th.- secon.l sta-e symptoms of increased leuMon s.;t m. he e>. pre . 11 til ' the appe^ranVe of iuHammatory ,rh,ucnn,a. beiijj: m lame, he; lull 1- =n.terior chamber shallow, iris dis<.olored, pup.l f^mm UlUK.USh.s lit THE CUoHullf. iHl ililitlnl iiiiil iiniiioliili', trii.siiiii clfvatrd. Tlic Icii.s later Im'ciiiiic.-, cliiinli'il, Mini, iM'sidcs tlic tiital Idiiiiliios, llic patifiit >iilTri> nain. A* tlifsc an- till' syiiiiiliiiii.-* of iiiflaiiiiiiatnrv jflaiicnina, ami. a> maiiv cax- all' hut mtii liy llir |)liysii-iaii until tlii?« >taKi' si'ts in. a (■(nrrct .li.iHii(i-i-> uttcii i.< inailr with ililllnilly. If tlii' cyi- he cimcli'ali'd at till- tiiiii'. it may lie l<iiin<l ul an inrjrular sliajx' tnuii luilginn of tin lar (•nat> iliii- tn jfrnwth nf till' tniiiur. i I'ij;. i.'(K). rill' third -itaKc i.-< that of iiriforation of thiTv rliall am ll'Xt ra-ociii (Ticwth of till' iiiiiior. I'rrforatioii occiir-^ l>y infiltration of the .sclera and iv|ilai'i'iiiciit of its ti.s.'<iii' hy the neo|ila.-<iii. The favored site is |iosteriorly. when the nodules of the tumor are iiivisihle until aftei emicjealiori. 1 lit if anteriorly, dark and hard proinineni'es m.iy seen devi'lo|iiii): ill the region of the corneal limliiis. .\ soon -iircoiim ..I (.rlji iMihii|liim',"tall. ongiimli^.rf in ehoroiilul itrowili; tlnr'l -Uue, iAit Kig. Wi.t 1- ih" neo|.l:t.sm has hrokeii tliroiijih the envelop.'^ ..; the eyehall, 'lir i:ie;it tension and eonseijuent pain usually .-eases, .1: d after this III' imiior irrows nipidly. filliiif; the orbit "with proje.tiiif; cauli- ' 'un-like excrescences. ( Fi>;s. L>()I and 202.) I'leeraiion of the ii|>erticial portion with hemorrhajies and foul di-(har>ie then ■rr\\v>. The neoplasm may extend directly into the iiei<;hl)oriii>r ."!' and luain. th<' patient dyinfr of septica'iiiia, from al)sor|)tioii ' th" ne<'rntic products, from hemoriiiajie or from implication of '><■ liraiii. I he lourtli stasre is that of met.'ista.sis and jieiioralization in the i lial I n Met :ans. usually the liver. (Figs. JUA and L'()4. i-tasis hefiins during the second .'ind third st iipes. and a diag- -I- "I internal disease cannot usually be made until the visceral 3«2 nil-: KYK. ,u,„ors an- sullici.-ntly larj;.- to ho anm-nut.-.l l.y imlputiun and '" S';n;!.u'ua uf tlu. c-l.on.i.l consist of eith.-r nnnul or spi.ull.. <-.lls. and usually contain niarv wi.k l.lo<.dv.;ss.>ls As lti«> '''^\' ' " • the the same as that ol ri'oniuia o FlO. 203. Vu; ■•.»- -Sart-oma »f orWt inclu.iinR e>-el«ll. urmimUiuK in cl..,roi,ial Kro«lli- third si.ii;e. ,Vu,m i«tium Bl.owii m l.g.an.i ,,,, th. only fonns of new pnsvths that hav been reiu.rted as ncciiirin"' in the ciioroid. , n i , . Dui and Prognosis. The first and seeond sta«..s usually a- „.n.e or four vears. Patients die in the tlnrd sta«e n,n, •'xl'; •> : ':;„.nsion im., ,1. l-rain. 'Phe fourth sta.e .s =''->>;;;';;';;'"' the two latter >ta-es usuallv cuhnn.ate ni death n. about a }(ar. "'k ona aire..,s^,he uveal tra.. and orbit h. .dnmt -1- 1- ^ ]. tions of UKdes and feniales. the average a^' l-u-K forty-...irht an^ m. al years. It is ..xtren.ely rare in children, so that a niahRuant p o v t ;. oping in an eyeball would, in all i.robab.hty, U- roRarded as •> insEASj-:s OF the viioRoiit. ^^^ -ilioiiia in a child and a sarrntna in an adult. Rcrurronrc tal<cs place in alxint S.N(> per cent. In primary uv<-al sarcciina wiicrc the cychall IS removed early the priifrnosis is more favorahle than when a'risin.r HI Ihe orlut, where recurrence takes place in 5S.() per cent. Sarcomata ot the nis and ciliary body ix'have in respect to their course anil iihimate outcome like those of the choroid. Treatment, llarly enucleation of the oveball, in which the optic nerve is cut a.s far hack a.s possible, is the treatment of the iirst stage II the neoplasm has affected the orl)it. complete exenteration— V e ninoval of the entire contents of the orbit— tofrcther with the perio.s- teum may be done in hojx's to prolong life. Kxposure of the Kl<i 201. Al>i{iminal coiiir! sjirco;im (»n(,'iimlinj; in i In "ici.iiilury KfiiHth luick nf liver. (Same case as Fig. . sht)\s ingeiKjriiiuu.s ■''"""■'I .'"-bit to tl... action of the .r-rav may then be resorted to as '" Ji'I'litional s..eurity against recurrence. Recurrence and .leath '\\i;\er, usually take j.lace within two vears. but a very small i)ro- ;."""" "I cases being cured by exenteration and x-rav expo.sure '"'■ "7" '" "f "i'' l'""rtl. stage, wluTe involvemen't of other ";:h!^ h:is uccnrre.l, is siniph- palliation of the patient's .sutforing iniunes of the Choroid. I'cirirotin,/ wnumls of the posterior "I"" "I tlie ey.'ball involve the choroid: tliev are likewise accom- 'i'i,.,l by injuries to tlu> retina and vitreous. If clean, thev heal bv "'I'l.'i ti.-..M,e; li septic, inflammatory changes result, producing '■'"'■•"""Klilis aiul iianophthalmitis. it .•J84 riij-: EYE. Huiitiirc iij the (Imroid. Tliis is prnduccd l)y a contusion, usually liy a liluiit iiistiuiiiciit : sometimes several, but jieiii-rally only one laeera m oecurs. On aecount of extravasation of blood into tiie vitreous and under the retina, this injury is not usually recojinizcd until some time after the aecident, when healing has already taken Jilaei'. (I'late \'II.. li.i Then, upon ophtlialnioseopic examination, a white streak is obserx'ed over which the retinal vessels run without ch;in};i' in their- Mirse; theedjres of the rent are ()bserve<l to be colored by proliferati' ' the pigment, localized detachment or rupture of the retina is jjenerally jiresent. Con- '•■"•■-'"■■'■ striction of the visual field and loss of visual acuity occur from atrojihic chanfjes in llie retina and o|>tic nerve. Treatment Treatment of this con- dition is absolute rest in l)ed for a week or more, to reduce the liability of hemorrhajie and retinal detachment, and instillation of atropine to quiet the action of the ciliary muscle and iris. Imme<liatoly after the accident saline cathartics may be j;iven as de- rivatives, and iodide of potassium later, to .aid in the absorption of clots or exudates. Detachment of the choroid is due to subclioroidal heinorrhase, which jjives symptoms of j^laucoma (one ot the so-called forms of hemorrluifiic glaucoma). It is ;d)solutelv fatal U) vision. This is one of the results of sudden relief of intra- ocular tension, and has been observed as an unfortni accident after iridectomv. made in fj;laucoma, and also after cat extrac- tion. Treatment. 'I'iie eyeball usually has to be removed in order to stop the henii)rrhaji;e and gvi\\{ pain. THE VITREOUS HUMOR. Anatomy and Physiology. Macroscopic Anatomy. The vitrcoii- (corpus vitreum) is a transi)arent, colorless, jrelatinoiis mass fillinL the posterior cavity of the eye. It is surrounded ])osteriorly an- laterally by the optic nerve and retina, ard anteriorly hy the cilian body and ca|)sule of the lens. On tin- anterior stn-face there is depression, the fossa palellaris, in which rests the posterior surface "' the lens. It is traversed from liehind forward by the hyaloid can.i which is a lymph space beginninji at the p.apilla and exteiidiiifr ' the posterior pole of the lens. DnriTig fn't.'il life the hva.loid .'irter runs in this can.al, and sometimes persists. The vitreous has i: bloodvessels, and depends for its initrition upon the surround! i. Severe siitKliurniiiul hetnurrhage. with ik-Uu'Iimeiit iif ehciroiM and retiiiu. fol- liiMUii; iniieetiHii.v fur giauconitt. tlMioto- KrHplicti from si>eciiueii.) THE VlTIiEOVS IIVMOR. 385 tis> „.. par..rularly tl,.- uvea: honce. aff.Ttions of the inner nu-n.l.ranes ot tlu" ,>y(N t!>,M-etn.a, aiul the ehon.i.l always i,n,,lic.ate tl.e vitmi^ Microscopic Anatomy. Th,. vitreou. k a tralK.par.n re cX.' .-."nmnng a c ear I, juid .uh^tunce, with roumi or hranche S whieh are mostly h.un.l in the out.-r hiyer, an.l are .supp, id t . be nuftra.e.! wlnte blood eorpaseles. The ext..r„al e.nelo i is ..rn,«l l.y a structureless layer, the hyaloid nieinbraiie liie yitn'ous serves as a ineiiiun. of support to the ocular tunics |>resery,ng the sph.-ncal sha,.e of the eyeball, and as a clemmed n P-.;.HUtu.K tlu. jmssafte of light and focusing of objects u no Diseases of tho Viteeous. Congenital Anomalies. I'ern,te,H Hyaloid Artery. Th( hyaloid art.;ry passes fro„, the cei>tral artery of the retina to the posterio >n.tac.j „l the lens occupying the canal of Cloquet in the hyaL.id '-'■a! . unng l.etal life, shriyels and disappean. about the sixth month ..prestation but occasionally persists: (., a filamentous stra ^- -l-'l to he .hsk or to the lens, the free end floating in ihe Miie.M.s. (,) a strand passing across the yitreous; (c) invgular ■n..M,„. bodies upon the surface of the ,lisk. Its yestigial rein a ins :"<• accountable for posterior congenital capsular cataniet There 1--. ns a rule, no def.rt .,f yision, ..xcept it be accompanied by opacity "I I lie lens or other congenital anomaly. ' ' Tlie wall.s of the canal of (-lo.iu.'t an.'sometinu.s sufheiently o,,ac|ue Hniil'v"'''" "Plithalmoscope or to interfere with central yisual Inflammatory Diseases. H,/aHHs. Inflammation of the yitreous |_ -M-yr primary but accompanies an.I is the result of inflammation " "'<• "'I";.'! Mild th,. uyeal tract, \ision is diminished from inter- •'•'■■;<•" -itlj the function of ti.e ret. ,a. and also by disturbance of 'I'" "i""m du.> to punetat. .spots in the yitreous, which the patient -.■< as llo.M ting specks. These are not to be confoun.le.i with musc.T. It. les. which are a normal plu-nomenon, being due to th<.am<eboid ' ;', i l'" '";■""■■• " '""'i ""' '■'''•"'•'>■ ■^*"" <'"t"l'i™llv by dosing ■n ..\ .1 In .,. la ter haye some error of refraction which shoul.l be ;;;■<;;! w..l. suitable lenses. A flne. dust-like mist occurring in se o. choroiditLs part.cuh.rly of th.. .syphiHtie >-ariety, can be , . ' 'V •'"'',?", \'' ^ '."'.'"'^ •^'"■'■'^^ ""•' "'^" ''V the-ophthal- i : Vl " '"""''' ''^™ ••',•' l"""'t»t'i- J" another form of the ; ' : , '',T "■''" •'■•^ '"^"'"-'''^'^ "•• a« "'">«♦<■ light-colored spheres, '" HjKi nyaiitis. ' "l.^niic. in (he Vitreou.. These are either fixed or moypble and ' -condary to other aflfections of the ivtina an.i choroid. Large "■'".Hies may form as the result of hemorrhage or inflammation, 2o 386 niK EYE. and arc rcadilv seen bv llic oplitlialiiuiscuixv, iiiipcdiun visum di- pciidiiifi upon" tlicir hication. (I'i-;. -'(Hi.) Tlic oplitlialnioscoiM' oifcis a sure inctlu.d of niakinj,' tlic diafiiuisis it' tlu- nicdia Ih' dear. A convex filass of from :> D. to 1.") D. is used to focus tiic various depths of the fundus, and tlu' i)aticnt diivctc.l to rotate tiie eye. l)y wliich tiie opacities niav i)e l)roujil.t into view, and tiieir dei>tli dis- covered hv the strength of the focusing fjiass, and their i)arahictic KlQ. JOfi. Striii rvtiiiic t: ■.in'iiibmiu- vilreii' ei chomiililis cxmhuiva. nioveineiits. Ilifiii defirees of inyojiia predispose to (h-generations <il tiie ocular contents, and usually are attende.l l)y nieini>ranes or opaci- ties hi the vitreous. Tiie several diath(>ses and fteneral di.seases ftiviiifr rise to di.seases of the retina and choroid are likewise prone to develop vitreal opacities. .... Treatment. The treatment of hyalitis and opacities m the vit- reous should he that of the cau.se, if such can be ascertained. Altera- tives, such as mercury and potassium iodide are sometimes us(>tul. Irrefiularities of tlu- menstrual function, disorders of the liver, etc.. <liould be treated: diaphoresis with pilocarpine (0.01 gm. liyp(.(lei- mically) once a dav, followed by a hot fieiieral bath, is somemiH- useful! I'lrrors of refracti(m and" bad ocular or bodily habits should! be corrected. • c ,i Hiinliiis Siippiiriilira. This is an infective inflanimation ot tii vitr ous c.HUsed bv entr.-uice of i)yogenic micro-organisms. It is -.^ ace, npanimi'iit of iridochoroiditis, and has been described uiul r that heading. Tilt: VITHEOVm Ill'MOR. 3^7 iWudouliowa. A circuiMsciilM.,! .suppuration <,r plastic inHaiutna- tioi. u tiu' vitn...us may .ktui- in tlu^ p.-npL.Ty „f the d.anii«.r near Uic ciliaiy .vfiion, bcinf; du.' to exudation from tlic ciliarv bodv and 1,. accompanied by loss of vision and minus tension. On .■.ccount of tli.. yeilowisl, reHe.x from ti.e pupil, sud. cases have l.een n:istaken tor true lilumiii of tlie retina, hut the evid.'i.ces of a K<-neraI uveitis and the decreased tension should ^ive the proper diapiosis lih,.„lrcs.scl Fonnution i„ l/„- Vilrc.us. After inflan.niati<.n or h|'ninrrhaKe mto the vitreous, organization and develoj.ment of i.lo.,. ves.seis may take place, forndnf,' a veil of freelv cominunicatuiK capillaries haying scH^mingly no connection with the hloodves.sels of the ictma. 1 hese interfere with vision, dei)ending uj.on the .•.mount and their po.sition. Degenerations of the Vitreous. Sywhms Corporis Vitrei Flmditi, n/ thr_ \ ,lm,us. The vitreous being dependent upon tiio retina and 'li'irnid lor Its nutrition, .luring the progress and as t!ie result of dis..a.ses ..» the.s,Mneinbranes, and in high degrees of mvopia, degen- "lalion ol ti.e vitreous occurs, ,so that its framework 'is destioved Insing Its normal con.si.stency and becc.ming a straw-lik<- li,|uid There air likewise, h.nmished teiisioiK hyj.otoiiy 1 and frequenllva tri^nulous Ills ini,loi...sis), an.! occasionally a luxated lens. This' (•< -idition is a II1..SI unfavorable factor for restoration of vision by cataract ex«rac- tUMi. treatment is of no avail. Sfixchisix Scinlillans. Chohsteriu Crystals in the Vitremis These •in. api.ar..nt to the pati.-nt by fla.shing sparks before the .-ves .•md t,. the ophthalmoscope by numerous gli.stening crAstals r.'flectlng lie light from the ophthalino^-coi.e in the for:n of a .shower of sparks Ih.y are compo.s,Ml of r ,te crystals of cholesterin and tvrosin,' .md Jh.' ophthalmoscopic j.icture is very brilliant and interesting As I us happens in ..yes that are more or less degenerated in oth.-r respects til.' vision ,s r..,luce.l. Th.> con.lition d.,es not vi.'ld to treatment ' I- alt,, Ikycmratwn of the Vitreous. In this c..nditi..n there are niiwa. vohlanles, an.l the ophthalm..scope shows numerous white di-t.'iimg spots evenly distributed through the vitreous. Th<. vision N -liglitiv reduc.-.l: but as this is an evi.lence of senile decav there i- no m.fication f.)r special treatment ' ' iMarhment af the Vitreous. The vitreous mav shrink in volume I'm, ,|..gen.>rative c!iang(>s, an.l the n-tina thus" lo.sing its .support ':"'">>i<'s .l.;ta<-h..l. It may arise from choroiditis, hemorrhag.. exten- :nv post.-n<,r staphyloma, and trauma. If the ."ve does not become '■'"■I'll..,!, then; IS no occa.sion for treatment. If "congestion, imin or uiil'atlietic .hsease set in, the eve mav be enucleated In]unes of the Vitreous. Loss of Vitreous. Prolapse of the vitreous "I" -■as an unf.)rtunate occurrence in pen(>tratiiig wounds of the ^'•'.•111. especially m ratar.ict extraction, an.l about nne-fifth of the I'pyus may be lost without materially affecting the functi..n of |;i"n, as the ..nvelopes of the eye accommodate themselves some- '^t to their diinmished contents. 388 THE EYE. Treatment. If due to penetrating wounds of the sclera, the bead of vitreous may Im! cut off, the wound stitdied, and the eye treated antiscptically; if occurring during cataract extraction, the toilet of the anterior chamber eaimot be jus rigidly made, and iris prolapses cannot always be replaced. The extruding vitrcoas should be snipped off, the eye closed, and disturbed as little as possible in the dressings. The extruiled vitreous retracts somewhat, and, if it does not become infecteil, the wound heals, but union is delayed. Heimrrluu/e into the Vitreous. This follows rujjture of the vessels of the retina or choroid, most probably the latter, cau.siiig loss of vision depending upon the retinal and choroidal lesion and upon the amount of bieeding. Spontaneous hemorrhage may occur in young adults who have irregularities of circulation and gout. As a rule, these are not entirely absorbed, but leave opacities in the vitreous, damaging the vision if centrally located. If the hemorrhage be extensive, the sight is immediately lost, and fundus examination IS impossible. The blood becomes absorbed, leaving numerous fixed or floating opacities. (Figs. 207 and 208.) Fia. 207. Fio. 208. no. 207.- Recent hemorrhage and exudation Into vttreoun, following penetrating wound of clUan- region. (I'hotogmphei' from speclruen.) Fiu. 208.-Organlzed eiudation and membranes In vitreous, following iridocyclitlB from pene- trating wound of ciliary region, (Photographed fro.u specimen.) Treatment. Mercurial jjreparations, iodide of potassium, pilocarpine, saline mineral waters, ergot, artificial leech on the mastoid, and, for the first day or two, cold applications, followed later by hot coni- |)ressing. Entozoa in the Vitreous. The scolex of pork measles, Cysticercu.x cellulosu', and of beef measles, cysticercus of Tirnia mediocanellata. have been occiusionally found in the eye, more fr«iuentlv in (iermanv, where it is customary to eat unc(K)ked or improperly prepare.! To acquire this complaint, the patient must first develop a tape- worm in the intestinal tract ; the egg entering the general circulation. IS carried to the eye, and grows therein as a cysticercus. It is mo.<' commonly recognized after it enters the vitreous, being usualh first deposited under the retina. The Filaria sanguinis hominis an^' THE VITRKOVS IIVMOR. 389 tlio ochinococcus (the youthful stage of the tapeworm in the dog) liav( likewise been found, hut arc of more rare occurrence. Treatment. Propiiyhixis is most important. Food should be well (■(.oked, and i)et animals not allowed to lick the hands. Attempts liave been made to extract cysticerci from the vitreous, but none as .\-et have resulted in restoration of vision; enucleation of the eyeball is therefore indicated. CHAPTER VITI. SYMl'ATHhyriC OPIITIFALMJA. Hy H. GIKFOHI), M.l). When an eye is painful di- irritated from any cau- >, it is liable to set up a syinpath(>tic irritation in the other eye, the symptoms consisting i.i more or less photophobia and lacrymation, sometimes with slight ciliary congestion, or shnj)lv in an inability to use the eye steailily either for near or distant vision. This sympathetic irri- tation must be sharply distinguished from sympathetic oi)hthalmia. It may, and freciuently does, exist for many years without any jkt- manent injury therefrom, and it disappears promptly wlien the other eye or the source of irritation in it is removed. This irritation IS simi)ly a reHex from one eye to the vasomotors of the other, and although in former yeai-s it was believed that such reflexes could cause plastic inflanmiation, and a certain amount of experimental evidence was produced in favor of th(> itlea, it is now generally con- ceded that reflex irntati,.n, if it acts at all in the production of a genuine inflammation, c;:>i ilo so only as a i)re(lisp.)sing cause, the presence of some chemical irritant, generally jjroduced by micro- orgamsms of some kind, being necessarj- to comjjlete the proces.s. Sympathetic ophthalmia is a plastic inflammation, generallv in- volving the whole uveal tract, occurring in the vast majoritv of cases alter a penetrating wound of the other eve. It matters' not how extensive a woun.l may be. if it heals" promptly, without symptoms of infection, sympathetic ophthalmia rarely or never r.>sults from it. But however slight the wound, if it is followed hy a lingeriiifr „igestion and irritation, the possibility of sympa- thetic ophtli.ilmia must be taken into account. On the other hand wlHTe an eye is severely injured, without anv penetrating wound long-contmued cong<>stion is .,uite common, but svmnathetic ophthalmia ran-ly n-sults. A few cases are on record where it has followe.1 subconjunctival ruptures of »he sclera, with or ^vithout luxation of the lens under the conjunctiva, also rarelv as the result of ossihcation o the choroid, and. rarest of all, from traumatic detachment <. th,. retma A perforating corneal ulcer .sometim.'s causes sympathetic ophthalmia, most commonly where a large defect hii.s been pn.duced, with subse,,uent entangl..ment of iris tissue in he scar. Tattooing .such sc,,rs has also r..,use,l svmpathetic o})h- thalnua A great number of other cau.s.'s of .sym,,athetic ophthalmia which have been described are the result mainly of the want of arMJ'A niETiv oj'jitjialmia. 391 iH'twtrn !syiii|)atliclic oplitlialriiia and syiiipatlictic Wiscriniiiiatioii irritation. licfoic tiio role played by iiiicro-ornaiiisms in the pioductioii of inllainMiati(»ii was understood, it was natural that the ciliary nerve llieory of von tiraefe, according to which syin|)ythetic o[)h'tiialniia IS simply the result of the reHex irritation from one eye to the other, should generally be accejjted. It was also naturaf that with the ailvent of bacteriology the almost (onstant connection between sympathetic ophthalmia and pem'trati.ig wouikis of the eye should .-UKgest that micro-organisms were the cause of the disease, and, alter the ai)parently convincing experiments of Deutschmann, which seemed to (leincjnstrate the easy i)assage of bacteria from the interior oi a wound.'d eye along the sheaths and lymph spaces of the optic nerve to tlu; chiasm, and thence down between the sheaths of the other optic nerve to the fellow eye, this view raj)idlv displacetl the ciliary nerve theory. These experiments, however, did not receive ^'.iieial conhrmation. The great majority of subswjuent investi- jlMtoi-s failed to produce anything like sympathetic ophthalmia in annuals, and it is only i- excej)tional cases that micro-organisms lia\c been found in eyes which have bwii enucleated on account of causing sympathetic ophthalm.a. Nevertheless, it is commonly con- ceded that such well-marked inflammation as that which usually occurs in sympathetic oi)htlialmia can hardly result from anything liul the growth of micro-organisms which reach the second eye from !li<' first, either through the lymph or blood channels, the congestion c.cuscd by the symjiathetic irritation jjossibly causing a focus of lessened resistance in the second eye, thus favoring the lodgement and growth of germs therein. The most ardent advocates of the ■.'crm theory of the di.sea.se admit, on their part, that the nature of tlie germ which caases the disease, and the path which it takes in icMciimg the .seconil eye, are as yet unknown, although the free cnmmiimcation between the eyes by way of the lymph spaces sur- loniHling the optic nerves suggests this as the easiest and most probable route, the main objection to it being the non-occurrence ol serious brain symptoms in sympathetic ophthalmia. These would ii.iiiiraily be expected if the germs have to pass through the cranial '"ivity on the way to the second eye. This objection is met, to -.111.' ext<-nt, by the suggestion that there is probably only a very -lender stream of germs passing from the first eye to the second, iiid that the.se may |)roduce serious symptoms onlv where they accu- Miulate 111 the terminal lymph spaces of the .second eve. It has, moreover, been noted ihat quite severe headache is not an infrequent "•••"ini'amnient of syiiii)athetic ophthalmia, and, in a few cases, 'he victims of the disease have iK'come deaf as well as blind. I li«' rare cases in which sympathetic ophthalmia has followed '^'Conjunctival rupture of the sclera, intra-ocular tumors, and other I'liclitions in which the eyeball has apparently not been opened for : !<• entrance of the germs, call for some explanation. They all have 392 lliis in coininoii, Tilt: EYK. tlmt the cxcitiiiK eve, a It hough wifht.iit iipimrontl I, is the scat of an activ iiitlainination, pro l)al.l\ of an inlVrtious .•harart-r. th- pT.ns in th.- .ascs of •^\''''7'J"'';- ^ rupture prol.al.lv havinjj ..l.tainc.l ."ntran.r through nunut,' ruptuns of'tlH. conjunc-tiva, while in th- nis.'s fron. n,tra-..cular tun.urs an. ossihcatiot, of the fh..roi,l the inf.rtion ol the .rst .v.- is prol.ahlj Either fron, the l.lood, ..r is a vival of s...n.. ol.l u.t.rtion. n...st of the ."VOrt with ossification havint; Iwi-n u.J'in-'l inany yrars i..'l(.ri. \ >infilar .'Xi.lanati..n applies to the eases in whu-h a sightles. stun.p n-uuiin-s ..uiet an.l harmless f..r many years alter th.^ oriKU.al u.jury, but l.ee..n,es inHamed an.l excites sympathetic ophthalmia upon re- c..iving a l.ruisc", or whet, the ,.atient catches col.l or luu. some genera inf..cti..n. Ca8i-8 of this kind have been reported after n.easl.'s an.l "'Formerly much str.^ss was lai.l up..n the s,K.cial ilanger ..f w..uni|s in the ciliary region, an.l this was sui.pos.'.! to give «np,.rtant t.-sti- n..ny in fav..r of the ciliary n..rve th.-ory. (Irantmg th<" prenus«v it .-an be explaine.l in..re satisfactorily on th.> germ th.n.'y .Sucli w..unds are among the c<>nun..nest ..f penetrating mjunes: th.-y are c.n.plicat.-d gen.-rally with pn.lapsos of iris or clu.n.ulal tissue, which ■ire ,vell-recogniz.-d fact..rs in favoring en.L.cular mfectu.u, and, Hnallv they lea.l into the soft tissue of the ciliary b.).ly which hits be.-n 'found to be an especially favorabU- I nrding-gniund for van..us '^*The<lictum lai.l <lown years ago. that .'y<'s iu which panoi.hthal- mitis has develope.l never cause sympathetic ophthalmia, has been slu.wn t.. be inc.rrcct, alth..ugh it is pn.bable that symi-ath.-tic ..nhthalniia is less c..mm..n after a violent .lestructive infianimation than aftfr a mil.ler and more chn.nic torm, this IxMiig .hi.' probably, in part, to bl..cking up an.l d.-struction ..f the lymph chann.'ls leading from the ove, and possibly, also, to .lestruction of the hvpoth.-tical germ ..f sympathetic ophthalmia by the rapi.l growth ,.f the pus germs whicli an- generally toun.l in these ca.ses. Rogardiiig the length of tim.- which elapses between the origma injury an.l the <.utbr.>ak ..f symj-athetic .,i)hthalmia, it may be said that the nu.st danger.ms perio.l is from thr.r to eight weeks after the injurv, alth..ugh a few .loubtful cases liave been reporte.l within from <.iu'"to two weeks after th.« injury, an.l s..me well-authenticat.>.l on.-s as earlv as two w.>eks th.'reafter. At the othiT en.l of the seal." there is n..' time limit: ca.ses have .iccurre.1 forty years after tl«- original injury, although always in the well-authenticated cases after a recrudes.-.'nce of an .>ld inHammati..n. Symptoms. Where the patient is ol.l an.l intelligent enough to give ac'urate testimony, the first symptom of synii)athetic ..ph- tlialmia in most, if n<.t all ca.ses, is a slight failure of vi.si.m. Alm...st oinci.lent with this there occur very slight signs of m.-ii.u-nt inti:^ in th.' form of ciliarv congestion (hardly noticeable in s..me ciisesi, with minute spot.s of dep..8it ..n the p..sterior suJ-face of the cornea T^TaaBT" rmsm ^'siBnn^mfmm^^'^t&M SYMI'A TIIETIC OVIITUALMIA. 303 III the aiitcriiir surfan- of tin- lens, thcw latter Ix-iiiR lianlly visihlo t\(i|it l>y strong iiiaftiiiticatiori. Tlicn, in tlic scvcriT cases, follow i;i|ii(lly adhesions Wetween the iris ami lens eapsuie, inerease of eiliarv coiijjestioii, turbidity of the a(|ueous, discoloration of the iri«; in short, •ill the symptoms of plastic iritis, and, in rare cases, hypopyon. The indications of sympathetic irritati(m, photophobia, and so forth, which were formerly much relied uiM)n as warnings of the ajiproach of sympathetic ophthalmia, a. ;;enerally conspicuous by their absence, and the pain is seldom j?reat, except in the later stapes. In the few cases which have been seen sufficiently early to jK-rmit a careful exain- mation of the fundus, slight optic neuritis has often been si-en, and ill some ciises the main symptom of the ilis«'ase has h-en a well- marked inflammation of the optic disk. H it ordinarily the vitreous hccomes turbid so rapidly that the fundui is never distinctly seen. Ill a few eyes which have cleared up after severe sympathetic oph- ihalmia, small roundish spots of choroidal atrophy have been noted by different observers. All grades of severity of the iiiHanimation ■ iccur; in some casi>s it never goes Ix-yc 'd what would be called a mild serous iritis, and yielils readily tu appropriate treatment. These mild cases are, unfortunately, exceptional; as a rule, in sjnte of all tiviitmeiit, the ilis«'ase progresses steadily, the iris, in spite of un- limited atropine, becoming adhen-nt to the lens, often not only at the |iiipil-margin. but over the greater part of its posterior surface. The I iliary congestion continues for months or at intervals for years, I lie nutrition of the lens Ix'ing interfered with to such an extent iliat it generally becomes opaque; and, while some eyes go through a stage of secondary [glaucoma, the end in the majority is a mild loriii of i)hthisis. There is nothing about the appearance of the I ye, ill .sympathetic ophthalmia, to distinguish it from any severe iiidocyelitis, although, since we fjerhaps see more eyes that have linii blinded by sympathetic ojjhthaimia than by any other form it plastic uveitis, the atroj)hic di.scolored iris, the shallow anterior iliaiiiber. and the grayi.sh immovable j)upil, which result from any >c\(rc and long-continued inflammation of the uveal tract, become a>sciciat<'d in our minds with sympathetic ophthalmia. Pathology. Comparatively few such eyes have l)een examined with '1h' microscope, the bulk of what has been written about the i)ath- 'I'ljry of .sympathetic ophthalmia referring to t^'> eye which has ' aiis<"d the inflammation, and not to the sympathizmg eye. In those \'liich have been recorded, the entire uveal tract has been found to '" Mie seat of an active inflammation, with numerous accumulations ■I li'ucocytes such iis, in a progressive inflammation, pathologists '" liive to indicate the pn>sence of micro-organisms, the same extend- ir lor .-iome distance back into the optic nerve and its sheaths. In ■ lew cases in which both eyes have l>een obtained from the same 'j-'-? the changes have been strikingly similar in each eye. One iliese presented the unusual occurrence of so large a number of lit ceils both in the uveal tracts and in the optic nerves that 3i»4 Tilt: i:ye. (limed. >''^t ■' '".'"r ' " 1 ..-n n „. ,.„„sul.ml ..V,. witl. svMM-to.ns of inf.-ct.oM wl.ir . Im. _ • 'f ';';.., ,„, i::r;;r; "\ ;; ;;:.l;.t;;:,:;;\: ;^;n.nt. it s..ou.a '.<• -p.ain..i ;;^t . V . i,U rpl.tiv.-^ tint tlxTi' is some danp'r whicii can oi U Ix 'v'l'iol'wih S, ^ M..^ .Ttainty ».y sacrificing the injuml ey.^ ,; i^ u V in, . assume the flight risl<, the operation need no liut II in i> "1111"^ I Tl,,.,, if flw> «viiii)tonis of nitec- ■ lij. SYMIWTIIETK' nl'lirilM.MlA. a!ir> ciihiimic. Ill tlic <'iisi' ut l)liiul t'Vcs wliicli arc entirely free fniu >\iii|il(iiiis uf (|ee|) iiil'eeliini, no interference is called for, in my opinion, excepl for cosmetic purposi's: l)ut in the cjise of a sijrlitless eye wliicli is the seat of ri'current deep-.'^eated intiammation, liie jiatii-nt >liould Iw warned of the possiliility of danger, and eviscera- liiiM advised even if the lilindness was lot originally caused iiy an Mijiiry. In ailvisinj; the |talient of the ilan^er of sym|iathetic oph- llialniia, fjreat emphasis shoulil !«• laid upon the fact that it comes, M> a rule, without warnin>{, and tiiat aftt-r it once apjK'ars all inaliiieiit may Ih- in vain; and in watching for its ap|)eai.ince physician and p;itient should pay .special attention to the slightest iliiniiiuiion of sight, daily tests under uniform condition.s of illumina- tion lieing made. As a purely prophylactic measure I always prefer evisceration to any other operati()n. Ii >liould Ik- unih-rstood that neither opticociliary neurectomy, nor evisceration, nor enucleation is an absolute protection .'igainst sym- p.iihetic ophthalmia. The disea.s<' has iK'en known to <iccur after all (il these Operations, apix'aring after a period varying from one III tifly-four days sul)s<'(|uent to the operation. Some of these after- ciM > aiv diliicult to explain u])on any theory, hut they arc prohalily due Id tlie infection having spread for some distance bat I. ot the rye before the Operation was performed. When .sympatheiic oph- iliahnia has alre.idy apix'ared, the tri'atment varies according to the .iiiiiuuit of sight in the other eye anil the length of time which has il:i|ised since tile first symptoms. If seen within a day or two after ilie iiist oii.set of the di.sea.se, I should advi.se immediate enucleation "I ilie other eye, even if it has u.seful sight. Hut if not .seen for X vir.il d.iys or weeks after the first symptoms, and the first eye |"'»ess fair sight or has a prosjx'ct of obt.-iining it by a cataract I \ii;i(t'">n or some other op^-ration, it is probably better not to Mf it,- ilice it; but if it have only a little sight, and tin re IS no prospect ■ver having more than enough barely to allow the patient to L'li amund, I should sacrifice it, even in the later stages of the dis- iH', if the second eye still had the better .sight of the two. In this I iliitcr from the majority of writers, who follow the rule never to iiiiiie;;t(> .iftcr all outbie.ik of sympathetic oiilithahnia, if the hrst VI' ||;ivc (ir can have useful sight. My reason for this is that the i:ilisti(s iiiilicate as plainly as possible that the second eye !ia.-. a Iter chance when the first is enucleated, even lone after the out- Ihe (1 isease. The case often cited in which, where an e nu- iiiiiii was recommended and refu.sed, the coiulemiied eye retained !iil >iglit while the other lu'canie entirely blind, should have little au.^e if the enucleation had !>een consented to, it might I veil much better sight in the second eye than eventually was I'jiii, d liy the first. The effect of lueleati in!!:'.!! d s sometimes so iften showing mo'^-t rs-nrkeii jinpro'.-c- '1' oil the day following the enucleation, that it s«'ems probalile '' tlie first eye exercises a constant influence on the inflammation 396 in the socoik (It luis l)et>n shown TJII-: KYE. I oithor 1)V roflox irritation or by the passapc of toxin (•(inclusivciv ni ral)l)its that toxins re iidily pi! from one ov(> t(. the oth«'r, causnin tnarkc.l inflannnation there witli- out any (Iwide.! meningitis or general .hsturbaJice.) Tins su( <len improvement following emirleation is, to be sure, generally of short duration in s<>vere cases. l)ut in the long run the comparison of a series of cases in which enucleation has been ]M>rformed with another in which it has not, sjx-aks plainly in favor of the operation. Knu- deation is n'conimended here in place of any other oiwration, because it takes out more of the infected tissue, especially if the iK-rve is cut far back, as it should be in such cases. It is not certain that enucl(>ation giv(>s better results than evisceration would, but where the outlook is so bad at the best, cosmetic considerations, which are the main argument in favor of evisceration, shou'd have no weight as against even a theoretical argument in favor of something else* Treatment other than surgical should consist in rest, the free use of atroi)ine, and large doses of salicylate of sodium, mercury, lodulo of potassium, or (luinine. I mention the .salicylate first Ix'cause it is the only remedy which I have known to exert a marked effect upon a severe case" of sym{)athetic ophthalmia. In two very severe cases in which I have us(mI it normal vision was restored in one, and liseful vision in the other, while in a third case, well marked but not so severe, normal vision was n-stored. By large doses I mean 10 to i;i grains in the course of sixteen to eighteen hours for each ten pounds of the patient's weight. That is, a man of 150 i)ounds would receive from 150 to 200 grains in the course of the waking hours. Thes(> amounts are borne best when given in brandy, 15 grains to the teaspoonful, followed by a cjuarter of a glass of water: but if this nauseates the patient, it may be given in capsules, brandy and water being taken .separately. Some patients may not stand such large amounts, and if there is any (|uestion of heart trouble, one should begin with smaller doses. FuJl iloscs can generally be borne for two (lavs out of three. In eases where the stomach rebels the remedy may be given l>y the rectum. If it has the desired effect, it shoulil be coiitiiUKHl, w'ith increasing intervals of entire ab.stinence from it fa large dose on two days in a week is better than half the amount on four davs), until loiig after the last sign of congestion has (Usai)])eared: aiid this rule applies to whatever form of medi- cation is employed, on account of the danger of relapses. Mercury is best given in the form of inunctions, a piece the size of the patient's whole thumb being rubbed in twice a day for four days in succession, unh-ss tenderness of the gums api)ears sooner: tiien the same amount once a ilay for the n-st of the week, after which an interval of .severtd days sliouhl occur Ix-fore the inunction^ are recommenced. If salicylate or mercuiy have no marked effect, large doses of iodide of jwlassium or <|uiniiie >lioiild be tried. ■:: they may be used in the intervals when the patient is not \xsiw .V YMl'A THETie OPHTHALMIA . 397 the otlicr roincdios. If this is done, it would jjrobahly be best to avoid following salicylate tvith (juiiiinc, on account of the ctTect on the cars. Asa rule, hot applications have a favorable effect, though in .some of my patients, when used in the ordinary way, they have seemed to do harm, while when emj)loyetl in the fonn of thick soft poultices, chanficd every ten minutes for an hour, four times a day, the effect has been decidedly bcneftcial. If other remedies fail, subconjunctival iujcctions of two or three drops of sublimate, 1:I00(), or ten drops of 2 j>er cent, sodium chloride every third day may be tried. If the first e\-e be retained, it should receive the same local treatment as the other eye as long as signs of infection continue. It goes without saying that everything consistent with rest which can be done to kwp the general condition food should be done. In s|)ito of all treatment, even when the ca.se i, seen at the start, the prognosis is bad. The iris generally a("!'.eres closely to the lens in s|)itc of idl the atro|)in(>ihat can be borne, and, besides the blocking of tiie pupil with exudate, sight is reduced still further by opacities in die vitreous and lens. Where glaucoma ensues an early operation fur its relief may be re(juired; in these cases the iris connnonly bulges ,it the periphen,', and a double tran.sfixion of it with a cataract knife should be tried In^fore resorting to an iridectomy. But, except in I lie case of glaucoma, no operation should be done for the improve- iiiciit of sight until all signs of active infection have been absent lor a year. Even then the results of operations are apt to be dis- ci uiragiiig. Good light sen.se and projection are retained surpris- iiifljy long in these eyes, and to a novice the ta.sk of restoring sight liy an iridectomy or extraction i>\ay seem simjjle enough; but when an iridectomy is attempted, it is generally found that only the anterior l.iycrs of the iris can Ix' removed, the pigment layer remaining to lilock effectually the artificial pupil. If the lens is extracted, the ^iirlit generally still remains poor, on account of exti'iisive vitreous opacities, and any oju'rative interference is a])t to ])roduce ii marked icactioii, accom|)anied bj the production of exudate which occludes the new pupil, so that repeated sul)se(|uent iridotomies or excisions <i| ilic inllamiii.itory membranes with de Wecker's scissors have to 111' resorted t<i. All these re])eated attempts should be made at cnnsidtiable intervals, and in a fair proportion of ca.ses patience will Ix' rewarded by a rea.sonable amount of success, III many cases no chance for ojx^rative interference is ever given, liic iiiflammation continuing until all sight is lost, while it some- nii's hajiiM'ns that in addition to blindness the jiain IxTomes so iiiinlciable that enucleation or evisceration of the second eye has to '■■■< performed. Tiie gloomy |)icture hitherto presented applies to the severer ciises, I id thes*', up to the present time, constitute a large nuijority of ise liescribed; but it is evident that of late more favorable reports :59.S 77/ A" EYE. .,r,> Lciiiir nTcm.l. This is iKTluips .luo loss f. in.i.rovon.ents i» m-U "S la to a .nun- wi.U.s,.n.a.l knovvl.-dp- a.ul an earluT ,uc' m o 1. disease. M..n-uv..r, it is prohahl. that nn hi h.r.ns V "it .■tic ..phthahnia an- .nuch nu.n- c-.„.nu.... than i..nn.-rly t^Z^Zd I have known it t.. .l-v.-lo,, an.l run .ts cours. .n two Inrac patients with so little .-onsestion ..r subjectiye .hsturhauc.. of mv kh. I that asthesifiht wasalrea.ly ol.scun-.l by the cataracts t he ; i,. wenAimware that any intla.nn.ation ha.l occurred. Where Iv n vSietic ophthaln.ia has occurred after enudea .on or eviscer- S le i)U s,. h;u- ahnost invariably b.-en n.il.l and ta.r or pertect ivSs a "^"n obtained. The sa.ne is true ... son.e extent o he eases which have occurre.l in conn..ction with oss.hcation of the ''"■Si''Treatment of Penetrating Wounds of the EyebaU. Where •1 Je-in "ut peni-tratiiiK wound of the eye, w.th.mt any prolapse; o irif ; mr id' 5 eons has occurred some days beh.re the patient 'on t ef te of the eye, as far as the infection is concerned, is " ; "llv l-H d behlreliLd. If the eyeball shows little or no c.m- S-io ..X ept ill the nei«hborhoo.l of the wound and no pa n « oxn HenH..l t is Renerallv safe to conclude that infection has In-en ' ; „ a i all tlKit is iinniediately required unless s<.<-oi.dary Slau- M,; i ' esent is to protect the ey.-. preferably v th s...ne lori.i of ' I K lai use su'tfii-ient atropine to keep the ins n.ni adhering e 'ns, mid keep the patient quiet. Of course, if a trauma ■ t rue is present, it may be extracte.l, if there is no increa..e n. the ;!;;." Kut if tlu>re is. it is l>etter ,.. put otT the extraction for a w rk or so treatiiig the lids with some astringent meanwhile. \\\Z' however, a fresh ,K.iietratiiig wound is seen, the treatment .Iw.ul.l b<>Lriii wherever possible, with a thorough irrigation of the : i 1 ctii s^c .n.l su/face of the gl..be with a steri^^e,l 0.5 ,K-r c solution of salt or ^onie ..th.-r sterile non-irritating solution. ¥l n a er the excision of anv l.rolapse.l iris or vitn-ous, should follow U ! pVotecti of the wound- with a conjun.tival flap: for it should ;, X'dthat nearly every conjunctival siic contains nu^r.^rro^ nt hogenic germs which .•annot be thoroughly clean-d out by .> ; Isun-s .•luMui.-al or mechanical, which it is safe to use: and w ule :;,„,e cases of infection tlie germs may be present on the offen.ling s ,bs nee before it rea,.hes the eye, th,. probability is tha in nearly i c lis the germs either are carried in from the surtace of the go . ,1,,. time of the hijnry, or they gain entrance from t he cnjunctn. I „ ft r the iiijurv has be..n inHicte.1. To prevent this latter (;<.n- ; ,; li^v t en is n.; protection ...,ual t.. that affonle.l by a conjunctival hT \V lere th<. wl.und is entirely in the sclera the b<>st plan is to !x se ingular bit of conjunctiva at one side of the wound, am lr.w .triangular flap ..ver this raw surfac- from the opposite side Uie wound bv one or more sutures. Where the wnun.l extends s rt way into the cornea the simplest plan is t.. d.ss.>c up the ;.,u u K-tiv al aroun.1 the cornea and draw it over the whole cornea S YMPA Tin: TIC OPIITIf ILMIA. 399 by !i piirsc-striiifj suture tightly tied. A more coinpiicat -d but on some accounts l)ett('r f)lan — as it allows the pliysiciaii to keep a lictler \vat<'li of the condition of tlie iris, and as permitting a better .•iction of atropine — is to exci.se a portion of tiie conjunctiva at hotli -ides of tile v.'ound, a.s inihcated in Fig. 209, a, and to (Iraw tlie loosen 1 ciinjunctiva over the.se raw surfaces and the woujid at the same time by two sutures, or, as in Fig. 209, b, by a single suture. Where the wound involves the central [)ortions of the cornea, it may be that the jmi-se-string suture will offer a sufficient protection, l)ut a more (crlain jjlan is to excise a portion of the conjunctiva all around the iipposite half of the cornea, as in Fig. 209. r, and bring a conjunctival liaj) from above clear acro.ss the cornea. It may be (|uestioned whether the use of a protecting flap is neces.sary in the case of clean- cut woimds of the cornea: imt wliere the wound is irregulai or ciiiitains iris tUsue or fragments of broken-down lens or vitreous, there can be no tloubt about its advisability. In the case of wounds Fig. -IO. b a D Thi' shiideil areas indicate the surface from which the conjuuctiva ahnuld be excised ; the dotted iincs. the outlines of the conjunctival ilaps. A. wound to be covered ; B, C, D, piiinti where luturea nrv Id be applied in drawing the flaps Into position. that are not above suspicion the edges should be touched with the ^.ilvaiiocautery or Paciuelin cautery, or, if tbese are not at hand, with a chemical caustic, such as carbolic or nitric acid, applied with I lie utmost care with a very finely drawn-out cotton swab, before ilr.iwiiig over the flap. To be logical, one should u.se the same line "t treatment for operative wounds where vitreous is lost or iris tissue 1- cauglit ill the wound. And it is certain that if the wounds had turn protected i)y a conjunctival flap many and probably all of liic cases of sympathetic ophthalmia which have been eported after ■■it.iiact extraction could have l)een prevented. The small conjunc- 'ival Hap. which is often made as the final step in the incision for :it,iract extraction is good as f:<r as it goes, but it is .seldom large ■iiniigh to cover fully the large prolap.ses which sonetinies occur !ir simple extraction, and if an iridectomy is made the points '' which the iris is most ajit to be entangled, nany.-iy, the angles of ■'• wound, are left unprotected. To make an effective Hup for "itectiiig an extraction or iridectomy wound, the conjunctiva should -lightly raised by the injection under it of a cocaine solution at 400 THE iiYE. tho point .,f pu..ctur,. and coanter-punr «ro, an 1 >«^ j^,^ '^^^^^^^^^^^^^^ s..nie (listauce out.si.U- o( tlu" fonuvi an.l pusso.l aU.ng un.loi '" \ tiv'i S<.re entoring ih" ai.tm.,r chanibi-r: tl.cn .n niakmg the Cnt^; pun tiro re should be taken t<. pass the knife along beneath tSJ > junS as far .us possible before piercing ,t In eases «^.m olapi of vitreous is expected, two sutures shoul.l be P"t " at the unue part of the conjunctival wound, and .Irawn well out of the «aj Ee e extraction is con.pleted. This, it se<Mns to me is th .^ les wav to protect con.pletely an extraction woun.l but ,t may be th'u to prepare a Hap above the cornea and bnng it .lown and hx U in tt mannir indicated in Fig. 209 a, or even to use a Purse-Jr ng suture will prove to be l)otU'r. Some such form of extraction Sugl too Complicated to lx>con>e popular at once .s eerta.n after the tedmique is mastered, to give a l^^'«e>; guarantet_ o an nnme- diate goo.l result and of safety from sympathetic ophthalm a After protecting the wound as well as possible from infection a ^Lul bandag'e (both eyes being closed ^^ ^.J, ^^ ,f i;^^^^^^ in severe injuries), rest, and atropine are all that will be requireu no LiLction has tak^n place. It may be ^l"-tioned w^t he. i is not best to applv coKl in some form during the hrst t^^ent^-toul ou s This is rLmmended by g..od authorities, but the chthcdt) of applving cold in anv etticient way, without danf?>r of di.sturbmg an nfecting the wound, is such that, on the vs^io e, I J'^l'^e ;is good nwults will be obtained without it. unless .lec.ded pain indicates that infection has taken place, in which case the continued use of ice. nreferably with a light rubber or metal coil or a small ice-bag fn- I entlv HUed with tmall bits of ice, should be employe, until the .!,„l ot"the first twenty-four hours, the eye being P'-;'t;'-te«l hy a pad of absorbent cotton which is kept wet with sublimate IM Later than this 1 prefer the use of hot applications for ha f an 1 ou to an hour three ur four times a day, where symptoms of mfection '"ln'!;irca.ses where infection is suspected or feare.l, besi.le the use „f cold or heat and rest. atropin.> should b.- use.l with extra liberal t . 10 to 15 drops of a 1 per cent, solution being inst.lle.l an.l alio ^ . 1 to run ..ut at the outer angle ..f the eye tw.) ..r three times a .la>. an. 1 rge .l..ses .,f so.lium salicylate .sh..ul.l be given. Subconjunc- al u.jections of 1 t.. :i .Irops of subHmate, 1 • 1^^), or 6 . Irops . cvani.l.- of mercurv. 1:2(KM), ..r 10 .In.ps of s.,.lium chlori.le, 2 m c-ent. mav be tri...l every secon.l or thir.l .lay. In s..me cases the. elTc't is ast..nisl.i.,gly g..o.l; in others. f''V'^ '^l'''^"'"*- 'T.orfc.'a a., .... go...l. or even .U. ham.. Where the ..nfecti.m is superhcia . i, so,... -cataract woun.ls or injuries of the c.,rnea a thorough application of the galvano or Pa.iueli.. cautery ..ft.-.. c.>ese|xcd^ servi<-e. an.l if n.-ither of these is available, scraping, followed b> api.licati..n of tincture ..f i.-.line ..r ..itric "^ ^f ^"'l"™'- .^J' ^'T ," times l)e as effectual. ' i desperate cases, where it is evident that pruleiiT rnflammation oi the' vitreous ha« started, the endocular S YMPA TIIETIC OPHTHALMIA. 401 use of 11h' puutcry has hccn reported to give good results; the tij) of tlie gulvanocautery having been phmged deeply into the vitreous as near tlie focus of infection as possil)le, and tlie current turned on whili' ihe point is moved slowly about. I have had no experience witli tiiis method of treating the vitreous, but have tried it in the anterior chamber witii a ba>; result. If it is tried in tiie vitreous, tlic wound siiould innnediately afterward be covered with a con- junctival flap. In treating prohip-ses of the iris much discrimiiuition is necessary in the use of the cautery. Kxcej)! in plainly infected cases, it is best not to use it if the iris can either be replaced or .seized with the forcei)s and cut off. Where this is not possible, as is fre- i|ueiitly the case with a prolapse of more than a day's standing, or where the prolap.se i.s apparently infected, it may be u.sed if the burnt tissue be immediately scraped away and the .spct well coveretl with a conjunctival flaj). To burn a prolapse, however, without iiiiniediately protecting the spot from .secondary infection is. I bt^lieve, (listinctiy dangerous. It is often done witli good results, but evidence is constantly accumulating to show that it has a decided iondoncy to favor the occuiTence of sym])athetic ophthalmia. Where a small prolapse is swni seven,' 1 days after the occurrence of the injuiy, and is evidently not infected, it is jierhaijs best to leave it entirely alone, unless the physician has had ex|)erieiice in the t(chni(|ue of ai)plying conjunctival tlajjs. The majority of such |ir()lai).ses subside (|uietly and are abundantly i)rotected by new- fi limed coimective tissue if the eye is kept quiet and hot applications arc used. The ideal treatment of iris jirolapse Ls to replace it. and thus restore the form of the pupil : but this .seldom is done after accidental wounds, partly because adhesions form so (juickly that unless the eye is seen MMin after tlie injury the iris cannot be replaced without t<'aring it; anil partly because when replacement is attempted in the ordinary way. the replaced iris is immediately pushed back into the wound a- the instrument used is withdrawn. A plan which gives better ivsults, es|)ecially if the wound has not reached the extreme peri|)hery uf tlie (ornea, is to make a new incision at some distance from the wound just sufficiently large to permit the introduction of a small sp.iliila, with which tlie prolajised iris can be drawn back into the anterior chamber, and as the first wound closes behind it there is little trndeiicy for it to be again exj)elled. Management of Foreign Bodit^s in the Eye. \\'here a foreign body lias entered the eye the management depends upon the presence or ilisence of infection and the nature of the foreign body. Wh(>re a piece • if iron or steel ha.s enten^d, it.s removal shoulil be attempted at once \\\\h some form of magnet. Other foreign bodies, except when ill I lie lens, nnist naturally Ix- removed with forceps or hooks, if they ic to be removed at all. Sometimes their removal is not neces.sary. i'iices of wiiud, stone, lead, copjier, and gla.vs may be tolerated in lie eye for an indefinite period if no infection has occurred at the 26 402 THE EYE. timo ..f tlu'ir cntranco. So that wl.il.', h. a recent case, if such a f..rnRn l)(„lv can .-asilv be seen an.l reached, its removal should he atten.i.tcl at once, it sh.ml.l l.e left alone if this is not the case and there are no svniDtoms of intVction nor other serious disturhunce, suice the attempt t;. remove it in the dark, even with the best localization possible by means of the x-rays, is more likely t.. do harm than good unless it be very large. The amount of toleration which the eye exiiibits towanl as.-ptic foreign bodies which have enten-d it without carrying in or Iwing followed by g.-rms from the conjunctival sac, depends primarily upon the amount of chemical reaction whicli occurs between them and the fluids of the tissues: secondarily, upon their becoming firmly fixed by fibrous exudate. ('oi)i)er, iron, zmc, and lead all are acte.l upon so as to pro.hice irritating compounds, copper inos markedly, lead least of all. Col.per is the only one which, without the aid of germs, will produce a purulent exutbte. It also has the property of producing a softening effect upon the tissues, so that^ m i.uil anumber of ca.s<.s. if left to itself, it will work its w.iy to the surface and be expoll.-d spontaneoasly. This h:us been known t.. liappen after a lapse of twenty-one years. In rare ca.ses a bit ol copper is encapsulated so completely that its chemical action appears to cease and it causes no disturbance after the hrst reaction ha.s sub- KXiWiX It is iini)ortant to remember the chemical activity ot copper in the eye, because a moderate amount of reaction, even when long continued, need not cause the same anxiety that would be natural if the inflammation were thought to be the result of infection. Ihe copper mav be merely working its way to the surface. It is not best, howeve' for the physician to assume all the reaponsihihty of advising against openition in such cases. Whenever the reaction is prolonged, there is a i)os.sibilitv of symi.athetic ophthalmia, which can only be obviated by removing the foreign boily or sacnhcmg the eye; and if it is .lecide.l t.) attempt to remove a bit of copper which has l)een in the eve for souk- time, it should be remembered that, however accurately it may have been located at the time of its entrance, it is liable to be found at some distance from this point later on. Lea.l oecurs in th.- eve chiefly or .-xclusively as the result of shot wounds. These wounds -ire p<'culiar in that in spite of iKMiig so small, unless tin- shot is going with sufficient rapidity to go clear through the globe, th<. impact of the blunt though small object is sufficient to produce so much internal disturbance in the form of heniorrhag.-s or detach- ments that the sight is lost or very seriously injure.l, even when n<. sepsis occurs, .\lthough the woun.ls produced by shot m the ..xternal tunics are so small that th- are generally left to thems<'lyes, fresh ones should. I iH'lieve. always l)e protected by a conjunctival Hap drawn far l)eyond their limits in the manner previously indicated. This having been done. I consider that any attempt to remove the >hot uiilc.s.s il can actually !k- seen with the naked eye, is a mistake If aseptic, as lh.>v usually are, shot will generally become encapsulate. I •uid cause n.: su"bs.M,u.-Mt irritation. These injuries generally cans.' ^ff*f-"^Bf-"*i^^ SYMPA TIIETW OPHTHALMIA. 403 s(i iiiucli tissue (listurlmncp that the congestion is apt to be prolonged, even wliere tliere is no sepsl.s, and if, some days after the injury, the anterior chamber fills up with blood from the vitreous, it is well to IM'rform a paracentesis, even repeatedly, to help clear up the vitreous. Siiots that go clear through the ball into the orbit need no aUenticm, tliDUgh they sometimes cause complete blindness by injuring the optic nerve, either directly or by the pressure from the hemorrhage which they cause. But even where the sight is inuuediately and completely lost after .such an injury, an absolutely bad prognosis -liipiild not Ix' given at once, because at least one such case is on iccord where the sight returned, j)robabIy because the blindnest- was due to pressure from lieniorrhage rather than from direct injury to the nerve. The diagnosis of shot in the eye should not be made too ha.stily. ( t( casionally a shot strike.s the eye obliquely, causing a hemorrhage :it the margin of the cornea and a rupture of the iris with hemorrhage ill the anterior chamber without any penetration, although at Hrst glance the physician is inclined to believe that the shot must be in tliecye. ( >tlier metals, except iron or steel, which will be discussed later on, (iccur so rarely in the eye that they hardly need to be considered. Small pieces of wood, glass, .stone, and other indifferent .substances :irc often retained indefinitely without disturbance, if they remain inminval>le: but if frot^, they oft<>n cau.se a mechanical irritation uliicli necessitates an attempt to remove them. In deciding upon ■■iich an operation tlio iaiiger of mistaking, for the foreign body, a bit nt exudate on the iris or lens -should be kept in mind. Such a mistake i- sometimes impossible to avoid, and it is probably often fnade. A small foreign body in the lens without infection is best left alone until the lens is opa(|ue, when it will generally come out with the latter, especially if a broad incision and an iridectomy are made. Ilvelashes are not infrequently carried into the anterior chamber "V vitreous; they of'':i cause no disturbance; but in the anterior ' liainlier they apparently sometimes form the starting point for cysts. Mild ill other cases the germs which commonly adhere to their roots nay cause the loss of the eye. The Management of Bits of Iron or Steel in the Eye. The manage- •iHiit of bits of iron or steel in the eye deserves to be considered ' |iaiat<'ly. both on account of their behavior in the eye and from the 't that, unlike all other foreign Ixxlies, a large proportion of them ■ ill l>c removed withoui their being visibit beforehand. Although a ■ ir proportion of them, if aseptic, become encai)sulate(l with so little ' "tion tiiMt the inifiression is given that no further harm will be '!(■ by their presence, .sooner or later they almost invariably "line (l('(iiiii])osed. and the .soluble compounds thus formed are v!!iijiaii'd through the eye. producing the cr,n<lition known an "■'i.v/.v, which shows itself externally by a brawn discoloration of iris, I'yes in which this decomposition has gone on for any 404 TUE EYE. IcnRtli of tiiiio iiliimst alw:iys, tliroiigli disorgiuiization of the vitreous iiiul (Iftacliiucnt of thf riMiiia, los(> any siglit tliat may liavc Ix'cn left, and rnMiuciitlv Ixtoihi- so irrital)lo tliat they liavc to lie sacriticcd, both for the .-Mkc of comfort and to avoid the danger of syinpatlictic oplitlialinia. A.-< an example of the danger of allowing apparently innocent hit-s of steel to remain unmolested, the following history may l«' useful. A young man was brought to me shortly after a bit of .steel, not largertlian half the head of a pin. had i)enetrated his cornea, iris, lens, and reMna, and remained so Hrmly fixed in the choroid and sclera that U.v giant magnet did not move it. As the opacity first i)iesent in the h-ns cleared up almost entirely and the vision'became nearlv normal, the eye In-ing e? tirely free from irrita- tion, it was thought best not (o interfere with it. This condition remained unchanged for .several montlis, when thi" sight iM'ga.i to diminish and the eve became irritable. He did not return, however, for nearlv a vear. and when he did the sight was entirely gone anil the eye was "so troublesome that it was removed. As illustrating what'nmv l)e accomplished in a similar case by bolder methods, there is one case on record in which the operator with the aid of the ophthahiiosco|)e loosened the bit of steel with a discission needle passed through the sclera, and then with the giant magnet drew it into the anterior chamber, whence it was easily removed. Where the piece of metal is very small it sometimes U'comes entirely disintegrated before the sight is wholly destroyed, and in this (■ vent the siderosis sometimes clears up, and useful sight is retained without aiiv oju'ration to remove the metal. in the management (. these cases the physician .shouUl have at least one electro-magnet, for while a certain number of bits of steel can be removed f' mi the anterior chamber, the iris, lens, or even the vitreous, withou' magnet, the attempt to do this will not infre- (lueiitly fail, an., laiiy an eye which might otherwise be saved will be lost' if no elficimt inagnet is at hand. If a man can have but one magnet, jxThaps the most generally available form is the small .>ne of ilirschberg or Sweet: each has several interchangeable points, of which the larger and !)luiiter ones should be tried if there is any probabilitv of the mct.il being near the surface, while the sinalU'i' ones can be passed into the anterior chamber or deep into the vitre- ous. , , • , -1 This can be oirrated ,.ith various kinds of galvanic batteries, hut it is much more satisfactory to have it connected with some power current, and if this is to be done, the voltage of the cunvnt to 1"' used should be mentioned in ordering the magnet. Hut to do tlw most satisfactory work in this line, it is necessary to have, in addition, a giant magnet or Haab magnet, a sideroscope, and access to an x-ray ap|)aratus. ( Fig. 210.) The Haab magnet may either be mounted oii a stand or suspended from the ceiling, and while it can be o{iiTatf.! with storage or other batteries, the connection with a power curreiii is much more desirable. Some apparatus for turning on the current SYMPATHETIC OPHTHALMIA. 405 (rnuliially is an advantage, but much the same effect can he pro- iliiced l)y gradually bringing the eye toward tlic niagn«'t. Tiic si(ienise()|M' of .\.snius consists essentially of a magnetic needle suspended by a fibre of silk. By attaching a mirror to tliis and view- ing tlinmgli a telescojH' the image of a light reflected from it upon a scilc at some tlistance, extn-mely delicate results can be obtained in detecting and locating bits of steel or iron within the eye; but as I lie instrument lequires a special room, at some distance from any FlO. 210. Iliiab'8 mognet . lley wires, it will ])robably be used chiefly in eye hospitals. Ilir.sch- ■v'l iiMs liMil M less complicatecl form of the sideroscope made which ly edtne into more general use. I'lie \ise (if the .r-rays in discovering and locating foreign bodies eve is, of course, not confined to bits of iron or steel. Their \\<f fj in determining whether or not any foreign IkkI}- is present. I lie body is large, it can frequently be .seen with the fluoroscojx', in 'li 'li ease a fair iilea of its location can sometimes be had by having Ilie ;..r 40(i THE EYE. the patient i.u.vc his <>vr in diflVrnit direct i..i.H .luring the obwrva- lion! the .sluuL.w iu..viiig with liie e.,ruea, if the foieigii btxly W lu Kio. :iJ. Uirschbcrg"* dlderoKop*. PlO. 212. S-.vt.vts avparstus f'>r liwallzliig foreign txxllcs in the eye. the anterior half of th" ^IoIk-: against it, if it is in tl'^x^f ^^^ l>;;'; Much n>ore !:,-euratc woriv may he Aon. l.y th.- method of S?«'-t. W .S VMPA TllEllV OI'lITllALMlA. 407 wliiili, in hru'f, cdiisists in taking fuo or nmn- radioisraphs with the tiilw in (litTcrcnt iiositioiis, the [il.itcs hcinn held in fxactly the sinie |Misitii>n l)y a wix-cial arranKcincm uliich ai .I>c sanir time lioiils two riictai iM)inls apainst the lids at a definite di.-<Iance from the platp. liy (•(pni|(ariiijj tiie |ii.^itiiins (if the shadows of tiiese points and of the loreijrn hody on the radiograph, and ean'fully plolfinj; the jiaths whieh the j--rays must take from fiie tulM- to the plate through a circle representing the position of the eyehaii, the location of tlie tnieigii |)ody rail he deterinineil with considerahie aceuraey i)y tho point at which the paths of the rays through it intersect within this circle. If Sweet's apparatus is not at hand, fair results can he obtained hy fastening three shot with collo<|ion and cotton on the outside of Kio. 2l:l. Kadiiigraph showing piece of iteel In the eye. iBweet ) i!ic closed lids, aixive, opposite, and below tho cornea. It is al.so M II lo do this before fluoroscopic examinations. Af an example • ■I liie advantage of having dilTereiit methods of diagnosis at one's M-l«>sal. a recently reported ca.se may Ik- cited in which, after an ury, a piece of .st<'el in the eye was su.spected, and where the sidero- -'■\»- plainly indicated the existence of such a fragment: the giant i;rnet, however, produced no effect ujion it, and tin- .r-rays showed ■ presence of a rather large foreign bo<|y in the ti.ssues under the L'c of the (irbit. The patient tlien remembered that he had been Mck in this locality with a piece of steel a long time before. \>Miiiiiiig ihrn that the jihy.sirian has all the desirable instrument.'; till' locating and extracting of bits of iron and steel in the eye, it lid be realized, in deciding what ca.^es it is worth while to use 4m ruK I /•.■ If || tlii-ni 111., tliat rniuiy jwtifiiis lul^' f, .n ijiii hoiji-s in tli esc withcitt kiii'wiii^ it Nlitiiy ciiscs ii' otht'i wiw uin xplaiitfil oik ilcd catant- m '.ouiij; [i-oi'lc arc Itn- to m rwcivol or lnii);-f(ii-};i ilcii 'ujuri-- \\] h si-iiictiii.'s \m\v iin-iii'li'il uif futraiicf of li'icijrii hodii- TJw f\, iici if -ulfTosj!>i will, ot criursc, always .siijyifsl ic pn'siiirc of in.ii or s'li! Ill whi < tlii-n- is ri" history of an ii ry. In many fri-slr niH's 'J • :istoi i "ill' t!ic oaticii! fn'<ni«'ntly • cm- <li''Ttly t.i icintraii- ill, tc fit •■i aw<- of a forcifrn iMuly into ic ex ■ Tin- |ialiint wiil. "iily .-loail "r uii iii nro^i :zal)lt> wniiiul or sv ir Uv\» sure that iir iihjsi hav( Uf.i strui-k by a 1 rvs' pit ro of metal, iK-caust- stales I" siti\ 'ly that li<' ;•, am yet lit' 'imnatioh till stil>siii ii his 'irs :'l t Im- ])l;i i-a ujif I'll st; it'HH'iiLs, a *!vini.i itctai . -<M\\ iii^-iwiT I csii •THiaufii 111 iiifial ■ stoii rJunL' m lx> susfi ♦eil ami ■ .«•»' .ivpv Uf.i strui-k by a the 'liow ah lost kiKH'l d I mi duuii, or li<'-u(l the |.n <■' diMpa't'r --rikiiin the .> i\v tliat 111. \vi .,iil -lioiihl in all cases of iiijui v from s ill the iiioNimily . i^n hody in ilie <'y( Mien mild leh roil; 'le •lit-: aftt I light at: 1 "his i- >ome the-e \y. by 1 5>iiqi S! ■i\-H . 1 Will -oiHC lilies ^ deniiv -■ 11 Miiil if a ' 't ^- Mist ; : : 1)1 it tt«- [I. iiei gi.i'H mag ict. nearly as possi Uicn irnidu r.nl III' a illo is (Icsi- hie when e.\; ij; -. t' hr I should 1m; e\.. >i. id K'si villi the opii' liiio- the fiehl of isioii .reign Uiidy is <'vi- lea or close to it, or pus- "ill. at til ..I a p • il ]>aiii when ' hange.- iito the .ther .x\ I'll •lul ti Uir suspecti :hrou8;h the ci - evidently foriimig, no time ini'd he with the use of the j-niv,s or the sidi" seoiw: r cociiiiiizatioii, should lie placed ipjic e th<- !• irectioi! of the wound canal correspi" ic i.s ' with the long axis of the magnet. '-ntit luna'd on or the patieii" - head is gnu! irht let, the eye being kepi brightly illi id •ved meanwhile. The first sign of tti^ -e I V fieijuently tiien be given by tin '■■ iris V iii'gin to bulge in some part of its ;k inn of :ie eye to the axis of the m.igni't shi to I'avii drawing the piece of niet;il through tin- juipi! ■rior chamber rather than directly through the iris root. I's the first sign is the su'lden appearance of the frag- posterior surface of the come!!, whence, as tli(> current 1 tri.n: vvitl sniu. Sleril? into iriied off. it generally tails to the bottom of tlii' anterior chamber. wliicli I can easilv be remove' ;! rough a jieripheral incision he sn iiaui" II magnet, or, in some (.i ■.-, with the huge one. The and the necessary instruments should previously be '! kept ready ;it hand.) If the steel cannot be drawn lior clianiber, nor through the root of the iris, it may III. 11, V to excise a piece of the latter, in order to complett the extrai-i ii:n. Where there is a fresh .scleral wound, or where then is a cliaiic of jireserving the lens clear, it is best to attemiit tjio extraction A t'MJ'A ruaw (ifUTU.iLHIA Am tlimiipli !ln' rf' |«'n(il \mhiimI, vUiicli slmuld 1 M- <'ih irRcd at «iii. mil If iiK'i-ion at lijjlit aiijflcs to i(t* iimin (liri-ctii>ri. Ii 1 sonic Midi asos til' >ii'c| .xluHits (lilt tliroiifrli the wouiul tn the JarKc iiiajjin i liiliiiv tin- laucr tiiuciif.-i the cyi": in hIIhts tlif st-lcra in tlir ni'ijjji- liiiMwl of the wniuiil may Im- sccti to lnilni', but llic cMract iiini >l«'t('i Ion cannot wiiliniil introducing the tip of liic Miiall nia^iict for a lort (li-?ancc In all ca.-^s wli<'n> the extraction is attempted IhrouKh -cleral \souii ii.'sfivaterdaiipTof iiiteetion should l.e kept in mind, precautions tin wound should Iw thorou);hl\ lid h'side tl • lolccitu l)\ rdiliai onjuiiciiv ■r al flap. U here, in using either the large iiiall magiii a gradual approach to the eye or to the su.H|)ected ..e.'itioii .f the loreig'i ImmIv tails to remove it, th tun ott and nil quickly several times, ddi'ii jerks thus prmluced may loosen it. e current .should in the hope that the Where the hit ol metal is •rohahly large— /. c, if the external v\nuiid is t!iiee-sixte<'nf'i- <.f ::,, inch long— it is |HThaps h-st not t< iiM' til. la I k'e magnet at hrst, Miice the foreihle tearing out of such a lr;t>:iiieiit lia> in some ca.ses caa-d the 1ok.s of an eye which might other- have Ih-cii saved. In thcM' eases and in others where tl !ii;igii« !, pr(Kluce> no result, the metal should he located ; }Mi~.>il)h', and if il is .supjxised to lie ;is ace in W\ arge urately ill!--, t Vitreous an angular coii- ival Hap should he dissected up. using the wound for part of it if tiu- is siiil.ihh located, and one of thchluiit tips of the small inagiu't itnidueed m short way iH-fween its iijKs. If several clo.sures of th( cir- ■ nil |indiiee iio result, a longer tip should Ik- introduced as near i .issihle fc. the supposed iocation of the metal: and if thisattempt fail, Mir lip -hoiild he moved -lightly in ditTeii'iit directions, and the •I' ng .iiid clo.sing fried ag;iin hefore it is withdrawn. Often a I'll' laiiseil liy the metal coming into contact with the magnet is II- 1 nil clnsiiig the .-ireuif. If it is decided to move the point to '!! ' iitirely different part of the vitreous, it is best to withdraw it iMss it in straight to the desired point, in order to avoid as If three or four pnssiiile disorganizatinii of the vitreo III finiluctinii>^ fail to bring forth the metal, it is best to desist, and, iNr cnvenng the wound with tl le conjunctiva, wait for further i''Vi|,,pm, Ills. Sninetimes a bit of steel that eludes the first attempt ■ lie heller located .'n I removed .-ifter the clearing up or extraction •I .'111 u ,tn t p.'ii|ue lens. Ill other ca.ses the signs of infection become lent that evisceration is called for. lien- a piece nf steel i- known t!i be in the opaipie lens, it may niestiniii'd wii'ther it is better to extract the latter fir.sf, with the I'latioii ihal ihe steel will come out with it, or to draw the metal lie anterior chamber with the magnet, and remove it before ex- iiiil till Th ■euvre lias al t.il in which I have "ling liie lens ri. -iicceeded in the -eason m were ( certaiiilv m xpellr 410 rut: K YE. Evisceration, Enucleation, and Opticociliary Neurectomy. These arc the (iperatidiis most edimnoiily eiii])loye(l as prophyhictics and to some extent as treatment for symimthetic ophthahnia. KviscKUATiox or I'xKNTKKATioN, as orifiinallv deseribed, consists in (hsseetiiifi Itack tiie eo?ijnnetiva for a sliort distance all around tlie cornea, making a small incision through the sclera about one-eijihth of an inc'.i outside of the former; then, with blunt-pointed scissors, which shoulii be kept between the sclera and chomid, comi)ieting the excision of the cornea, including a narrow riuf; of sclera; then, with a narrow blui ' patula loosenin>j the coimections between tlie sclera and the choroid, :lien, with a broad, flat, sliarp-ed^ed si)oon severinj; the connections Ix'tween the choroid and the optic nerve, and by pushing with the spoon from behind and pulling with a forcejjs from in front, removing in one piece choroid, retina, vitreou.s, lens, iris, and cornea. Any bits of choroid or retina which may have escaped this jjrocess are then scraped out, and, after irrigating th(> cavity, the conjunctiva is drawn together over the oiK'uing with a purse-string suture. (Fig. 214.) For obtaining pathological specimens this method is no. 214. FlO. 215. Fm. 214. Fill. ■Jl.'i. -Slump after evisceration. (DE Weckib.) -Mule«' vitreous sphere*. undoubtedlv the best, but it is followetl often by ([uite an extreme reaction with long-continued pain. For the comfort of the patient strictly simple exisceration — ('. c, without excising the cornea— is much "suiierior. This is done by i: akhig an incision clear across the cornea, extending for a short distance into the sclera on either .side, utilizing any extensive corneal wound which may Ix' present. Through this the entire contents of the globe are scraped out with an evis- ceration spoon, especial attention tn'ing paid to the ciliary region and to the posterior part of the cavity, where, otherwise, fragments of choroid or retina are apt to be retained. The cavity is then tilled witli peroxiile of 'ivdrogen, and after this has mo.stly boiled out the size of the cavity is reduced by ])usliing in the front of the globe about half-wav toward the posterior wall; iodoform ()r .somethint; similar is dust('d freely onto the surface, some of it entering the cavity ; a bit of gauze is j.re.ssed against the semicollapsed ball, the lids allowed to cio,se ()v;t it, antl a firm bandage applied. The gau.'.e .should tw removetl on the second day, when, if there has Im-cu no pain, the first dressing sliould be made, anil, if any considerable pain occurs. 6' YMJ'A TUKTW OI'IITIIA LMIA . 411 luit iipijlicatioiis for lialf an liour from one to throe tinics a day. (•(iiitiiiucil for three or four <hiys, will control it. The reaction fol- lowiii}^ this oiieration is comparatively slif^ht, and the cosmetic result is much better than where the cornea is excised. Where, as is the case with most subjects under forty years of age, the (juestion of the after-ajipearance is of much nnportance, Mules' operation or some modification of it should be employed. The essence of this operation consists in adding to the evisceration the introduction of a filass ball into the scleral cavity. As originally performed, the (•ornea with a trianjile of sclera at either side of it is excised by two curved incisions, the contents of the glolK- scooped out, a hollow glass ball introduced (Fig. 215 and 216), preferably with the aid of Fl(i. 216. Introducer for Mules' sphere*. Mules' injector, the elliptical o|)ening closed by catgut sutures, and over this the conjunctiva is brought together by silk sutures, so aitanged that the line of union is at right angles to the scleral wound. Tiiis, on the average, gives an even Ix'tter stump for an artificial eye liiaii the simi)le evi.sccration. Its main drawback is that as the cavity contracts the .sclera is sometimes so tightly stret^-hed over tiie enclosed ball, Ix'fore union of the wound is complete, that tiic latter reopens and the ball is extruded, somethnes months after ihc ojM'ralion. Something may be done to lessen the danger of this l>\ uniting the scleral wound with a contirmous silk sutun' and .Iniwing the conjvmctiva from above down at least three-sixteenths "i an inch below the scleral wound, where it is anchored by stitches p:i>siiig through the episcleral tissue. More time is given for a firm union of the wound if. instead of • M-ising the cornea, the latter is left intact, and after dissecting up ihe conjunctiva around and for some distance back of it, the contents nl the globe are removed through an angular .scleral incision, one arm ■ 4 \\\\\c\\ should be al)out three-(|uarters of an inch long, ruiming I lack along the border of the sujierior rectus muscle, the other from "iii-<|uarter to one-half inch long, parallel to the border of the '■.iinca. three-sixteenths of an inch back of it. This W( und sluaild iir held widely open with hooks while the evisceration is being com- I'lrtrd, and sjiould be closed with a single silk suture at the angle, lie conjunctiva being then drawn over the cornea by a purse-string iiture. It is more ditlicult to evisc(Tate the eye thoroughly through nil an incision, but it gives a better stump, and if the glas,s ball i.ouM ever be extruded from the scleral cavity after it, which I i\ »■ never known to happen, it would .still lie beneath the ccnjunotiva, 412 rilK EYE. ;;;ri.S ilt h.^Si i -usi.!; ..., inu.rf..n.nce .hi. vv.arujg 1 t, i, s.-leeting a ball for this ..lu-ratiun, ..no of m.t inon- uS; i;;?;>f u!; ail^u.,.? ..f tlu. ..y.. .h.,uUl b.. tak..... a,ul .f the cornoa - .•x..iso.i a still ..n.^.. j;;;;;;-::;;;';:;;'^,, ., ,,„„,, ,..ui plating; FlO. 217. Laer'B eye speculum. Fio. 21S. Fox'B fixation foroeps. Fio. 219. IriB Bclasors. U,. l.ttor IS intr.Hlu.....l proporly. an.l son,. ..f thnu an- .listinctly "' Kvrn K UH.N .,.• <l...lling tl... .-v.-ball out of its capsulo is ,M^rfonue.l SYMPATHETIC OPHTHALMIA. 413 disc, or if syinpathetir ophthalmia is present, and dotachiiig the olili(|iit' muscles as tlie hall is drawn forward. A pa<l of wet gauze or cotton is then pressed against the lids, to check the bleedii ^. iodoform is dusted in freely, and the eyelids closed with mthe i tight bandage, plenty of cotton being ased beneath it. Many op. atois close the conjunctival wound with a stitch or two, but I have never found this necessary nor advantageous. In cutting the rectus- icndoi.s, sufHcient of the external one should Ix' left attached to the glolx- to afford a point of attachment for fixation forceps. Where the oiieration has been preceded by long-continued or s<'vere infiani- niatioii, Tenon's sjiace is sometimes so nearly obliterated that the globe has to be di.ssected out slowly, great care being necessary to Mvoid ])erforating it. To obtain the Iw^t i)ossible stump after enucleation, each of the rictus nniscles should Iw secured by a catgut suture as the tendon is divided, and, after introducing a gUi.ss ball into the cavity left by Fia. 220. KnucleattoD Missors. Fig. 221. Strabismus book. tlic globe, the nuiscle.'; shoild Ix* united in jiairs over its surface, tlii' conjunctiva Ix'ing brougiit together over them and united to iliciii by silk sutures. Enclosing the ball in a thin layer of sterilised -| Hinge probably favors its ntention. I have had no "xperience with iliis operation, and it is too .«oon to .'-ay how well the glass ball is nt:iincd and tolerated after it. If retained, it . -tainly will give a iiiudi better result than can Iw obtained without it. Kven where an ye lias iMH'n enucleated for some time, the attempt to introduce a u'l iss ball into the orbital tis.sues is justifiable, and has given, it is ■ lainied, excellent results. n'TKdcii.iAHY Nki'KECtomy. This operation, vdiich practically has - |i"rse(lcd the previously |)roposed neuro+omy or simple division of III' iHTvcs, consists in making a three-quartets inch vertical incision iniMigli the conjunctiva, over the insertion of ihe external rectus. 'iviiiing the tendon of the latter so as lo leave a stump one- ■ Mil nth of an inch long attached to the sclera, securing .he 414 Tllh: EYE. l,mp ciul wit'p. a suture which is .h:i\vn well to one sulo, passing siio'ifi eurved scissors aloiisi the nl<'!)e until the optic lUM've is reached and plahilv felt, which can i)e facilitated i)y drawni); tlie eyebiill forward as far as possible: then dividiiifi the optic ni-rve as far hack as possible, rotatinR the posterior end of the jilobe forward until it can be seen, cutting off the optic nerve stump one-sixteeiith of an inch back of the gVAn\ clearing the posterior poh' of the latter by curvetl scissors of all connective tissue and possible ciliary nerve attachments, replacing the globe, uniting the ends of the rectus tendon with two hue silk sutures, and closing the conjunctival wound. Immediatelv after cutting the optic nerve the lids should be closed and hrin pressure made upon them with a cotton pad for at Iciust three mhuite.s: unless this is done, the bleeduig hito the orbital tissue is such that the ball sometimes cannot be replaced. Kor the same reason it is important to complete the operation as rapidly as pos- sible and hold the lids clos.-d with a Hrm bandage. It is sometimes necessary to sew the lids together temporarily, in order to protect the cornea. In spite of these precautions it may become necessary to enucleate the globe, and the possibility of this shoukl always be insistetl upon to the patient before doing the operation. Choice Between These Operations; Their Dangers and Advantages. Death from meningitis has been known to follow each of these operations. Kvisci-ratioii was first systematically employed to avoid the ilanger of death after enucleation during panophthalmitis, and, altlu)ugh tleath has U-en known to follow it also, it j robably is less dangerous tlian either of the others, since there is less chance in doing it of infecting the orbital tissu(>s. The danger is slight in anv event, but its possibilitv should be kept in mind and the strictest precautions to avoid it observed. Whether any operation beyoiul freely incising the globe should be ihme in florid j)anophthalmitis is a moot pohit: but, on the whoh", a simple evisceration, followed by the free use of peroxide of hvdrogen in the cavity, is the most rational procedure, though it niu.st be admitted that where the intlanuiiation has been especiallv violent or long continued the sclera itseil is occa- sionally so thon.ughly ii-.f>'cted that it becomes necessary to excise it later on. , • • i, • Enucleation is the ojjeration preferred by most authorities, it i> :i necessity in cas<'s of intra-ocular tumors of the eye aiul m some '.■i..;.'s of malignant .lis(>ase of the exterior of the globe, or of the con- iimctiva or orbhal tissues. It should always be preferred m the tn'atiiK'nt of an actiiallv broken-out .sympathetic oi)hthalmia. Ihe nnin advantages in otlier ca.ses are tiie slight reaction which gen- eraliv follows it and its greater simplichy as compared with Mules oi>eration or opticociliarv neurectomy. The dangers connected witli it are first, that of enucleating the wrong eye. It would seem iihuosl incredible that this muKl ever hai']M>n wn- it not that H has actuallv occurred. A good ey^' has b.>en enucleated and a bim.l one left, this danger is not i)cculiar to enucleation, for, while it C; iSaSBH "«M9fWn^«lli!" a YMI'A TIIETIC Ol'IirUA I.MIA. 41 -• liiis not hccii known to omir with cither of the other o|}orations, iImtc is n;) reason why it might not occur with thcni also. In sonic clinics it is customary to guard against tiiis possibility by marking \itli pencil or ink the l)row on the side to be operated upon. Death iriiiii hemorrhage has been known to occur after enucleation, also iirliital cellulitis and orbital abscess, but these accidents are of the iiuiiost rarity. Evisceration is, in my opinion, the operation of choice as a prophy- laitic for sympathetic ophthalmia, although the weight of authority is in favor of enucleation. Where the sinii)le evisceration is done, it i> easier, .sa."er, and much more likely to give a gooil stump than ( Mudeation, and the reaction following it, if hot ajjplications, or, as Minie i)rcfer, ice, are employed for a few days, is little, if any, greater. The same advantages, excej)! that of simjjlicity, with the additional (iiic of giving a better stump, pertain to Mules' operation, and the iMct that the eyeball does not have to be entirely removed induces >onie peoj)le to permit evisceration where enucleation would l)e ntused. The objections conmionly urged against it are the great icMclion, which, as has been said, can be jiractically done away with if I lie simple ojjeration is done, and the greater danger of sympathetic nplithalmia after it. an objection which, in my opinion, rests upon I'litirely insufficient ground. Another pos,sible objection is that a Miiall choroidal .sarcoma whose existence was unsuspected might be <'\ iscerated without being noticed, although retrobulbar mctasta.ses were already in progress. I know of one such case, and only one, wliire a subse(|uent evisceration of the stump showed a retrobulbar ^:iic(piiia In the rare cases where there is the slightest (|uestion of iiiytliiiig of the kind this cfn generally be guarded against by careful iiis]icction of the contents of the globe and the inner surfaces of the -ilcra. .\n infectious necrosis of the inner layers of the sclera hits liiiii iiientioiied as a possible complication of severe or long-continued I'.iMiipiitlialmitis, which .should contraiiidicate the use of the glass ball 'Alicfe the eye is eviscerated under these conditions. ' ipticociliary neurectomy is highly reconuiiended by a few opera- ' lis; but since it leaves the choroiclal ti.ssues intact as a breeding- .'I'liiiid for germs, which, it has been shown, can pass freely out of the ••\a\v nerve stump, it jjrobably is the least efficient of any prophy- iiiic iiperatioii for synijiathetic ophthalmia. It shouhl l)e recom- iiiidcdas a prn|)hylactic only where one of the other o|)erations is ■■ tiisi'd, or when>. in the mind of the operator, the risk of .symjiathetic I'liilialmia is so slight that lie feels warranted in a.s,suming part of the -liiiisibility for it. In ca.ses of absolute and [lainful glaucoma it "Iteii efliciciit, though not so certain in its results as evisceration. advantages are, that it will sometimes be consented to where i ' I- operations are refu.sed, and that, although the eye thus saved -. Iddiii as good-looking iis an artificial eye, it is less troublesome, i ill i-hildri'ii it permits normal development of the orbit aiui pi'ial region. The evisceration can be performed later on in life 41U THE EYE. if it is (U>siml for cosiiiPtip i)uriK.scs. The operation is inoro dithcult and prol)al)ly n. on- dangerous tlianoither evisceration or enucleation. Artificial Eyes. An artificial siiell may l)e nis.'rted either into tlie cavitv left l)v enucleation or ov.-r the stuni|. ohiained by an evis- ceration ;.r one of its inoditications. This shouUl not l)e ( on.; m any event until tlie wound is entin-ly heale.l, wh^h is usually in froin ten .lavs to thr.-e we.-ks after the operati.)n. The use ..f an artihcial cv.> shoul.l ahvavs h- a.lvise.1, f..r. in a.l.lition to its csmetic value, it" pn-vents th.- irritati..n ..f the conjunctiva which results wh.-n the lower lid lM'coin.-s inverteil. To insert an artificial ey.'. tl- J lid sh.)uld be .Irawn f.)rward an.l th«' larger end of tlu' slie. ■!) shoul.l Ik' nioistene.1. sliiiiM-.l vertically under it. Fhe l..wer h. . then lM> depr,-s.se.l. an.l the sh.>ll sU.wly rotate.l int.. its hoiy. .. tal nosition Th.' shell is removed by slii)ping a small hook under t ..• low.T e.lK.', an.l th.-n making gentU- traction upon the lower lul downwar.1 an.l while the shell is .Irawn f..rward. The •' ref..rm eye has broad, smooth edges an.l is better adapted to some stumps. \s the enamel covering the eye soon U.ses its p..lLsh, great care should l)e taken to preserve it as long as possible. For this piu-pose, Fni. £0. Artiflclal human eyes. as well as f..r the opportunity offere.1 to flush the socket with some n.il.l antiseptic l..ti..n, the eve should always Im> remove.l .luring s.eeii. a,„l, after careful wa.shing, tlu.r.mghly .Iri.-.l. If. as s..m<.times hap- pens, the li.ls a.lh.-reto the shell, a little vaseline may '«. lutroduc.Ml int.> the s.)ck.-t : but if the onjunctiva Ix-wmes rough.-n.-d an.l catar- rhal it luav be neccssarv to discontinue wearing the (\ve f.)r a tune, until the m'ucms membrane has received proper treatment. As a rule, an artificial eye re.piin's repolislung after eight.'.'ii months of coiitinu.ms use. . . It sometimes haDpons that an artificial eye cannot b.- r.;tam.Ml on acc.unt ..f a deformitv in the c.)nt..ur .)f the s.)cket. llus liap- ,„.,.s after burns an.l l..ng-stan.ling diseiises ..f the conjunctiva whi.'l. ;,censi..n cicatrices, an.l lu.t rarely aft.-r the use of ill-htting ..r ba.ll> p.,lishe.l artificial ey.-s. Vn.ler such circumstances an operation is iec.-s.sarv'. One of the best of these is the proceilure of Harlan Transi)lantati..n into the orbit, after excision ..f the cicatrices nt Thiersch grafts or mucous membrane from the lips or vagma. H:'^ also been tried with success. . de aohwelnlii and R«n<liill. Amertcn Textbook of Dleua of the Eye. p. W. «Er»» ^ CHAPTER IX DISEASES OF THE RETINA, OPTIC NERVE, AND ITS CEREBRAL ORIGIN. By T. holmes SPICKR, F.R.CS. THE RETINA. TnK living rotina is a transparent membrane of a slightly purple color, poiitaining the expanded termination of the optic nene. It is in contact with the choroid on its outer surface, and with the hyaloid membrane of the vitreous within. It extends forward a» far as the ora serrata, where it ends in a wavy edge near the base of tlic ciliary processes. Beyond the ora serrata it is continued in a riidiiiientary form over the ciliary processes (pars ciliaris retina') and ilir hack of the iris to the edge of the pupil (pars iridica retina-). Tlic ])arts <if the retina which ciin l)e identified are the optic disk or p,i|iilla,atwliich the retina starts, and the yellow .spot or macula lutea, a horizontal yellow oval patch at about two and one-half optic disk liiaiiu'tei-s outside the disk. At the centre of the macula is the fovea n iitralis, a .small i)it or (lepres.sion, where all the layers of the retina, I \((|)t that of the rods and cones, are absent; cones are present only ill the fovea. The rods become numerous, and the cones decrease ill iiuiiiber as they recede from the yellow spot. Till fibres of the optic nerve within the eye, consisting of axis cvrmil IS only, radiate in all directions from the disk and form the inncriiiost or nerve-fibre layer of the retina. The retina, in sec- ii HIS made perpendicularly to its surface, is found to contain the fallowing layers' I. Xcrve-tibre layer. ■J. (ianglionic cell layer. :'«. Inner molccul.ir layer. 1. Inner imclenr layer. ."). Outer molcular layer. fi. Outer nuclear layer. 7. Rods and cones. '^. Hexagonal pigment cells. Tlicre are al.so an inner and an outer limiting membrane, the latter ■ iiit: between the outer nuclear and the ro(l and cone layer. ^|o«t of the fibres of the nerve layer end in the cells of the ganglionic (T but a few are continued into the inner molecular and inner rlcar layers. The molecular and nuclear layers of the retina con- 27 (417) 418 Adjtoent to the choroid. Tin: t:YE. Fi(i. .-a. AilJHiiMil 111 llie vitreous. . ^ . . ' Stlifiiic of the ntniotiirf "f the hiinmii reilo'i. t llnri/..MlHl sfctlon. li!em.it..xyliii stnin. I I-itjinent cpithelUl Uyer. II. Ijiyer of ix.ls aii.l com« <i KMinml; I-. ImcriiiiUlemints, III. ExlernalUmlllnK mumbrnne. IV. Kxtornal mole< u- inrluycr: f. Fibre l.iyer. V. Ksteriwl gramiliir Uyer. VI. Inlernal moloculur layer; ./. "P""!--'"- blii^s;- SiiHiortinR lihn-^ol MiUUt; / Nuclei of the same VII Internal Kraiinlar layer. \I1I Uver'i.r i!iii!?H"n eell« IX Nerve liiire luver. X. Internal lliuitlng membrane. ii Denion-^tiali..,, ..II. i li.e m,tl.,«l ..f (Jolgi. I. Pigment epilhelial layer. II. Layer of t,Kis an.l cones III Molecular a.i.l vi~u.il eelis. IV. External i.lexlf.irm layer. V. Layer of h(,ri/.Mital relU VI Lav.T of bipolar cells. VII. Layer of amacrine cell.. VIII. Internal plcxiform lay.r (lil.re layersi. 'iX, I^iver of ganglion cells. X. Nerve-libre I»ver : 1. Diffuse amacrine .-ells; -•. im- f.ise aanglioM cells ; :i, (Vulrifugal nerve ilbres ; 4 A>.MHiatl..n.araacrlne cells ; C. Neupiglla cell, . I. Sii'.porting tibres of Mailer. ::;ist of nerve cells or of their jiroeesses. The rods and cones :iiv iiniiedded !it their outer ends in the retinal pigment, a layer of hexiij:- ..II. 1 cells: the inner smfaees of these cells are imilonped into tiii-' processes, which p:iss between and among the outer parts of the ro.i-- ■uid cones. Under the influence of light tiie i)ipnent. comes forwani into the anterior part <'f the cell and is found between the rods; m darkness it is coUectetl ii^ the body of the cell. The function of tin- pi-'inent is to renew t!i<' visual jiurple or rhodopsin, aft<'r the hitl. r hirs become bleached l)y the influence of light. There are certain other Hustentacular or supporting fibres in the retma, jjassing fn ;■ llie anterior to the [joslerior limiting ni-nsb-rane— fibres of Mnller Th(> vessels of the retiiiU are tlerive.1 from the central artery :i' '1 vein of the retina. Tnese start at the disk, dividing and subdividii :, umm --%• IlirnSA. OVTIC SERVK, .IM> ITS CEHKIIIIAL ()1U(1I.\ 11!) until tlicy rcarh tlic poriiihcrv, but tho hranchos do not aiiafitoinosc witli one another; tlic circulation is terminal. The importance of this is sliown in the interference with the circulation of the eve by blockage of a vessel. No assistance can 1m> obtained from the circulation in thi' adjacent parts. There is a limited collateral 'ir- culation between the retinal vessels at the marfrin of the optic di.sk Flii. r.'.". I'iffmt'ril citidu'liiini (if the human n 1 mil branches known as the ;i ri'liiial vess( of the short ciliary arteries, circle of Zinn, ami sometimes I mav arise entirelv from this -"Urce; it is then known as a cilio-nt'nial I -SI I. The vessels li(> in the innermost or M(ive-fil)i-e layer; hence the outeriijost {)arts ■ 111 not receive nutrition from the retinal Msscls, but fiom the rich choroidal cai)i!- 'iiiis, with which they are in close contact. I l\i- retinal capillaries are extremely fine, and ilii'ir meshes are closer at the yellow sj>ot and i'- immediate neighborhood than toward the I ' lii'liery; but at the fovea or central de- i i'>sioii the capillaries !ir(> entirely .absent. Tlie retina is the es.sential organ of vi.sion : i -lit entering the eye traverses all the laycik of tho retina until it ■ iclies the posterior surface of the layer of rods and cones. Tlie light iniuli are received by the rods and cones, and, are transferred by ' i alls of the optic nerve to the brain, where they gr\-e ri.se to the im- n ssidii of sight. The region of acute sight is at the fovea, a .small fression at <he centre of the macula which corresponds with an area ■ 'he centre of thr-vi.-ua! ti(!t!,;)ne ainloiie-lialf degrees in diariieter. ' 'ii elements of the retina at this point are ,3// apart ; this is exjjre.ssed -t by saying that two bodies in the visual field are not seen clearly ninnaii rtxl .uul lune. (lilIAt:rG-S.4E.MISCII.) VM THE EYK. \ II ,n.l.-s sul.t.-nUih. Ml. anpio ..f at l.'ast aV . The marve Bupply of the f..v<'a is inor.' al.uii.lant than tl.at of any part of tlw retina. In- ., .-w,. ill vvl.ici; ,,n(-l<.rtiftli oiiiv of llu' fi<'l<l <»f vision was lost. BuiiKc fouiKl an alrochv "I' al)oiit on.-.|uart.'r of ttu- wiiole optic n<TV«>. Tiir niclullarv sliratli nf the oi>tic nerve til>res ends at tiie lanunii rril)rosa. I)ut it" is in rare cases prcs<Mit in the disii and extends to a Flu. 'Ui. ' aHliim thrniiKh (lie inacula (i.kai tK and Saembch.) This condition is iviiown as opaque varying extent into the retina. nerve fihns or retained nerve sheolh (Fi};. 227.) It may affect a por tion o'r the whole of the disk, and Mi:iy extend a hniR way into tht n'tin.'i. In rare cases separate islands o in the retina. -f opacpie nerve fibres are seen These fibres, of a pure white or greenish-white color. Opaque optic nerre llbrcs. are denselv opa<|ue. wilh a >iriati>d surface and an ak which can be seen to spread out along the fibres of the nerve. Tlie retinal vessels are .-ci'ii on the surface of the opa(iu(> (ibres or lie buried or partly buried beneatii the surface. The portion of the ivlina affected wii!: <)pa(|ue nerve fibres is blind. .After severe ()i)tic neuritis or neuro- retiiiitis, these fibres have been found to disappear. !fB*! mmmmmm KEllSA, OJ'TIC .V£,7i' »•/;•. .I.\7> ITS ( KRLliliAL UUKUS. 421 Retinitis. Iiiflaiiiiniitioii of llic ri'tiiiji may orcur .is ilic rc><ull of an injury or from the ('oiicciitratioii of lirilliant li^lit ( '' tlic sun or of ilu- I'icctrir an- U|)oii it ; l>ut, as a rule, il is tlic matiifistatioii, often tli<> <inly one, of ^ravc <'oiislitntionai disease, sucii ;is albuminuria, };enerai arterial sclerosis, syphilis, Icuka'inia, or dialii'teM. Mypera'tiiia or conjrestion of llie retinal (•■•ipillaries caimot iw recoj;- iii/.ed, the retinal capillaries Ix'iiin themselves invisible, hut tliecon- .lition of the visible bloodvessels may often cjiablc one to diapnose a condition of jreneral retinal hyiK-ra'inia, such as larpeia'ss or tor- tuosity of the arteries, and distention, tortuosity, and d;irk color of I he veins. All pathological chan>;es in the retina show them.>'elves by a loss nl' transparency, the alTi'cted parts become gray or white and opaijue, the vessels are indistinct or entirely obscured, and the undeilyiiiK ilioroid less clearly seen than in other places. In .some cases the red nliex from the choroid is dulled, so that the retina apjiears to have .1 smoky hue. This opacity may be diffuse and occupy a larpe part ■ if the retina, or it maybe limited to one region, or may show it.-^elf ill circumscribed areas separated by healthy retina. Inflammatory changes ;ire often accompanied by hemorrhages into till' retina. These may be linear in shape, and iiuiylM-ar a relati()n 'm a visible bloodvessel: they may be punctate, streaked, or flame- -liMped. owing to the direction of the nerve fibres in which they lie. They are generally rounded iii the (U-eper parts of the retina: the niily symptoms pre.-^cnt, as a rule, are diminution of sight with occa- -ioiial Hashes of light or flickerings, distortion of obj<cts, such a.s ~iiaight lines (metamorphop.'^ia), diminution in size of objects (mi- 'i'lipsia^ or night blindness. In some oa.«es floating specks are seen 111 lure the eyes, which are ascribed to bi'iousnrss: and ophthalmo- -iiipic examination may be the hrst indication afTorded of severe iniislitiition.al disease. Syphilitic Retinitis. Syphilitic retinitis may show itself either ill association with choroiditis, as choroido-rotinitiK, or as a pure iiliiiitis. It occurs during the secondary period of syphilis, betwet n the sixth and the eighteenth month after the pri uary sore. It occurs ill congenital, as well as in the acquired di.'iease, and g( nerally attacks I'litli ey(>s. It runs a very chronic conrs*-, lasts many months, an<l -liows a marked tendency to recur. The ophthalmoscopic signs are 11 exudation into the vitreous, generally into its posterior j)art. This \tidation is very fine, but can generally be resohcd into actual iiist opacities by the ophthahiiosco])e: it obscures the fundus lid may hide the deeper parts (<ntiri'ly from view, but it is iteti ].nv;v:i!>!c fu PToguizt- thfoiigh the Ir.ixe tl-- hyp-''";! niic cni)- 'iiion of the ojitio <lisk, with great enlargement and tortuosity of "ith arteries and veins. Then may 1m> spois or white areas of exu- iation into the retina, and heniorrliages are olten pn.-ent. In \\\o i i n ti I iL vi-.'. later >t;i;i<> ihr vitn-oUH r THF fry !ll ftlZC, ;i;ii 1 iH.ih arteries anil veins then finitiil (li!iiiiiishe<l are slieatlietl III white. I retina lears; tlie art tries an I'maiiix ()|i:i<|ne am I fibrous lodkind, ami contains piKii iloiiK I he slieat!i> of liie vesseU or scut jHTipliery. il'i»£ -->» ' tiTcil irregularly, chid' it the Atr.,ph>- or retina. I'lsment.tlo., -.f -heath, of retinal v »el. after «''•''''"''« """'•'L!'."^"'^ llne« along tfo retinal veius ; plgmenuition of vel..- at periphery, armngement of pigment bet»f*" thu mam vesaels rraerobllng rellnltli pigmentoM. Th.' lo^s of siftht hears no relation to th(- lithalmoscopic chanps. It nun Iron, tlie Hrst he nuich n-duce.l, an , after suhsidence of the diseasi' niav remain so; while in other eases the sipht generally niav • - I - " t;i:iiM iMi RETrSA, 01 lie SKRVE, AXD ITS CESEB- ilGlX 423 !H'(niii*i<l(r.il>ly Tstdfi-d, but blind un-uM (sci tiiinal. "i ii riiiff ^IuiimhJ uri'ii iif l>liinlii'-M (uiiiuilar sct)t(iiiia) iiuiv Im" k>f' Im-IuikI. Tn'iit- riM'iit riliiHilil lit- iM'pun wit! iit ilclay. It in<rciiry Ix- given to the limit "I Mifi'ty, tlif rounw' of llu' ili.st'iiwt' tnuy Ixj shortfiicd und Miriip of its worst clu'ct.'' avoidi-d. Iniitution i.« pfrlmiH tln' most sitisfiicl.iry II fthfxi of pvinc niiTcury; it Hlnnild In piifhcd until llicic is sliftlii tciidcriicss in thi- ftutns. This may Im' iltcriiatcd with siiliciifaiiioiis mjfctinns uf mirciirv, nr uitli nicrniry with '-halk, taken liy till' mouth The mcrcuria! fn-atmi'iit sliouhl Im- carried oU' iiiilil the dis<:ise hii- comf to an end iid siifTu-ient time hiw piiK'til to Albuminuric retlnttla In *. CMe of acute nepbritli. ibowInK «reM of soft-edged, (edenutoiu- looklD( exudatloa lato tbe retina, with bemorrbanet. reii(k>r HTurrences improbable. To thu* treatni.Mit should bo a<l(led Turkish baths, subc taneous injections of pilocarpine, and iii the I iter stJines ioditle of jHJtiissiuni. At the same tinio dark glasses -liould Im- worn and all ase of the eyes prohibited; the glasses should \<>- domed, of neutral color, and rather tlark shade, with sides pro- ■rted by gauze or crape, to exclude light; some surgeons speak iisrhly of sfv'ctrum blue glasses Tt is doul)tful whether other local i-isures, such as leeching or counter-irritation, have any effect. Albununaric Retinitis. Inflammation of the retina associated ith renal disease occurs very often during the course of a chronic 42) THE EYE. intorstitial lu-phritis or jiranular kidney. Tt occurs also in chronic pari-nehvn.atous nephritis, in the i^i.hley disease of |)rf'KJ'ancy, ai"! also less"coninionly during an attael< of acute nephritis. ( ;ig. 229. it is convenienl to chiss all these varieties under the heading of albu- minuric retinitis, althougii it must be understood tiiat albumin is not present constantly in all cases: it occurs in two fonn.s, at least: the inflammatorv and the degenerative. Intlammaior,, Retinitis. Where the disea.se is running an acute course whatever ;)e the fundaiiH-ntal nature of the kidney aftec- tion we meet in the retina with soft whit.> flocculent patches of cxu<lation, combined with (edema covering large areas, with swelling and haze of the disk. Heinorrhag.'s are sometimes present as small red points or Hame-shaped masses of blood in the nerye-hbre layer Thi.s form of retinitis is not alwavs associated with much impairment of vision and is seen less fre.iuently than the other form. It is most commonly met with in the chronic large white kidney stage of neph- ritis- it persists for a f<-w weeks, .-md, with general treatment, it may disappear and leave no trace. This exudative or inflammatory form of retinitis is fieciuentlv accompanied \y a great deal of exudation into the optic nerve, producing a condition closely resembling the optic neuritis of intracranial disea.se. _ _ The other form of retiniris the dcqcnerative, is sometimes seen after subsidence of the acute exudation, but generally occurs independent y. It consists of verv brilliant dazzling white spots about the macular redor. Its most 'characteristic form is very like an astensk radiating from the vellow spot. I'aeh dot of which the a.sterisk is made up has a sharplv defined or hard edge, and the surrounding retina apjiears to be darkened, possiblv from contrast with the brilliant exudation. The exudation .-onsists mainly of granules mixed with fatty deiH.sit in the n. ivous and supporting elements of the retina, and probably owes its peculiar arrangement to the folds into which the retina is thrown bv (edema. H(>morrhages are generally present also, and mav be punctate, .striated, linear, or tlam'.-shai)ed The tendency is for "the exudation to become absorbed -md for sight to be somewhat imt)rove(i It is rarelv (.ntirelv absorbed, howevei , and months after H few dots mav generally Ix- seen near the yellow spot : the hemor- rha<res also bec-ome absorbed slowly. A peculiarity which is seen in .onVe cases is pigmentation of the retina, which ha.s l>een found on microscopic examination to lie outside the external limiting mein- brine In severe cases of albuminuric retinitis accompanied by marked ..apiilitis the recovery of sight i.ever proc(-e(ls v<>ry far, and if the disk becomes af-Mpliic, vision may be almost entirely lost. Night may be lost also in kidnev disease without the occurrence of retinitis. The sight fails rapidiv an.', completely without any cause being di.s- cernible bv the ophthalmoscope; but after a few hour.s recovers slowly the patient h:is headache, vomiting, and the other symp- toms of ura'inia. and the blindness is i'r,nuic amnimmx. In the albuminuria of picfiuancy the retinitis may come on comi)aralively BJCTiy.'., Ol'TIC SERVE, ASU ITS CEJtEllHAL ORluLV 425 cMrly, or may Ix- dclayod until near the ond of the prPRiianry. It |(,ll<i\vs a'-> acute course, and is attended hy great tli.sturhance of finu'tion, out eonijjlete recovery is often ..htained. {{ecovery is more likely to occur in the inflammatory or exudative form of retinitis than in tfie degenerative form. Changes in the vess<-ls arc marked in the degenerative form. The small arteries are thick- ened and rigiil, esjieciallv the iimer coat, and their lumen becomes diminished: the capillaries particii)ate in this rigidity. (Fig. 2;«).) This change shows itself verv clearlv by the ophthalmoscoj)e, as has been d.'scribed by Marcus Cunn. the smaller arteries of the r< (Uia have their central light streak wider and more brilliant than usual, Fig. 230. Mbuminuric rellnitls. (iranuUr kidney. Note hard-edged "Mterl.Hk • exudntion at y t, the .liver- » ire conditiun of the aileriee, and the punctate and linear hemorrhages. Ml that the whole vessel appears like a piece of silver, or rather, of -old wire, and gives one the impression of being hard, round, and uiwe. At the same time the artery shows signs of degeneration ill the form of small l)right spots in its coat. \Vhen> it crosse,- the M ins the blood current in the latter is interfered with, so that the nlumn of blood apjiears to l)e cut in two, and the distal part is dis- iriided bv the obstniction. In more advanced arterial disease there ■ire slight ine(ni!ilities in calibre of the arteries in different places, and, .ceasiimallv, sm;..l aneurisms may form on them. The distended \rin< sometimes rupture, owing to degeneration of their coats from -i.isis of tlu- blood within them, and they may undergo lusitori.' ilargement. Hemorrhages may occur also from the arteries them- 420 THE EYE. I I II K,.lv,w ( )...- ..f ll>.- .•oinnu.n results of this fcrin of arfrml . r^ciKTii- ,i„„ i^ ,h,. .KTU.n.nco of an area of tl.ron.l.os.s of th. vo.n at the „ wlu-rr it is .toss,hI l,y a., art.-ry. Tl.is is follow...! l.y an mflan.- ", rv -uaati..n, .•..n.pl..t..ly ol.s.-urinK tlu- vossj-ls at t «« pla.-.- ..f ,. nta.-t. wl.il.- luMn.,rrl.aK..s an- p.u.n.l .mt from tl,.> voin iH.y.m.l 1 . ;,.,s,r,u-ti.m. Tlu-s.. .-han^.-s in th.- v.-s.s,.ls arc- s..,-,, R.-n.-ra ly at. about fortv v.<ars ..f a^.', hut may ai.jH-ar ..arluT-~u|.l.;.Ml ahn..st at . v..«'«- ■'n'..'v n.ay Ik- sai.l to U- ahnost ohara.-t.-nst.c ..1 granular khu-v. although thoyar.. .s.H-n fr,..,u.;ntly h, patu-nts m whom no oll',.rsi«..s of granular ki.lney .-an Ik- foun.l, except, ix-rhaps, a har.l, iiiconiDressihl.' art.-ry at die wrist. . ? Sosis. This is t.. iK. r..gar.l...l from the p..int ..f vu-w of r.>.-..v..ry „f visi..n an.l also with h'simh-I t.. the .hrat.on ..f h .■• As hiu, ten a i. he .-xu.lative or inHanuuat..ry f..nn of r..t.n.t|s ,nay be Xorbnl Vntin-ly an.l leave the visi^.n littl.- .mp^.-r...!. The . -gen- ,,-ativ.- form takes nmch long.T t.. Ix'con.e abs..rbe.l .s l''>> 1^ ly ,„ b,. absorlH..! at all, an.l n.ay leave ,>en..anent changes .n tlu Lu-ular r.-gio... which may i.iterfere gn>at y w.th v.su.n. Ih,- prep- .- fornrsar.. lik.-ly to n-cover, provi.le.l that pr,.gnaney .s near s ! ,rl.r if it .-an Ik- .l.'t..rmine.l by pr..n,atun« .lehvery. As n-ganls th.-'.luration <.f life in the ..xu.lative forn.s aee.-mpanvmg paren.-h>- „nt..us u.-phritis, although the rethial .'hanges nuiy be v.-ry gr.-at. 1^ .gnolis is n.>t .-xtHMuely grav.-, for the eon.ht.on ..f the k>.lne> v' b.rr.M.ov..r..,l fr..m. In the .leg.-nerat.ve <"•">-',*■"";;•';: '>^^,^ granular kian..y the .lun.ti..n ..f life is short, m '"-P'tal !« • >jl^ ;,,,-,-.■ .luratu.n ..f life has b.>en not.'.' l.y M.ley anu.ng 4.) .".s.-^ t.. 'b, u.;:i.T four .n, nths, an.l the extr.MU.- .luratu.n un. ler t^^^ y'■a-^■ ,,,, .„lH.r .>bserv,-rs have not.. I less untav..ral,le ^^f^; ' ' ^ Inn.'utiun of lif.- s<HMns t.. .h-i,en.l up..n the anu.unt of .-an- t ut a ... Taken of the health. Thus an.,ther ..bserv.-r f..un.l an.ong ... , pati.'nts that all th.- men .lied within two y.-ars. an.l t,S l..-r e.-nt. ..ft. on.en, a...l an.o..g privat.- pati.-nts ..nly 5'. ,«. e.-nt^ ut the n.en . .i„,l .-,:{ p.-r ••.M.t. ..f th.- WO..UM.. A f.-w .-x.rpt.onal .•ase> 1 a^.■ i...n ,,..■< .nl.'/l in which hf.- was proh.nge.l f..r s..v..n <.r «-v(:"tw.-lve y.-ars^ Di-oetic Retinitis. Although th.- .•xist.-nc ot a., .ntlamnu.tu.n o ,„., ,,lina p.-'uliar to .liab.>t..s is n..t a.lmitte. by n.any auth..rs >. , vtinal .•hang.-s a.v n...t with in .liab-t.-s wl.u-h are .hstu.ct frm "„.et .Tth in a,.v other .liseas.., an.l suHi.-.ently hke .-a.-h ..th. iustifv th.-ir <.c..gniti..n as a s..,>a.at.. var,.;ty. /h.. t..n., «1 mh JHi.- V..tinitis takes is that of a group ..f l.nlhan.ly .•eH..ctn,g Ao^ .,, ,n.ns of .(.•g.Mu.rati.... in th.' retina, vury.ng .nu.-h n, size a ,rroup..l an.un.l tlu' v.-llow spot. Th.- app.>a.-anee .. .-a.-h .lcg<'"era ' u,. is tnucl, lik.- .hat ..f the in.livi,!ual spots n.et w.th m ='' '""|"' n.tinitis, but th.Mr an-a..g.-..u>nt is n..t lik.- the .spok.'s of a ^vhc'l, ra 1 ..ih„- fron, th.. vllow spot, but like the c.r...unfe.vn.-e ..f a «h ' . rr,n....l ,-.n.un,l it. .\t th.- sa...e tin.e tlu-re are nm ...n.us pm..- .i. ;;;„i irn..ar h..n,orrhages in the n-ti..a. This for... .>f exu.lat...n p.. si.sts for a v(.ry long tin..'. wm Rl.TlSA, OPVW SEIiVE, AA'D ITS CEnEUiiAL OJiltilX. 427 Leuksemic Retinitis. ( )wiiig to the poverty of the hlooil in colorinp;- iiiattiT. Olio of the most striking features of the fundus in tliis (Usease is that the color of the choroiihil reflex, instead of heing a full, rich red, is 111 a light-yellow color. The retinal veins are large, flahby, and tortuous, and have the appearance of flattened bands. Retinal licniorWiajres are j)resent with white masses of exudation, due to extravasations of white blood cells into the retina. These spots are sometimes surrounded by a fringe of colored bloo-l. (Fig. 231. > FlO. 231. t^'iikn^mlc rt ; inltln. Note the Indlntinctneiw of the ill«k ; the eiiorinoui.ly rllsiiMiduil veins ; and thu hemorrhages at the yellow fiwt surrounded by a light halo. Treatment. The treatment of albuminuric, diabetic, and leuka'ii ic t'linitis is tiie treatment of the disease which is the cause of Im' retinitis, ainl calls for no remark here, except that rest of he eyes should 1k' enjoined and the use of dark protective I :i>s(s. In retinitis occurring during pregnancy, the (piestion of I'lcing premature labor often ari.<*es. If the retinitis be seveix', ; i- advisable to induce labor: but this should be postponed as nir .'IS possible, if it can be done with safetv. in order to save ■ .liild. Hemorrhagic Retinitis (Thrombotic Retinitis). The ophthalmo- "pic jippeariiiices in this disease are the formation of a very large iiiher of small flame-shaped hemorrhages all over tlie retina or 42« nn: AVi-;. Pio. 'JS2. Tiew of inverted iirnme) Fin. 23S. .heath of llie vii.. ^houi^l U- iilioU. KETIXA, (H'Tir .VA/.TA", AM) ITS CKHEItHAl <HiliilS. 429 over a portion of the ictiiia drained hy a s'nglc vein. ( Figs. 232 and 2'-\A.) At the sanir time tho veins in this region are enormously dis- Fio. 2»4 Bemonb«ct<! retinitli. (Jaeoeb.) Fia. 2S&. *'{e ^iihhvHlnld hemnrrfanip^ lit yellow upot, which han buret thmtiKh Il« (interior limiting mem* '■ (.' iitKl fiirniiil H rjrrurascribed hemorrhHge ; a tieooud BUbhyAluUl hemiirrhHKu In seen at the T imrt iif the liiiutils. 3j.'^"isK^fla&-T;Lit'r^r=3*- 4:}0 Tin: i:yt-- I! ft I ' 4:}0 n.tina is ,.-.u..liy -«-=;;: ^.^^.^ u;::;;;,,...; ..r tlu. trunk of ais.MS<' of 111.- valves ..t tin '" :\V ,,.,.,, rs inH-n-' those wl... l.avr n-. -- -"VV« !'"' •^'"V:;:;i[ " 'l "n'lu;; s...onaafy to orl.i- ,r,s,.ov.Tal.l.> .lisc'asc '''f'>.'^'"\;. ,',,., „r .li^-asc of the cavernous tal aiseas,.. suel, as .■ellulit.s. ' ^^; ''^j;' ; ,. , ,,„„. ,1„. ,...ur,-e of sinus ana the ^^^^^r"''' ^TZ-^nt^t^^ .l.-'l'ti." -•-'• - ,„.„. nveulat- '-'-;f":;,;:;£.; 't-isher-s observations. 1-neath hvaloia nu'inhrane. ana •<""^"'> ,1,,. .-unture of a vessel, prohal.lv tl,. nuMnl.vana li.nitans n.terna, t.o.n ' ' ^^ ^j, ,,, , „a „,,.„- \ retinal vein, h is ^.Mt.-n.lly ;;•;;:;'",;:',,;;.«. a^^oeiatea with ,,i,.s the yellow sp... >•.'!.....'. l"^;' J ,; S nuieh itnpairea. hut as the lu-n.orrhaK('sni..therpait.. . . .^^ l„.,.„nu-s exposed. ,,,.,„„,,„,,,,. ,ets slowly a bs 1> ' . ;,^.,,, ,„. .,iff,„„, i,„o ,i,„l vision ts restorea, o. ' " . ;,;i.,ia .ne.ni.rane. (V\?.-2^.^ U,MUorrha-<s an- also "" ; ' .^^J„f „„, ,i,i„. l.ar};e retnu.l a,„vloU ais..ase. purpu, u ^"' '''"'i;^ ,\,,, ,itreous are seen oe.a- ,„„i„,,ha.es whieh -"""7';^ ^,,„ .^ .>. Souu- of the patients .sionally it. y-mttfl aaults ^v" '< ' P-' " ', J'.,., ,,,,,,1, ; sueh p.^tients .„.,. a ueniic. others are ai.pai.-ntlv u. 1 ' ' ,„.,.„nlinf: t.. I'.nles. ;;;.. ...uerally suhje.. to --;;i^;^:- ^ ' j'^U'i.rn.s of .et inn ,s who tirst aes,.nl.ea the.n. Ih ^ •' .^ j,,„,„ p.jjularaoses ot l.lue ^,„i,. ,-,.„lr.. .-h..!..'"' "■ ll«- l""l> ■ ■ t ,; ,i nil l.l.-.«-l.l« <.r l.v any „„,„ ,|,,,„„|«"...K i"»"";»' »' , , ■,,„,|„, ii, tto ro(,na. II ™s?;:';^^.5.HS"'s;ri,:Jt.'......... >«, r- "< « ';j;T;^cr,i,i;;;™.* m.-*--" -' -i;:: retuia. 1 ne>'- i'''-- ■' ■ , K.,>.,ai.ts mve wav. tornunp penou"'*".' I.-: »'- *''•■»"■ I'" ; ,:: ; "';.Tn.i»iJy h- •.'» ««i" ■" "»■ iiETixA, orrw .\j:i:yj-:, a.w ith cEnEitUM. oiuais. 431 whuli llu' l);iii(ls of fibrous tissue form in tlu' rctiiiii itself, and jieiicr- ally fiiliow tiic course of tlu- bloodvessels. Retinitis Circinata. Tliis is a rare atT(>(-tioii, in whieh larKc areas (il biilliant white exudation with dots of dark color on them are f(irtue(l ill the rcfiion around the yellow s])ot. The central jiortion of till' retina itself has iinderjione nuich dej;eneration, and is jrniy and ii|>a<|iie; the aitpearanee of the white jiatches in the retina is rather like tiiat of passover bread. Ilemorriiafies nenendly accomjjany the disease. It occurs mainly in very old |)eo|>le. (l''ift. 2H(».) Flo. 23<i KinniiisrircinKta. Note the Kray (le(ieii»nition of tliv retiiiB ul Iht yellow »i«)t. uiid the white t'xiiilutiuu conieutric with the jtllov,' simt, huviliK the a|>|iearuliee oi i«.>»over breml. Sxanmetrical Disease of the Macula in Toung Children. This ' liiiiti, liist described by Tay. associated with disease of the cere- ■ ;! <()rtex, is a rare disea.se: it <iccurs iluriiif: ihe first two years of , ireiierally amonfi the ofTs])rin}i of Jewish jianiits. A white 'ih i>f exudation having a ('herry-re<l sjiot in the centre is .>^eeii 'III Miacuhi: the optic nerve slowly atrophies, the ciiild becomes . i. :i;id dep'iier.-ites !nent;dlv until 'ieath ensue< after some ■■•lis. F.mbolism of the Central Artery of the Retina. W Ihi: i his occurs, 11 is sudden and complete failure of sight. The iiatient is ibout "idinary oc''upat'o!) and is conscious of snineihintr [teculiar in 432 TIIK EYK. his sijilit. Oil (•((VcriiiR oiio rye ho finds that tht-rc is only faint |MTcci)tii)n <if liplit in the :itT('cic<i cyp. (Fiji. 2:17.1 When cxiiniincd by tlic n|>liiiialni(>sf(iiM> al'tiT :i few Imurs the arteries itrc fnund to Ijc iiiueh sliniiikeii, luit jjcneraiy not i|uite li'.nodlcss; the veins an* of ni)nna! size "r ratiier sinalliT, i)nt tend to i.KTear-f in size away from the disk. The whole retina is whiter t'nin nonnal, tlie whiteness Ix'inn most marked aronnd tlie yellow spot. The fovea a|>|)enrs hy contrast l>ri<;htly red, as if there had ?K-en a hemorrhage in it.^ This apiM'aranee is known as "the eherrv-red sjiot at tlii' macula." The whiteness nl' the retina is due to ledema, and this is most marked just around the yellow spot , where the n tin i is thickest ; the cherry- Klll. 287. Embolism of centnl »rtery of the retln«. (Liebbeich.) red spot at the fovea is owinf; to the red of the choroid fjcing seen thnniv'li the retina, which is very thin at this spot. The cherry-red spii lias JM-eii seen within twenty minutes after embolism has taken place. The column of l)lood present in the vessels is sometimes broken uji and moves about in an irre<;ular manner, sometimes from one vein to another; sometimes in a reverse direction to the normal. .Ml the small vessels in the re<j;ioii of tlie macuLi stand out very dearly asjainst the opaipK- white retina, .\fier the tirst tew (lays there i- freiiuently .sliftlit imjirovement in sisjrlit, owing to paii'.al restoration of the circulation from anastomosis of small ve.'^sel. situated around the entrance lo the oi)tic nerv(>, but tlie hniirovement is v<-ry slight; the (ed'ma clears up in a few weeks, and atrophy of the di.sk follow> lit I HKTISA, Ol'TlV .SKUyt:, -I.V/> ITS VKHKURAL OHUilS. 4:5:1 „„uHiin.-s only a branch of tho central artiTV is afr.'ctr.lMvitl. ,1„. .orrcsiM.n.linK iK.rtion of the r.-thm. In one j.uhl.she,! ca«- the „,„.„lar region wsus su,.|.lie.l l.y a cili..retinal i.rter>-, an.l central vi'.; Ml was retaine.1. althoURh all the oth.T parts ot the retina weiv l,li„,l A cas«- has Ix-en seen recently in which cnibohsni of one artery wi-i loUowe.l l)V a sitnilar acciih-nt in tlu- other eye. OauM The "most coinnionlv lussigned caus<' is the s«>|)aration of an ,,„lH.lon from a .lis«'as«Ml valve of the heart. ( Hher caus.-s are uth.- ,,„„.i „f the aorta or other lurge vess<'l. aneurism, pn-Kiiancy. <.r Uriehfs ilis..as.'. But cases are not ran- in which there is lu. cause ,,t this s„rt to Ih' found by most careful examination, and it is ,„,,|,al.le that many of the ca.s.-s presentiiiK typical featu.rs ot em ...- Lni ar." really cases of sudden thromhoms of tli.' central arterj-. due "" Treatment. '''".\s to treatment, nothing can he sui.l to he henefi-'d with certaintv. Paracentesis of the anterior chamlx r and iridectc have Inrn tried without result : massage of the eye may !«' In.d will, the hope of causing the emholon to move to some mure distaii part of the circulation: it has Imm-u successful, hut it must he api n- d radv a id vith force. ,., • • ■ . Thrombosis of tte Central Retinal Artery. I his i^nes ns. ,, <vi.i|.toins an.l oplitlmlmo.scopic apiK-aiaii'-'s uUiuical ;vil h Iho.^; o ,,„h,.li-,i. the uain .iilu-rence being that m thrombosis the pa n,ii i- w.iiT v' ' V irorar>- failures of sight which pas.s away, until -ne ..(•luiv w i.rt's not clear up. Quinin'.^iiuiiaeas. v>>'e Optic Npr>-e.) Meet of Light on the Eetina. The effect of hgld on the eyo ^how,. ii.lf in the conjunctiva and hi the retina. Kxposun- l- ih' -un, ,,„.ducing sun blindn<-s.s, or to the electric arc. as a n„, causes inteiis,. conjunctivitis, a comlition amdogous to blistenng of the .kill bv direct sunlight. Thoughtless exposure of the eyes to tli.- sun, „r to ihe ravs of a powerful arc lamp, may produce r,.su!t,-< on h- .vtiiia which' are sometimes penimnent. Many instances are rec ..led i„ which patients have stared at the sun during an ecli|-..<'. llu- rrM.lt has been in ...-me ca.sos a persistent positive scotoma, pi-ducmg indi.stinctness or a blur ..ver every object directly looked at, l.i ,,th.T cases, 'vithout the sight Ix-ing at all dim, the consciouMu ^.s n mains of a col..red spot in the centre of tlu- held, s.-en gen.-r.dly nheii a white background is looke.1 at. Other cas,-s have been ,v,-,.r.ied in which a permanent central scotoma with loss of a cut e- „...s of vision has lK-<-M left behind. ObserA-ation of the f.n.-a in such ,as..s has .-hoNvn it to b'- swollen, or to have a hemorrhage at its -iiiti-e. or. at a h-t.-r stiijx? , to be atrophic. Treatment should be liy vr-\ and dark glasses v.orn for a prolonged period. Atrophy of the Becmi. .\trophy of the- retinr. may occur as the vsult . f i<,ng-(oritii.'ie<l !>n-vious inilammation. It may be the con- -.•,,uei..,. ut a-i cnibolisi..i"..r thrombosis of the central retinal artery. 28 434 Tin: KYK I It \ li ii in 1 Or II iiiuy In- a s|MTial afffctioii (•lianu'l<'iiz<'<l l)y tlir forniatioiuif new niniMciil, ami known as retinitis inpnii-ntdsa. li.linilis I'uiimnliMi. This disiasc is cliaractcrizi'd at its (ins«'l l»y loss (if iM>\v<-r to s.-.' at niplit «>r in twilight (night hliiiiliiissM, the visii>n ri'iuaining K»)tMl during liaylinlit. If tiu' fi<'l<l of vision Im- taltrn at this tinii-. il will Im- foun.i iionnal or nearly so in hriglit iigiit : Imt if the ilhmiination Im- diiiiinishetl, some reduction in the sizi- of tlie fields will Ix' found. As the disease progresses tlu' fii'ld Ix'eonies eont ran. -d. even in bright dayliglit, and the eontraetion may advance so far that the patient has dithculty in finding his way aN>ut: in extreme cases the field is reduced to a mi-re point Kven in this stage central vision may be almost unimpaired: in some raws the whole of the field is luit lost, iuit a zone or Ih-U of the retina l)ecom<>s blind, giving rise to a ring scotoma. Hy opiithalmoscopic examination the retina is found to contain a large amount of pig- ment in its anterior layers, deposited in the fonn of (U>ts or islands, shaped much like Ixme corpuscles, having branches which coninnmi- eate with other ni'ighboring dots. Pigment is deposited also along till" sheaths of the smaller vess<'ls. In more advanced cases the red background of the eye app<>ars to Im- covered with a delicate bl:ick lacework: in its most severe form the pigment is so dens*- that little of the red choroid is visible. The general arrangement of the jiigment is in the form of a zone situated about midway between the peripherv of the retina and the optic nerve. This In-lt is densest at the centre, and thins otT at its inner edge, toward the disk anil also toward the jwriphery. The retinal vessels Ix'come reduced in size; the arteries may Im- mere threads; the disk under- goes a peculiar dirty yellow atrophy known as imst-rttinitic or \mx!i iilriiplni: the leiis " may become atTected with jjosterior jxilar cataract, and opacities may apix'ar in the vitreous. Although this is the usual character of the dis«'ase, cases are occasionally met with in which night blindness .and loss of helds are present and some post-retinitic atrophy of the disk is seen, but in which no pigment can be seen in the retina, or in which, instead of jngment, a iuuuImt of soft-edged rounded yellow-white spots are seen. These two condi- tions are spoken of as rilinilif />((/'"<"'"•■>" irilliout piipmnt and ritiuHi" piinrldin (inivsrrns. The retinal hexagonal pigment is gradually ab- sorbed or travels forward to the antenor layers of the retina, so that the choroidal vessels ainn-ar to stand out very clearly. There is soni'' doubt at present as to whether this disc:- ' should Ix' considen-d as choroidal or retinal in origin, as, ■.icccriling to Wageiunann. if the choroidal circulation is interfered with by division of the ciliary ves- sels, a migration of pigment forward iiito the retina takes jjhuy like that seen in retinitis ))ignientosa. The lis<'ase is first met v.ith in 1 111 conseqiience of the ooiifuslmi which has arisen with n-ttiircl to the wonln nyctalopl* an hcmeraliipla, Ihcy beinit iiwl in opposite nense? hy Kuglish and Continental wrlten. It la better i n«c tlie terms ninht anil . y bliiidnem. which explain themselvea. n RETISA, OPTIC SEHVE, ASO ITS VEREHHAL OHIUIS. 4;Ji> .liil.lli.MMl.or iiUnH puU-rly, ami julvaiiccs f«l<.wly lo iiltiioxt n.inplctf l,liii.|ii.r.s iilttr miiiillf life; it attack;* Inith cyi-s. Its <-au!^' if tinkiiown. h i- livquiMitlv luTcditarv.aiul occvirH in those wIk.sc parciits wen- 1,1 1 rrlatioiislM'lon-iimrriauc. (MIkt defects of the i.ervous system ,1. utteii present. s\ich as deafness and want of mental (Miwer. No irraiment is known to Im- successftil in thi» dis«'ase. Iodide of jxitas- Muni and strychnine may Ik- tried, with the application of the constant riirrenl. , , ,. , The prognosis is had, althouRii complete bhiidness may not come oil until verv late in life. . The alrophv which follows syphilitic n'timtis. esjK'cially in ehild- |i,.,mI. i> often' similar in apiK-ai-ance and coursi' to true retinitis piji- iHiiiln-^a; Init. as a rule, there is .some evidence of involvement of the 1 lidinid in the syphilitic affection. »1o. 2SH. Deucbment of the rctinu. (Jaeger.) Detachment of the Retina. The retina i.s continuous witii the optic .v\r at thi' ilisk, and is atniched to the choroid at the ora serrata; ,;it l«'tweeii lliese jxtints it is iield in apposition with the choroid only ,v the support or pressure of the vitreous within it. It is lial'le to .i> detached from itsjiosition by various causes, such as injury, ex- i.ivasatioii of blood or serum, by tn.ction from within, from bands in r..- vitreous, by tumors of the choroid, or cysticercus. It is met with ,1-1 cummoiilv in mvopic eyes. (Fig. 2.'JS.) The eau-sj- (If the detachment hits b. 'n accounted for in many ,v,_by exudation of fluid from the clioroid. by sudden oxtrava- 'iMi, ,,fbl„„d from the choroid. Neither of these theories exi)lains ■ larjie number of ca.ses in wiiich the detachuient comes on suddenly MICROCOPY RESOLUTION TfST CHART (ANSI and ISO TEST CHART No 2! A APP LIED IISA ^GE Inc ^^ '655 r-as' Mo ^ '-"Ml =^ Rochester. Ne« ■■J'' ' *609 i'^ '.as ('16) -S^ - 030'j ■ Phone 436 TUE EYE. without sign of honiorrhago. It is owins to the work of LoIkt ami Xordeiison that the theory of shrinkage of the vitreous was estab- lished and most of the difhcuhies of the subjt ct answered. Accordnig to their observations, the vitreous beronies fibrillary in structure while retaining its transparencv. This ehange is due to a shrinkage from inHamiiiatorv processes in the choroid or ciliary body: serous Huid l^ecomes poured out into the vitreous chamber to fill the vacuum ciustvl by the shrinking. The traction on the retina produced by th.' shrinking vitreous lea. Is to ripture of the retina. The .serous fluid Iving in the vitreous chamlxr passt>s through this rent into the subn-thial space and allows the retina ><> become suddenly detached. More recentlv Raehlmann has explained the iletachnient on Xhv (Illu- sion theorv: the Huid behind the retina is more albuminous than that in froiit of it; (Uffusion ten.ls to take place more rai)idly towanl the fluid of greater densitv-that is, from the vitreous to th(' sub- retinal snaces-than in the opposite direction, .\lthough this theory may explain some of the slow detachments, it hardly sutftces tor thoac of sudden onset. The detachment inav take place at any part. It i-^ less common al the macular region than at the periphery : but wherever it Ix-gias, it soon settles to the lowest part of the retina, owing to gravitation of the fluid, while the part first detached may liecome reapplied. It mav remain stationary, but it generally progres.ses until the whole retina is detached, so that in a jwst-min-tem examination of the eye the retina appears as a cord going from the optic disk to the back of the lens, containing the shrunken remains of the vitreous, and spread- ing out thence to the ora serrata, forming an umbn'lla e- convolvulus flower-like detachment. The evidence of inflammatorv changes in the eye is generallv present in the signs of iritis or iridocyclitis or opacities in the vitreous. Secondary cataractous changes in the lens generally appear late in the disease, with a reduction of tension, except in thost>" cases where the detachment is caused by a choroidal tumor. Mvopic eyes are those most subject to detachment of the retina, l)ut it "is not always tho.se in which th(> amount of myopia is higliest which sutter from ("letachment. \'ision may not be much affected if the vellow spot be not involved, but there is always a considerable loss I)f field, which may be detected by the )x>rimeter, by the hand, or by the light projection test; the part of the field which is lost will cor- resi)ond with the ojjposite portion of the retina. If, owing to opaci- ties in the media, it is not possible to use the ophthalmoscope, it is generallv possible to diagnose the presence of a detachment by testing the projection of light. In the first stages of a detachment exami- .ation .f th(> field of vision alone is insnflieient, as the retina may retain its function for some time after the detachment where tne latter is not verv dee]). The oiihthalmoscone shows a changed color m the reflex from the fun.lus over th- detached area. The be.st way tn s<>e this is to observe the fundus reflex from a distance of about 14 with the ophthalmoscope mirror alone, and to get the patient to look RETINA, OPTIC NERVE, AND ITS CEREBRAL ORIGIN. 437 ill various directions, so that tlie whole of the retina is brought under iil)s('rvation, and one part may be compared with another or with the otiier eye. The reHex, even in recent cas<'s, is generally slightly iliillcr over the detached area than elsewhere, and in old detaciinients 'lie retina may apj)ear opaiiue and gray. It may often be seen to lluat about with movements of the eye. The detached area should then be looketl at by the direct methoil, its refraction estimated and I -nipared with that of other parts. If one part of the retina is iiuich more hyjjernietropie or less myopic than another, suspicion liDuid Ix! directed to detachment of the retina. The retinal vessels ill the detached area appear much darker than normal, owing to loss nt their central light streak and to the difference in transillumination. Ill their course toward the jx'riphery they can be seen to disappear into folds and depressions in the retina: rents in the retina may be seen at times, showing the bright choroidal reflex l)ehind. In some cases of shallow detachment the retina api>ears to be thrown into innumerable Hne ripples which have very much the appearance of tlic ves.xels of the choroid seen through the retina: it is possible that this ap]x'arance may also be due to detachment of the choroid with liic retma. hi determining the cause of the detachment, regard should be paid t(i its seat and extent, its shallowness or depth, its translucency and ininiobility, the condition of the vitreous, and the hardness or tension III the eye. New-growths of the choroid generally fortii globular |ir(iiiiiiieiit steej) detachments, sometimes dark in color, < ing to the ]iigiiient they contain, sometimes showing vessels n(>t of retinal origin. The vitreous is not opaque, and the tension of the eye often is raised. It the detachment lie due to shrinking of the vitrecms, there will lie vitreous oi)!icities, a widespread detiichment.a floating retina, probably (iiiitaiiiing rents through which the choroid may be seen. Treatment. The tn-atment .should he directed toward producing ab- -iirption of the exuded fluid. For this purpose the most efficacious urent is complete rest in lied: the patient ,«hould \ye kept on his back inr a month or six weeks, his diet should Ix" limited in regard to lliiids, and free action of the skin should Ix- provided, either by vapor iiMtlis, which should be given in bed, or by the subcutaneous adminis- ! ration of pilocarpine. This may be combined with the use of the inilides of ammonium and potassivim internally. At the same time the "\e should be kept bandaged under moderate pressure. If more rapid I i 'appearance of the flui I be desired, the situation of the greatest 'illcction of fluid should be made out by the ophthalmoscope, and 111' fluid tapped through the sclerotic. This is done Ix'st by a broad "I'llle or a (Iraefe knife, which should be introduced through the ' liiutic into the subretinal space in the eijuatorial region at a spot " twccii the insertion of the nuiscles. If the knife then l)e turned 11 II 111 its long axis, an opening will be made lx»si(le it, which will allow !n' albuminous flui<l to run out of the eye. Before introducing the iiiii' the conjunctiva should be liisplaced by tk ii.xation forceps. 438 THE EYE. V so tliat when tlic knife is withdrawn the conjunctiva may shp back anil the wound in the sclerotic be covered. Fluid will pi - - draining away into the subconjunctival connective tissue after ' u knife is withdrawn. An addition to this plan, which has been n ■omniendecl and has met with some success, is to burn tlie sclerotic slowly with a cautery throu<;h its outermost layers, until the choroiil is just reached. By this means an adhesive intlanmiation is .set u]) in the choroid, which aims at bindinji; the retina to it.self by die after-contractinf; process. No metliod of treatment is very hopeful. The retina may In-come reattached for a time, but it s -freiiuently displaced apiin on the patient resuminji ordinary rouiine. It is not possible to overcome the tendency to contraction in the vitreous, and, if the retina Ijeconies reapjilied, it is likely to be dis|)laced again by continuance of the con- tractinji |)rocess. ( Jther methods of treatment have had success for a time. Schoeler's method of injectinp; iodine into the vitreous cavity, which scoreil some successes in its author's hands, led to disastrous results in other ca.ses. Deutschmann's \ liod of inakin<; a punctinv throufih the sclerotic, choroid, and retih i into the vitreous, and cuttinji on each side of this track to divide tlu' l)ands in the vitreous, has lot turned out more successful than other methods of treatment. Cysticercus of the Retina. This is a very rare disea.se. Its diag- nosis dependN mainly upon the appearance of the parasite. It is subretiii.il as a rule, it has the appearance of a flattened cyst, it is light gray in color, with light edges, and undergoes s])ontaneous move- ment: the head may occasionally be made out. The only treatment is to cut down upon it and remov(> the cyst. Injuries of the Retina. Mesidcs detachment, the retina sometimes after a blow on the e>e will be foimd to have an injured area, white or nearly so in color, with ill-dehned edges. This condition, which usually ])asses aw.-iy in a few days, is probably due to a local trau- matic (edema. It is known by the name cummotio rcliiin . Holes at the Macula, .\fter injuries to the eye. especially from concussion by a stoni i)all. or other large object, in which the glolx' is not rujitured. there is freijuently associali'd with loss of central vision a remarkable appearance at 'he yellow spot. The retina ceases ab- ruptly, so that tlK're appears to be a circular hole in it at the centre of the yellow spot, e(|Ual to I'^out one-third the diameter of the disk. The Hoor of the hole is formed by the choroid, and is depressed a measunible ilistance behind the retina. .\Ilhough no pathological e\ainiii;',lion of the condition has ever been maile, it is higiily probable that this a]»peMrnnce is really due to a hole at the fovea, caused by lupture of the retina by cimtrccoiip: the elastic retina retracts and leaves a de.Mr roimd hole whose edges an- placed at a distance which can be readily appreciated from the choroid behind. Tliere is usually considerable loss of vision. Glioma of the Retina. This is tlte only form of tunmr that attacks the retina. It occurs in early childhood, iH'foie the age of three RETISA, OPTIC SERVE, ASD ITS CEREBRAL ORKUS. 439 Glioma of the retina. (Leber j years. It is soiiiPtinies congenital, ami is met with in rare cases ut a later afje. It starts from one of the graimlar hiyers of the retina, and either grows inward toward tiie vitreous or outward, producing ill tacluiient of the retina. It consists of cells arrang»'d in long tubes amuiid wide bloodvessels. The cells vary in size and shape, seme c.f iliem being glia cells or ganglion cells, others being cylindrical in >hape and representing the layer of rods anil cones. Tlie exact nature 111' the glioma is still a matter of doubt, but it is probably to be icgarded as an endothelioma of the retina. (Kig. 2.'^!).) The first thing to call attention- to an eye affected with glioma is the presence of a gray or white reflex from behhid the pup'l. If the eye be carefully examined, it will be found I hat there are one or more white masses no. 239. i;ii)\viiig from the retina, containing blood- vessels. There is no pain: the ey(' is not iniigested. At a later stage the mass ])ro- jects more forward until it fills the eye. Tension is usually rai.sed during jjart of the lime, and the eye becomes painful. In the third stage, the growth invades the ojjtic nerve or finds its way out of the eye by 111 her channels, where it forms ma.s.ses which fill the orbit and produce great j>roptosis. The growth may find its way backward to ilie brain through the ojitic foramen: it may invade the frontal lobe I if the brain by absori)ti(m of the roof of' the orbit, or it may be icjirodiiced in other distant organs of the body, chiefly in the liver. ir left, the mass of glioma grows through the front of the eye, gen- eiallx at the sclerocorneal margin, and forms a fungating, ulcerated, lileeiiiiig, painful mass. In its latest .stages it produces death from e\haiisii(in or by its attacking vital organs. (ilioma should k- distinguishe<l from purulent exudation into the vitreous— /),sr(((7m//!'on(rt. The ab.sence of pain, tenderness, and in- llaintn.Mtion in the early stage, the raising of the tension hi the later Mages, and the absence of retraction of the periphery and of the iris, help to distinguish it from jiseudoglioma. Treatment. The eye should 1k' excised as sotm as the disease is dis- '■'ivered. If this be done before the growth escaiies from the eyeball, Miere is a good chance of eur(>. If the disease has advanced further, 'he .(i-b't should 1k' emptied, if possible, in order to save the chilli I rum sutTering, produced by the fungating mass: but in such a case iiriigiiosis is very unfavorable. Congenital Pigmentation of the Retina. .\ numlier of cases of i'iL'inentation of the retina have Ix-en described by various authors. I |iigmentation occupies a section of the retina imly, and cim.sists I ciillections of small round or angular masses of pigment grouped f>,._reth..r somewhat like <-Av<'mxv They .ire unassoeiatrd with anv liiifoKlal change; they lie on the surface of the retina, and some- J40 TUt: EYE. \ J tiiiifs cover tlic retinal vessels. They have i)een considered a.s anoma- lous forms of reiinitis jiijimeiitosa, but they are not progressive, they do not accom|)any loss of function in the retina, and are probably of congenital origin. Infantile Amaurosis. The history given by the parents in cases of infantile amaurosi- is tluit the child was able to see well and noticed things, turned toward the light, grasped at objects held before it until the onset of com|)lete blindness; this generally occurs 'inder twebi' months of age. The chiid may develop other signs of i. iiess at the same time: general restlessness, feebleness of limbs and of back, or a condition of cervical oi)isth()tonos. .\n ophthalmoscopic exami- nation in some cases shows much dust exudation into the vitreous, with signs of syphilitic choroidoretinitis: in others optic neuritis due to tubercular meningitis may lx> j..'esent. Hut in many of the infants nothing can be seen by the oi)hthalnM):.e()pe at all, or a slight pallor only of the tlisk is seen after the blindness has conti: icd for some lime. It is in these cjuses that retraction of the head is most fre- (piently met with. The cau.se is a posterior basic meningitis with (listention of the ventricles of the brain by fluid. It usually happens that t'.e blindness ])ersists for some montlis and th"n recovery may take place, and even complete restoration of sight may follow. It is )K)ssible that the pu])ils may contim:e to res])oiid to light during the wholi' attack, showing that the seat of disease i - above the basal ganglia. .\n opinion is also sought by parents whose infants have never b(>en able to see at all; in such cases the ])upils may respond actively to light, and the o])tic nerve and retina are jjerfectly healthy. .\n examination of the head shows the skull to Ix' very small in its ui)i>er part, the sutures to be prematurely united, and the fontanelles closed. !^uch children are microcephalic idiots, and no im])rovement is to be expected in their sight ; the fault lies in imperfect development of the brain. Treatment. The syphilitic choroidoretinal cases recover to a great extent under inunctions of mercury. The posterior basic men- ingitis cases recover if the health of the child is restored. The idiotic children do not gain any sighi, and, although the condition of synos- tosis of the sutures has been met by craniectomy or removal of a jxirtion of the roof of the skull, such nu-asures probably do no real good. THE OPTIC NERVE. The oi)tic nerve has its origin in the retina, pa.sses through an opening in the choroid and scl(>rotic, tlie latter consisting of ;i fenes- trated membrane known as the lamina cribro.sa, traverses the orbit in a double curve iii order to allow of free movement of the eye, [)asses through the optic foramen at the apex of the orbit and enters the skull. It i.- there joiiied bv its fellow on the o|>po«ite side, to form the optic commissure or miasma, where semidecussation of the nerves HETISA, OPl'W NERVE, AND ITS CEREBRAL ORIGIN. 441 t.iki's placj". The two halves of each nerve are continued backward Iniiii tlie chiasnui in one cord, the optic tract, which winds around the cms cerel)ri and end-s ni the l)a.sai gaiiRlia on each si.ie. The basal piiifilia arc the ."xternal c()r|)ora geniculata, the anterior corpora (luad- iiP'Mn.ia, an. the oi)tic thaianii. From tliese ganglia fibres pitss in tun niani bodies tn the oculomotor nuclei and to the cerebral cortex Hi.; part of the cortex to which thoy are distributed is the mesial smtace (jf the occipital IoJk", the cuneus, an.l the neighborhood arr.und the calcanne fissure. It is probable also that some of the optic ii.Tve film's pass on .lirectly by the corona radiata to the occip- ilal c.)rtex, without enterhig the ganglia. (Figs. 240 and •>41 ) Kiii. 210. OpMc radiations. (Edinokr.) The Sheaths of the Optic Nerve. The coverings of the optic ■ IV.. aie three in number, corresjx.nding with the membranes of the ■i:iiii. Ihe dural sheath, continuous with the .lura mater, forms a ■•'-.■ covering to the ner^.•. the pial sheath closelv surrounds the -IV.' an.l sends .septa to enter its substance. Between these two is !"■ mt.rvagmal spa-e .'ivi.le.l int.. two by the arachnoid. The fibres ' III.. ,,i,tic nerve at their entrance into the eve through the lamina iil'n.Nt contain a me.lullary sh.>ath: as thev pass thn.ugh this struc- :v t!u'v !,.s,' their medullary sheath -nd are oonlhiu.-.l as transluc-nt .H-cylm.i.'rs only. Like the re.st i the ner\-ous system, the fibfs 442 Tin: EYE. I : of tlu- luTVo lire nia.lo up of neurons, tho rolls of wim-h lie m Ww UiinKlion-coll lavcr of the retina, in clos.' union with the visual epi- th..huin, the lav.T of rods and eon.-s. At tlwir other ends th.| hl.res end in brushes, chiefly in the external geniculate i.odies an, optic thalaini. These are known as r(<tino-thalainic neurons \ isual hbres Fio. -Ml. Visual cortex, (j^tarb.; tn the cortex also take their oripn in th(> cells of the external Ronicii- late bodies and optic thalaini and pass upward to be ,listnbute.l to the region of the cuneus ami calcarine tissure-thalanio-cortical neii- ^ rons. There are other neurons whicli have their nuclei in the basal ganglia anil their terniiiial branches in the retina, and probably some also which pass from the retuia through the chiasma and optic tracts to the cor- tex direct. (Plate XVIII.) The chiasma lies in a groove at the base of the sphenoid bone in front of the iiifuiidibulum. In this commissure th<> optic nerves un- dergo a partial decussation. (Fig. 242.) Tlu- fibres from the right half of each retina meet in tiie chiasma and are omtniued on m the .ight optic tract: the fibres from tiie left half of each ivtina unite in the chiasma to form the l.-ff optic tract. The right optic tract Decuasation of optic iiurve librus. (Welis.) IL PLATE XVIII. LEFT VISUAL FIELD. RIGHT VISLAL FIELD. Fixatuml\>Oit. ftxaiumfhutt. LlntCapsu/c h Ocnpilf^ ^" i in I !;!i RKTI.\A, OPTIC .SERVE, AND ITS CEREIiRAL ORIGIN. 443 |i!iss('s Up to thr> occipital cortfx of the ligiit side, the left tract to that on the left side. From this it will Ik- seen that the left half of ihi' visual field in each eye is served by the rifiht o|)tic tract and \\<i.\\\ cortical visual centre; and the rijjht half of the visual field in each eye is served by the left optic tract and left <'.rtical visual centre. The division does not pass directly through the yellow spot; if one optic tract Im" destroyed, the edj;e of the hiind area does not pass tlinuiph (he yellow spot, hut leaves it intact 'ii e.ach eye. This is cNplained by the yellow sp \ beinn sujiplied by fibres p«ing through each tract, -is the nerve enters the retina, the most |M'riplieral fibres -upply the parts around the optic nerve, and the central fibres are di-tributed more to the periphery. The fil)res of the nerve which >upply the retina Ix'tween the papillii and yellow s|M)t, the papillo- iiiacular bundle, are the most important, as tl«'y sub.serve the pur- Section of oiUc nerve. (Graf.fe-Saemisch.) li<is(>s of acu'.e vision. Immediately Ix-hind the eye they occu y iliout one-third of the area of the nerve, in the form of a sector with ii^^ apex at the centre and ba.se outwanl. I''urther back, these fibres lif in tiu' axis of the ner^-e. From these anatomical arrangements '\r are able accurately to localize the seat of some lesions of sight. I lius, if one eye only be blind or defective, due to a nerve lesion, the -I at (if it must be anterior to the chiasma, while affections of vision I conjoint halve.- of the retina are due to di.''-ise of the tract or of Mil' visual paths at)ove it. Defects involving , le fixation point, oeii- 'I'.il scotoni", are due to diseases of ♦he pa])illo-macular bundle. In bitemporal hemianopsia the seat of the disease is \\\ the chiasma. I I one o])tie tract be affected, producing l)lindness of the .same side ■ '-ach retina, a condition known as hunionynHius hemianopsia, the iijiils will not react to light thrown upon the blind halves of the 4M riit: KYK. i rHiiu. l.nl tlu'V will r.act tu li^l.l thn.wn u,...n tho sonnR Iml s (W.Tiiick.-s lH.n.i..|.io pui.illaiy r.-arti..i.). In this caM- wli.n- » nunillarv li^l.l n-tll'X i' i"t.Tl.T,..l with. th. Usum ...u.t Im- m h. i.. tract iM-low th.' .urpom .,ua.lrig.-...i.m, ,.m..nu<-h as th. imthul , L pupillary li«ht ntlex is tro.n th.- ..,.ti.- tract to th- ••«'n><'^>^ M""; " ip-nina. then.-., t.. th. thir.l nm-.- nu.-l.'us. ">" ''"p^f'' ! J'"^/ thini I..TV.. t.. thr |.upil. If th.- inipils ros,...n.l to light t» rovM Ih" h halv.'s of tlu- P'tina-. th.- lesion is higher up, either ui the ..pf- thalunius, internal eapsule. or the cortex. FM. 244. McUardy perimeter. Tn .H'^eases of the optic ner- the sight may Vk- impairo<l in various wavs central or peripheral vision may Ik^ intorfere.l with, the vision eadi eve mav Ik- lost, or the jKTcei.tion of . .,lo.s may k> .lestroycMl. I'.Tiph'eral vision implies the ,H.rcrptio.. of obj.-cts all arouiul the point 'lirc-tlv looked at. Thus, if wc cross a street, a though we may b,. looking .lire.-tlv in front of us. we are conscious of the movement or api.n.ach of vehicl 'S on each si.le of us. We are als<. able to aj-i.re- ci:ite generallv tli.M,ualitv of the surface on which we are walking, an. to avoid obstacl.'s in our path without dir«>ctly looking at them. 1 this iMnver were al^sent. as it is in some .liseases. we should l)e in the position of a person looking down a long tulie: it would »><' /'•m''" ' for us to find our way about; all I'ower of orientation would be lost. RKTISA, Ol'TIC SEHVk, Alfl> ITS I REBRAL ORUilS. |45 The wlitilc uH'si from whirh tho oyi> is rnpahlf of rc'civitift inipn's- 'iciiis is called tlw field of vision, aiul it is capuhic of JH'iiifC iik asun N' •■ »i and. Normal Held. 446 THE EYE. in several wavs; bv the hand, by lipht niovo.l bef..ro tho eye or nu.ro accuratclv. b\- an"instrument called the iM-riineter. I' '?•-«•' ^[ ■■ .1:.. ti.A.\ i„. th^ hnnil the mtient is placed with his back measuring r'thV tield by the hand, the patient is place FlO. 247. Riijht Eye KcrtM.tric conlmclion .,f tl«M us sc^n In Br«y airophy "1 the o,.U.- nerve. Flii. JW I/// Eye Ecc«nlrle «,atr«cUon of Held u «e.i In gr»y atrophy of the optic nerve KETIXA, OI'TIf yKJiVK, .l.V/> ITS CEREBRAL ORIGIN. 447 t<p tlio light, tlio hand hold in various positions l)of()r(' liini, and lie is asked to i)oint out its direction, at the same time l\eepin>j his eye lixcd on the observer's face, (Hrectly in front of him. A small i)iece Fio. 24a. Right Eye HomoDymouB quadrant hemianopsia. Fig. 250. Homonymraa quadrant hemianopsia. 448 Till: EYE. of wliito i)aiMT nmv be used witli tlic same (.bjfct. If the siplit is in.i.airc.1 bv .lis.^as;- cf the front of the ."vc. wo can gc-t sonio knowl- ,.,li,. of thi" condition of tiic visual ticUl by holdnig a candle ni Kia. 2&1. Ijft Eye ivntral srntom« hb 8ecn in toxK nroblyopia. Left Eye \ I n ScotnmBta «s wen in dlsseminBtert choroiditis. HETtSA, OI'TW yEJi VE, ASD ITS CEBEBRAL GRIG IX. 449 various pdsitions before the eje, or by throwii.;,' ii])oii the eye tlic lifllit retleeted from an oplithalmoseope mirror— tlie ^.rojectioii test. The perimeter eoiisists of a (|uarter or half-eircle of metal, revolving .iroimd a \\\i'i\ i)oint, iit wliieli is plaeed a .>mall white spot, the object 111 be looked at by tlie eye lUKJer examination, the fixation jHiint. The eye is plaeed at the eentre of the eirele, and another wliite s])ot is made to travel along the eirele from the fixation point until it can no jonfier l)e seen; the ])oint of its (li>apj)earanee is the limit of the visual li'ld in that (hrection. In jiraetiee it is customary to star with the travelling spot at the extreme perii)ht , -■, and to mark as the outer limit of the visual fielc' the i)lace at winch it hrst becomes visible as a distinct spot of white This limit is a constant one hi healthy eyes. The visual field extends about 95° to the temporal side, about »)0° upward, ,i()° inward, and S0° downward. ( Figs. 245 aiid 2-l(). ) The limit upward and inward varies with the prominence of the brow and no.<e, but it is,ai)art from this, less than in the temporal direction. The size of the travelling spot used varies according to the degree of affection nf sight. It is well to use as small a spot as can be seen with ease for this ])ur!>ose: 5 mm., 2\ nun., or even smaller s])ots may be used. Hut where the acuteness of sight is mucii reduced, it is necessary to use spots 10 nun., 15 nun., or 20 mm., in diameter. In doubtful eases it is also desirable to take the field with diminished illumina- tion. The color fields may be taken in the same way as the field for white by using a small colored object instead of a white one. The size of the color field varies with the size of the object and the iirightne.ss of the illumination. A\'ith very bright light and a sufK- eiently large mass, color can be recognized at the extreme periphery nt the dsual field, but with small-sized objects the periphery of the retina is incapable of appreciating their color. The field for blue is I lie next in size to white, then follows red, and, lastly, green. It is important to take the color fields in seme cases of o|)tic nerve disease, ,is the test is a more delicate one than that for a white sjjot, and often indicates very early stages of optic nerve atro]ihy. (Mgs. 247 and 24S. ) Kel'eets in the field of vision may take the form of a concentric con- ' I act ion, or they may be limited to (,ne portion of the field, such as a ictioiial aii'a triangular in shape, with its ajiex at the eentre, its I'ase at till riphery (Figs. 249 and 2.50): ( r there may be gaps in 'lie field or blind spots of various shajies. These are known as seoto- :uata, ;Mid may be either at the point of fixation— central scotoma 1 ig. 251): or outside it— paracentral scotoma. They may form a lind ring around the fixation point— ring or annular scotoma: or Ih'v may lie situated in other parts of the field, where, as a rule, III y are of little jiractical sigiiihcanee. (Fig. 2.")2.) It should be 'ited that the entrance of the optic nerve nito the eye, inasmuch as ■ I'ontains no retinal elements, is a blind spot. It is placed about "'' 'nitride the fixation point. (Figs. 215 and '1\{\.) SmliiDuiln may be either positive or negative: positive when they 111! a dark s])ot in the field of vision, which the patient is conscious 2» 4r)(» Tin: i:yj:. (if: and lU'jiativc wlii'ii tlicy form iiicirly a fia]) in tlii' Ik'1.1 wliicli is l)lin<l, l)ut wliicli is not ol).icctiv("ly pivscnt as a dai k area to tlic patiiii: At;ain. sc-otoiiiatu are citlx-r absolute or ivlativc: ahsolutc wlicn all i.circ|.tion is lost, relative .hen i.envption is merely ilulle.l. Thus a M-otoma is said to i)e absolute when all perceinioTs ol lifiht and t'orm is lost in it; relative , wh.'U ther.' is loss of pereeption of color onlv. The Light Sense. (See pajie 8').) Congenital Peculiarities. Coloboma of the Sheath of the Nerve. This eondition. due to imperfect closure of the fietal cleft in tiie nerve, is sometimes asso- ciated with coloboma of the choroid and sometimes occurs mdepen- dentlv. It anpeais as a very lar-ie and deep excavation of tlie lower part of the neVve. the whole disk beinj; s(.nietimes very nnich ealarfied. Opaque nerve fibres are seen on the disk alone sometimes, but they fieneraliv spread out over tiie retina. (See Hetina.) Pigmentation of the Nerve. Th.' optic n<'rve is sometiiues very luKhiy colored, of a dull reil-firay hue: this condition, which may be mistaken for optic neuiitis, is coni^enital. \cuif "ptii- niuriti-. N-U' ilisk much s»(.lU-n: . .tim«tal ai 7 l>. K.lBe iurtistiiiii ; vessels ol».eii.e.l III cHlKe, Uirgc iiuniber (if hemorrlmges unminl Ihe .lisk, i«iielie.s uf ufleiiiu in the relinu, veins very tnrtuuna. Inflammation of the Optic Nerve: Optic Neuritis. Inll.unmation i,f the optic nerve may take i)iace at any point in the course of the Kj:n.\A, oi'TK y.jiVE. asd its ' ereurm ouiaix. 451 iiiivc. If tlic intni-dculiir |)((iti<iii is iifTcctcd, tin- (liscMsc is spokon i>t' ;is papillitis; hut if tlic trunk of the ncfvc only is afTcctcd, tlio iiillaniniation <l()cs not show itself oplitliahnoscopically in the head of the nerve, and it is known as a retrobulbar or retro-ocular neuritis. 1 Fi-:. •2h:i.) Papillitis. Inflammation of the Head of the Optic Nerve. Tins -iiows itself in two main forms, hut there i.: no sharp .ine of divi- -ioM between tin'in. and many eases have eharacteristies which will brinii; them imder each heading. I. The swelling is sharjily limited to the disk; in the earliest stages I lie edges of the disk appear blurred : the natural striatioiiof the r<'tiiia Swollen disk in a oaseof clirouic nieni-iKitis. (I.ikhkkrh.i 11 !lie edge of tile disk is more marked; at the same time (he disk ii-.ii jiecomes redder in color, the veins are full and siiow tortuosity, wih 1 tendency to disajipcMr into the (edeni;iloiis reiiiiM at the edge ■'I the ilisk. (Fig. 2.")4. ) The vessels as they emerge from the central I'ii appear to come markedly forward. :iiid a movement of paralla.x - iiblained against the background of the nerve. Uy this test, if lie vessels he kept ill view while the head of the observer is made ■" move a little from side to side, they will appear »o move again.sl Sir edge of the disk behind them, showinsr that they ;ire not in con- iit witii ii. bu! lie ,ii Mniie distance in front of it. .\s the disease dvances the papilla becomes niore and more prominent and stands lit into the' vitreous. The nerve may bo uicreased in reihiess, or I! i 452 it iiiiiv Ix'coiiu' pale I'ri'iu l>r« rilE EYE. 'ssiirc 1)11 It, an 1 inav contain masses ol f •xudation. Tlic artcru ire small, the vcnis vcn V full and tortnoiis WlUTC tl IC V('SS( Is pass over tlic cilgf < f the disk they may disappear into the (I'dcmatous n tina nr i)cliiiid the i)ronmir lit and ovcrhaiiniiiK head of till' ncrv the direct met Flic amoui t of swelling should !«■ cstiiiuitci ,,,.,\vitli the ophthalmoscope. At the same time mm. )und the disk. The retina iid is l».ix of retinal hemorrhafies may ap|)ear an „,>ol Kim.ii ' H frciuentlv ii'dematous. a...- iK.tvveeii the d.A =""'>; : , , .i,,,,,. "si.ot an.l coiitainins tllir'h'' "-t- Tl.i« v„ri,.ty ..t ..|,lic ,».urm» .« k,,...,, ,s ,M.«I '''■}'■ I„ tho other form, ,U;fen,lm.j mi.rilh, ih' il,fl-,mmalion is not »"™ '";;;;ir=i!i»';r;'e.;s;i irri-... ;n«,.. ,„ t„e ':::;; t ;, r;,™ .v !»;.• ...iH-r.-..!..-- ..f..i..; ....... .^;;; ";,";-« S iln.„; it .....y Ik. ,1.,.. to |«.t..rior l.as,c ■."■■'"'f ';';;'»• '>>,1^,^^. 1 -;;;;? ;:;;;;;;:::,: ^; ;S;;:S;l;:.„ti; ,;; :::s::!,:;^^ ™...i..- r' T, , . - i -l."!.' i..tr....r....i..l en'"'!'' "' ""'■>' I*""'- "''"■ " , n, .r,uloii« sw». (iuiimial.. an. II..' ...... '■"......"" ?-" -;;;:r.j;:l::;;;s^:^"-.™;^;"r.!= h'-^i^eiuV-Tlu. presence of a fiumma in the brain not m KETIX.X, OPTIC yERVE, ASD ITS I EREBIIAL OllldlS. 45;$ oi>tic tnu'ts or cliiasiiia dirpctly, or it insiy in some cases form in tiic licad of the u\y\\v nerve nsvU—.-niihililic fxipUlitix. Tlic neuritis is peneraliy double, l)Ut intiannnation al)out the apex iif the orl)it, the optie foramen, the s|)henoi(hii fissure, erysipelas of the in .! extendiiift to tile orbit, or distention of some of tlie fossr^ of tiie nose jiressinj; on tlie nerve, may give rise to un optie neuritis eonfine(l to one side only. The general or systemie causes of ()])tic neuritis may Im- pneumonia; exanthematic feveiN, such as influenza, ty])hoid, measles, scarlet fever, etc.; severe ana'mia, h-ad-jHiisoni'-.g, suppression of menstruation, _)ost-i)artuin C( ■ ditions, or sudden loss of blood. Course and Symptoms. The optic neuritis may exist for a long time without disci>very, the failure of .sight being often so .slight as to 1m' unnoticed by the ])atient. If the attack is rapid and not severe, the ojjtic nerve may recover and only show by the ophthal- moscope that it ha.s passe<l through a conditicm of neuritis. On the other han<l, the failure of sight is sometimes very sudden and ciimjilete. In one ca.se the failure was so sudden that the patient (■omi)laiiied that someone had turned down the gas. Failure may go on to coinjilete blindness, and yet recovery may take place; in other ca.ses vision fluctuates very much. Occasionally cases are met with jiresenting all the signs of cerebral tumor: headache, vomiting, oi)tic neuritis; the optic neuriti" may subside, leaving the disk more or less atrophic and the vision impaired; the other symptoms may cea.se ami the patient may be restored to a condition of perfect health. ( )thers again, es])ecially childre.i, pass through a very severe attack of double optic neuritis without the general health ap])earing to sutT< . in any way at the time, and recover with perinaneiitly i)ale disks, and never have another attack. It is probable that the cause of the neuritis in many such cases is tubercular meningitis, which has lx»pn ivcovered from, or a mass of tulxTcle lying in the brain, shut off from tlie tissues around it. A temjiorary disturbance in the mass of tubercle M'ts up an inflainnmtion around it, produces neuritis, and then rajiidly -iibsides, giving no further trouble. In other cases the (luiescence is not ])eniiaiieiit, but recurreiic(>s of cerebral irritation follow at long intervals, the patient iH'iiig in good health between them. I'.acli attack corresponds to a period of advance in some slowly growing • eivbral neoplasm. One such case was that of a girl of about 'i^hteen, who is still under observation, who has been known to have had o])tic atrophy following neuritis for ten years. She has periods of good health, "and then attacks of very intense pain in the hi'.id, vomiting, delirium, etc.. recurring at intervals of several months. In one of these attacks she had violent epileptic fits, which produced petechial li(>morrliages of the conjunctiva and face. The disks are (|uite white and .she i.s jiractically blind; although she has central virion of "-, it is at such a jiin-point area in the centre of the blind ^ isual fiekfthat it is with the utmost difficulty that she can find the ■bject she wishes to look at. 454 TllK KYK. Tlic -itl-ick-i vary vcrv iimoli in tlifir duration: sonic of tiicni an- v.-rv la'i.i.l an.l pass awav entirely in a few weeivS. en.lin« in r.rovery with or without .lest ruction of sijjlit: in others t lie eonihtu-:. is very ,.l,n,nie the appearance of neuritis in tiic disk hem}; present for months' As a rule, attacks are sinjilc. hut cases have I n descrilied hv \udcrsoii, (lowers and others in which second attacks have heeii observed, and Cunn has s.-en oi-tic neuritis occur u> a well-(h"veloi.e(l form in a disk wiiich had pri'viously Ixrn noted to he atroi)liic. Optic neuritis occurring; .lurinj: or after pre«nancy is probably .lue to some toxic condition arisiufi Iroiu the uterus. It subsid.'s alter a tunc without much iinpainiH'nt of vision. \n'cmi'i may give rise to the most severe optic neuritis ami very ureat' swelling of the disk. This may Im- a .simple swellinR consisting niainlv of (edema. <.r it may Im" accompanied by large numlH'rs of retinal hemorrhages and exudations into the retina. Optic neuritis ,lue to ainemia is often verv sml.len in its on.set. It pmsents a con- trast to that occurring in cerebral tumor. In addition to making an examination of the g.'ueral state of healtli of the imtient, with analysis of th<' urine, it is advisabl(> here to make an examination of the blood, counting the number of corpuscles. Suiii)ression of menstruation from exposure to cold is said to cause rapid failure of sight after oj.tic neuritis. It is possible that many such .-auses may come umler tlu' heading of aiuemic or chlorotic Optic neuritis in jead-poisonmg varies m degree from the slightest haze of the disk to a severe acute swelling of the disk with hemor- rhages It .sometimes extends widely into the retina, i)roducmg an ophthalmoscopic api.earance not much distinct from albuminuric retinitis of granular kidney. In this case it is probable that the cause lies in the granular condition of the kidneys, caused by Bright s disease, which is verv likelv to occur in those sutrcriiig from leail intoxication. Tiie urine shoiild be exaiir --d, an.l other signs of lead- pois.)ning sought for, such as the iiresence .if a bluf line on the gums. Spurious Optic Neuritis. Mention must be ma.le here of a oiuhtion of the disk, which is s.imetimes met with, resembling optic neuritis in the acute stage. Tlie.lisk is re.l, congestcl, with blurred e.lges, an.l a measurabli- amount of swelling, or it may apjiear bhirre.l and rather jiale, as in a subsiding neuritis. The vision of the eye is normal, the visual fields are normal, the eol.ir visi.m and the light sense are normal, and there is n.i hi.story of any previous defect of sight. Many of th.'se ca.ses have hei'U watche.l for years and n.i change has been iiotice.l in the ophthalm.iseopic apiiearaiices. A smaller .legree of the same c.iti.iition is not uncommonly met with in the red ami streake.l ilisk of hv])ermetr.ipia. In Ixith of thi's.' con.iiti.ms the appearance of neuritis i.s prol)abiy due to a congenital peculiarity of the ..ptic I>apilla. , . , • 11 Cause. The causes of ojitic neuritis in their relati.m to cerchrai tum.ir have lieeii .liscusse.l at gr.-at length by many writers. \'on ItETlSA, IH'TIV SKItVE, AXD ITS VKREUUAL OlilGLS. 455 (Inu IV cxpliiiiicd it jis IwiriR a swelling imxlupcd by a lilockinpof the cavfiiiniis sinus and of the trihiitaiy ()|)litlialiiii(' vein, licnc«' the name '"chdlicd disiv." Schini(it-Hiin|)l<'r and Manz showed that the fluid displaced by a cerebral tumor found its way into the lymph spaces of the optic nerve, the intersheath spaces became distended with liuid, es|)ecially at liie ocular end, where there is an am|)ulla-likp iiilarjii-ment nf the inti'rsheath space. The pressure of this fluid passed into the optic nerve and compressed the retinal vessels, by which the thin-walled veins were affected more than the arteries. Il( lice, a hindrance to the exit of fluid was produced, which gave rise to the choked disk ajjpearance. According to Leb-r, the presence iif this fluid sets up a toxic condition and gives rise to an inflamma- tion of the nerve. Other 'vriters have Ix'ld that tfie neuritis i.s a true descending one: they nave shown that there is an increased cel- lular exudation in the ti.ssues surrounding the cerebral tumor, which extends the whole way from the tumor to the nerve and along the latter to the eye. Wliether this be the fact or not, there can \)c no doubt tiiat a great deal of the swelling in choked disk is caused by the pressure of fluid in the cranial cavity, and secondarily in the -uiiarachnoid .space of tiie nerve, inasmuch as relief of pressure iMUses reduction of the swelling in the disk. The results of Hors- l( y's work have shown that trephining the skull in ca.se.s of cerebral tumor causes diminution in the optic neuritis, even when it has been found nnpo.ssible to remove the tumor. Prognosis and Treatment. The j)rognosis depends vvty much on the nature and cau.se of the neuritis. In a case of cer'bral tumor wiiicli is incajjable of removal, and which is steadily growing, the prognosis is serious; the treatment is that of the cerebral tumor. But even if th ' tumor be necessarily progressive and incapable of removal, life may still la.st many years, and, if the sight can l)e .saved, it shouhl lie done. It may be .said that the operation of incising the di.stended -lieath of the nerve behind the eye ofTeis no prospect of relief, but I lie results of Horsley's work give great hope of lessening and even "I stop])ing the optic neuritis l/y trephining the skull and relieving iiilraer.-inial pressure. In suitable ca.ses this plan should be carried "lit: it is .scarcely nece.s.sary to use it where theoj)tic neuriti.s is not very severe and does not interfere much with the vision. Much Mihietion in the amount of .swelling can al.so be .sometimes ob-tained l'\' the use of iodide of |)ota.ssium. In chloro.sis the prognosis is good, liiit it de])<'n(ls on an early recognition of the cau.se. Treatment -liii'ild be in th( main by iron, aide<l .-sometimes by arsenic and l)y I'gulating the other factors of health, e.sj)ecially by relieving con- lipation. In cases a.ssoeiated with disorders of men.s-truation hot 'i.illis should be given and leeches applied to the temple. In the MUte specific fevers the progmwis is good and treatment calls for no -!"!'i:d rejiiark. In le.Md-jioi-r .'vi^ the prognosis is not very gODil; h" cases go (;n f"re(|uently to atrophy, and the po.ssibility of renal '■niplications arising should be borne in mind. The treatment is 11 HI 456 THE EYE. that of Ica.l-poisoniiiji generally. 'I'lu" <^r-."s occurriiiK in prcpnaiicy recover without Koinji on to complete l.limhiess; they re(|Uire no siM-cial ocular treatment. The sy|)hiiitic cases sh..ul(l Ih^ treated acconhiiji to the seat of tlie syphilitic lesion. If it Im- a local atTec- tion of the h.'a.l of the nerve, .svphilitic optic n.'uritis, munction of mercury should 1m- ti.sed; if this Im- carried out efficK'ntly m the early stajre, the prospect of recovery is good. In the other class in which the optic neuritis is secondary to Rununatous disease of the hram, the prognosis is less pood and the treatment shouhl be in the main i)V iodides. . , , ■ e ' Retrobulbar Neuritis. Hctrobulbar neuntis, the other mam lorm of iuflanmiation of the oi)tic nerve, as distinpuished from papillitis, shows itself l)V chanpes in the nerve behind the eye. an<l only ai)pears in the papilla" at a later stape. It jjroduces a diminution of central vision, the jK ral area of the visual field beinp unchanp-d. It has iM-en investigated bv maiiv observers, of whom t!ie earliest were Samelsohn and Net tieship. The results of their investigations showe, that it was tin- i)apillo-macular bundle of fibres employed m central vision which was affected. The papillo-macular fibres supply the yellow spot region, and in the optic nerve occupy the temporal .side of the disk. In the anterior part of the nerve behind the eye they form a wedge-shaped segment, whose apex is toward the centre, and ba.se toward the temjioral border of the nerve. Further back in the nerve these fibres occujiy a more central jjo.sition and do not reach the edge of the ru'rve: in the .skull they form an oval ma.ss below and to the temporal side of the centre. In inflammation of this bundle of fibres there are proliferation of the cells of the neuroglia, engorgement of ve.s.sels, and interstitial neuritis, and at a late stage degeneration of the axis-cylinders from i)ressure. The effect on vision of this inflamm;iii..n of the papillo-macular fibres is the for- mation of !. blind spot in the visual field, extendi' , rom the na.sal side of the point of fixation longitudinally outward as far as the normal blind .sjiot. The density of the scotoma varies from an ina- bility to (listing' li color o' a lessened jyerception of color at the ,.,.„,■,.,.— relative color scotoma— to a loss of percei)tion of form- absolute scotoma. The cau.ses may be classified according to their ,<eat and nature into: Lt.cal causes -orbital cellulitis, erysipelas, local ])('riostitis, sviihilitic or not: tubercle or .•<ei)tic inflammation from the neighboring sinuses; of the.se, the sphenoidal sinus is the most likely one to give trouble, as it is sepjirated from the optic nerve by only a thin laver of bone, ricneral causes : gout, diabetes, the various jioisons, general septicicmia, hereditary retrobulbar neuritis, ,•111(1 disease occurring in the optic nerve as i)art of the nervous sy.stem generally. The disease sho-vs itself in an acute and a chronic form. Anilf' lirlrohiilhnr Xciiritis. This is manifested by a nipid failure of sigiit on one eve. generally jm-cedc-d by neuralgic pain in the toni- ]>le. ]<tnn in i)ressing the eyeball back into the orbit, and in movenient of the eve from side to side. As a consequence of the pain elicited as RKTiy.i, (H'tic seuve, asd its veheiuial oniais. 457 !)>• iiiovi'iiH'iil of the cyi's, they arc frcinicntly kept clowd. At first tlicrc is scjtrcrly ally ()|iiitlialin(isc<»|iic cliaiijit', hut later on the disk Imcoiiics paler ami the vessels may heeotne contracted, the pupils ,ire dilated and sonii'what inactive to liftht: or if the reaction is pxid, it will Im- found that the contraction on exposure to light is not main- tained, the pu|)il quickly n Ixiunds. I'ailun- of sight goes on increasing for four or five days, reaches its height, and, after a week or so, hegic;, to recover slowly, the |K'riod (if recovery occupying a month or six weeks. The (h'feci is often descrilx'd as a mist or dark sjiot which covers the ol)jecl> looked at, and gives the ap[K'araiice of a gray-brown spot r)n a white surface. The vision is worse in bright light and imi>roves after rest, as in the early morning after u night's rest. This etTect of bright light is probably caused by over-stimulation of the weakened nerve ele- ments or by their imperfect insulation. It was noted by Herry as a point of ditference b'tween papillitis and retrobulbar neuriti.s" that the light difference, as tested by Hjerrum's types, wa.s .scarcely j)resent :it all in papillitis, but was str(>ngly marked in retrobulbar neuritis. The visual fields are not contracted in the ordinary cases, but there is a central defect of vision extending from the yellow sj)ot and including the o[)ti? nerve entrance. Sometimes, however, central vision does not fail, but a iMTijiheral contraction of the visual field may be present, as in the ea.se of jxTiostitis in the oj)tic canal, when the defect in the visual field corn's|M)n(ls to the .seat of jjressure cm the nerve. Hock believes that it is pos.sible to indicate the .seat of the disea.se by the direction of the movement of the eye, which j)ro- duces j)ain, this iM'ing due to stretching of the .sheath of the nerve. Thus, pain on looking uj) would indicate the lower part of the sheath of th(> nerve as the seat of the inflammation, and the upiwr {)art of the visual ve.s.se! as contracted. This is certainly not always true. .Vfter recovery ha-s set in, the process may continue until the sight is (|uite restored to the normal, or there may be jiermaiient loss of vision. In tho.se ca.ses where the focus of the disea.se is clo.se behind the eye. the papilla is involved, anil it is not easy to distinguish the lase from one of ordinary papillitis. In ordinary papillitis the failure of sight comes on later in the di.sea.se, even after the attack has begun to subside, while in retrobulbar neuritis, failure of sight occurs at I lie very Ix-ginning. Treatment. In addition to the treatment of whatever may l)e I he obvious underlying cause of neuritis, such as syjihilis, tubercle, iiout, etc., much may be done in the way of local measures. Dark ^'hi.s.ses or goggles should be worn in bright light; leeches or the arti- ficial leech, or blisters should be applied to the temple and all use '■f the eyes forbidden. Iodide of potassium should be given and any liical disea.se in the nose shouhl be dealt with. C/miiiir Retrobulbar Xeuriti.s. Under this heading we find the \ arious forms of toxic amblyopia, the most common of which is that I'roduceil by tobacco or tobacco coiubined with alcohol. Other k ! k II 458 THE KYE. niiw'!* air l>i.-<iil|)hiil<- of carhoii. iiscti in tin" ciiriiiK nf vulcanite, iiMloform. u<i-aMonally s.mmi ali.T its use in snrncry: nitrulx-nzol. (lynainitc. niciliyl alcnhnl, |i-ail, male IVrn, |M.nii'nranatc root, .laniaica >;in>;i'r, ami otliiT sul)stan('t•^*. Till- (|uc?'ii<>n of till' fxistrnccdf pure aln>liulic aiiil)lyi>|iia a|'|K'ars now to Im- . -lalilislini in tin atlirinativc, liiif tor a ioiij,; titiii' it wan a iiiiicli ilis|niti'ii point, for no case of aiiililyopia was iiii-t with in which there was an entire aliseiice of the use of toliacco. Alcohol (liM-s uniioiihteillv fre(|uently influence the course ami nature of the toliacco anililyopia. The \.orst cases met with ami the ones which n-sult in iiiiiM'rfect recovery are those in which consiileralile ainimnt.s of alcohol have Im-cii taken in aildit'- • ■ the use of toliacco. Diabetic Amblyopia. The questio.. of anililyopia has also In-en discussed from the point of view of its j ssocialioii with dialn'tes tin a cause, rndoulitedly dialM'tics are ver.v su.sceptihle to the influence (if tobacco, which is apt to produce in them a toxic aiiiMyopia. The rapiility with which this may lie lirouftht aliout is shown liy the case of a p.-itieiit, aned fifty-four years, who had been known to have dia- t)etes for at least two years, .\liout four months iM-fore he was first seen he had retired from active work, and, time heiuf; heavy <in his hands, he had taken to sinokiiiK for the first time in his life. He smoked verv moderately— not more than one pipe a ilay~and his sifiht hepan to fail alM)ut three months after iH'jtinninft to smoke and almut one month Iw-fore he was seen. His sipht at that time wjus !{• " . I" ("u* "'■ '""' '"' <'''"^''"' color scotoma, in contraction of his visual fields : hir^ optic disks were rather pale. Me at once dis- continued tobacco, liiil his si>;ht cniitinued to fail, and two months later was reduced t«i ^^ in eiu'h eyi-. His optic nerves were then very pale. .Mthoujih mot of the dialierics who have come under obser- vation with central scolom;i have been users of tobacco, a few ca.ses have been met with, some of them amoii}; women, in which ♦ here appiari'd to be no cause for amblyopia apart from the dialM'tes it.self. Pathology. The chanjies that have lu'eii found post-mortem have been coiitiiicd to the paiiiilo-macular fibres of the optic nerve. They consist in thickeiiinj; nf the coats of the vessels in the optic nerves and an iiitei-stitial neuritis or increase of the connective-tiss.ie elements ill the optic nerve with atrophy of the nerve fibres. Lately opinion li:,s been leaning toward tiie view that iheehaiisre bepns by a dcpener- alioii ill the macular rejrioii of the retina. The exiieriments of I.ang- ley on the influence of nicotine on the activity of the gaiiplionic cells has further stimulated iiKjuiry in this direction. Xiiel has held from eN.'Uiiinatioii of a section of the yellow spot that the disea.se starts in the macula lutea. Whether this chaiifre is due to the action of nicotine, or, iir)ssibly, some of the other constituents of tobacco smoke, notably pyriiiirie, on (he >;a!ij:lioiiic ceiis or ijieii' .-yna]i.s<s, or whether tlii' chaiifres found in them are due to an interference with their blood simply, must, for the present, remain undeterinined. h! HKTISA, Ol'TlC SEHif:, A.\D IT.S VKHKHRAL (tRKllS. 459 Sjrmptomi. There arc soiiietitneM pnwnt the symptuniN nl getieriil liil(:i(((i-|)oi.M>iiiii>t, riipidily of the heart-h-at. ^leejilessness. loss of ;i|>|Miite. tremors, ete.: hut these may Iw eonspieiiously al)seiit. Thi' >iKht i,-* ilim. there is a mist or a fog over the objects Ilireetly looked at, and an iiiahihty 'o (hstiiijruisli colors, as, for instance, to tell readily a sovereipi fi .m a shillinij. The sijflit is worse in a hright than in a sulxiued liKh the acutenes.s of vision may Ix' eonsideraidy led need, from g to,,,, or even lesv.. Ophthalmoscopic exjirnina- lion siious slight haziness nl the disk generally, with pallor of the lemiM.nd half. In other res|)ects the fundi are normal, and -vcn these changes are hy no means constant or easily n-cognized. The visu.il fii'lds in true tohacco and)lyopia are of normal extent. Hut at the fixation point there is a .scotoma or hiind area for colors, extending from the fi.xatioii jMiint to the blind s|H)t. The size of the ,-cotoma and its densiiv vary very greatly; its average size is an oval, h.iving a horizontal diameter of alwiut Jn°, with a vertical diameter '!* I"°', '^'"i"'^'""''* '' '■'< larger and extends outward almost to the limit of the color field, when it is sometimes difhcult to discover the natiiri- of the .scotoma, unless we use test .spots of con.sidernhle size. I'erception of green is lost first, then of red: })ercej)ti<)n of blue and y( !iov are le.ss fre(|uently lost. The |M)int of greatest .saturation of the color defect lies outsi<le the fixation [loint. It is nearly ahvav." possilile to make out at thi.ss|M)t that the scotoma is absolute— that is that jK-rception of everything is lost at it— but the examination ni|uires care with a very small test object. It is sometimes difficult to obtain good evidence of the .scotoma, In-cause of the inability of the patient to fix the object steadily. This is most commonly found when t!ie condition of tobacco shakine.ss is far advanced, arid csik'- I iaily hen it is complicated with chronic alcoholic jM)i.soning. The -liit'tn..'ss of the eye under observation and the wandering attention I't the patient are well marke<l and almost characteristic. If this dricct be met with, the best method of making the examination is to cut out a piece of paper, re<l on (.ne side ano ^reen on the other, .iboul ") mm. s(|uare, and stick it into the nib of a pen. Armed with this, stand directly in front of the patient, and tell him to look steadily :ii liie jioint < 1 your nose, one eye being covered. It is possible then I" change rap <ln- the [josition of the color s[)ot, and, at ti:.- same lime, to k.'cr a close watch, on the fixation of the eye. In this way I he examin; ion \y made accurately iind rajndly. If it is desired to keep a record of the size of the .scotoma, it .should be charted on the perimeter In addition to finding the scotoma, it is necessary to see 'hilt the fir. , of vi.sion is not contracted, that the jjallor of the di.sk i- litiiit<Ml to the temporal side, thai there are no other signs of nerve li-order, like talx's or insular .sclerosis, before coming to a conclusioe >- to the nature of the di.sea.-e. Prognosis and Treatment. TIk- prognosis is good, provided *hat !ie patient will abstain from all u.se of tobacco; imjjrovement nay 'liow diminution of the amount used, but it is well to insist that all is i» IL 4G0 Till: EYE. t(il);u'e() sliould ho fiivcn up, as ;i very ,• small amount is often sufficient to koci) up ilic irritation 111 addition, it is well to frivc sin; ill dailv doses of stryehnine. Improvement f;enerally sets in a_ weeks and pies on to complete recovery fter about two \s to whether the patient niav resume si iioking after rec )verv or not, lie may do so to a very moi lerate desiree after an interva that tobacco has on many c habit has been broken, for it not to be resunu l"of months; but, seeiiis the hold nitirnied smokers, it is well, when the d, for relapses, although ncominon. may occur 11 aico Ii 1 some o f the worse cases oi tob:i hoi blindiH'ss the loss of vision amounts to all but a ])erpepti(>n of li'dit 111 such cases strvchnine should be jjiven in full doses. It is uM'ful to combine it with nitroslyc'rin or to fjive inhalations ot •imvl nitrite: at the same time the general health must be considered, •IS Mich iiatients are often broken down, and .sometimes on the l)rink of delirium tremens. Sleep and a sufficient amount of nourishing food must be secured. ,,.,,•■ r i Bisulphide of Carbon. The svmptoms of l)isulphide of carbon jjoi- soiiiii" resemble much those of the most acute of the tobacco-alcoho cases'" Thev are giddiness, pallor of face, unsteadmoss of Rait, and tremors, with failing sight, a mist before the eyes, dilated pupil, and ophthalmoscopicaliv disks which are pale or hazy all over. 1 he effect of carbon bisul|)hid<> is more severe than that of tobacco. In ■I collection of cases made by the Ophthalmological Society of the United KiiiKdoiii, :« per e(>nt. recoven^d vision, 25 per cent, improved, and _'() per cent, did not improve at all. This disease is verv rare now. owing to improved methods of veiiti lation in factories, In- which the vapor is not allowed to circulate among the workers, but is ilrawii out of the room by ])roi)er extrac- tors, so that cases rarely come under care. Treatment is that of tobacco aniblvojiia. Chronic lead-poisoning is churacterizeil, in addition to the general signs of pluml)ism, by loss of sight, often of the central scotoma type, slHit ••lironic neuritis of the optic nerve, passing on to atroi)hy, with some contraction of the field of vision. In addition there may l.e the signs of albuminuric retinitis secondary to granular kidneys, caused bv lead-poisoning. . Hereditary Optic Atrophy. This disease, which is characterized m it-; ..iwet by loss of central vision, the peripliery of the visual field beiM<' retained, prob:d)ly belongs to the retrobulbar neuritis grou]), •ilthougli the oiihlhalmoscopic apiiearaiices, .as a rule, are tliose of simple atniphv. It begins in early adult life, generally from eighteen to twenty-five years of age. attacks the m.de members of a family mo-^tlv is transmitted through the females, and generally appears in successive generations, .\nolher feature of the history of these fami- lies is thelargi' number of early infantile ileaths which it reveals. Thi. j!i=p;(se is geiiendlv slow in its progress and is unaffected by any treatment. It'^loes not go on to ( iplete blindness, a certain amount of periphera' viMoii being retained. KHB^HNM ^nv^io KETIXA, OPTIC SERVE, A.XD ITS VEREBliAL ORHilX. 4(J1 Amblyopia is said to bo produrod by a very largo number of apoiits. Hut siicii oaiisos aro very imt'ommou; the only ono which calls for s|(i'cial mention is Quinine Amblyopia. This may bo caused in susceptible individ- uals by comi)aratively small doses of tho salts of (luinine: but tho doses known to have caused blindness aro from 15 jjrs. to r>j, taken in the tlay. Tho loss of sight comes on rapidly and varies in degree, but it may bo total. The pupils are dilated and irrespoiisiv<' to light: ophthalmoscoi)ically tho disks are seen to bo pale, tho retinal V('ssels very small, like the aj^pearancos in atnjphy of the optic nervo. (Kdema of tho retina is sometimes present, and a chorry-red spot at the macula, like tho a])i)earances in embolism of the central retinal artery, is met with. It can sometimes be recognized that the visual fields aro strongly contracted. Recovery takes place first at the c('ntre of tlio field for form and then for color, but a certain amount of contraction of the fields of vision often remains permanently. Prognosis. In most cases recovery takes place to a certain extent, but tho process goes on for months before it is c( mplete. Relapses may occur if tho drug be again administered. The oxporinionts of Mniuner, Baraba.schew, and do Schwoinitz have shown that tho lesion is a peripheral ono, depending on defective nutrition of the nervo and retina, from oxtromo contraction of tho retinal vo.ssols. There is no neuritis, but thickomng and obliteration of the lumen of tho arteries supplying tho optic norvo, chiasma, and optic tracts are .soon. Accord- ing to tho experiments of Ward-IIolden, in dogs fed on (juinino tho I ' uigc first .shows itself in tho ganglionic colls of the retina and nerve tibres: by tho forty-seveiith day tho ganglionic coll layer and norvo- lilire layer had almost disappeared. He holds that with a los.-^onod blood supply the loss resistant elements of the retina— the ganglionic rells -break down, and that there is an ascending degeneration of the nerve (ibres secondary t ) this change in tho nerve colls. Treatment. .\dministr:ition of (juinino and its salts nnist bo -■tiipjicd. Nitrite of amyl or nitroglycerin internally aro the best tmius of treatment. Strychnin:-, digitalis, and iodide of potassium in.iy also bo used. Retrobulbar Neuritis Due to Disease Affecting the Nervous Sys- tem Generally. The most fn^piont cause under this heading is insu- lir sclerosis. There is nuich similarity between certain ca.ses of acute ivtrobulbar neuritis and insular sclerosis, and al.so between the latter iiid tobacco amblyopia. In insular sclerosis optic nerve changes ire not infro(|uent, and also loss of vision without ophthalmo.scopic iiins. probably duo to an actual aflection of tho nerve. The insular I 'rrosis attacks tho norvo as it attacks other parts of tho nervous \-^teni in tho form of islands of sclerosis, in which tho nerve elements 'AX be interfered with or altogether destroyed. The method by liich tho pallor travels from the seat of tho sclerosis down the disk lint explained. It may possibly be due to wasting of tho con- it'ugal fibres, which go from the bisal ganglia to tho retina. il 462 TlIK EYE. Optic Neuritis with Dropping of Watery Fluid from the Nostril. \ few ca^cs have been ()l)scrvc(l in whicli there was a persistent How of fluid from one nostril, with lu>a(laehe, vomiting', .Irowsiness or ,i,.iiri.i.n, and an.hlvopia. Optic neuritis is present at the same tune. The fluid analyzed lias been found to resemble eerebro-spmal fluid, in s„me, if not all of the eases, and there is great probability ot its e«cai)e from the skuil through the eribriform plate of the ethmoid The prognosis is not good and no treatment has hitherto been found " Atrophy of the Optic Nerve. .\troi)hy of the oiitio nerve is either ■X primarv disease ( >■ is s.rondary to some previous atleetioii of the optic nerV.", like optie neuritis, embolism of the centra; .rtery of the retina or to retiiiochoroiditis or retinitis i)igmenlosa. (lig. ^aa.) Fio, 2r.r,. Ophthalmoscopic appearance of disk i.i atrophy l.)llo\vin« hemorrhage. iJaeukr.! I'rhwini optic utrophy, also known as simple or progressive .itroi)hv is charact.Tized l)V gradually increasing i)allor ot the optic 'nerves' wit liout signs of inflammation. The disease is generally biiiteral. The .-<mall vessels of th.' nerve disai.pear, the retinal arte- li, ~ dwindle, the veins beeomi' funnel-shaped at the disk, and the disk a-^Mimes a delicate !)lue-white tint. The vessels make a slight iMMid it^ they i)ass over the edge of the disk, owing to a slight atrophic evc-iVMlion of the <lisk; the stippling of the lamina cribrosa becomes marked, tlu- sight undergoes jirogressive diminutu.n, percei)tion of color i'^ lost, and the fi(>lds become contracted, generally concentrically, but iierhaps more in one part than in another. The most coimnon cause of primarv optic atrophy is tabes dorsahs. The atrophy is often the earliest sign of tabes and may i)recede any otlii'r syinpti.m bv vear* (lenerallv where the sjaiial symptoms come ..n early, the 'oi.tic atroj.hv is late in ai)p<-arance. .\niong the other signs are smallness of" the pupils, spinal myosis, the Argyll-Rolwrtson RETIXA, OPTIC yi:jlVi:, AXD its cerebral ORKIIS. 463 [tupil, loss of the knoo-jcrk, and loss of oquilihrium (Romhenfs si/nii>t()m), x\w ataxk- Rait, while the patient may complain of j)eri- ixiic acute attacks of indigestion (gastric crises), lijjhtninf; j)ains in the limbs, or girdle pains about the body. The atrophy of the optic nerve may go on to comjjlete blindness without the ajipear- ance of any of the other symptoms, the i)atient remaining in good iiealth. In some of the cases the disease comes to an end, the optic nerves only are affected; probably these should be regarded as cases of arrested tab(>s, but generally tlie signs of ataxy develo]) later. In complete tabetic atrophy the retinal ganglion cells have Ix'en found to (lisai)pear: Ward-IIolden discovered only degenerated ganglion cells here and there, even in the macula. If this be so, the atroj)hy of the nerve it.self is jjrobably secondary to that of the retinal ganglion cells. ()|)lic atrojjhy also occurs in insular sclerosis and general j)ar- alysis of the insane, and it ha.s in a few rare cases been found asso- ciated with diabetes insij)i(' is. It may follow local changes in the orbit, as the jm'.ssure of a tumor. The.se fonn.s are characterized by their being one-sided and affecting only one portion of tlie nerve. Sim])le atr()i)hy is rare in children; it is most conmion after middle age. It is often difhcult to distingui.sli primary atroj)liy from the atrophy which accompanies very chronic glaucoma. The difference can generally lie made out by the fact that in the latter disease perception of colors is not lost, and the oi)hthalm()scoi)ic appearances show that the excavation of the disk is very much greater in glau- <onia than in primary optic atroi)hy. The prognosis is generally unfavorable; primary atrophy leads almost certainly to blindness. Treatment should be directed to the disease underlying the atrophv; I'nr the optic nerve itself we may give strychnine or iodide of |iotas.sium. I'ont-iicuritic (itmphji is the last stage of an ojjtic neuritis. It differs in oi)hthalmoscopic appearances from primary atrojihy in the .ippearance of the disk and pjirts around. Instead of being <|uite ' lear and sharply defined, the disk is covered by a light haze, as if it iiad been washed with Chinese white, the veins are still distended ind tortuous, an<l both arteries and veins have white lines along ihem, owing to thickening of their sheaths; the lamina cribrosa is iii<lden by the remains of the inflammatory exudation and there is ■ ■■ disturbance of the choroid around the disk. In many ca.«es, how- ' ver, it is impo.ssible to say with confidence whether the atrophy is .irimary or post-neuritic from the ophthalmoscopic a])pearances alone. I'ost-cmholic and I'ost-thwmbotic Atrophy. These are ilistinguish(Hl '•'}■ the obliteration of the affected ves.sels, which may have liiunk to white bands only c- may contain .a small visible column i iilood. and by a certain amount of change usually .seen at the yellow \y\. The tialiin- of {)ost-embolic atrojihy can generally be deter- iined by the history or by the mode of on.set of the affection, that is \ its absolute suddenness. 464 THE EYE. r„M-rcHnUic Atmplni. IIV/jv Atrnphj, I'oM-rhowidHtc Atrnphi. Tlic t)ai>illa ill this disease' appears to liave a dirty yellowish-re.l (-(jlor. the vessels are narrowed, and there are sij,'ns in the liindus ol oh clior- oi(hil or retinal disease. . In filauconiatous atrophy, tyi)ical plaiicontatous excavation ol the disk, where the vessels disai)pear at the niarfiin of the disk and are dis- placed toward the nasal side, is tin' distinRnishiiiR featnre. Tumors of the Optic Nerve. Tumor of the oi)tic none occurs rarely In vol. xi.x. of the Tmnmctionx <>J the Ophthobnohunnt Snriehi of the rnilnl Kim/chm. Huller and -Marshall f..un<l only i:}0 cases recorded in literature. The greater number of cases occurred Fio. 256. Coloboma of opilc nerve. before the ape of ten vears. and the liability to the disease dimim.shed with afie. The svniptoms of the affection are rajud loss of sight, for- wan' a'lid outwaril |)rotrusion of the eyeball in the line of the axis ot the orbit, little or no limitation of inuv(>meiit, and no pain. 1 Fig. 2,)t|.) The tumor niav be felt in s e cases behind the eye. The seat of the growth is mosl'lv in the central portion of the optic nerve, and it is not ..nnim.m for tlio <'ve to be involved. The kinds of growth found after n-mov.Ml have' been gliomata or tui;;ors of the neuroglia, sarco- imata or endotheiiomata. Tuberculous tumors have mala, myxosarcoii !i!so been se<'n. (he Treatment. 1. Uenioval of tlu' tumor with iireservaimn ol llie eye. This may be done l)v dividing the external rectus, rotating the eye inward and removing the involved optic nerve, replacing the eye and RETINA, OPTIC NERVE, ASD ITS CEREBRAL ORIGIX 4(j5 suturing the external rectus: the external wall of the orbit may be removed to faeilitate access to the tumor (Kronleiu's operation). 2. luiucleation of the eye with the involved nerve. ;{. ivxenteration of the orbit. Having to deal with a malignant growth, it may be (juestioned whetlK'r it is worth trying to save the useless eye. which is a great hindrance to the easy and efficient removal of the tumor. Having regard to the life of the i)atient, it is wi.se to remove the growth as widely as j)ossil)le. Injuries to the Optic Nerve. These are caused most fre(|uently by falls on the head. The base of the skull is fractured and the optic nerve is ru|)tured by si)lhiters of bone, hi the optic foramen. Sight may be lost without rupture from hemorrhage into the sheath of the optic nerve. The optic nerve is sometimes injured by foreign bodies penetrating the orbit without the eye Ix'ing injured. I'he most famil- iar instance is by the ferule of an umbrella or walking-stick. The optic nerve is .sometimes divided by bullet wounds traversing the orbit, frecjuently in ca.s(>s of attempted suicide. In some of these ca.seb ra-ocular hemorrhages and ruptures of thechf)roid have been found, although the track of the bullet was far removed fro-ii the back of the eye. After rupture blindness comes on at once; if the pai)illa appear to be pale immediately after the injury, the nerve has been ruptured in front of the entrance of the central retinal arterv. If the rupture Ix- behind this, the pallor of the di.sk may not come on for three weeks or longer. Loss of Sight after Severe Hemorrhages may result from optic nerve atropiiy: it may come on from surgical or post-jiartum hemor- rhage. It most commonly results from hemorrhage from the intes- tinal tract; at first there may be crdema of the retina followed by atrophy of the nerve. If loss of .sight be coming on, the patient should be placed in a horizontal position and if possible intravenous injections of saline .solution should be made without delay. Sometimes the less of sight comes on .several days after the hemorrhage. The cause of tliis is not clear, but it is thought by Leber to be due to hemorrhage into the sheath of the nerve creeping forward from the base of the skull. In .some cases of injury the blood travels forward and may lie .seen jifter several days beneath the conjunctiva and even in the lids. Treatment should be rest horizontally, iron, proper feeding, etc. Hyaline Growths in the Optic Papilla. " Hyaline nodules growing from the lamina vilrea of the choroid are very common. In rare cases they ajjpear on the disk it.self; they are gray nodules clustered together, generally at the edge of thi- disk. They do not as a rule in- terfere with vision, an<l no treatment is called for. Ocular Signs and Symptoms Attending Diseases of the Brain. fipiic neuritis and loss of sight may indicate tumor of the brain; ihey are of value as showing tJ _> presence of a tumor only; they have 30 4G6 THE EYE. S 1 no localization value. The form of oi)tic neuritis known as choked disk is the one which conunonly attends eerehral tumor, hut the neu- ritis may also he coinhined with retinitis witlumt nuicli swelliiifi, and niav resemhle alhumimn-ic retinitis, even when the cause is an intra- craiiial prowih. In case of iloubt, examination of thi' urine should be made, ""in meningitis and Iivdrocephalus ojitic neuritis may also l)e l)resent. Cvsls and hemorrhages, as a rule, .lo not give rise to ocular symI)tom^■, but an abscess of the brain may do so. Optic neuritis m ceri'bral tumor occurs earlv. but it may be delayed or it may not occur at all. The sight may be i.iiaffected for a ionp time, but tlu- field of vision soon becomes somewhat contracted. In other cases ill wlii'h the neuritis is axial, loss of vision in the form of a central scotoma ma V occur I'arly. ( )ptic neuritis may l)e caused by a tumor of any size in anv jjart of the brain. Timiors of tin- cerebellum and at the base of the brain are more likely to produce optic neuritis than tumors in other parts, jirobably owiiift to i)rc>ssurc on the yems of Galen. The next most important ocular sign in disease of the brain is hemianopsia or loss of half of the field of vision. This i> due to a dis<'ase of the chiasm, of the optic tracts, of the cortical centre of vision, or of some part of the l)ath coiuiectiiif; the optic tracts witji the cortex of the brain Local di.seaseof the eye producing lo.ssof halt the visual field is not included under the name of hemianopsia. When hemianopsia occurs, the fields are u.-;ually both affected, one-half_ot <.ach field being normal, the other half iu'ing blind. The dividing line between the two is a vertical on(> through the centre of th(> fiehls, but usuailv turning a.side a little at the fixation point in each eye s(; as to leave it unafiected. In some ca.ses, however, it goes through the fixation point. It sometimes hap])ens also that the line of .separation is not <iuite vertical, but somewhat irregular, so that the s( cing half of the retina passes over the middle line. The blind i)art is generally absolutely bliiiil, but in some cases color i)erce|)tion only is lost, so that we have a condition of hemianopsia Tor colors or hemiachroma- to|)sia. Ill .some cases the defect is sectorial, and in otlier rare cases it is tlie upper or lower halves that are defective. The most freciuent form is one in which the corresponding halves in each eye are want- in<r for instance, the right half of each field may be blind, miplymg the loss of function in the left half of each retina, or if the left half of the field be blind the right half of each retin.a will be functionless. This is called homonymous hemianopsia. (Figs. I'u and I'oS.) Many cases of double homonymous hemianoiisia have been descnbed due to disease of the cortical" visual centres in each hemisphere. Most of the ca.ses have begun with loss of vision in corresponding halves of (>ach eye, followed at a later date by loss of vision in the other halves, whereby total blindness was i)roduced. In a few of the ciises the macula Was left, .so that there wa.s fairly good vision while looking ahead, but the ])atients haii no power of direding their movement.^ owing to the small size of the visual field floss of orientation). Loss of the outer halves of each visual field or loss of function of the two BETISA, OPTIC NERVE, AM) ITS CEREIiliAL ORIGIN. 4«7 iKisal halves of tho rotina is known as bitemporal hemianopsia. Nasal lii'tiiian()i)sia is blindness of the inner half of eaeh visual field, and i:- due to a want of function on the temporal side of each retina. To Len^lded hemianni«ia. Fig. 258. Left Eye IxKtiitsA bemlanopaU. 468 rUK EYE. \i oxi)laiii tho cause of tho honiianopsiii in those atfectidus, it wu! he lu-Irf^sary to p. <«v."r afresli tlie course of tiie visual fil.res from tlic retina to tilt' cortex of the brain. • i r Tlie nerve fibres from tlie corresponding or homonymous halves o c-ich retina-tiiat is, from the nasal half of the riRJit and the temporal half of the li'fl retina-pass tiiroU(jh the chiasma and umte to lorni the left optic tract ; simiiarlv fibres from the temporal half of tiie riftht and luusal half of the left retina l)as.s through the chiasma to iorni the ridit ol>tic tract. The fibres from each tract pass into the basal eaiiKlia the optic thalamus, the anterior corpus <,uadnReminum, and the external peiiiculate body; thence thnuigh the posterior I)art of the internal ca])sule, and tho optic radiations to the visual centre This i^ situat>'d on the mesial surface of the occipital lolx" ill the region having the middh- part of the calcarine hssure at its ^Lesions of the Chiasma. The most u.'^ual sign of atTections of the chiasma is bitemporal hemianopsia. This is duo to mvolvemont of the decussating fibres at the anterior or posterior border of the chi- asma Tiieso fibres supi.lv the nasal halves of each retma, which 'ire conseiiuentlv bliixl. The affection (jf sight begins by a limitation of the outer jwrt of each visual field, or one-half may be afTectcd bef<«re the other, according to the position of the lesion. The lo.s.s of sight may for a time be onlv a color blindness, but later on light and form seiise are involved also; the lo.ss goes on to total bitemporal hemianoi)sia. In m:>.!iv of the ca.ses, owing to advance of tho disease, the uncrossed fibres become affected too, and the result Ls total blind- ness. It has been demonstrated by Nettleship and others that chi- asmal disca.<e fretiuentlv begins as a central scotoma, and as such may bo mistaken for toxic amblvopia. It is believed in such cases that tho disease starts in the anterior part of the chiasma. where the macular fibres are situated. It is common in most of tho caso.« to have a certain diminution in central vision. Tho optic nerve becomes atro- i)hic there is generallv great headache, sometimes loss of mental power; optic neuritis is not often present, .\ffections of the outer side of the chiasma prodiu-ing nasal h(>mianoi)sia are very rare; hori- zontal hemianoi)sia may bo caused by pressure on the chiasma above or below. The causes of chiasmal diseas(> are acromegaly, tumors of the pituilarv bodv, meningitis, fro(iuently syi)hilitic, periostitis of thi' bodv of "tlie sphenoid, tubercular mas.ses, syphilitic gummata, cvsts and exostoses, and hydroce])halus jiroduced by distention of the tiiird vcMitricle. The treatment must be in accordance with the dis- covered cause. Much good may oft(>n be done in syphilitic cases l)y apitropriate troat:nent. . Lesions of the Optic Tract. Th<" characteristic symptom of lesion of tlu' optic tract is homonymous lateral hemianoi)sia. This may fie comi.lete or partial, involving only a (juadrant of each retma, as in a case related bv Honschen, in which there was a defect of tho field of vision in both left lower ([uadrants, caused by a tumor pressing on the warn mmm RETIXA, OI'TW XERVt:, AM) ITS CEHEUBAL ORIOIS. 469 uiUMT part (.f tho right oj)tic tract. Tho defect may bo relative also — that is, there may Ix- half-vision for color only — form and light perce))- tion iH'ing unaffected. ( )\viiig to proximity of the trunks of the nerves at the base of the brain, there may be paralysis of tlu' parts sui)j)liecl i)y these nerves owing to pressure from a tumor of the tract. Optic neuritis may be |)resent in localized meningitis or in tumor, and primary optic atrophy is som<'times met with; both these manifesta- tions are often more marked in one eye tiian in the other. Homony- Mioiis lateral hemianopsia is shown by blindness of the correspond- ing halves of the retina, for instance, the temporal half of the left retina and the na.sal half of the right. Wernicke's .sign or the hemi- opic pui)il is frequently present, and is of great value in localizing the .seat of the affection: it consists in the fact that light thrown u|)on the blind half of each eye |)roduces no pupil reaction at all, while light thrown upon the acting half of each retina gives rise to non^al pu|)il reaction. Afferent impulses proceeding centrally from ' le retina are interrupted at the .seat of the disea.se in the tract, and lo not pass to the basal ganglia and third nerve nucleus, while lesions of tiie visual path above the basal ganglia producing homonymous hemianopsia do not interfere with the path of the impulses, which |iass from the retina to the basal ganglia and thence to the third nerve nucleus. It is conceivable, therefore, that there might be .sym- metrical le.sion.s in the hemi-sphere, which j)roduced double homony- mous hemianopsia, and therefore total blindness of each eye, and which yet left the pupillary light reflex unaffected. The hemianopic pupil icnction is not ea.sy vo obtain, inasmuch as it is difficult to keep the lijrlit passing to one side of ihe retina from illuminating the other half t(i a certain extent. But it is generally jKissible to establish a differ- ence between the reflex action of the pupil, when light is cast from opposite sides on to the retina in di.'seases of the tract. (For the method of api)lying the test, see page 34.; Symptoms of disea.se (if the optic tract may l)e produced by the pressure of tumors of iicif^hboring narts, of the temporosphenoitlal lobe, optic thalamus, or cnis cerebri. Lesions of the Basal Oaitglia or Primary Optic Oang^Ua, External Geniculate Body, Optic Thalamus, and Anterior Corpus Quadri- geminum. These ganglia undergo degeneration after removal of the < ye: also after lesion of the occipital lol)e, degeneration can be traced ilnwn to them: the\ are therefore in the direct line of traasmission of impulses from the eye to the brain cortex. Exterrml Geniculate Body. All the fibres of the optic tract enter the external geniculate body, and a lesion here always gives rise to hemianopsia. It is probable also that its upper and lower parts supply the u])per and lower parts of the retina, respectively. If so, homony- iiiKUs quadrant hemianopsia may be due to di.sease of the external '^rciiiculate body. ()l>tic Thalamus. Lesions of the posterior part of the optic thala- mus, the pulvinar, have in many cases been found in association with 470 rilE EYE. hcniiunopsia, Init in an r<nml nunilH-r d' caw's lioinian<)i)siii has not hiTii lounil. It is prolKiliic thai tiic lesion of liw o|'ti<' tiialanms itself lia.s not given rise to hemianopsia except indin-ctly from press- ure on the optie traet. CorimniQiKKlriiieininn. It is not certain that tumors ot the cor- pora .lua.lrinemiii'a give rise to loss of sight. A few «l()U»)tful eases have ijeenreeonleil in whieh there was blindness from lesions m thu situation, hut then- is a far larger numlnT of eases in which tumors of tiie corpora (luadrigeniina produced no blindness at all. (l'<>r oculomotor atTeclions following lesions of the corpora (luadrigemina, see page ISO.) • i i:i Lesions of the Internal Capsule. The cours*' of the visual hbres fr. m the external geniculate body to the optic radiation is not yet known. Fibres are traced to the external geniculate body through the posterior third of the posterior limb of the internal capsule, and it is a.sserted that a lesion of this part of the internal capsule causes hemianojjsia. On the other liand, Henscheu lias shown that lesions of this part do not necessarily cause hemianopsia, and that when they are associated with it, the external geniculate boily or the optic tract is interfered with at the same time. Lesions of the Optic Radiations. It is unknown with accuracy how large a jtortion of the optic radiations is occui)ied by the visual fibres. According to Henschen, only the central portion is so occu- pied. Other writers agree with him that the optic radiations contain many other fibres than visual ones. The importance of this lies in the fact that in a 'I'sion of the optic radiation, although we may get hemianopsia, we get also other symi)toms, which may aid us to recog- nize the lesion and to distinguish it from a cortical one. A subjective sensation of blindness is caused by a lesion of the radiations, in the form of positive scotoma, but it is not present in a lesion of the cortex. If tile lesion extends lieyond the visual fibres, various other syiiii)tonis are present, such as iiu.id l)lindness. word blindne^ r alexia, visual aphasia, dvslexia, amnesic color blindness, or visual ucinations. Alexia nr Word Blindness. In this affection persons are unable to read words; the print or writing is ])erfectly well seen, the letters themselves, except in rare cases, can tx- made out, but the power of combining them is entirely lost. The patient can write (|uite well, but is unable to read anytiiing he lias written unless he is allowed to go over it with a i)en. In some cases even individual letters cannot be recojrnized, but ilgures can as a rule be read. Word blindness may Ix- combined with an inability to write. Alcsid w ' Aqraphin. This alexia is due to interference with the fibres ])assing from the visual memory to the siH'cch centre, and has a distinct localizing value as the lesion has Ikm-u recorded from post-niorlem examination in five cases in tlie left (KTipiia! lobe. Alexia with agrajjhia if. thought to be due to a lesion of the centre for visual memorj- in the left angular gyrus. The a.'^.sociation of alexia with right homonymous hemianopsia is to be explained by the IlKTLSA, OPTIC SERVK, ASD ITS LEIIEUHAL ORlUlN. 471 ncaiiHss t)f tln' visual t'cntrc ami pii'lw to the lesion which cuu.>»(' alexia. Iliislfsia. In this affectum there is no loss of sight, but a .Hiinjile inability of the patient to rea<l continuously. A few wonU only can be read, then the book is thrown aside: the effort inuy 1m' n'|K'ated after u time, but power of continued reading is absent. In most casen dyslexia !>as In-en a.ssociated with hemianopsia and other cerebral symptoms. It is caused by degeneration of the cerebral vessels and generally has a fatal termination: it apjK'ars to have little value as a localizing sign. Visual Aphaxia. The |)atient cannot rememlxT th(> names of things seen, althougii (|uite familiar with the things them.selves, but can re- niemlM-r their names if he can n-cognize the things by some other .sense than that of sight, as, for instance, if he can touch them. Conversa- tion of patients suffering; from visual aphasia has certain well-marked peculiarities- the general avoidance of names and the use of circuitous methods of spe<'ch, in order to make up for the defective power of expression. Right homonymous hemianop.sia is almost always \)n's- eiit and sometimes alexia and agrajjhia. The lesion is believed to be in the l(>ft occipital lolie. Loss of Color Memory — Amnesic Color Blindness. The patient is able to perceive the colors and to match them correctly, but is unable to give them their names. This has always been found associated with right homonymous hemianopsia, and is believe-l by Wilhrandt, who de.scrilM'd it, to lie an indication of disease of the occipital lobe on the left side, preventing communication In'tween the color centre for vision a:.d the sj)eech centre. Visual hallucinations sometimes occur in the l)lind side of the field: objects are seen in the blind area which are not in view at all. This is thought to be due to irritation of the centre for visual memory in the occipital lobe, but a ca.se has been published by de Schweinitz ill which hallucinations occurred in the blind side of the field, due to a (ruiuma pressing on the right optic tract. \'isual hallucinations are always accompanied by right homonymous hemianopsia. Hallucina- tions of vision due to focal brain di.sea.se are generally Jis.sociated with oilier signs of focal brain di.sea.«e. and may be distinguished from other \'su:il h lliicinations, such as those occurring in delirium tremens or lever, by their occurring in the filind jiart of the visual field. Mind Blindness or Visual Amnesia. The sight is perfectly good, intelligence is not affected, the patient is able to read, but he lias lest tiie power of recognizing objects seen: if they lie presented to him by one of his other senses, he at once recognizes them Pcojile, even most intimate friends, are not recognized by their ajipearance, but are known at once when they begin to speak. This failure is due to a le>iion of tlie centre for visual memory, which is supposed to lie distinct fidin the visual centi although situated close to it in the occipital lobe. It serves for the storing up of pictures in the niemorv' of ob- jects or scenes that have fallen upon the retina, and whenever a picture 472 THE EYE. is fnriiiod on the n-tinsi the .stores of the visuiil mcinory optitro art- liiounht out iitid raimcki'd for coinparisoiis or tin- new picturi" is storcil awav for futun- uw. Hoiiionyinous licmiunopsia is present in the majority of cases of mind blindness. It oeeurs in |M'rsons iH-yoiul middle age, when the lesion has In-en found to l)e hemorrhages, softon- iuRs, or tumors: it occurs also in general paralysis '>f the insane. Lesions Affecting the Cortical Centre of Vision. AceorditiR to the most recent nwearclies of Ilenschen, th s lesion is placed about the mid.lle part of the c.ilcarin:- ti.ssure. the upiK-r edRe of the fissun' rep- resenting the upper homonymous quadrants of the retina ami the lower edge of the fissure, the lower homonymous (luadrants, the macula centre lying in the fliM)r of the fissure. Other hser\ers think the visual centre extends much more widely, even covering the whole mesial surface of the occipital lob<', but they agree in giving special imi)ortance to the calcarine fissure. Destri tion or lesion of the cortical visual centre leads to absolute blindne^.. of the (•orresjM)mliiig halves of each retina, iiUd con.setiuently to homonj-mous hemianopsia of the op|M)site half of the field of vision. If the lesion Iw confined to the cortex, there is complete absence of any other sign, such as paraly- sis, ansesthesia, word blindness, mind blindness, visual aphasia, visual hallucinations, and the hemianopic pupil. For instance, there is com- plete absence of sensation in the blind side of the field, but the patient is not conscious of the defect Jis of a dark area, as he may lie in lesions f)f other parts of the visual path. If the lesion be bilateral, of which many cases are on record, the symptoms arf» bilateral hoinon\Tnou9 hemianopsia, which means complete loss of vision. In small lesions less than half the homonymous fields may be lost and partial |H'rij)h- eral or more rarely scotomatous defects may be left. But these par- tial homonymous" defects should lx> upmI with caution for localizing |)uri)oses, as homonymous fM'ripheral coiu.actions of the fields of vision are found in patients without lesion of any part of the vi.sual path. Sometimes the blindness is incomplete— that is, |>erception of light may be retained in the blind part of the field In other slighter cases again only the color .sen.se in that half of the field may be lost (hemiachro- inatopsia), light and form sei <> b'ing perfect \'ariou.s degrees of loss may be present in different parts of the affected fields. It is unknown whether the centre for colors is different from those for form and light, or whether the different colors 'i ivo separate cells devoted to them: but there are cases on record of homonymous hemianopic losses of ]jercei)tion of one color which would give suiJiM)rt to ♦his view. Probably there are not separate centres for light, form, and color, but a loss of the latter indicates a less .serious injury to the centre than when its other functions are lost. It has l)een stated that in most cases the dividing line iM^ween the two halves of the fields is not a prfectly vertical one, but th.at it <!eviatps so as to include the whole of the fixation pf)int in each .seeing half of the field. Two expla- nations may be given of this: (1) That the whole of the macular region of each eye is represented in the visual centre of each siile, so HETIXA, Ol'TlC yERVK, A.XD ITS CEREBRAL ORIOIX 473 that carli macula Iuik a (IduMp ncn-o supply. nn<l if (iim> viHual ornfre is (lest n •>•(•(!, it Mill retains its nerve 8Up|)ly to the v.-iial eentn- «pf the opiHisite side. C2) Tlie other explanation ftiven for retention of the whole central vision in lesion of one visual centre i.s that the centre for the macula in the cortex is more vascular than the rest oi the visual centre, an<l receives nutrition fnmi anast«)mo8es even when parts aroiMKJ are cut off. It lias Ix-en supjjosed by .some writers that there is a higher visual ciiitre : 1 the anpilar gyrus in wliich the whole of tlie op|M)site field of vision is repn'senfed, that of the same side fn'ing al.xo n-presetited, hut in a lesser degree of intensity. Lesion of this centre is snid to cans*- Miiihlyopia of the opfHwite eye by lowering the function of the whoh- ntina and n-ducing the size of the visual field generally, without pro- ducing hemianopsia (croxxeri nmblyopm). It also pnxluces a slight constriction of the field of vision of the .same side. Ferrier's experi- iiients on animals sup|M)rt the view of the existence of a centre for vision in the angular gyrus, but the evidence in favor of it in man is very slight, and many writers do not believe in the existence of crossed amblyopia. CHAPTER X. DISEASES OF THE CRYSTALLINE LENS. Bv KDWAUD C. KLI.KTT, M.D. Anatomy. Tl.c crvstallinc l<>ns, ..r, as it is eoiimiunly called, the Ion. i. a l.in.-ivcx traiisi-ainit b.-tly which lies in the anterior por- ti„n'..f th.' ev, and. t..seti>er with its suspensory hga.nent, servos to separate th.^ vitn-ous chamber l.elnnd from tiie aqu.M.us chan.heis in 'front (Fig. 2.19.) The posterior surface is the more convex. Fia. 259. Curnra Ills Anterior Chamber The antrrior segment of the eye. <M.»lHi«l fmin v.mf^ A.mtomy.) The l.Mis is con.pos.Hl of a harder central portion known as tl"' ""cleus • a \ .ofter outer portion known as the oorfx. The l.oun.hir> hn.' 1 ; lien t^hese two .or.ions is not sharply defined, tl.- •;- --^-V; i„. i,s greater density from a l^roc-ss which consists esMmtial> n loss of thii.l, and this being a pr.,gressive process he •«;"■<'- reases in si7,e at the expense <.f the cort.'x m proportion t.. the aj: ; ,;: i, dividual. The nucleus has a >.llowish coh. - --^-a-i to tlu- cort.'X, and also a pr<>at.>r refractiv power. In .ilderl) pu- ns these properties fre.,uen,ly make the lens as -'^'- ;'-^-^^.^, pupil present a gravish or opaMue appearance, .lue to incnas. 1 re ecti m of light from th.- surfa.r of the lens (increased lens reflex . m t is mav be mistaken for opacity of the lens, allli.-.ugh the v s,,. fs n.!t hnplSed bv it. and exail.ination with ...Hected light (ophthal nioscopo) shows tiu' lens to 1k' perfectly clear. ( 474) smsm^mmmmmsm m D/SKASES OF TIIH VHYSTALLISi: LES.S. 475 Tlic li'iis .s C()iii|i()S('(l (if prismatic liln-cs joined tojifthcr liy a small amount of cement suhstanec. (Fig. 2(50.) These i;rismatic fibres Xoruittl lens tilirts cui hiiigUudiimlly, x lOU. (Fr<;p«red by Dr. E. S. Thomson, in ihe laboralory nf the Manhattan Ejreaud Eur Ucspilal.) lie elongated epithelial cells, and are arranged in hundi.s, tliese uindles iH'inp; so placed that tlieir lines of union form a stellate figure Fio. 261. *4fcr^ ^y Sectors in eryttalline lens (TtMiT.) idiating from the centre of each surface of the lens, and often visihle n ohli(|ue illumination in the normal eye. (Fig. 261.) Besides 476 THE EYE. % i the nucleus and cortex, we distinguish the poles of the lens; that is, the centre of its anterior and jjosterior surfaces, known resjiectively as the anterior and the i>()Sterior poles. The circumference of the lens is known as the equator. . The average size of the lens is 9 nun. in diameter and 4 mm. in thickness at tlie central or thickest part. From the centre it slopes awav gradually until the two surfaces meet at the thin edge ore(iuator. The lens is" eiiclos<'d in a delicate structureless lining inemhrane of perfect trans) )arencv, known as the capsule. This is divided into two portions: that oil the anterior face being called the antcTior capsule, that on the jjosterior, the posterior capsule. The ant<'rior capsule is lined on its lenticular surface with a layer of epithelial cells, from which new lens fibres are develo|)ed. The lens rests in a cup-sha|)ed cavity of the vitreous, called the fossa patellaris, or hvaloid fossa. In front it is separated from the pupillary border of the iris bv a thin layer of the aiiueous humor, this lavtV being so thin that the pupillary border of the ins and the anti-ri(>r lens capsule mav lie considered as being in contact. The lens is held in place bv its suspensory ligament, called the zone of Zinn. Tliis is a fibrous structure which ari.ses from the jwrs ciharis retina' as far back as the ora serrata, the surface of the ciliary body, and the ciliarv processes. It leaves the wall of the eye at the ciliary proc»s.-ies. and ilivides into two layers, an anterior and a posterior, which unite with the anterior and posterior portions, respectively, of the lens capsule. The space between these t\^ layers of the susi)ensorv ligament is known as the circumlental si)aee, or canal of Petit, ami is more or less completely divided into two i)arts by a delicate septum running from the ciliary processes to the cijuator of the lens. The anterior laver of the suspensory ligament jiresents numerous small openings whereby the canal of Petit communicates with the postiTior chamber, both lieing lymph spaces and both con- taining aqueous humor. (Fig. 259.) The lens is an ehistic body capable under certain conditums ot changing its shape, as is described in the account of the function of accommo(lation. The l(>ns does not contain any bloodvessels, but derives its nutri- tion i)v imi)ibitioii from the fluids .surrounding it. The absence of bloodves.sels prevents it from i)res(>nting phenomena of inflamma- tion, and the way in which it is nourished oxplains why inflamn'atory coiulitions of the" choroid exert a deleterious l.ifluence on it. Embryology, ^'erv <'arly in the tlevelopinent of the embr\'o the outer layer, or ejnbla.st. is "thrown into a longitudinal dorsal furrow whose sides close over to form a tube, the medullary tulx'. From the anterior end of this tube are thrown out i)rocesses on each side, called the i.rimarv optic vesicles. Ivich of these vesicles is C()n- verted into a cup bv the anterior wall receding against the posterior wall. The layer of epil.last over thi.' -up-shaped cavity thickens, dips into thccup, and this portion gradually b'conies cut off from DISEASES OF THE CRYSTALLISE LESS. 477 tlio rost of tlic ppihiast ami forms an i> lated mass of pijihlastio tissue lyiiifj in the cui) of tlie optic vesicle. From tliis mass of tissue tiie lens develops. This nia.«s of epil)Iastic cells is composed roughly of two layers of cells, an anterior and a povsterior. From the j)osterior layer, by a process of elongation, the lens fibres are formed, the anterior layer of cells remaining as a thin la- of cells just under the anterior capsule. F-om the most e(|uatoiu..iy situated of these cells additional lens fibres develoj). The lens attains its full growth about the eighteenth year, after which time the formation of new fibres continues much more slowly, at a rate to compensate for the dimhmtion in size of the central portion from contracti(m. It will be seen that at one time the rudimentary lens occupies nearly the whole of the rudimentary eyeball. At the time of birth, however,the lens has become reduced to almost its normal relative size, although, as stated, further changes occur until the eighteenth year. The lens capsule is developed from a layer of me.sobla.stic tissue which surrounds the plug of epiblastic tissue when it grows into the optic cup to form the lens. FlO. 262. Fio. 263. no. 264. Kidney-shaped leiu, coloboma Inward. (Baas.) I.«ntic(>nu0 Anterior. (WlSSTER.) Dislocation of the lens. Congenital Anomalies. Congenital anomalies of the lens may alTcct its size, shape, j)()sition, and transparency. Anomnlief of Size. Congenital absence of the lens (aphakia) has been noted a few times. It results either from arrest of development or from disease. The lens varies in size at different ages. The only anomaly of size usually recognized is that in which the lens is too small (microphakia). riiere is often a relaxation or absence of the su.sj)ensory ligament at the same time, which permits the lens to change its position. Aitomaiie.'i of .v/irt/jc are of two sorts: (1) cololK)ma lentis, and 2) ienticonus. Coloboma of the lens is the name applied to a condition in which ijic edge of the lens jiresents at some point, usually downward, a '"caiized flattening or a distinct notch. (Fig. 262.) It is due to in arrest of development. This apj)eiirance varies in shape and posi- ioii, and while usually single, the edge of the lens may be notched 478 nil-: EY^:. ill scvcnil plan's, or s.Tnitcd. Tliis aiuniialy is often associatc.l witli coloboiiia of liic uis and clioroid. Lcnticoniis is a condition in wliicli a more or ii'ss pointed projection exists on the anterior or jiosterior suiiace of the lens. (!• i«. 'IM.) The projection is transparent as a rule, hiit an o|.acity may exist at its apex. The cause is olisciire. Inomilirs of i><»<ili<'ii are grouped under the name ot ectopia ieiitis or displacements of the lens, ilxcept in the rare eases where there i- an anv-l of devi'lopmeiit of the whole orjiaii and liie lens remains in its fietal position, in the vitreous chamber, the di>location occurs in the .lirectioii of the e(iuator, and is <lue to faulty dev.lop- meiit and conse.,uenl \,eakness of some i)art of the susjiensory iifia- ineiit This weakness fieiierallv exists in tlie lower jiart ot the eye hi the position of the fu'tal cleft, and the dislecation i< in the <ipi)osite <nrectioir. that is. ui)ward and inward or upward and outward. (l'i<:. •_'t>4 ) The whole lijiament may be absent, permittiiif: tlii' lens to pass thron-ih the pupil and lie in the anterior chamber. This con- dition is usuallv bil.iteral ;'iid syinmelrical. but may be unilateral. It is also frequentlv hereditarv. wlien the aiioma y i^' found m suc- cessive paierat ions' of a familv. The displacement v, ries much in de<'ree, so that the patient mav see either through tlii' le is or through th^ part of the pupil which contains no lens, or, according to the ix.sition of the he.id. either through the lens or unobstructed inipil at will. The lens is at first clear, and remains so in the majority ol i'ases but mav become o])aqui' in time. Sometimes it is fixed in its abnormal position, and sonietiines freely movable, depending on the condition of the suspensory ligament. The treatment of ectoiiia lentis may often be satisfactorily con ducted bv means of correcting li'uses. If the dislocated lens is so situated as to allow vision always through that body, or alwavs through the unobstnicti'd pupil. glass(-s to crrect the retraction, concave as a rule in the form<'r case an.l strongly convex m the latter (just as in aphakia), will often give useful vision, hi other cases it will be imix.ssible to secure satisfactory vision m this way, am the lens must be remove.l by the operation of solution, to be .lescribed later. This treatment results in absorption of the lens, leaving the eve aphakic, and iniuiring strong convex glasses, as will be men- tioned in considering the treatment of cataract. W heiv the lens l)e- comes opaMue. it is usuallv advisable to remove it by tli<' same means Aiinwtdirs of Iron-^ivirnini include the various iorms of congenital cataract. These are: 1. .\iiterior jxilar cataract. 2. Posterior polar cataract :i Lamellar or zcmular cataract. .\ detaih'd description of these and the metho.l of treating them will be given in consider- ing the sub'iect of opacities of the lens. Wounds and Injuries. Injuri.'s tothelens areof two kinds: I'lrst, the ]ru^ is .'.isplaced frr.ns it^ normal position, cnstitutmg traumatic luxation of the lens. Secon.l. the lens is the seat of a penetrating wound which is usually followed by traumatic cataract. DIHEASKS in- THE CRYSrALI.lSE LESS. 479 'I'nmiiiMiic (lis|)l:icciiicnts(^f tlic lens arc the result nf injuries to the sus|iriisiir_v li«nnieiit. The (lis|.hu-eiiieiit iTiny he partial or {■oiuplete. Partial .lispi;ieeiiieiits of the lens (suhhixatiou) result from an injury whosectTeet is so localized as to rupture only a portion of t! .• Mi>pcns(iry li<;ainent, and without leaving; its normal position the rdirc if ijie lens nearest the seat of nii)turc tilts forward, causing a>tit:iiiatism and consociuent disturhance of vision. The lens, as a •Mile in these cases, remains transparent, and the treatment consists I correctinjr the resultinji astigmatism l)y jiiasses. Considerahle -|Mintaneous improvement m;iy occur, or the lens may become opa(iue, when it is dealt with as if the opiicity resulted from" other than tpau- Flu. L'65. Ml! liual«l upon the clllar.v IkmIv. The lens Is becoming catoractous nnd is twun.l down by ■ ms tissue. From an eye which eaiiseil syrap.uhetic irritation in the fellow eye. x 15. (Pre- .■•I tiy Dr. K S. Thomson, in the laboratory of the Maiihiittan Eye and Ear Hospital.) itic causes. ( Kif;. 2fio.) 'l"he lens may in its now ])osition cause inuch inflammatory disturbance as to result in the lo.ss of the eye. Complete dislocation of the lens follows an injury which causes •iiplete ru|iture of the susi)en,sory lijraineiit, tluispermittiiifi the i- to leave its^b<>d entirely. Tlie capsule of the lens is generally ' ruptured. The dislocation may occur in one of .several directions: forward into the anterior chamber. 2. Backward into the Vit- us clunnber. 3. Through a ruptum in the coats of the eyeball 'the capsule of Tenon or under tl ^ conjunctiva. Owing to the -licity of tiie latter membrane, it w 1 sometimes not yield to an iiy which ruptun •, the sclerotic, choroid, and retina, and the lor- I 4«0 THE EYE. l)a.s.siiig through a nii)turo in these coats lodges under the ronjunctiva, which stretches to accoiinnodate it. . , ,. , ,• Tlie symptoms of dislocation of the lens are, m the hrst phice. dim- ness of vision. Hv removal of the lens from an eye whose retraction is hvperopic or moderately myopic, rays of light are no longer focused on or sufiicientiv near the retina to i)ermit of clear vision. Other conditions svhicli result from the injury may also contnhut(> to cause dimness of vision, such txs vitreous hemorrhages, rupture ol the choroid, hemorrhage into the anterior chamber, etc. There are two conditions in which dish.cation of the l.>ns would cause improvement instead of .leterioratio.i of vision. These an- when th(> lens is oi)a(iue an.l when the eve is highly myopic. In both of these conditions oi)erations for tlie removal of the lens are resorted to for the purpose of imi>roving vision, bv reiiKJving a mechanical obstruction to .sight in the iivst instance, and by changing the refraction oi the eye in the second instance. . , , -i. i „„ If the lens is dislocated into the anterior chamber, it can Ix; seen as a clear or opatiue disk, as the case may be, in this position, (big. 266.) If clear, the iris and pupil can be seen through it. It is apt Fio. 266. Opaque leru dijlocated Inlo Ihe anterior chamber. to excite inflammation in the eye, and invariably does so in that part of the cornea with which it is in contr.ct. It may also cause glaucoma. It should be removed from the eye by solution or extrac- "if' dislocated into the capsule of Tenon, which is very rare, or under the conjunctiva, the lens can he seen in its new position, and its absence from its normal position is indicated by the fact that th-' refraction of the eve is highly hyperopic and the catoptric images camiot be sc^en. If not itself disturbnl by the injury, the ins is sejni to be tremulous on movement of the eye, because it no longer has its normal support behind. The pnivity of this conchtion does not pertain to the lens or its new po.sition, but to the rupture of the coats of the eye and vari.-s with the .>ite and extent of thi? rui)turc. The lens may be left alone. If it is deemed advisable for an v reason to extract it, this should not be attempted until the sclera DISEASES OF THE CRYSTALLISE LESS. 481 wound has liealod, as wp would othrnvisp conv»Tt a simple scleral wouikI, to l)orro\v an analogy from general surgery, into a compound one, and through this, protrusion of the other coats or ocular con- tents may occur, adding greatly to the gravity of the injury. When the scleral wound has healed, the lens may be removed through an incision through the conjunctiva (and capsule of Tenon when neces- sary), placed as far as possible from the scleral scar. Dislocation into the vitreous cliambe- is by fur the most common form t)f traumatic dislocation. The lens loos, :;>(1 from its attach- ments sinks downwanl and backward into the vitreous, where it may be made to rise and be seen through the |)upil by up-and-tlown movements of the ball .similar to those practised for the study of opacities in the vitreous (ocular ballott«>ment). It was formerly the custom to treat cataract by depressing the lens downward and backward into the vitreous, and we have abundant records of the effect of this form of dislocation. Sooner or later the lens, acting as a foreign body, will e.xcite inflammatory and tlegenerative changes in the vitreous, choroid, or retina, which destroy or greatly impair The sight. It may also cause glaucoma. For these reasons this nu^thod of treating cataract has been abazuloned, and for these rea.sons it is desirable to remove the lens from the vitreous if possible. The operation is dangerous on account of the tendency of the vitn aa to escape from the eye when an incision is made' into the cornea. The lens, too, is far from the corneal incision, and must usually be brought for\var(l by means of a delicate wire loop. To facilitate the capture of the lens, it hiis been suggested to operate with the patient lying face downward, this favoring the seeking by the lens of its nat- ural position, or the lens may be coaxed into this position and fi.xed tliere by a two-pronged needle or biilent thrust into ttie eye through the sclerotic behind the ciliary process, and thus Ix'hind the 1. ns. \\\\\d\ it holds in place by pressure. The ste|)s in the removal of tlie lens will fje sufficiently detailed in speaking of the treatment of cataract. In whatever f)osition the lens may be ilislocated, it almost invariably becomes ojjaijue sooner or later. WmmdK of the Lens and Traumntie Cataract. It is very nearly true that a wound of the lens means traumatic cataract: but trau- matic cataract may be due to other injuries than wounds of the lens. In other words, traumatic cataract may occur without rupture of the lens capsule. This is not common, but it has been observed that contusions and concassions of the eye may be followed either immediately, or after some days or weeks, by the formation of opaci- ties in the lens. These opacities may be statioaarj- or progressive, although there is very seldom any clearing up of them observed, and It is certainly not to be expected. This form of lenticular opacity w more apt than any other to remain stationary, or if it progresses It does so at a slow rate. The prognosis to the eye from this form of '•ataract, per se, is therefore good. Progressive opacities of this .SI 482 THE KYK. cliaractcr rfiiuirc removal of the lens by operation, citlier l)y extrac- tion or l)V solution. The clioice l)et\ve<Mi these methods will, as a rule, depend on the consistenry of the lens as estimated by the age of the jiatient, solution beinj: adapted to patients under twenty- five or thirty vears, and extraction to patients over that age. We take advantage of the possibility of causing opacity of the 'ens by contusion without rupture of the ca])sule in the operation ot massage of the lens, which is sometimes performed to hasten the maturation of a cataract, to be described later. Traumatic cataract from rupture of the capsule of the lens usually result.s from a i)enetrating wound. The formation of this variety of traumatic cataract deiieiids on the fact that if the afpieous humor comes in contact with the fibres of the crystalline lens it causes them to swell and become opacjue, and in time completely d' solves the lens after it has undergone the i)rocess of swelling and opacification. Fio. 267. Traumatic cataract. ,h„v , splitting up of flbres and formation of spherical tna^. There are numerous swollenrtbn* which show iransver^rtriatlons. ■ 100. (Prep.re.1 by Hr. h. >. ThoM9o>, in the laboratory of the ManhatUn Kye atul V^t Uoepltal.) (Fig 'tlT I Rui>ture of the caj)sule and traumatic cataract may result from a contusion ..f the eye, but for the purjiose of stu.ly the process is observed best where it follows the operation of needling the lens. Here a wound is made in the cai).sule and lens with a needle thrust through the cornea. By ot)li.|u<' illumination and a magnifving lens the n-nt in the capsule can be seen at onc.>: but the ti-u'k r;f th< wound in th<' substance -f the lens is not usually vi.sible f„r several hours. As the a«iueoiis gains access to the lens through the rent in the ■aiisule, the portions nearest the oi)eniiig iM-coine opaque and swt.llen. aiul are apt to be extruded into the anterior DltlKASES OF THE CRi'STAlLISE LESS. 4^3 rliiiinlxT. as thfTc is not room for them in their swollen rondition uitlini the eapsuie. \\e ean tlius find one or more masses of opaciue lens matter !yin<: in the anterior chamber. The process continues more and m nv of the lens breakmg down and Iwing pushed out int<! I lie anterior chamber. Sometimes when the wound of the lens i.'^ <iiiall the ari'M'ous humor filters in alon^ the wound path, and finds Its way from this alonR the intersjmces between the lens fibres, show- iti^t as Ix-autiful festoons of opaijue lines, sometimes respnibli'iig the skcm hpures seen in the process of karyokinesis. In the process as described, the ab.sorjj/on of ihe lens is supposed lo advance m a gradual way to its compk tion. It very often hap- pens that the wound in the capsule is .so large that a considerable l.ortion of the lens is subjected to the influence of the acjueous, and liccomes swollen at once. In this case the auRmentation of the nilra-<K-ular contents is so great that the tension is increa.sed and ■rlaucomatous .symptoms apjx-ar. Penetrating wounds of the lens are necessarily complicated by a wouml of .some coat of the eye, generally the cornea, through which I lie wounding body reaches the lens. Fre(iuently the iris is al.^o wounded, and the ofTending substance may go through the lens to tli<' deeper parts of the eye. The wound may be .so extensiyp that liie injury to the lens becomes of minor importance comi)ared with llie serious nature of the injury to other structures. We h.aye spoken only of traumatic cataract resulting from tlie .iction of the a(iue()us humor. In a few cases it has been obseryed that the posterior cap.sule alone was ruptured, and opacity of the l<iis resulted from the action of the vitreous humor. The action of ilie vitreous in this respect is very much less intense and rapid than 'lat of the atiueous, but it should be remembered that traumatic • alaiact may follow a rupture of the jxisterior capsule. W'iiere the injury is wrought by a small f vign body, this .some- iiiiies lodges in the lens. Its princii)al eficci is the production of cilaiact, the j)reseiice of the foreign body adding very little to the ^lavity of the ca.se. liven if the foreign" body is infeVted, the lens I'liiig peculiarly resistant to infection from pathogenic germs, sup- puration in the eye does not necessarily follow. Wiien the wound of the capsule is' small, it may clo.sp so (juickly '"' '^o < ipletely after the wound is made that the lens sub.stance - not exposed to the action of the intra-ocular fluids. This is analo- L us to the manner in which the corneal wound clo.sps behind the '"•' '" ♦•if' operation of discission, and the aqueous humor does ' iT escape. A rare form of traumatic cataract is that caused by heating of ■ ai|ueous humor in ai)plyiiig the actual cautery to the cornea in ■■ !taiii diseases of that menihr.Uic. Treatment. The treatment of traumatic cataract consists, in the 1 place, in an effort to secure mechanical and surgical cleanliness 'lie wound on the surface of the eye. Any protruding i)ortions 484 ■nil: K VK. ,.f iris or ..th.T ..f til.- ..fular rcnt.-nts an- ropiar.-.l or oxcis.-.l and tlio conjunctival sac Huslu'.l with u n.il.l antiseptic suiution llns part „f the trcatnu-nt is .icait witi. in.lctail under tin- licad of Wounds of tlie Cornea and Iris. Atropine is instiil.-d. and the patient i-iit to ix-d. Tlu" object of tlie atn.i.ine is to !)hice tlie eye at rest, aii.l, by vvithdrawinp the iris int.. the p.-riphery ..f th.; anfrior chamber o alK.w r...m. f..r the swllii-.e ..f th.- l.-ns ihe s..!uti..n n.-n.'ra 1> used is of ti>e strength ..f four Rrains ..f sulphat.' ..f atr..pu..- t.; tlie ounce .)f .listille.1 water, tii.' sohiti..n an.l .In.pp.-r \mn^ st<;rihz.-. . It is a K.....I l>lan to inc-.rp..rate some non-irntatinR antis<'ptic, such as boric acid, with th.- solution: otherwise it is .liHicult to ke.-p the s.,luti..n sterile, as the r.'ceptade containiiiR it is frequently ..penod and th.> solution .•xp..s,Ml t.. the air. .\ light antiseptic .Ir.-ssing an.l ban.lage are appli.'.l, at least until the exfrnal woun.l has '^ "iTn'action is excessive, it is controlled Ix'st by the application of ice c.,mi.resa.'s an.l the internal administration of cal.mu-l in .l..ses ot ..nc- t«Mith ..f a grain, combine.l with bicarbonate of sodium, every h..ur until fr.'e purgati..n <.r " t..uching ..f the gums' mak.'s it a.lvisable to discontinue it. .\s calomel is giv.-n in this way for Us antiph -gistic etlect. an.l ..ften fails to purge, a saline cathartic ha.l b.'st be als.> given, an.l the patients general 1 h an.l secretions k.;pt in g..od c..n.lition. rn.ler this treatm.-nt ..umatic cataract will ..ft.-n be Era.luallv dissolve.l. Kxcessive swelling of the lens may occur, pro- ducing glaucoinat..us svmi)t..ms. The eye bec.im.-s the seat ..f inten.>-e pain whi.'h ra.liates to the fn.ntal. temp.md, malar, an.l <'ven ..ccipital region. Conjunctival inj.'ction is marke.l. and palpati.m reveals an increas.'.l intra- >.'ular t.>nsi..n. Th.'s.- sympt..ms an- r.'a.lily .-xplaine.l bv finding the anteri..r chamber fille.l with th<" swollen an.l ..j.a.pie lens matt.'r This c..n.liti..n necessitates evacuation ..f part .)r al of the leu- ,. 'itter bv the oi)erati..n of simi)le linear extraction, which will be d.'scribe.! in c..nsi.lering th.' tr.-atment ..f cataract. It i.s best t., rem..v.' all of the lens matter that can be rem.)ve.l, since this n..t onlv more effectuallv reliev.-s the glaucomat..us symptoms but reii.lers th.'ir r(Turn-n,'.- l.-s's pn.babl.- an.l hastens th.- cur.- .>! the con.liti.m by l.-aving ..nly a small ain.)unt .)f the lens to be .lissolved by th.' a.iueous hiim.ir. _ ,, i **„, \n..th.'r p..t.'nt reas..ii for evacuating th.' sw.illen lens matter when c.nsi.lerable in amount was m.'nti..n.'.l in sp.'aking ..t .lisloca- tion ..f the Umis hit., the ant<'ri..r chamber, namely, that pressure ot the lens on the p..st.'ri<.r surfac of th.' crnea may excite inflamma- tion or ev.'n sL.uglnng ..f that m.-mbrane. . „ , ,, I In s..m.' cases of traumatic cataract, especially where the wouiu, is imall the l.'ns b.'c.mes opa.|ue, but is m.t absorbed. I iider thesr circumstances it sh..ul.i be rem..v.'.t In s..lution or extraction m Av same manner an.l for the same reas..ns as if .l.'aling vyith a monocular cataract .lue t<. other than traumatic causes. In chil.lren a cataraci in one eye if let alone for a long time may produce amblyopia trom DlStW.SfCS Of THE CRYSTALLiyE LESS. 486 <lisii.xc, and tlic (ipcration wlicii ultiiiiatdy pcrforineil may not be tdlldwcd liy a good visua' result. rrauinatic cataract may he followed hy the formation of a second- ary capMilar cataract, or after-cataract, wliich must be dealt with hy capsulotoniy. Opacities of tbe Lens. All opacities of tlie lens and its capsule are included under the name cataract. This name is a relic of the lime when the nature of these opacities was not understood, and no distinction could be made betwwn the dilTeient kinds of opacities. I sape has established the name so firmly in our nosology that it will probably be permanency retained, and great confusion "wouhl follow- any attempt to abandon il. The following classification includes the forms of cataract met with clinically: I'apaular opacitiei. lenticular opaclllea. Aiiteriur Citpiiular. rotterlor cnptulir. Secondary, or after^calaract. Stationary (partial). I'rotrreMlve, \ Congenital. ' Acquired. I Zonular rutarart. 1 Circumscribed opacltlea. Nuclear. Cortical Ciipsulnr ralnrnctx are, as the name implies, opacities confined to the ca,isule of the lens. Anterior capsular or polar cataracts are of two kinds, conveniently considered as congenital and acquired. We have seen that the anterior capsule has an epithelial lining on its lenticular s'lrface. .\ntt>rior capsular cataract consists in a proliferation of these e|)i- tlielial cells, which become elongated and form a mass of o])a(iue li.-;sue resembling fibrous tissue, lying between the clear cajisule and tlie clear lens, neither of which is affected by it. fFig. 268.1 This mass is not fibrous ti.ssue, for it develops from epithelial (epiblastic) <i'lls. In the congenital form of ant(>rior cajisular cataract the con- ilitioii is due to some develoi)meiital error not yet determined. In the acquired form, which arises, as a rule, during childhood, the first step is an ulc(>ration of the cornea, which ])erforates and allows the .niueous humor to escape and the lens to fall forwartl and apply itself to the opening. By contiguity infiammatitm is set up in the •apsular epithelial ceils, and they proliferate. Closure of the corneal 'i|iening and reaccumulation of the atjueous humor results in replace- Mient of the lens to its natural position. \\e can see the corneal "pacity, suggesting the cau.se, anil sometimes a thread of tissue m.".y iie seen connecting the corneal opacity with the lenticular one. In 'lie.se ca.ses there is, in addition to the epithelial nia.ss beneath the .■il>sule. usually a plug of connective tissue deposited on 'he anterior urlace of the caiisule (pyramidal cataract). Posterior capsular or jiolar opacities have a very different origin ml are always congenital. In fo-tal life a bloodvessel, the hyaloid I 4S8 THK KYK. V i artiTV, runs tlirmipli the vitri'inis, cunni'ctiii)! itic optic disk aini llif |i()slcri(ir siiifacr uf tin' lens. This usually atr<i|(liii's, iiul sniiii'tiiMcs a rcuuianl uf lissuc rcniaius at the site uf tlii' junctiirt' of ihr livalniil artiTV and the [itwU'rior surface of tiic lens, and this constitutes Kli. I ^1 "11 Epithelial pniliferatiim (at A Ai bcncHtll tho c«p«iile. Krum » i;\k <'t ch(ir..lilal Mirc.nitt. r„ stiow the histol(«y of aiiterinr <Hi»\ilar culHrart. ■ Imi. il're|iarcii hy Dr. E. S. Thu.vi>os, in tlie laUjratury of tlie Mttiiliaiwu Eye aii'l Ear llinpltal.) posterior capsular cataract. (Fip. I'fiO.) As will he seen, it differs from anterior capsular cataract l)y lyinj; on the surface of the capsule farthest from the lens, and in heiiifi fibrous (inesohlastic) instead uf epithelial. Sonietinies the hyaloid .artery does not disajipcar, l)ut remains in its entirety. Capsular cataracts are stationary. I*))sterior i>f)lHr cntHract. 11 it Ijnlindar rt/wc/7(t'.s are far more co, ' on than capsular oi)acities, so nuich so that the word cataract, unless ([ualitied, is usually taken to mean an opacity of the lens itself. I,enticul.ar opacities are caused by anylliiiij; th;it intertVres witii the normal growth of the lens. In this way errors of development, such as faulty, delayed, or imperfect development, .-ienility, ccmstitu- lUslAshs or THE < hystm.i.im: less w, lii.n;il <lisf;i>cs, :iii<l ntli.r .liscascs (if tlx' rvc, csii.'cially tli.' .Ii-<fafi»..s ol III.' iivciil tract, wlii.li is .vsjiccially ( ('•.■riif.l in tin- niitritidn nf iIm' .-vc, act as causes uf cataract. TJic l.nv-uradc clii.niid;,! inflarii- iiialit.n. .Irscnl..-(| in tli.' living as •■rli..rni,lal .lisiinliarwr. • hn.iiKlit .iliuui hy cyi'stniiii atlcn.liiiK iinccirrcctcci or iiiipn.|i.iiy currccicil rrrursuf rdnicticn. is Ik'M ti. he a i»itciit caws.' ..f lonliciilar cataract. The writer lias staled the causes in the toreRoin^r nuinn.T I.ecaiise iliat idea hesl explains the {rreal'-r relative frc.|iienev of c;ifaract in ihe illiterate and ignorant ehisses— c. ,/., the iienn.fa.'e— in whnni errurs ..f refraction are rel.atively raiv and iis<' of th.- eves in a manner ral.Milated to cause eyestrain very iiinisual. Cataract is coniriion 111 irlaxi, lowers and others whose occiliialiori ex|i(i-. s tli'iii to lii>;li leiii|ieratures, |)rol)al)ly I ause these excessive temperatures cjtuse Plo. ro. IVftliininc CBtamct. The nucleus Is begluning to shrink, and a numbtr of separation- in the fibre ■.■.hown. Thf«e se|«rat:on.« are lilk«l with Kranular matter which staiti^ .teeply. x lUU iPre- ircd hy Dr. K. S, Thomkon. in the lahoratory of the Manhattan Eye and Ear Hospital.) ■'lilar conditions of the choroid. The manner in which these eau.<*ps 't is understood best when we consider the Pathology of Lenticular Opacities. The lens grows, as we havo ■ "11. hy the formation of new fibres from the laver rtf epithelial cells Inch underlie the anterior cap.sule. These cell.s become fibres by a ;oces.s- of elongation, and p. to make up the cortic;il porti<m of the IIS. The tendency of the (■.•insular enitlielium to !:!ke on thi-- filin-.U'J nicture has been >een in considering .anterior capsular cataract. 'le nucleus is the oldest part, and hy contraction and lo.ss of fluid idiially becomes more dense and smaller. If the growth of tho 488 r//A' A)A". lens is arrested l.v senility or by any otlier eaiise wiiieli interferes with its jrrdwtii, the nueieus continues to siiriiil<, and small spaces are created bv its drawinfr away from the cortex. (Fip. 270.) These ; ii senile catamct. The cortex i. homogeneous. Deeper in, the fibre. »« "l-^f* 'hjough shrink- ing of the nncleuK. and the -pheres of .Morgagni are forming . 100. (Prepared by Dr. f. S. THo« son, in the laboratorj- of the ManhatUn Eye and Ear Hospital) F;n. 272. Senile cat«r..ot. ■^pnniti..n of tihres and formation of spheres of MorKSgni. ■ '-W. (Prepare.1 Ml ir. K s THoMsos, in the lalK.ratory of the Ma.ilmltan Eye and Ear H<»^pilal.) DISEASES OF THE CRYSTALLIXE LENS. 489 Spaces, thcicfiiro, as a rule, lie in tho jxTinucloar rcgioti, ospocially toward the ('((uator. Tlicsc s|)af('s l)ec()iiie filled with an albuminous fluid, like serum, which, while clear, appears opacjue as compared to the filires, on account of the difference in the index of refraction of the two. Thus the first appearance of cataract when seen in its period of development is of opaque lines running from the circum- ference, liy obliiiue illumination these lines api)ear gray, but by reflected light they appear black, as they interfere with the light icHected back from the fundus. The albmninous fluid in the spaces fietween the fibres coagulates to form drops, called the spheres of Morgagni. (Figs. 271 an<l 272.) The lens fibres next to these spaces Flo. 273. Senile caWraci Tlie Hbre« are beginning to break up, ind the lent looki granular ami homogene- <'U.>. luo. iFre|«red by Dr. K. S. Thomon, In the laboratory of the Manhattan Eye and Eur IlivpiUI.) Iiccome clouded by minute fatty drops, and swell and become more ;in(l more ()i)a(|ue by fatty degeneration and imbibition of the fluid. (I'igs. 27-'i and 274.) This j)r()ce.ss may 1k> arrested by the removal of the cause, and. (>xce|)t in senile cataract, the lens resumes its norinal growth. The nucleus, being more (len.s(>, is usually the least .itTccted by the process, and in many cataracts it is yellow and com- |iaiMtively clear, while the cortical portion is milky and opaque. If llie cataract i)rogres.-<cs to complete opacity of the lens, the same lliiid is secreted betwi'«'n the lens and the capsule, and tends to ;ji;ir:itc llictn. i Figs. 27.T and 27(5.) Thi,-; makis rcninvai uf the liiis easier, and explains why we prefer to delay the extraction of ;in)gres.sive cataracts until they are fully opa(|U(' or "ripe." When 4yo Senile rataract. Showing leparatlon of Hbres and granular di-bria. Fibres cut transvirscly ■ liio. (Prepared by l>r. E. S. Thomson, la the laboratory of the Ma.'-.attan Eye and Ear Hospital.) KiQ. 275. (Hlaraot following irldocyclUiB. Showing •nftenlDg of the cortex anil wparation i>r the onier layers nf Ihe nucleus. < l.'i. (Prepared by Dr. E. 9. Thomson, In Ihe laboratory if the Manhaiinu Eye and Fm Hospital. j DISEASES OF TUE CRYSTALLISE LESS. 491 tliis stage is readied, the whole lens contracts until the increase in size, due to swelling of the fibres of the cortical portion, is lost, and the lens regains its original size. The degeneration of the Hhres con- tinues until the cortical portion is converted into a jjultaceous opatjue mass, which becomes finally perfectly fluid, and in this fluid the still firm nucleus floats. This condition is known as hypennature or .Morgagnian cataract. The fluid portion may become clear and the lens in a measure regain its transjja.ency, but not its consistency, and some improvement in vision takes place. The luicleus never entirely disappears, although it becomes progres.sively smaller. V\w- lesterin crystals may form in the fluid part of a hypennature cataract. Fig. 276. ^iiitc cataract. The cortical layers beneath the capsular epithelium are Boftencxl, and .several iHrge swollen nucleated celU show. Below these are a few vacuoles between the libres. • 2tX). Irtpated uy Dr. E. 8. Thom!"— . in the laboratory of the Manhattan Eye and Ear Hospital.) The symptom acuity of visio, li'iis differing in lyo])ia, or mu. Act consist i)rincipally in diminution of the .tie early stages the presence of areas in the ive index from the lens itself may give rise to >ision, but this is not verv common. The eve surgeon is usually consulted on account of dimness of vision. If the opacity is peripheral, it causes very little inconvenience a.s long as the central jiortion of the lens remains clear. Such a person .sees lii'st with a contracted i)ui)il wlien the opaijue jjortifnis are hidden tM'hind the iris. On the other hand, if the ojiacity is central, the patient .sees b(>st when the pu])il is dilated — e.g., iit night — when the ii'traction of the iris permits the pa.s.sage of rays of light through :'ni- dear peripheral portions of the lens. .\s the o])acity progresses the vision is jioor under all circumstances, and the |)U|)il assumes a notice- iliiy gray or white color. The vision is never entirely lost from 4;t2 THE EYE. uncomplicatPtl cataract; that is, tlie patient can always not only per- ceive light, but can tell the direction whence it conies. If a patient with cataract is unable to determine the location of a lightetl canillc at a tlistance of fifteen feet in a moderately darkened room, we inav be sure that some lesion of the retina or optic nerve is present, and that removal of the cataract will not be attended with anything like a perfect restoration of vision. The imi)air;nent of vision which is observed in the development of a cataract is sometimes due to another cause than opacity of the lens. It freijuently happens that prior to the development of any consideraiile opacity the increasing density of the lens renders its refractive index higher and its action as a lens stronger. The result of this is to make the eye myopic, and this is the condition which constitutes so-called "second sight." A previously emnietiopic or hyperopic eye becomes myopic, and if the patient is at an age when jiresbyopia has appeared— anil this is usually the case, since this con- dition is seen oftenest preceding the development of senile cataract — he finils that he is enabled to dispense with his presbyopic glasses and read with the unaided eye. The dist nt vision is, however, reduced. Careful examination of such an ye will seldom fail to show commencinjr ataraetoas degeneration of the lens. An attempt to correct this ner\- aci;'i'r;-d myopia by glasses is not very satis- factory, for although the patient may read the letters on a test-card with much greater fluency, for some reason the gla-sses do not seem to render him much practical aid in vision. The writer luis frequently seen cases of this character in whom gla.sses would raise the distant vision froi)'. 20 100 to 20 50, or more, but who preferred to be without them. For their influence in relieving eyestrain and promoting nutrition of the eye, tlu-se glasses should be carefully fitted and worn. The course of cataract is variable. We may except the diiTcrent forms of stationary cataract, in which there is no tendency to change, and speak only of i/fogressive cataract. The tendency is for the opacitv to advance, but this occurs at a very variable and uncertain rate. We are, therefore, not able to jirognosticate with any certainty the length if time which a given case will take to arrive at maturity and he ready for operation. The process may advanci apidly for a while, and then remain stationarv for years, or, after a long period in which no i)rogress is made, suddenly advance rapidly. In case both (-yes are affectcfl, we can argue with some degree of confidence that the last eye to be affecteil will run the same course as the first one did. but there are many excejitions to this. A plain statement of all thi'se facts had better be made to the patient or the patient's friends at first. In a general way, it may be said that alxiut two years is an average time for a senile cataract to arrive at maturity, while the jirogressive forms of cataract in younger jieople are apt to advance more rapidiv and on the whole with greater uniformity. The value of this staiement lies in the fact that we may inform the j>ati(>nt that it is not likely that the eye will be ready for o|)eration DISEASES OF THE CRYSTALLiyE LESS. 493 in less than two years, nor is it apt to be longer than three or four. But this statement should be made only as a mere apjiroximation, !<ince there is no way of arriving at a more accurate prognosis. Progressive cataracts follow a course in their development which admits of division into four well-defined clinical stages: 1. Incipient cataract. In this stage second sight may be present, but the opacity is recognizable, especially with the ophthalmoscope. No other changes have yet occ^/red, and vision is present to a useful degree. 2. Intumescent or swollen cataract. The lens is now more opaque, although clear areas may still be found ; but the fibres are swollen, the lens is larger than nonnal, the iris is pushed forward, and the anterior chamber is shallow. 3. Mature cataract The lens has resumed its normal size and is opaque throughout. 4. Hypermature cataract. The cortical portion has undergone soft- ening, or even liquefaction, vtu'i may have cleared up to some extent. DiagnosiB. The diagnosis of cataract is to be made by careful examination with both oblique illumination and with the ophthalmo- FlO. 277. I Niiclrar caunct. 1. Section of Itni; opacity densett at centre. 2. Opacity as seen by tram- mitted light (ophtbalmcacoplc mirror), with dilated pupil. 3. Opacity as seen by reflected light I focal illuminatloD). The pupil is luppoeed to be dilated wiih atropine. (jcope, and should aim to determine not only the presence of lenticular opacity, but also the precise location, stage of development, and kind uf cataract, together with the cause, if possible, and the condition of all of the other ocular structures. It is important to examine the lens with the pupil fully dilated by means of a mydriatic. It is extremely important, in ciises seen early, to make a careful examination (if the fundus of the eye, since the opportunity to do this may soon he lost, and a knowledge of the conditions within the ball is highly advantageous in arriving at an intelligent opinion as to the cause and course of the cataract, as well as the chances for a good visual result following operation. By oblique illumination opacities in the lens appear as gray dots, iiia.sses, or streak against a black background. (Figs. 277 and 278.) If small and situated deep in the lens or very near the eijuator, ♦hey may not be visible at all by this method, and their density is, ass a rule, not easy to determine. Opacities in the anterio layers of the cortex or op the anterior capsule are easily seen in this ..ay, and we c!in also judge of the depth of the anterior chamber and the condition •f the iris as to color, motility of the pupil, etc. 4Jt4 rilK EYF.. . we (Ictcniiiuc wIk'ii a cataract is iiiatun' by concpiitratiiiR light oil it fruiii the side (ohliciiic iiluiiiinatioii). If the cortex is not <>pa<iut'. tlic iris tiirows a very inarivPtI siiadow tiirouph the clear outer Fill. 278. C'ortic*! catmract Referencra aa iu preceding llgure. layers on the opatiue central portion of the lens. (Fig. 279.) If the lens is fully opa(|ue (mature cataract), no shadow is thrown. liy ophthalmoscopic examination opacities appear black against a red background, and on the wholi' are more easily seen. We can judge very well of their density by this method according to the degree of blackness. Faint imclear opacities can be ilet«cted which escape being seen by oblicpie illumination altogether. Kxcept in patients whose eyes show glaucomatous tendencies, the jnipil should always be dilated with a weak antl evanescent mydriatic, such as a 2 per cent, or 4 per cent, cocaine solution, or a 1 per cent. euphthalmine solution, or a combination of the two in a 5 per cent, or 1 per cent, .solution. Otherwise peripherally located stria', the form in which senile cataract often commences, will be hidden from view by the iris. (Fig. 27.S.) The dilatation of the pupil also enables us to judge i ;,. ■■^Imdow of the iris seen from in front In Innnature cataract /. Eqiialii aource of light. L L, Shadowof'the iris upon the lensseen in fichematic cnwt-section. L. EqnulB source of light. (Ft'CH>«.) of the condilioti of the pupil as to its motility and the presence of posterior synechia'. The extent of central opacities may be clearly defined th'iiugh 'he dilated pupil, and the condition of the fundus stuilied througli the clear periphenil portions of the lens. Tlie liiciUlnii uf llij- Djiaeity, if small, can be made out liv ophthal- moscopic examination by observing the motion of tlie opacity in regard to the Miotion of the pupillarj' edge of the iris. If the opacity is on the anterior capsule of the lens or in the anterior portion of the DJSJiA.SES OF THE CIlYSTAhLlSE LESS. 4!»o cortex, it will aiipcar to move in tho sanio direction as the eye moves, I. upward if the patient looks upward. This is determined by Flu. SO. Fia. 282. I'ingrammBtio repreronuilon of method of detecting location of lenticular opacities by their ■niiieni in relHlion to tue movement of the edge of the pupil. Fig. 2S0. the eye is lookine ia,Kht aheHd. Fig. -«1, the eye I, looking upward. Fi.g. 282. theeye is l<x>kingdo»nw8n3. , Iri, lens. O. Observer, a. Anterior opacity. 6. Central opacity, r Posterior opacltv. Oc Line of ">o!i of tibserviT. tiiiR its (li.stance from the edge of the pupil. If the opacity lies .ir the posterior surface of the lens, it will ai)pear to move ia the 496 77//; i:yt:. ()j)j)ositc (liroctioti to tlic iiuivt'iiicnt of tlic eye — /. c., if tlic pnticiit looks upwiinl. tlic upi.city ajiiK-ars to nn.vc downward. A c'litnil ojjacity— tiiat is, ono (M|ually distant from tlic !\\m surfaces— will move vcrv little or not at 'all. T'lis is shown in Figs. 280, 2S', and 2S2. Hch Ics notiiiR tho condition of tho lens and anterior scgnipnt of tl> wc should, if the condition of the lens perinifs, examine care- fully lor opacities in the vitreous and for evidences of disease in the optic nerve, retina, and choroid. The latter lieing the nutritive coat of the eye, the presence of any disea.se of it will throw light on the cause of "the lenticular diseiuse. I'A-idence of disease of the optic nerve or retina will govern us in arriving at a prognosis as to the visual result to be attained by oiK-ration. If a view of the fundus cannot be obtained, the condition of the deeper structures shouUl be determined by measuring the Held of vision. This can be done even in mature cataracts by means of two lighted candles. It has Ijeen stated that cataract alone never causes loss of the ability to perceive light : hence, in the abscMi'-e of other disease of the eye a fairly normal visual field can be demonstrated by the candles. Not only .should the limits of the field be mapped out, Init the central region studied in the .same way for the existence of scotomata, the presence of which would modify the prognosis materially. The con<lition of th(> conjunctiva should be noted for evidences of present or past inflanunation, and, above all, should we carefully examine into the condition of the lacrymal apparatus, both at its ocular and nasal extremities, and determine if the appanitus per- forms its drainage functions ])roperly and is free from inflanunation. The lacrymal apparatus is probably the most fruitful -source of post- operative infection of the eye. The eyeball should be palpated to determine if ' iiderness exists and if the intra-ocular tension is increased or diniiiiislud. The sig- nihcance of these conditions is stated elsewhere. The general condition of the patient's liealth. secretions, urine, etc., nuist all be looked into before our investigation and diagnosis are completed. Prognosis. The jirognosis of cataract, except from ojierative treat- ment, is for permanent blindness. From time to time other treat- ments are exploited, but none so far ailvanced ])osses.«es any value. .Ma.s.sage of the eyeball through the clo.sed lids ha.shad some supi)ort from reputable ]irofessional sources, b\it has practically been aban- doned as without value. Other treatments by the instillation of cer- tain drugs, such )is cineraria maritima and other substances, and various "absorption treatments," have emanated from unprofes- .siwnal siiurces or from charlatans, for commercial rea.wns, and are also worthless. Spontaneous clearing of cataractous lenses has been occfisionally reported by observers of repute, but is extremely rare. Ri.sley has I)i.s/:asi:^ of Tin: cnvsr allim: i.e.w- 497 c.-ill eel :iltciiti()ti to tlic fact that some, at least, of tl ii'i! li'iiti. icsc casi's were ir ( iliacilics, l)ut iiiflaiiiiiiatory deposits iM'tween the |k.. leiior ea|)siile ami the vitreous, and were of choroidal origin. It is easy to understand the disa|i|iearaiiee of these iiroducfs, I few instaiiet's clearinf; u|i of true leiitieular ojiacilies has I to occur. These cases are ophtliahnoloKical curiosities >ut HI a K'cn .seen Cataract is sorneiinn dislocation of the lens. 'cured" by the spontaneous or traumatic II In cataracts which are allowed to advance t( hyiKTinaturity, the uhstance .sonietinies becomes suHiciently clear *o jx-rmit uid cortical onie restoration of vision. tl I he jirojin.isis from operation is pood. In uncomplicated cataract e operation of removal of the h-ns should vield a good visual result m about ',»() per cent, of ca.ses. The pro^iio.sis is rend(>red less favor- alile by coni|)licatinK (lisea,-*e of the eye and bv certain depressed states of nutrition, as in diabetes. A careful examination, as was mentioned undiT the head of Diagnosis, will lead to the detection of these conditions, and the prognosis can be inodiHed accordingly. Ill considering the (uiestion of operation for cataract on patients who, for some incurable local or general di.sea.se, such as suppurative condition about the eye, trachoma, or diabetes, nejihritis, pulmonary phthisis, etc., offer a bad prognosis, the matter should be explained fully to them in regard to the risk that they run of losing the eye, and they should then be advised to have the operaf )ii performedi for the rea.son that in the event of failure their condition is no worse ihan if they were not operated on, that is to say, they are blind hi either event. The clinical varieties of cataract have been - ted in the Drocedinc pag-s. ^ ^ Capsular Opacities. 1. Anterior cajmilar or polar cataract is lilher congenital or is actjuired in infancy as the result of corneal ulceration and perforation. There is a subcaii.sular hvperplasia of the epithelium, and in the ac(|uired form fre(|uently a depo.sit of lymph on the anterior surface of the capsule, forming what is some- I'.iies called inramidal cataract. From this a filament of organized lymph may sometimes be seen to run to a small corneal opacity. 2. Tosterior capsular or polar opacities lie on the posterior layer I't the capsule, and are caused by failure of absorption of the ti.ssue uiicre the fu'tal hyaloid artery joins the lens. Sometimes the hyaloid iitrry persists, and may be filled with blood or may have its "lumen ■■l>hterated and api)ear as a connective-tissue filament running from I III' optic disk to the lens. ■{. Secondary or after-cataract is the name applied to portions of lie cajisule left behind in the pupillarj- s[)ace after removal of the '••lis. I'nless the lens is removed in ifs^eajisule, a secondary cataract ilways remains. This may be .so thin as not to interfere with vision, id then is (.f litJe clinical importance. On the other hand, it may ■ i|i"itc dense and augmented by particles of lens m.-itter enclosed 32 I 498 77//; i:Yh:. lH>tWf..n the postcru.r capMilc ai.-l tin- nM.uiins of ihc antcnur .-apsu <■. a.ul furtli.T \h\rknm\ l.v a .l.'p-.sit ..f lyn.i.l. tl.r.mu ..ul ...... tl.c iris .luring tl..' iril=s wliich ..IKm. follows op.-ration for oatarar . (FiK -'Sa ) If ilK- c'litral portion of th.- secondary cataract is sul- Kemainsof k... afler a normal catanu- extraction. Showing swollen lens nhre. .urronn.le, by irir.^"'l"a,v e.nrtau-. Fron, an eye which wa» enucleate,! .,n the tenth day for lr„ .Hy.l . s 15 a'llp^r^l b"l,r E S TnoM«.N, h. the laboratory of tbe Manhattan Kye and K.ar Momh.hI.) ticicntly <.pa<ni.- to int.'rf.'rc witli vision, it ro.iuircs treatment by tiie operation of capsiilotoiny. . • r i i f Lenticular Opacities. 1. Stationary opacities of the lens are oi ^'T«rrirc'iins.ri!..'.l opacities of llie lens may f.^ll.'W a penetrating wountl confine,! ,o a small area. We cannot count "»;•"';"•;»•';:; this character remaining stationary, but the clinical tact is tha thev sometim.'s .lo, an.l may even .lisai.pear. It has l.eeii sal- tha"t in some of these cases the wound in the capsule is mmute and i.Ktantlv doses. keei>ing out the a.iueous humor. Ihe opacity >> „„,„ a,.;, to mechanical disturbance of the lens hbres. ( ircumscri bed opaeities of (Uher than traumatic origin are sometimes s,...,,, and an ,;i.„,„ute explanation of them is hard to give. Ihe most c.muiH rorin is that in winch opaque .... .-s a.ul spicu a' ex.s >•'";";'• ^,,„, i„„„,. ,|„„hant of the lens, a- descnb.Ml by . . h. Hiomps -. This i. the form of senile cataract which is most apt to remain i.aiti.il for a I"...' time. Other forms are i.unctate opacities, which are , "•"'-"" , .,,.,.,„,..;,:,,„. .,t,.!.ir(.i>acities, which niu ti|.l<' and iii;iy ,,rcupy .l!:uM^t au\ w.-tti .n. -i. . .ir < - " '•.,,,. .,re imusu.al in the pt.sfrior central reg.on an. ofte.. a>s...i.. . I i^th n-tinitis pigm..n...sa .,r chon.i.lal .lisease, -'''v-tr-usopacit s^ central cataract, an .-i-acity lying n.-ar the centre ..f the lens, an.l JUSKAst's OF rill-: cnYsT.xLLisi: i.i:.\s. 49U spindle or axial cataract, which coiisi.sls dI' a fiisit'i rill opacity ruiiriinj; iVoiii i)cl'orc backward through the centre of the lens, with lli"e lliickesi portion at the centre. (/<) Zonular cataract is a common form of coii>;enilal or infantile IKS a cataract lis arrest of ceases to projjress, cataract. From arrest of development or growth of the It ■ I'jtins to form in the perinuclear rejjion. The cause of tl development orpowlh hein>; removed, theojiacitv llie surrouiidinj; and sub.s<'(iuently formed lens siih.stance liei'n« clear. The condition is tlien that of an opa<|ue shell Kiiif; in the lens, en- closinj; a clear nucleus and enclo.sed hy a layer of clear corte.x. A repetition of the process at a later d;ite may "result in the formation of a .second opa(iue zone, .sejiarated from the" first hy clear lens tissue. Zonular catanict niav l)e( ome i)roKres.sive by flie overlving laver liecolim IK opaque. This may be foretold when p( rijilu'ral oj picula- are .seen lyinji ii; front of the opa(| from their relation to tl ue zone Th. i|ue le opa(|ue '^one are ci led ri.l spiculii ('!> Hy >les an immature ol)lii|ue illumination this form of cataract re.seml projrressive cataract. The ophthalmoscope shows the centre to hi slijihtly clearer than the peripheral |)ortioiis of the opa(|ue area, and surroimdiiiK the opacity a clear area through which a bri>;lit reflex is obtained and the fundus can be .seen. {V\g. 2.S4.) The upj)ear- Klil, 2>« l.aiiitllarcalaracl 1, J, :! A« Ixfaru. 4. .Suows hlnjlii gmynewof the uiidilatwl pupil owini; to the layers of o|tt('lly being deeply seated. ■mce of clearness in the centre is due to tin- fact th.at the opa(iue layers are further .separated here, while ;it the edye of the o|)acitv the iwo ojiaque layers are .so clo.se that they have t!;.- etfect of one "thick i.iyer. Zonular catanict is associated .so ( with a history of lonvulsioiis due to rickets that they .are penerally believed to l")ear I causal relation to it. ''•) .\iit<'rior and posterior cortical opacities are sufficieiitlv de- ■iril -d by their name. They are lenticular opacities, in coniradis- iiiction to .anterior ;iiid posterior c.apsul.i.- cataracts, and their .special .uis!- is not uiid( r.^iood. 1'. I'ropr. ssive cataracts include the vast m.ijority of opacities of lie lens. W aile sometimes .«(.(.ii in young adults, tli'ey usuallv afTect Tsons over forty years of age, and constitute what are .siM)ken of ."ilMt rill I VI' i -! • i\ •1, -.nil.' cMlaiu't-. ll iiiu>l lint !■■ i'^W M.u ili.ii pr-.-nsMv.' ral • Hart- 1I1MV 1... sell in iiilalu-v - in- rA. at v ,',■. \WU -i- \\m- aj;.- nl tl.irlv vrals ••ataia.'ls ,.arlakr -i tlir rliaia.l.liMirs ul ll..; li-mml Irn- ill'llial llirv ,,lr •■oinpo-r,! iai-civ of ll,r .u.t.T M.M rnMlcal l"-!-- li.Mis iii.l Hi iviaiurlv liiilf mi.'l.iH. S.nil.' rat iiart-. on tl,r ulhii |,..|i,.l 'law iclativrlv laiv;. r mi.'lri, ali<l aiv call' hafil .ataniHs. .n ,li-tiiirii.iii iL.tii iuvciiil.' ur soil ..IK'S. ' .■ I" 1- ,.,uays. . y;ii m tli«- as:,.,!, a lavcf ,.f M.ll.Tr..rtrx aluMI..! t!, :, , ' 1-. . 'Imtiull ^i'l> 1- !'>^. :„ a '■•.■. I. Val lailr, ti U\vv the |.ali.-l I. • .ml. iv, u-' Oi>tlli;iui>l. -ull rn.iii liani .■alaia.-t>, wli.'ii matiitv Ia 'if t ■ 'li^'i ll"' ''"'""T .„,. ,,|- ., „„„,. iiiiilniin aii.l mval.T w iir,,.--. .'I .1.' lli- l:ill''i- 'iiay !„■ ...lit.' l.f..\vi., ilii.' t.. tlif larj;.T l.f..« nu< ••••i-. \ v. r,>. laij:.' ■•'i>'l ,|aik iiu.'I.Mis .-aiiM's wliat i< .-all.'.l Ll-'.-'- .ataiaci , a:,., mi- .'atara.'! i.iav !..■ all im.'l.'.i.- an.i ii.-vn- I..MM,-nr i..m: > n\'- .iM.a.'ts lM.ss.'s.- Inlir lailiv w.'ll-Wcliii.Ml >la,ur- as I,.,- ..■.•!, ii nf. i I. |iiri|,i,'iit. •_'. lunmi.'-ccni ;!. Mat^i'-. t. il- i.. ruialtuv. Complicated cataract i- i '■ i.'fm appli..! i. cat act- !.■.•. m- |,;ini.'.| l.\ Mih.T intra .Mailar di^.a-,' <.f su.-li a iialiliv - t" 'A-^'' I'.sc In c.iini.Hcali.iUs .luriiis: llif |HTlnMMaMi'.. .,1' llir ..|..T: i h.r lli.'ll- ivniuval. Tlnis fi.riical .ii.acitics wlii.!, . .Ii-ciiir ilic vi.v ilif t-l'l ,,1 ,,|„-iali iiiti.- a.llH-i'.iis whi.'h I'iiid tin' I. lis in \ ■■>■, i\u\'.>'y ,,l 111.' vitr.'c.ii-, ivn.liiiii^' its isca|M' lik.'ly .liiiini; tln' oicran..ii. af. ciuiiilKih- 111.' .'xi^trii.'.' ..I wliicli w.HiM justify ilu' naiiH' .'t ('..inpli- cal.'.l <'!• cMiiiilical.' •■alaiacl. < »ii lli.> otlwr liali.l, runjilii.-livili-. ,|a(•^\o(■v<lili^, .i|.tic ii'fv- atropliy .tc, may i^ili at. M'ii..iisly ajiaiiist tlir suci'i'ss of ilic "|H-rati.)ii. Imi ciist.iiii iln.-s iH'' sanctiDii tfii' il.'si;:iiati f .'alaiai-ls acciiiii|'aiiifil liy liicsi' .-"ti 'i'.iis as (•iiiM|ilifalc catai'ai-t , A siu'i-ial f.ifiii .if <Miiii|ilicat.M'atafact is tliat \\\\\<\i isscii I'.. i..\viii.i ii.'fil.rt.il iritis, Tli.^ impil i- ^..ntractcl to a i-iui. ami tlii- small ,,|iriiiii}r 1- lillci with an .■xinLiif so intiinat.'ly a.lli.ai lit -. tlic i^ap- stilc whicli is als.i opa.iu.'. a- !•■ '■niistitiit.' a capsnlMr cat iiaci . Thr irir. i- fiv.|inMilly l).>iiii.l to tli. .apsul.' I)\ iliis ii.iiiIh >• .'V.T its \vlii>l. r\\r\\\. a"...l •'' lens is oft.'ii .ipa.|ii.'. Iriii- ..t in- \.'rii\ i> fiv.|ii.'iitlv acc.inj.aiii.Ml hy .■yclitis. as a result >'i wlu'li tl n.na- lu'ular t.•ll^il>n is lowered. Etiology of Cataract. To rcs.'rve until now a con-i.'.iati.in of Uif caiiM's ..f cai.-.ra.'t is iner. ly t.. r.rite as caii-.'s ■ ..iiditi,.iis wlms.' iiiiiihis .^irnniih lias l..'.'n .lisciiss.Ml aii.l will r.'adii or imd.^rstood. C.l.p'nital i-ataraets ar.' .lu.' t.. d.'f.M'ti vi^ d,\ . |o| in.Mit, wIimIi in turn i- .111.- to --oinc local or ^'.nei-al .lis.;:-' ■■< '.lie m.itli.T. Syplnli-. tiilM't-culosis. or ..till '■ diatlietic .•onditi.m i ^- a.'t in il.is way. 'In.- d.f.'ctive d. velopin.-nt ..f one or iiioiv ol ilie pn.din-ts ol twin r tri;'ieprei;iiaii.'y niaye\pP-< itself in this form, .■.'ithniis.di seld.iiii in:i.s- so.aate.l with oijiri ph\-ir.ii and pi)s-:'i!y loriital dti-vt-^. Tr:-^^^ ^' .■ith.'r .lirectlv ..r in.lirectly to tli.> len- i- a eause. <irn.ral di- whieh affect tlu' nutrili.-ii! an.! -milily tliro.i:.h a Minilar .■e>sati trr'iwlh. have been .liscu.ssed a.- .•aiis.'s. Local .liseas.s ol t!" /'/sA'|h/.v 1)1 fin-: ' i;ysi hum: /,/■;' »>1 *liniikihi.' lenH in u cn-f.- of irl-j tiiry )ii Tiiov-s, ill Ih' ubipin- I 5 ■ 1 l)lulii>is lin;i)i loUiiwinif inilocyelitls. l."i ITcparfil 'v lir E. in the lalM)ratory ol the Mantmtlaii Kyeand I'-tir llii«i>ilal 502 Till-: i:ye. i.art'iculnilv clionmlal .liscasc. arc I'niitful causes. (Fij:. 2^^->.) Cho- roidal caiaVact is a wcll-di'tiiu'd variety, and is .seen often in young Kio. an. section from a c««! <,f phthisis, btilhl with owlfled choroid, showing the lens .■oi.vcrtcd Int.. u ,„■■* of llhroi.s ii.s..e. X 1.-.. iPreparcl b.v Dr. E. S. THOiisoN. i.i the Uboratory of the .Manhol an I.M' and V»j Hospital ) Fiu. 2SR. Wrinkling of lens c«i>»\ile ami Kinenlng "f cortex -.inder a large Irii adh-wlon ,artlflclally fopa- raicli. Fn>.naca.«e..Hrldnchorol.mi.. •: im) (I'reparwl by Dr. E. ». THonsor. in the lat jratory ni the Manliattun Kye anrt Kar Hiwpilal ) hisKASES OF ruK chystallim: less. 503 IK'rsoiis. In tliis fdrin tlie lens is very a])t to undergo caloiircous infiltration, and presents a porcelain-liive wliiteness. Diseases of the eye whieli terminate in atropliy of tiie ploln' Tiearly always produce cataractous lenses. (Fips. 2Sfi and 2X1.) In the same way coiiffeni- tally microplithalmic eyes have opa(|ue lenses. I'lyestrain from inicorrected errors of refraction acts as a cause by proikK'ing a choroidal disease of low tyix' hut long duration, and thus interfering with the nutrition of ti -^ lens. Iritis sometimes causes cataract by the tracti.tn of the result: .g .synechia'. We cannot say whether this act.s by first producing a rent in the capsule, or by the disturbance due to traction alone, acting just as a contusion or massage of the lens does. (Fig. 2SS.) In chronic glaucoma the lens usually becomes opa(|U(> in time, due to nutritive disturbances in the eye which result from the glaucomatous process. (Fig. 289.) Flo. 289. Deformity of lent In a cataract from chronic glaucoma. • 15. (Prepared by Dr. E. 8. Thomkn, in the laboratory of the Manbatlan Kyu and Ear Hoapllal.) Treatment. The treatment of cataract varies with the variety. It will be convenient, in order to avoid rei)etition, to dp.scril)e in a M parate .section the operations to be performed for cataract. Capsular Opacities. Anterior or posterior capsular and polar lat.iraets are, as a rule, so small that they do not seriously inter- fere with vision, .mikI may be let alone. In case thoy do, and treat- ment is necessary, we have no means of attacking tlio oitp.^uiar ifsion MJoiu , but discission of the lens must Im' performed and the case siib.se(|uently managed like a soft or traumatic cataract. Iridectomy, .")04 Tin-: i:yi:. often (if viiluc in sonic forms of piirtial cataracts, is nsually valnelcss in anterior and posterior iiolar cataract. Secondary or aftcr-cataraci is to i)e treated i)y operation if it inter- feres witli vision to any considerai)le extent. Tlie treatment is by tiie operation of capsnlotomy. Lenticular Opacities. Stationary (partial) cataracts reqinre dif- ferent treatments, according: to tlie inipairmeiit of vision wliicii tiiey cause and the condition of tlie other eye. Zonnlar cataract is, as lias been said, the most coinmoii variety of Iciiliciilar cataract seen in children. If the oi>a«iue portion is small ill diameti'r, it will be fouiid that dilatati(Hi of the JHipil will .so exjMise the dear ln'rijiheral i)ortion of tlie lens as to permit very satisfactory vision thronjih it. In such a case, while permanent dilatation of the pupil by contimioiis instillation of a mydiiatic may be piacli.sed. it is inconveiiiiiit and not free from the possibility ol a delct<'rioiis effect on the eye or fjeneral health of the patient. I'or these reasons il is preierabie to make a portion of the clear periphery of the lens available iK'imanently for vision by the i)erformance of an iridectomy. Tliis should be done in an upward direction, and the coloboma mad" of moderate size, but exteiulinj: to the base uf the iris. The refraction should then be cai. fully coirecied and leases Riven for constant use. If both eyes are affected, Ixjth should be operated upon. If only one eye is afTected and the vision of t!i(< other eye is jjood, this ojieration should not be performed. The alTected lens slidiiid be treated by solution or not at all. If the cataract shows a tendency to pro<;ress, the oix-ration for solution (discission) should be |)erformed. as iridectomy will a''nr(l only tem- porary relief. T" the absence of any contraindication, the treatment by solution should be i>erformed in all cases as affordiiifi the l>est visual result. 'tVe can count on securing normal or nearly normal vision, and can be sure that the effect is permanent. Both eyes should not be operated on at once, as some accident or iiiierciirn'iit di.sease may cause tlie h-^ of both. Hy oiM'raliiif^ on the two eyes at different times, we profit in the second eye by the ( xperience gained in tn-atinj; the first, as to the peculiarities of the patient and the behavior of the eye jus to reaction, etc. The same rule .-ipplies to all double cataracts. Circumscribed stationary lenticular opacities .should be treated on the same iiri.iciiiles. If the fellow eye is good, no operation is neces- sary on the alTected one. If it is defective or has been removed, the (lueslion of operation will be determined by the amount of visual impaiinii'nt. the jiresence of eomiilications. ami the help afforded by cornrtiu}: lenses. The o|)eration will be that of solution or extrac- tion, accordin-: to the jiatient's age and the consequent hardness of the lens and the size of its nucleus. i'rogre.ssive iciilicular opa.-iliis should, if slicht, \v fri-:ded by what nie.ans we have to retard tlie progress. Careful correction of r"fraction. including the ac(|uired myojiia. and nie.asures to iruiirove di.si:asics of the vRYsrAiuyt: less. 505 tlic RciHTiil lu'tiltli, togctlicr witli th<> troatincnt of any proiiouncci! ilysfrasia, such as (lialh'tos, iu'i)hritis, etc., will often render excellent aid in retarding the development of a cataract. Correction of the refraction lessens the choroidal disturbance caused by eyestrain, and in this vay contributes to iM-tter nutrition of the lens. The iiiiproveinent of vision which lenses bring al)out is also a source of I lie greatest .satisfaction in .some ca.ses. There is ])lenty of evidence show that the.se mea.sures are of undoubted value, and tliev should til tried faithfully. We have .spoken of the futility of "ali.sorpti( )n drugs. Alteratives undoubtedly exercise a beneficial (reatnients ant( ii inthience in some cases. As in zonular cataract, so iu progres.sive lenticular cataracts, dila- laliiin (if the jjujiil by mydriatics or the performance of an iridectomy may assist in obtaining temporary improvement of vision. As a rule, these measures are worthy of trial only when the vision of the other I ,.' is .seriously iini)aire(l or altogether absent. In behalf of iridec- lipiiiy, it may be sai<! that its performance at some tune before extraction of the lens renders the latter operation ea.sier and safer. Ill some cases contraction of the pupil by myotics (pilocarpine aiiil eseriiie) will be found to improve the vision when the centre of the lens is d'-ar or tolerably clear. In deciding on the use (,f mydriatics or myotics, it is best to test till' patient "s vision with the eye under tlieir influence at his occu- pation or in going around, to see if 1 m condition is improved, before .-•uggesting their use or advis'ng an iridectomy, for, although they may help the jiatieiit to .see li.uic letters on the test-card, they may lint render his vision any more u.seful in any other way, and their use would be wholly unsatisfactory. The utility of rii)ening '^^'Tations for hastening the maturity of leiiticul.'ir o])acities is (jiiesti.nable. Most operators prefer to extract .111 unripe lens rather than resort to them. The operation of removal of the lens in progressive ojiacities is, as a rule, best deferred until maturity. This is not necessary in soft cataracts— 7. c, in patients under thirty-five years of age, in whom the operation of solution is aj)plicable. In senile cataracts it is best to wait until maturity. The lens is tlien removed by extrac- lion. When the patient has a mature cataract in one eye and the lens of the other eye is clear, it is well ♦(> advise removal of the 1 -liariict for the following reasons: it improves his field of vision by • iiabling him to .see at lea.sf large objects on the affected side, and iliis prevents him from beinf .-'n into or from running into objects iiid other persoas. The ey ■• i> from accident to the other or the development of cataract or ' ■• li.spase in it, be at some time his niain de[)endence, and tlie \ . will be I)etter if it is allowed to lie (>xercised by removal of the tens than if it is excluded from the visual act for years maybe In- the cataract. Amblyopia from di=use Mi.iy develoj) in an eye which is affected with cataract, particularly ill children. 506 Tin-: EYi:. t'oiii]>li(':iti'(l cataructs arc a law unto ihcinsclvcs. In pcnoral, if tlic other eye ])o^^! >,-;(- ^oiui vision, coniplicatcd cataracts had better l)e let alone. If ii.e imIkt eye docs not possess and cannot Im- made to ol)lain useful vision, i(|»eiation should he resorted to, even if the chance of success is small. Solution or extraction should be per- formed, according to the af;e of the patient. The operative treatment of cataract comprises several operations. For hasteniiifj maturity in unripe cataract, various ripeiiiiif; opera- tions have been devised, i-'or the removal of opaipie lenses, the operation may be that of depression, or solution, or extraction. For tile membranous oi)aciti<'s classed as secondary or after-cataracts, the operation of ca])sulotomy may be done. For occlusion of the pupil after the rem()\al of the lens, various operations on the iris, such as iridectomy, iridotomy, etc., maj' 1k' re(|uired. General Considerations, See Chapter XI\'. Thk ()I'EH.\tk).\ of DKi'KK.ssiox was formerly extensively practised, but was abandoned liccause the eyes were sub.se((uently lost, eitlier from glaucoma or iridochoroiditis, cause-.', by tlie lens acting as an fin. ■y» FiXHtion forceps. V\a. '.w. <»C Uayes' kiiifu acudle. Fig. jy;). Brua'l (oracenteBia needlu. irritating substance. The o])eration consists in displacing the lens downward iUid liacKward into (he vitreous. Tiie instruments re(|uircii are a wire speculum (Fig. 290), toothed fixation forceps (Fig 291), and a broad needle (Fig. 293). The lids Ix'ing separated by the VISt'AHEil OF Tin: CRYSTALLISE LESS. O07 spcdiluin, tlio conjunctiva and subconjunctival tissue arc grasped with llic fixation forceps to steady tiie eye, and the needle entered either at the margin of the cornea or in the sclera behind tiie iris. It is jtlaced against the posterior surface of or thrust into the lens, and Fin. -.'31. struight cataract neeille l\v a Icver-likp action forces it ilownward and backward. The needle is then carefully and ([uickly witlulrawn. The innnediate results of this o|)erati()n are brilliant, unless the lens rises to its normal j)osition again. The ultimate results are usually loss of the eye from subse- (|uent inflanunation or glaucoma. The operation is only justifiable in those so feeble from age or disease that they would i)robably not do well uniler the o])eration of extraction, but to whom it is desired to give some sight during their short remainder of life. TiiK ()PEU.\Tio.\ OF soiATiox or (liscis-Hioii is apj)licable to catiiracts in young people. The age limit is variously stated as from fifteen to thirty-five years. We would prefer it on patients under thirty years of age. The operation eon.sists in making an opening in the anterior capsule and lens, and submitting the latter to the action in the acjueous humor. We have seen that this causes the lens tihres to become opa(iue, swell, and ultimately absorbed. Anterior and posterior capsular cataracts (if they re(|uire treatment), zomilar cataract, progressive juvenile cataracts, and other ojjacities of the lens in young people, ;'.re to be treated by this operation. The |)upil i.s first fully dilated with atropine. The lids being sepa- rated and the eyeball fixed, as in the preceding operation, a small I die, or a knife needle (Fig. 292), is thrust through the cornea well toward the peripher>', and carried to the centre of the pujnllarj- space. The point of the needle is entered through the centre of the capsule into the lens, and in withdrawing it the opening is slightly enlargecl. The needle is ijuickly withilrawn from the cornea, without, as a rule, losing the aijueous humor. It is well at the hrst operation to makr: M V(>ry small opening, since we do not know how the lens or eye will react. Should no irritation show it.self, and the change produced in the lens l)e slight, a freer opening may be maile in a few days ■md in the same manner. A generous central T-sha])ed or crucial incision is a good form, and is followed usually by rajnd swelling of I he l( !is, which protrudes through the capsular opening and fills the inferior chamber with broken, swollen, and opaijue fibres. These iiiiiy be removed from the eye by simple linear extraction (q. v.). I'ain in the eye and increased tension (glaucoma) necessitate this ^peratiim at once, ihhI it pronijitly relir-vi-.s these synsploms. If Miis is not done, the lens slowly absorbs. This process may l>e iMstened by breaking down the larger masses by needling or 508 Tin: IJih. furthor oijoniiip; of the capsule. ('(Hiiplctc altsorption requires from two to six inoiitlis. iitid (luring this time the eye should be kejit eonstaiitlv umler the intluenee of atropine. A drop of a solution of to tl le ounce IS ins two to four firaiiis to four timi's a day. On accou ahsorl), it is advisalile to remove tilled into the eve from one nt of the time it takes the lens to •iome of it by siini)le linear extrac- tion wlien possible. The absorpuon of the lens usually leaves an after- or sec dary cataract, which re(iuires peration. After this the eye re(|uires a hit;h strong cotiv<'x lens to enable it to sen-. When the result of discission, a the lens has been partially ab.sorbed a method to hasten thi' attaimnent of visic has been jjroposed by Dr. (!. (". Savage, and is as follows: A needle is introduced into the eye and the centre of the lens cl( ared by pushing the fragments towaid the jieriphery. In this way a clear pupil may be obtaii..'d some weeks before it would be availa!)le l)y the process of absorption. ( (perations of discission, ami capsular operations may be considered "office operations," and can be done on a couch or with the patient sitting in a chair and resting his head against the body of the surgeon, who stands behind him. Subse(iuent rest is desirable, but subse- (pient immobility is not essential. Ripening Operations. These consist in procedures whose essential ]iart is till' ajiplicatioh of massage to the lens for the ))urj)ose of .so disturbing the superficial portions tiiat opacification of the outer cortical portion is ha.stened. Their main influence is exerted on the peripheral layers of the cortex anteriorly. McClure'.' iris sclMors. InKlrumrnlx. Speculum (Fig. 2!M)), fixation forceps (Fig. 29\). keratome or paracentesis needle (Fig. 29:^), blunt probe or tnnvel- sliiiped spatula, iris forceps (Fig. 295), and iris scissors (Fig. 297). DISEASES OF THE I'KYSTALLIXE LE.VS. 'iOit An iri(lcct()iii\ or simple paracentesis cdrneie is done, and mas- sage applied to the li'ns, either directly l)y tiie probe or spatula introduced into the anterior chaniher, or the lens is niassajjed throu;tli tlie cornea. Tlie movements are rotary and very Rentie. Discission *=C^ CVlWlltSO^S Hseder's kiilfe (right and left). is also sometimes used for the purpose of rii)eninR cataracts. The present vi(>w of the method may be well expressed in Knajjp's words: " .\11 these procedures have the disadvantage of heinp, in a number of cases, either totally or partially inethcient, besides adding to the removal of the cataract another surgical procedure which has not always |)roved harmless." .Most operators prefer to extract immature cataracts rather than resort to any metliod of .artificial ripening. Extraction of cataract is tlie term a|)5)lied to o])erations whereby the lens or the greater i)ortion of it is removed at one sitting. The <iitTerent pr()ce<lures may be groujied under the heads of (1) simple linear extraction, .uid (2) extraction of hard cataract. Sini])le linear extraction is applicable to soft cataracts—), r., in pi'rsons under !he age of thirty years — and to traumatic catara-cts. It is performed as follows: The j)upil is dilated with atropine, local ana-sthesia induced, the lids separated by a speculum, and the eye grasped with fixation forceps, as already described. A narrow keratome or broad needle i> entered through the cornea just within its clear margin, and usually .It the point nearest tiie external canthus. By jju.xhing the instru- ment forward, and, if neces.«ary, by a lateral movement in with- dr.awing it, an incision about .') nun. long is made. The instrument should be withdrawn very slowly to permit gradual emptying of the anterior chamber, as rapid evacuation of the aipieous, especially if the tension of the eyeball is increased, may be accompanied by -ciisations which cause the patient to become alarmed and move. !!' the npcratidii Im jjndertaken a« the pnir.ary "pcrati'in on a soft I'Mtaract, the capisule may be incised by the same instrument which makes the corneal incision, by directing its point backward, or this may be done with a cy.stotome (Fig. '{(K)) after withdrawing the 510 THE EYE. f i first instniniont. Frc(|U('ntly tlic opcriition is doiM on traumatic cataracts, or on soft cataracts already (liscissioiiod. In citlicrof llicso events the anterior ciiainl)er will contain lens inatliT. This is re- niovi'il i)y opeiiiiif; the corneal incision by nressure on its jM)sterior li|i with a (lelii-ate s|)alula or spoon (Ki;;. ;{()4), and the escape of the lens matter further facilitated hy gentle counter-pressure and strokinn at the i)oint opposite the incision. Tiiis manceuvre is con- tinued until the lens matt'T is evacuated as thorou>;hiy as possible. The eye is tln'ii bathed with an antiseptic solution, atrojiine instilled, and a monocular dres>inj; a|)plieil. It is rarely necessary to combine an iridectomy witii tiiis method. A modification of simple linear extraction consists in extraction of the lens, when svifhcieiitly fluid, by suction. A curette with a hollow handle and jiartially covered bowl is introduced info the eye, and, by means of a rubber tube attached to the end of the handle, the ojjerafor draws the lens matter out by suction with his mouth. The same result is attained by means of a ]>iston syringe, but this method is not much ]»rac- tised. AnotluT modification consists in irriftatinji the anterior cliam- ber, as will be described in treating of the extraction of hard cataract. It occiLsionally hapi)ens that a patient over thirty years of age desires operation on ;i cataract which is either congenital or a])i)eared during cliildhood. It should be treated as if it had developed but reci'Utly; that is, by extraction, as if it were a hard cataract, which it will have by this time become, if not manifestly hypermature. I'lxtraction of hard cataract may f)e performed in one of three principal ways: 1. After a preliminary iridectomy. 2. Combined with an iridectomy done jus a step of the operation. 3. Without iridectomy (simple extraction). 1. KxTHACTiox .\KTKK I'ltKi.iMiNAHV TuiDhXTOMY. This is probalily the safest of all methods of extracting a hard cataract, but has the dis- advantage of subjecting tiie patient to the danger and inconvenience of two openitions involving opening of the eyeball. With much to be said in its favor on the .score of safety, it is practi>'<ed comi)aratively .seldom. 'l"he iridectomy is to be done as described in Chapter \'II., about six weeks before the extraction of the lens, which should not be undertaken until all signs of irritation foh ving the first operation have di.sippeared. The teehni(|ue of the extraction will be ti.e same as to be i)resently described. 2. KxTiiAcriox wrr!i ikidf.ctomv is the l)est operation for those of limited experience with the cataract operation. Its difficulties and dangers are fewer than those of the simple method and are easier to avoid. It is usually iierformed ;>; follows: Inslnimrnts. A (iraefe knife (Fig. L'OS) (it is well to have two at hand), a stop s|>eciilum (Fig. 2(H)). lid elevator, fixation forceps (Fig. 291;. iris foreej-.- {Fig. 2!).")), iri.- =iv {I'ig. 207 i.i..-.* knife (l'"ig. W7] or scissors for enlarging the corneal wound, cysto- tome (Fig. ."^fX)), silver s|)atula (Fig. .304). spooTi (Fig. 'M)'2), wire loop (Fig. Wi), and blunt hook ( l"ig. ;5()1 >. Tlie lids may l>e se|)arated JJIHEASEii OF THE LU)iSlALLlME LESS. 611 with a six'diluiii or hy a lid clfvator uimUt the u[)Imt lid, hcM l)y an assistant, who draws down tlio lower lid with the finger of the Kki. XO. Uimefc'n cjritolome Fio Wl. Tjrreiri blunt hook. Kli;. 3IV2. lel'i len^ » Fill nns. I^cvis' wire loon. Fin. 304. Spatula, ahell or silver. Fiu. 3I». Weckefa Iris Kisiora. Fig. set. ' incision in cataract extraction. l*tiucture and counter>puncture have beei made The sec- I'" -111 paiwln its whole extern exa<:tly through the transparent margin of the cornea, the knife lUMiiiiing in the same plane throughout. (Slightly modlfled from de Schwelnlu, Diaeaaea of the ':.ve, third edition.) Fid. :W7. Deamarrcs' secondary knife, stniight. 612 TIIK KYE. otliiT liand. As it is often iicrcssnry to o|M'ratc wWlioiit skilli'd assistance, or witiioiit an issistaiit to wlmni tlie operator is accus- tomed, it is desiralile to !iel in liie liahit of operatinn without an assi>tant. It is |irefei:il)l< to liave no assistant ratiier tiian a poor one. Tlie operator stands l)eliind tlie patient. Iiol.lin^ the cataract knife ill the ri,i.'lit hand anil tixat'oii forceps in tiie left for the rijiht eye, and rivf virsii for tiie left. The eye is jiraspeil l>eh>\v the cornea with fixation forceps, and if a lid elevator is used, these forceps may now serve to hold tlie lower lid out of the way. The incision is to he made in an upward ilirectioii. The eyehall is rotated dowiiw.ard and the point of the cataract knife entered just within the dear inarjtin of the 'oiiiea, and at a point which is the temporal extremity of a line parallel to a tan>i<'nt to the corni'al summit, and dividing the cornea into two portions, the upper |)ortioii of which is one-third of the cornea. The knife eiitiis the cornea at right angles to its surface, and as .xoon as the point is seen to have pt-iietrated the cornea the handli- is depressed until the point of the knife is directed str;iiglit across the :interior chamher from the site of the ptincture. and the surface of the iilade lies i)arallel to the surface of the iris. The knife is pushed forward, emerging from the cornea at a point (counter-puncture) diametrically opposite the juiiictiire. (Fig. -Wy) Ip to this time the ai|neoiis humor is preserv(>d. and the point of the knife seen through it lies farther backward than it seems. The handle of the knife should he carried well backward toward the external canthus. or the iHiints of punctun' and counter-puncture will Mot correspond, and an irregular wound will be made. As soon as the point emerges from the eye the blade is piishe<l firmly inward and niiward to its full length, and then drawn back, still pressing it ii|iwartl. The.-^e two cuts will sometimes sever the cornea throughout its extent, but fre(|uently a bridge remains re(|uiring further to-and-fro moNements of the knife to divide it. The knife should be helil with lis bl.icle parallel to the plane of the iris throughout, and if this is done a sinooih corneal incision results, with a small conjunctival flap at the a|ie\ of the corneal flap. The knife is now Laid aside, and the fixation forceps turned over to an assistant or dis|(eiised with if the patient is docile. The surgeon takes the iris forceps in his l"ft hand between the thumb and index fiiigiT, and the iris scissors in the right hand. The closeil iris forceps are gently insinuated inl<i the wound, passed to the pupillary border of the iris opjiosite the centre of the wound. oiK'Hed slightly, and made to grasj) the iris at the pupillary bordiT. They are then witiidrawn, bringing with them a i<M of the iris, which is drawn out of the wouiul as far as possible .-hkI cut otT smooth with the cornea by means of the scissors. The tixaiion fiice|)s niay or may not now be reapi)lied. The cysto- tome is tlic!! v.: ■•m!u(" 1 flatwise, carried In the centre "f the pupillarv space and turii'ii, so iliat its point '- directed toward the capsule. This is then ff 'ly cut. not torn, in >ucli a ni.iiiiier as to give a siif- ticient opening I the lens toe.^caiie. - une o[)erators make extensive DISEASES or TUE VKYSTMLISE LkSf>. 5i;j iiTcciilar iiu'isidiis. others inakc incisions in die .-'i:i|)c of a cniss. the IfltiT A, an inverted a. 'T like the (;re<'k letter -. Kn.i|.|i makes :i i-aiisular incisiim parallel {.■ the corne.il iiieision ' |ieri|ili( ral caii- sulot(iiriy). The eystotoine is Hirneil ami withilrawn carefully flat- wise anil tlie surireon t;ikes the s|ioon in one haml and the wire loop in the other. The speculiiiii or elevator inav l)c reinoxed at this time, (lentle pressure is ma<le witii one of ih.>e instruments just helow the eiljre of the eonie.i, the l>ressure heinj; first ii.ickward and then Upward. The lens lilt.s and presents its r,\(ro in the corneal wound, whicii >;;ip.s from the pn'ssure lieiovv. If it does not. it is !ri;ide to do hi liy pnssure on its upper lip wi'li the instrunient held in ;he othi'r h;iiid. My coniinuin'r the upw.ii I pressure the lens is -lowly delivered from the eye ( Fijr. ."JOS) and caught .vitli ene of the instruments held hy the operator, and removed from the e\c. If the spcculinn or (levator lias not .dre.idy heen nrnovi'd, it should lie removed now, and the patient allowed to rest, with the a.— urance Flu. ant. Flu .WO. li'i. 308.— nellvcry of the Itiis. The lens is i.rcwn'.ii'K lit the wound (eapsulotomy has U*'n jif-rfiinnt'il!. (lit- soliweiulu, l>i!«aw» nf the Kyi', thirl i-diiliiii.) Km 3IKI.— The miimicr of upplying the drcsMugs after cataract extiaction. iliat the o])eratioii is over. In a few minutes he is told to open the ■ ye, and tiie "toilet (if tin wound" is made. If any portions of the lens n>in!iin in the eye, they are coa.xed toward the corneal w. und liy stroking th(> cornea with the Imck of the spoon, and (leliv(>red ius 'he lens was hy pressure on the cornea. It is best not to introduce my instrunicnt into the anterior chainlier to facilitate removal if this di'hris. A .slender .spatula is introduced, however, to ensure li.i'iHness of the wound, ;\vA t" rei>!:ice by »;e!it!e stroking tlie edff-r-s if the cololxmia of the iris. .Ml the clotted blood and other material > removed from the conjunctiva by moist pledpet.s of sterilized gauze ir by the iris forceps, the small conjunctival (iaj) smoothed out, a 33 flF" A14 Till /.•)•/■;. (Iri>!> i>l' Mti(i|iiiic instillfil. iikI iIm ilir-^^^iiijf^ appiird. TIk'M' CDiisisl iiiil two Iivrrs iliick, of ^"luarr?* Ill -ii'rili/.i'il ;i:i(i/,i' ;wii mchr- -■iiiirc a vi't with li.KHNI iiii'i'i'iiric clilnriilc. tli Hiiiall |'"l • sti'iilizi'tl ahsiirtifiit cuttiiii. Iioili I'Vo Ix'iiiK >' cuvitimI. atu' • ' .mlt' Ik'IiI in jilacc liy strips of isingla> ur atliir^i\i' pi islcr applied as i'.-'InWM: Thf first strip ^>us,s«'s dvit ImiiIi lirfssincs from tciiipli' to tcinpli'. A sccofiil strip j.is.-i's fri'iii tin' rlitt'k of ihr iipcratcii side Upward and iliu.ird art'oss the pad omt iIh' oprr Ii'd eve to iiic fonlirad ovtT ilii' snind i-yc. A tliird passi-s fmni Ih-' ciicck of tlii' sound side across tli<' pad over that I'vc to the forrhcad over the oporati'd eve. (Fiji. -Ml) < Ivrr tliis is placed a mask made of some li^ht stiff mate- rial, to protect the eve from accidental injmy. The hands of the patient may Ih- fastened liy a strip of handap'tied to each wrist and to the post at the foot of the hed oil the same side, these strips lieilift just short eiioiijih to prevent the patient touching th" eyes with the liand. The writer prefers the almve dressiii); to the roller-liaiidajie, because it is easier to ipply, do«T« not necessitate raising the patient's head, and is cool, clean, and eoinfortalile. It makes snflicieiit pressure, and this cannot lie inerea.sed liy tiirniiif; the head. The strinns to the mask can h" e;isily insiini.'iied under the |)Mtii'nt's head without inii\inn th'- head, and should lie of unequal l''iiKth. so that the knots will be mi the side of the face next to the operated eye. In this position the patient will not !!'• on them, and they are acc«'ssi!ile. '.i. l-;.xTHv«'Tio\ wrruoir ikidi'ctomv. ..r .-iinple extract'on, is the <iperation of selection by many surjfeoiis of hiifre experience. It leaves the eye mo,-e natural lookinjr — indeed, in some cases it cannot be told that an operation has been done on the eye. Hut it let* never I II shown that the visual results are better than by the i-ombined method, while its |ierform.ince reipiiris more operative dexterity, and convalescence is apt 1o be interrupted by certain comiilications which do not obtain in the combined operation. The same instruments are rei|uired as for the conibini'd operation. Till' operation is performed in the same way u[i to the -laij" of makiiif; the iridectomy, except that it is import. int that the incision lies within the clear cornea. Tne cystotome is introduced immediately after the incision is comp!"ted. and the ca|isnle cut as already d(- scribed. The speculum may or may not Iw removed at this time. ,uid the li-ns delivred as .ilrejidy described, i'articles of lens matter are coaxed into the pupil and thence out throujih the wo'iiid, :is in the other iperation. The iris is then carefully repl.iced by strokin<: with a spatula. I*' it I'efuses to stay in position, but jirolapses in pite ot beiny. reduced, a portion of it should \w excised i iridectomy >. Th.- Isrnised .ir u-.rv. \:\- delivery "f the lens that V is best to excise the bruised part. ( )therwi.se, e.serine fV gr, to 1 nz.i may be insiilleil to keep the iris drawn inward from thf> wouml, and the dressing aiiplii'd. rBt.1 DlSKASes <>F TitK ril\sT\Ll.ISK LESS. 5i:. ModificatioM of the Operation, lli-- orijrinal (•alunict cxtnictioii :is vvliat \^ kiii.un u.s ilie li ii' ()|MT;iti..ii, tlu- incision (•(.iiipnsing was vvliat is known a- one-half of tlic lorncul circiniilrrcnct varionsly nMHiificil, so as oiK-half of thf forn<-a. A '.\ i. Hap i riic length of liiis lias iM'cn to iiicliitle any portion from one-fourth to i^ popular. \ very iiiiportaiii ii . r '"short Hiip, " us it i.'* railed, liticatioii was (iraefe'.s [n'riphital line.ir incision, corneal margin am The knife was eiiteicl at a jioint I mm. from ilii 'ent to its summit, and brought 1 2 mm. Iielovv a tar Ixnit nut at a -imilar i.oint on the other .-ide. The inciMon was a III mm. long, t.nd hut slightlv curved. Iridectomy wa.s always done The oiHTatiou is not popular, Inraiise the ( ' 'metiva is cut tn-ely and bleeds to all annoving degree, and the i.,,Mtion of the woim I favors loss of vitrei lus and cvcli'is. .Mention ma: l)c iiKide of the Instead of delivering i downward incision, and of <ine lying in tlie coriua and near its centre. These are nirelv used. he lens by pres.-^urc below with a spoon, the 1 and the incsMire made vvitli the Kiwer lid. be irrigated to remove fragments of the iiid. i'his is done by specially eoli- I and flattened points made of gold icculum may Ix' reniovei The anterior ciuimber mav ns cortex which remain 1 slructed svi-inges haviiiir (■mve( ilulion, which should be warm rhel>e>t fluid is a O.t) |>er<'ent. saluH' so _ Mud of course, sterile. Boric acid may U- used, but stronger solutions I'his method is not much in vogue, lis it sill damage the cornea. i- somewhat tnmblesome and not s])ecially advantageou iH'tween the simple ami combined i hods has been i iiimisi .\ con •ITected une o|ieiMlors follow* in: lead of grasping 'he iris at it illarv l>or(!er with 'le iris forceps, withdrawii idecfomv. a smal il id of iris is pii ■ked up midv t of that membrane and its pu) )illarv border, draw uni ■ut off. so as 'o leave a small hole in the iris. ■aves a round j)!' lil, and by jitTording a ] assage liumoi from the posterior to the anterior cliamber i. ii' I making the I. ! ( fion i/li.H)US inieal r)f till ^.mml, 1- tiM.uglit to be less likelv to be followed by prolai).se oMIu iiis. In .ertaiii ca.ses where j.rolapse of the vitn'ous is especially ;i|it to occur, or as an extraordinary precaution against prolapse ■• o f f ( ) t KIWI , 'H iir* iiii ' .-VI » i»"i ^»«">" / J ■ - .- r- . . th.' iris after the simple o))eration. Kalt has proposed the cornea -litch. It is of tine .silk, and is inserted before making the r',,r.,eal Micisioii in the same nianiKT .'is the beniberi intestinal sut-ir i.-^ in- M.rted. .\ tine rounded iieiMlle is used, and the central loo,, > left vrry long, so that it can be irawn out of the way of the instruments u^ed during the o|KTatioii. After the cimipletion of the operation -he ends of the suture .ue drawn taut an<l tied. A portion ol the Ulterior capsule mav be !.mo\.-d bv specially devised forceps, or b^ iris forceps. This isdesirable if the capsuK' is thickened. An attomi.t ^liouKl be made to make a more or h - circular cut with the cystotome I this procedure is contemplated. Some operators omit the capsulotomy, and attempt to rupture the iniuile of Zinn aiul remove the lens in its capsule. This is done by ol« THE EYE. pressure with the spoon at the inarjiiii of tlio cornea. It renders loss of vitreous more proliaiile, l)Ut when sueeessful leaves a pei.';'ctl)' dear pupil. It is not much in vogue. Choice of Operation. The safest method is that of preliminary iridectomy, followed by removal of the lens after some weeks. The patient is suhjected to the danjjer of two operations, but the operator w'll have ijaineil the patient "s confidence and some knowledge of his beliavi(.r and that of the eye. It should certainly be done if the other eye has been operated on unsuccessfully. The choice iR'tween the wo i)rinci|)al methods, with and without iridectomy, is a matter on which o])inions ditfer. The occasional operator had better use the former method, since it is, on the whole, easier to perform, and the visual results are (juite as good as by the simple method. It is well, at any rate, to make the cori'cal incision as above described, and do the iridectomy if delivery of the lens is not ea.sy, or if the iris tends to prola|)se. When the iris is rigid or in the least di.scolored, ,:r if the patient is restless, or if the incision has been placed other than within the clear cornea, it is better to do the iridectomy :it once, as the iris is likely to jjrolapse and necessi- tate its performance later, and prolong the healing. An operator who is not ambidextrous should take his position in front and at the left side of the patient in operating on the left eye, and, inserting the knife with the right hand, cut ujjward — /. c.away from himself. To av.)id the necessity of assuming this position, angular knives (Fig. '2!)!)) have been devised, by which the incision is made l)y entering the cornea to its njusal sid(\ They are seldom used. Accidents during the Operation. The knife may be inserted upside down. It should be turnecl in the wound and the o|M'ration ])roce«'(|e(l with, or the knife may be withdrawn and the operation postponed. .\s (he ai|ueous is lost by withdrawing the knife and the iris and the cornea lie in contact, the knife caimot be reitiserted. The iris may fall ovit the edge of the knife. By raising the knife it may bi' disengaged : but if not, the incision should be completed, the fold of the iris being cut through. Then with the iris forcejis, the cut jjortiou of the iris is drawn out and the wound made as nearly an ordinary iridectomy as possible. Loss of some of the vitreous liumor is a commo'i accidetit. It is rendered less :\yX to occur by removal of the speculum at the com- pletion of the capsulotoiny. If this is not done and a bead of vitreous presents in the wound at any stage of the operation, the speculum should at once Ix' removed and the i)atient allowed to rest a moment. If the lens has not been extracted, the attem])t to deliver it by ])r(»s.s- ure in tile usual way would probably result in loss of the vitreous. Therefore, no pressure should be made on the l)all, i)ut the lens should be removed by the wire loop gently passed through the wound and under the lens. Lo.ss of vitreous usually occurs aftir delivery of the lens. Fluidity of the vitreous or a sudden, voluntary sijucezing of DISEASES OF THE CRYS'j. LLINE LCXS 517 Ili(> musolos around the oyo, or an involuntary contraction of the recti muscles, may cause the loss of a consiilerahle amount of vitreous. If this 's not suiHcient to cause collapse of the globe, it is usually not a serious matter and recjuires no treatment; but if the eyeball collapses, warm sterilized salt solution (0.6 per cent.) should be injected into the eye by a j)i{K'tte introduced through the corneal wound, until the ball resumes its rotundity. This will generally pre- vent any permanent ill effect from the accident. If the wound is too small to allow the easy passage of the lens, it should be enlarged. This can be ilone by a blunt -pointetl knife (Fig. .S07) or fine blunt- pointed scissors, such as Stevens' tenotomy scissors. Under no cir- cumstances should the lens be forced through a wound which Is evident Iv t(K) small. The lens may be dislocated. This is usually done in the attempt at capsulotomy when the capsu'e is thick or tough antl the suspen- sory ligament frail. The dislocation is generally backwanl. The lens should be caught by the wire loop passed through the wound, and gently drawn from the eye. Hemorrhage into the eye may occur from the cut iris or from the rupture of a choroidal' vessel ilue to lack of support to these tissues which oi)ening of the eyeball entails. The former i.s usually a trivial matter, the hemorrhage ceasing spontaneously or being made to cease by com|)resses wet with hot ^^^ ^^^ Mhtise-ptic "solutions being applied to the closed lids. Blood left in the an- irrior chamber at the termination of I lie operation may be exjjccted to ab- sorb in twenty-four to forty-eight hours, llemnrrhage from the choroid is fatal 1(1 tiie eye. The patient at any time alter the completion of the corneal in- risiiiii, or even several hours after the o|i(Tation is finished, complains of -cvere aching pain in the eye, and tliere occurs gaping of the wound, then lo: ■ of vitreous, and a free How :.f blood filling the ball nd pouring Until the wound. .\ compress and liMiiuagi' should be applied, a hyjioder- iiiicof morphine given, and the jiatient made to sit up. The bleeding will cea.se in from a few minutes to a few hours, hut the eye is alwavs irretrievably hist, and subseiii.ently shrinks, lis. ■"ilO.") The paiii may continue to such a degree as to justify 'iiucleatiiin. The accident is rare. Sniiietimes after the cataract operation the ])atient will develop a niaiiiacal con<lition, probably due to the combined mental effect of nervousness from operation, exclusion of light, and the lack of any- Speclmen of chorolilal hemorrhage following caUniet exiraciion. The globe is filled with blond, anil the retina and vitreous have been cupelled. The darlt line is the choroid, which has been everywhere torn loose ,lifc tl«). (Pre- pared by Or. E. S. Thomson, in the labiv ralory of the ManhatUn Eye and Ear Hospital.) 518 THE EYE. tiling to ocotiiiy his attention. It is treated by sedatives, allowing him to use llie imoi>erat('d eyt % and l>y having someone remain by his bed to talk to him and otherwise " kcH-p him company." Patients aeeustonied to the free use of alcohol frtMiuently develop delirium tremens after this oix^ration, as after other surgical operations. The After-treatment of Catanwt Extraction. In a cas(> which runs a normal course the first thing to be ob.xerved is closure of the wound and reformation of the anterior chamber. .\s lont; as jjatency of the wound ptTtnits the aciueous to How away the anterior chamlK-r is empty a td the iris rests against the corncii. Closure of the wound is shown by accumulation of aiiueous forcing the iris back to its normal position. I'ntil this hapiH'iis we nmst feel some apprehension of |)ossible infection, and, in the sim|)le o )eration, of prolapse of the iris. Closure of the woimd usually occ irs within twenty-four to thirty-six hours, .\tropine may be used i'limediatelv after the opera- tion in cases where iridectomy is done: but after the simple operation should not be used until the wound h;is closed, for fear of inducing ])rolapse of the iris. The eye should be dres.sed daily, and the con- dition of the lids ol served for swelling or other indications of inflam- mation. The lids should be separated and the ball ins|)ected, too, and in cases done without iridectomy the wound should be looked at to see if i)rulapse of the iris has ()ccurre<l. As soon as the wound doses the p.itient i";iy i)e allowed to sit up and the sound eye left uncovered. .After fortv-eighi hours inire the dressings may be left off and dark gin.sses or i sliadi substituted. Coiilinement to the room is necessary for at least a week, and atropine •<houiil be kept up, usually three times a day, until tlie eye is entiii'ly free from redness. The (n'es should not be used for reading or other near work before this time. The immediate or early use of atropin.- after cataract extraction is justitii li by the freijuency with which the operation is followed by at least a mild di gree of iritis. We Mini to secure dilatation of the pujiil before tiiis occurs, which is ueniTally about the second or third day, or later. We observe injection of the ball, especially in the pericorneal zone, slight pain and tenderness, photophobia, aiid a tendency for the iris to adhere to portiniis of the cajisule and any remaining frMgiiicits of lens. In favorable cases these symptoms disappear in al)out two week>, I'atients coinjihun bitterly of p.iin in I lie li.ack when confined to :he bed in tlie proi'c position fur twelve hours or longi'r. This may be n'iicved l>y slippuig a small pillow under the sntall of the back, or i)y Mirnio'!; the i)atient gi'ntly on the side away from the operated ey^ (ntii tin wound closes, only food which dois in.* re(|uire chewing sho;ild be .illuwfil. and thi- patient should be made to use the bed- p.in uid ui nial if pofsible rather than rise or sit up. The open method of treatment, cir thai of placing no dressing at ,ill on the eye proposed by Hjort, has not foinid followers. Anomalies of Healing. Delayed closure of the wound may result from entanglement of a tna of capsule or other foreign matter in the DISEASES OF THE CRYSTALLINE LESS. oiy wound. If tiot dosed in thirty-six hours, can ful search should be made tor sucii cause, and th.- particle removed with forceps. 1-re- .,uently the wovuul heals .sh.wly from a i)oor .state ot nutrition or from no api)arent cau.se. Conjunctivitis with discharfje may arise from the action of the occlmhnp i)anda(ie. The dressinps .shoul.l Lh- li.rlitened or left off entirely, and the eye fre(|uently irrigated with al)oric acid solution. If the discharge does not cease, the lids shouh l.e everted and a solution of nitrate of silver (4 gr. to 1 oz.) applied to the conjunctiva. Kven if the wound is open, this siiould he done, lis the risk is less than that of allowing the .lischarge to c<intmue. If the wound has closed, the (lanfcr of infection is lessened. Intis occurs very fretiuently. It usually yields to atropine, hut if severe may recjuire re.st in ImiI. the adilition of cocaine, leeching, ice coin- jiresses, and antiphlogistic doses of mercury. Ice acts far bettor m these cases, which a'-e >raumatic, than heat. Iridocvclitis an '. iriilochoroiditis are to be treated m the same way. They an- much more serious than simi)le iritis, and may result in destruction .if the eye by sub.se(|uent atrophy. In cnnmon with iritis, thev tend to form exudations in the pui)illary space, the mem- branous secondary cataract resulting being very tough and dense. In iridochoroiditis in i)articular we notice chemosis of the conjunctiva, and in all the intlammatorv states which may follow the cataract oiK-rations the lids swell, especially at tiie inner cantiuis. In the absence of this .sign an.l discharge we may feel rea.sonably sure of liie absence of undue reaction. _ r i • i i'rolapse of tlie iris is the nu st common compl'-.-ation of the simple ni cratioi, and constitutes the greatest objection to it. It occurs m In.m .'} to 10 per cent, of cases. Its (k ■urrence is often announced bv a shari) i)ain, but as often bv no unusual sensation. I' diseov- .■red before infiammatorv action has sealed it hrmly to the cornea, tiie i)rolai).se should be excised and the margins of the colol>oma dressed back into the eve. It is hardly wise to rei)lace the prolapse and trv to hold it in place bv eserine. though this is sometim.'s done. Ii tlie" prolapsed portion is Hrmlv aled in the wound by mdam- mation it mav be incised, tmicheil with the actual cautery, or left .done It wilfeventuallv shrink and Hatten, so as to have no trace I. in a small pigmented spot in the wound: but as .■ntaiiglemeiit of the iris is apt to leail to iritis or iridocyclitis 'Kig. ;{n). or form a path for infection, it should l)e excised when |)ossibh'. Otherwi.se, to let it alone is preferable to incision or the use of the cautery. Septic infection is a dreaded and u.-^ually fatal comi'lication. It mav arise in the wouiiil or from the iris (suiipurative iritis . or more rarely in the vitreous. The tirs^ is usually by infection In.m without after operation, the other two torms by operative infection. Sup- puration of th" wound is most common. It is annoimced by pain ■ iiid marked infiammatorv svmptoiiis, and the wound is toiind to I. resent swollen edges and a vellowish infiltration along its c(mrse. Till- mav spread toward the corneal centre or around the cornea, 520 THE EYE. like a rinn. Tlic whole cornea Ixm-iiiiics op.'Kiuo, and usually slouftlis off. The eye sul)se(|uently shrinks. Soiiietiiiies the suppuration is limited, and healiiifi may oceur with some remaininjj; sijiht or a po.ssiliility of ohtaininn some hy operation. The treatment should consist in thoroujih t're(|ueiit cleansiii'; of the eye with 1 : 10,(KH) mercuric chloride and the application of tiie actual cautery or pare carbolic acid to tiie line of the wound. Tiiese measures may he repeated. Suhcoiijunctivai injections of mercuric chloride may Im' tried, hut are very painful and usually useless. Hut the coinse of the condition is nearly always unchecked hy any treatment. If th' sup- l'riilai«c nf in- hIIit I'atKrii'l i-xtractiim. Thi' ciiriu-nl lip nf 11, |. u.iiiii.i iv iiilillmtuil iiiiii ilis- placi'd. Thf liniiT )«rl C.I ihi' iris i» ilrauii up Iry Un' •■xinlatc, Kiiucl.'iHiun i.ii llif ir-nili ilay l.il- limiim ilii- i-xinii'iioii. • l.\ (i'n'i«n'il liy Iir. K. S. Th(jji,-c.n. ill tbe labomiiio ul Uiu Maiiliaii.it' Kyt' HU'I F.ar llo-'i-ital.) puration is from tlif iris, or if pu- is seen within liie anterior ( liamlici-. the wouml shouiil III- opened and the anterior chamber irri^taled with a boric acid solution The introduction of powdered iodoform or rods made of iodoform and >;i'laiin ha^ been recently tried in this condition, and promises lietler results than any other Iri'atnienl. If the infection is primarily in the vitreous, injections of mercuric chloride into th.at boily may be trii'd. Traumatic stripeil keratitis is the name t;iven to a foiin of corneal intlammation manitested liy p.arallel frray lines runninj; in the corneal substance from the wound toward its centre. It is due to bruisiuf: DISEASES OF THE t'HYSTALLISE LESS. ;V21 of tho antt'rior Hap In- tin' lens, aiul is caused by a too small wound. It subsides in a few days. Occlusion of the pujjil l)y the iris is due to entanglement of the iris 111 the corneal wound. It may occur after either the simple or conihined operation. The iris is stretched over the entire bottom of the anterii ;• , hamber, or a small jjiipillary o|M'ninn may be left near tiie wound. The treatment is by iridotomy. ( 'ijstoid ( 'iaitrix. This is a bulginp of a portion or all of the corneal wound, due to the cicatricial ti-sue yieldinft to intra-ocular pressure. The adjacent conjunctiva is sometimes involved. It is to Im- treated by a firm compression baiidajre ivorn for several weeks. This some- times fails to relievo the condition, under which circumstances the site of the oriftinal wound may be exposed by tuntiiifi u|) a small conjiuictival flap, the leaking jMiint found and touched with the g:\lvanocautcry. (Ilaucoma .sometimes develops after cataract extraction, probably beiufi induced by the u.se of atropine in eyes predispo.sed to the disease. It is to Ik- treated on the .same principles as glaucoma occurring under other circumstances, but as a rule yields to the use of esciine and heat. If not, an iridectomy, sclerotomy, or even ,sym- IiMthc'toiii\', may have to l)e done. Secondary or After-cataracts. In a majority of ca.ses there ii'inains after the removal of th" lens a membranous opacity, called secondary or after-eataract. This consists of the posterior ca|)sule, with ]Missibly some of the anterior capsule, ai d it may 1h' thickened liy the deposit on it of intlammatorv exudate from the iris. Secoiid- iiy cataract varies, therefore, in lensity from a filmy membrane whicli offers no ob.stacle to vision, to a d(iise, tough membrane coin- |iliirly abrogating useful vision. Provided the vision is not better than 2().")0 and the reduction of vision is not manifestly due to -oMii' other cause, the membrane should be divided. The operation i- known as (•;ipsulotomy. It should not be done until the eye is .■iiiiiriy free from the redness and inflammation following the primary 'i|ieralioH. Iiisiriiiiit fits. S[¥'cuhini (Fig. 2!KI), fixation forceps (I"ig. 291), neeille .'Unl knife die (!• ijr. - i'li' 1 Treatment. The |)Upi! is dilated witii atropine, the eye aiuesthetized. ilie YuU -I'panitiil hy the s| X'cuhin l)s. .\rtifii 111 light is preferai)le. 1, and the eye grasped with fixation hirci die field of operation bv means and sliould be concentrated on •adiiig-glass held by an assistant. The knife needle is entered near the corneal margin, and the membrane penetrated and cut through in such a manner as to leave an opening III the centre of the pupil. This is \ctv well accomplishecl liy making 'he incision ill the form of an inverted a. the totigue-sha|M'd flaj) iMing imshed b.'ickward by the needle before it is withdr.iwn from die ev. If too rigid to ri'inain lient out of the way, it m;iy be par- bv a third incision. The cutting edj:.' ally divicled acrr t' the knife needle should be extremely sharp, and the membraii 522 THE EYE. fut throiijrh l>y rapiil short siiwiiif; strokes. Tliis is <loin' to avoid traction of tlic ciliary hody, .vliich would i)rol)al)ly cause cyclitis. If tlie nieinliiaiie is too tough to cut readily, it siiould Ix' transfixed tii-st hy a needle, then the knife needle entered tiiroujth the oi)|)osite side ot the cornea, and thrust throufih the nieinbratie near the needle. It is made to cut away from this point, the needle actinji as the pohit of resistance, to protect the ciliary Ixxly, or two ii(>edles may 1k> entered on opposite si<les of the cornea and made to pierce tlie mem- hraiie near tlie centre. My approximatiiifi the handles of the points separat", the cDriiea at tlie site of [H'netnition acts as a fulcrum, and the menil)rane is torn. Flti. 312. IveucKvlic iiitiltration of lens. From a case of Irldocrclills following a wnuml In the ciliary region. ■ luo. (I'repareil by i»r. K. 3. Thomson, in the laboratory of the MuiihaltHii Kye and Eiir Hoyj'ital.) When the pupil is small and uiuhlatablo, Noyes proposed to enter a thin cataract knife throuf^h the sclerotic behind the ciliary hotly, and to transfix and cut the meniltrane from behind. If the ])ui)il is occluded by drawiii}.' the iris over it, this sliculd l)e ilealt with by irldotomy. The iiici.xion may be iiia<le with the knife needle or with Wecker's scissors (Fig. ;{().')), introduced after making a sutticiently large corneal wound with a broad needle or keratonie. The scissors are irtrodureil do-^ed, <)|M'ned in the anterior chamber, and one blade made to fx-netrate the iris. The iris lying between the blades is then divided, usually in a V or cross-shape. DISEASES OF THE CR YSTALLIAE LEyS. -)2S After the (•(Uiii)loti(>n of (•:ii)sul<»t(tmy or iridotoniy atKipiiif if< instilled iiiul the eye covered with a dressing. The patient siioulil he ke|)t in bed for twenty-four hours, and the least sign of iritis should he |)ronii)tly met hy ieeeiiing ami iee compresses. Otherwise. iiiH.immatory products will s<Mm fill the oiK'ning and nullify the effect of tiie operation. Arriilenh. The accidents most likely lo hap|KMi are infection, glau- coma, intense intiammatory reaction, and detachment of the retina. The treatment of these conditions is given elsewhere. Aphakia, .\pliakia is the name given to absence of the lens, and is the condition that exists after a cataract has been removed. Its principal characteristic is an increase in the refraction of the eye by the dioptric value of the lens, usually lU I), or 12 I)., loss of all |jower of accoinnuxhition, and in cases of cataract extract i<jn by the de- velopment of corneal astigmatism at right angles to the direction of the corneal incision. This astigmatism is great at first, usually from .", I), to 5 I)., init as cicatrization progres.ses it diminishes, usually to 1 I). Some patients possess a sort of |)seudo-acconunodation, wliich is generally jx'rformed l)y s(|uinting or partially closing the lids. The refraction should be worked out l)y the same means as used in esti- mating refraction under other circumstances, and reading-glasses of :<..">() D. or 4 D. stronger than the distance correction also given. Mifocal lenses, or, if only one eye is useful, reversible frames, are to Ik- given. The strength of the correction for near work must be made to accord with the distance at which the patient will u.se his eves most. Inflammation and new-growths of the lens do not occur, although th<' lens may be the seat of infiltration of leucocytes in cyclitis. (Fig. 312.) m CHAPTER XI. GLAUCOMA. By K. THKACHKU COLLINS, F.R.C.S. Exn. TiiK term '• jrlaucoiiia " is dcrivcil from tlio drook word y/.a'jxo;, sig- nifyiiij; sca-prccii. It was used hy Hippocrates, ami was applied oriniiially to affections of the eye in which a green or preenish-grny reHex was obtained from the pupil. At different times the disease has ix'eii resrarded as an affection of the crystalline lens, an affection of the vitreous humor, and an effusion hetween the retina and choroid. It was not until the discovery of the ophthalmoscope in 1S.")1 that these several theories respectinj; it were found to he untenable. .Mackeii/ie, of (ilasRow, in 1S;{(), first drew attention to the increased tension of the eye in glaucoma, which is now known to he its essen- tial factor. .Vs Wits |)ointed out first hy von (Jraefe, all the other .symptoms can he ex|)lained as the result of increaseil tension. (ilaucoma may now he defined as increa.sed tension of the eye, the result of derangement in the circulation of the intra-ocular fluid. A green retlex from the pupil is not always present in glaucoma, and it may i)e met with in other conditions in which there is no increase of tension. A derangement of the circulation of the inlra-ocular fluid causing increase of tension may occur in a variety of ways. It may occur in an eye which in other re.xjM'cts is apparently healthy, or it may he the result of some obvious precedent disease. In the former ca.se the glaucoma is termed pri)iiiir}i. and in the !;itter sccoiiildrii. The Mechanism for the Maintenance of Normal Ocular Tension. Thi're :ire three sorts of fluid within the eyeball, v.-iriable in amount: blood in the bloodvessels, lymph in the lym|ilialic spaces of the uveal tract and the perivascular lymphatic chamieis. ami the intra-ocular lluid in the aqueous and vitreous chambers. The amount of blood in the inlra-ocular bloodve.-jsels is sub.j(>ct to constant variation from many ciuses. such us alterations in the blood pressure, changes in the shape of the iris and ciliary body, and varying amount of pres.s- ure from the surroimding muscles. The lymph is ilerived from the bloodvessels, and its amount is dejiendeiit on the blocil pressure. '{"he intra-ocular fluid containecl in the aijueous and vitreous chan".- bers is of practically the same con>istency. Its composition is esti- mati'd as <K» per cent, water, 1 percent, salts and extractives, together with a trace of albumin. HI (lL.^uco^r,i. ■»2o In the vitn'oiis this fluid i-; loiljicil in a network of fihri's much Ukc water in a sponp', and is siirrnniiileil by a iiyaloid nictnhraii ■. It is this arranncmcnt which gives to the vitreous humor it.- gelatinous (•(insistency. The inlra-oculHr fluid is a secn'tioii, anil not a mere exudation from llie hloodvessels. If it were an exudation, it would contain a larpe i|uantity of albumin, like lym|ili. There is consi(|('r;ii)le exix'iiniental and clinical evideinc to siiow that glaucoma is |iroduced I'v the secretive action of the .'inthelium covering the ciliary body. 'I"he folds of the ciliary process ])rovi(le ,1 comparatively large epithelial coNcred surface overlying a dense plexus of bloodvessels. Then' arc, moreover, uii the pigmented layer numerous little tubular reces.s's, presmnably giant's, concerned to some extent in the elaboration of secretion. Ivxperimentally it has In^en found that after excision of the iris and ciliary body from the eye of a nibbit, the .-iccretion of the aipieous liinnor is arrested and the vitreou.s shrinks. Also, that subcuta- !ieously injected fluids tnake their app<'ar;ince in the eye first at th<' ciliary body, and thence spread to the vitreous, and through the iipil to the anterior chamber. Clinically, we find that when the pupil lK>comos clo.sod by a com- plete ring of posterior .synechia' the a(|UPous humor accuiiuilates behind tlie iris, bowing it forward. I'urther, that all the vascular structures within the eyo, other than the ciliary body, may be absent, nr h;ive their ves.sels occluded, without alt-ration in the amount of the intra-ocular fluid or the tension of the eye being noted; whiie destructive process(^s involving the cili.-iry body cause shrinking of liie glolx'. Tlni.-, the tension of the eye and the intra-ocular .-ecretioii liave been found miaitered when the following conditions were present: congenital an(l traunci::c aniridia, embolism of the central irterv of the retina, congenital absence of the choroid. The tension '<'-.<> al.^o l)«" i; known to remain increased, where all the bloodvessels <ui>plying the retuia and chdroid nave Ixcn cut through, after the per.ition of optico-ciliary-neurot(.my performed for absolute glau- .■^ome of the secretion from the cihiry !)ody pa.'i.ses directly forward between the iris and lens into the anterior chamlK'r. The main exit I'lr tluid from the anterior chamber is, a-; iirst [Toved by Leber, at its angle. It passes through the sp;ices of Fontana in tlf ligamentuni pectinatum, into the canal of Schlennn by a proc(\ss of iiltration. .and turn there into the .anterior ciliary veins. .\ certain amount. Nuel' h.is >hown. also escajies through the iris, entering the openings on its .interior surface, which are situ.ated mostly near its ciliary and jjupil- !;iry m;i:giiis, then into the iritic veins by liltnition through their walls. .\ part "if the secretion iif tlu^ ciliary body pa.sses to the vitreous iimor. I'roiu tiir- vitreous a small amount of fluid may escape along ' Arch, d Ophlalrool . April, 1900. ? 29 THE h YE. tlic lviii|(lijitics aniiiiul tlic rcnlml rcinii! vosmcIs in tin* nptic norvr, or hy liltration into tlir Inrjjfr vcswls ;li('in!<('lvc«: inosl linwcvi r, after pcrincatiiiR tlic anterior li> iloitl iM'inhnine ami sns|M'ns(irv lijra- nicnt. |)a-H> iltrough the lirciiniicntal spac' ami [tiipil into tin- .•interior ciianilH'r. In a liullow sphere (iisiemlcii wiili llniil the aiiimnil "f pre ure on the \vall> is (■■|iial at all |M>ints. In the i-ye. whieh is ihvideii into two chatnlwiv. the aijui'ous and vitreous, by a diaphragm consistitifr of till' lens and its sus|H'nsory ligament, it is coiM-eivalile that the pressure in one or the otlxT initrht 1h' trn'ater. In the norniMl eoii- ditioii this is not the ease. The pressine in the vitn-ous chairiln-r The kuk • >i ilii/ ..ivrliir chambur In a heslthy eyi', »hii» tiu Ihv canal i>t Seblemiu, tbe ii):auientuui linllnalinn, ami lympliatic cryptii at tip- < . rl|ihery of Uu iris. and in the all! "rior ehaniber. measured experiinentallx I>y a nianoni- I'lei, has Imi'ii I'luind lo Im' ecpial in eacii to a cohnuii oi' mercury about 2^ luiii. in heifrht. The ei|nality of pressure is miimained by the p(i--ibic iree isc;ipe of thiid from the vitreous into the anterior ehanil" 1. and irrt- esiape of lliiid from the anterior chamlier out of the <-\\ In spile of chanfies which aiv constantly occurring to alter the amount of blood in tlie iiitra-ocular blood\issels, in the normal con- dition the tension of the eye. as estimated by the linger pn'ssurc. remains practically uniform. My :; mere aciive secretion of the ciliary body, or by a more nipid .■s(.ipe of iluid. llii' eye has the |towcr of adajitiiig itself so as tr maintain an eijuable amount of jiressure upon the structures con- t.ained within. It would seem natural le suppose that tliis regulating power which iiioMtains ,, uniform degree of tension is the result of nervous in- J (ILAUCOMA. 527 tliicnrcs. (hir knowlcflKf, iKtwcvcr, of tho infliirnri's of tlic ncrvitUM .•-vstiin (HI the tciisiitn of flu' (■>•«• is iit pn-sfnl far from (•oiu|)l('tc. Hill, ii I some r('S| M'cis, (Mmtni<lictorv. V«' sliould like to know if tin- eye, cut off from all iiillui-nct-M pro- (liiii: to it from the (•cn-hro-spiiial or sympathftic nervous system. IS rap if maintaiiiinjr normal tension riie 11 suits of the openition of opiico-eiliary-neurotomy offer us -I'liie eviiienee on this point. When |>erforme<| on an injured eye as a prophyiaetie against sympatiietir opiillialmitis, the tension fn'(|uently Iteeomes iliminished. and. in some eases, tliis diminution of 'elision Ih> the di lit iti d not d bv eausec the affection of the eye for whieh it was perfortned. When i«'r- lormed on eyes with absolute Rlaueonia, when- presumably the chan- nels of exit of Huid from the eye aif clos«Hi, the tension remains increased. Nervous intiuences may [iroceed to the intra-oeularstnictures either ihrouRh the trigeminus or through the syni|)atlietic nerves. The ex|)eriments of dividing or irritating the trigeminus in ani- mals have not imxluced uniform results. Some observers have found itsdivi.sion result in dhninished tension, and its irritation in increased tension (I)onders), while others have concluded that its division or >hiiiulation had no influence on ocular tension (W'egner). The operation of nMiioval of the (ia.sseriaii ganglion has now been performed a numlxT of times on man for the relief of neuralgia, but in the description of such ca.ses no reference is made to its etTect on ocular tension. It is po.ssible that, unless specially looked for. some slight variiitions in tension may have Im-cu overlooked. In the affrction known as herpes ophthalmicus, which is <lue to a lesion of the Gas,serian ganglion, diminution of ocular tcn.sion is sonietimes noted. Kxperiments on animals have shown that section of the cervical sympathetic causes diminution of ocular tension, while irritation of it occasions a transient increase of tensicm (Wegner. .\dainuk). Removal of the superior cervical ganglion has lu'en i>erfornied in man. in patients who had no ocular affection, without any alteration ill llie ocular tension being appreciable ( F'. V. Burghard'). Uemoval of the superior cervical ganglion in patients with primary ■_'l:iuc<iiiia sonietimes reduc<<s the tension (.I(mne.«co'). In some cases lit' ))aralysis of the cervical symi)athetic from injury or pressure. ,'\ -light diminution of ocular tension has Ix^eii noted. In cases where symptoms of stimulation of the cervical synijia- I lietic arc present, as in (Jraves' disease, glaucoma has not been proved to 1m' of unusually fre(|uent occurrence. .^Stimulation or removal of the superior cervical ganglion causes several changes in and about the eye, which it is conceivable would Bnttah MeiiUal Journal. October io, 1900. p. 1175. Wiener kiln. NViicbenschritt, May 4, 1899. MICROCOPY RESOLUTION TEST CHART (ANSI and ISO TEST CHART No 2i 1.0 I.I 1.25 ;-iiiiiM m " lis illlM 1.4 1.8 1.6 j£ /APPLIED IM^GE Inc ^.■i-'-'.e^fe'. New T^'t. 't&Oi i,7'6i -.8^ <JiQO Phone 528 Tin: EYE. tend to iiiHiiciiw the iiitra-ooular pressure. Tims its stiimilatioii causes: I. Dilatatinn oj thv piijiil, wliieli inijjlit iin|)e(le the exit of fluid from the eye l)y iiarniwiiifi tlie oritices of the lymphatic spaces on the anterior surfac' of the iris, or by approxinfatinf; the root of the iris to the hack of the cornea in the rejiion of the spaces of l-'ontana. ■J. Incnii<al hliiod jirtssmr. which diininishes the amount of hiood in the eye, and so lessens the amount "i its contents, hut also |)rohahly increases the amount of lymph in the intra-ocuhir lymphatics. ;}. I Hcrmsvd scrrcllnii jrmn tin; rHiiiri/ botlij, which tends to inerea.M' the contents of tlu' eye. -1. ('onlnirlioii oj the mistridlcil iiin ric fihrcs oj Miillrr. which by compression of the efl'erent veins c.in\infi from the eye delays the exit of blood from it. l{emo\al of the f;an}rlii;n jinxhices just thi' r(>verse effect: it con- tracts the pupil, lowei's blood jiressure, diminishes .•secretion, and allows of relaxation of the muscle Hbres of .Miiller. .\nother factor callin}; for consideration in the maintenance of nor- mal intra-ocular tension is variation in the composition of the intra- ocular lluid. It has to escape from the eye, as already mentioned, by a i)rocess of hitration. Containing, as it does in the normal state, but a trace of albumin, this filtration may readily take place. Should, however, the anterior chamber be |)mictured and the ai|ueous luunor alloweil to escape, the fresh aiiueous humor, which is formecl much more rapidly than under the usual conditions, is found to contain ;» considerable (luantity of ;dl)umin, and will conso<iuently take much longer to filter out of the eye. The Effects of Increased Tension on the Various Structures of the Eye and Their Respective Functions. Tiio maintenance of the normal amount of intra-ocular pressure is most essential for the regular performance of the functions of the different structuri's com|)osing the eyeball. We shall now proceed to descriiie the chaiifri's which are proihiced in an eye as a result of a disturbance in the intra-ocular pressure, resulting in increased tension. Sclerotic and Conjunctiva. A sudden onset of increased tension .so disturbs the iiitra-ocular blood circulation as to cause for a time a general congestion of the ciliary bloodvessels in thi' sclerot'c, and often al-o of those of the conjmictiv:i. Ill the most acute cases this congest-on is acci>mp;tiiied liy ledema of the conjunctiva (chemosisi. and sometimes even ledema of the eyelids. Till' vessels being mostly engorged witii venous blood, the injection has ji characteristic (lusky hue. The main exit of blood from the uveal tr.-ict is by the verue vorticos^e: the channels in the sclerotic through which these pass run very oliliquely, and when the sclerotic is stretched, as it is in glau- coma, they easily heronie clo.sed. The result of sui'li obstruction is to ratise considerable enlargement of the anterior ciliary vt'in.s, which OLA UCOMA. 529 „f hl<...(l into tli(> cy.' gradually, instead Wl„-.. the- ''"-^'\";7;;;''; \^; " ^^^^^^^^^^^^ hlu.,,! circulation to „f suddenly. ^^^\!^^^^'^'^'''yl J^^ ^'^Av 'ind the violent disturb- „,, alt..n-d c.n.lit.ons is "•'''*• ''''^^r'''^ (.^Ue place. Indeed, Tl„. ,.fT«-t, ct mcn.,sr.l '"'™; '''\^ ,; ! ^ ,1, ■ iwot'lc i» an ™s'a,u,--..'.'„-t'^ !;:"s5 i='.vS a:'?;::;"^^r:5 S;."';";r,r*^ » *.' .1- «'"'«• '<■»'■«■» ""■™'"" '""""■ ■" ,|„, ;,nten..r lamella "^ J"''"^'^;^,";. 1 ,, „„.t .vitb between the surface -'V'l'"'"''"1^ ;; MnS CiaS n^M^Jmine, between the epi- 'I'"'"''""" "' , h, , channels in the anterior lumting „,.,Hal cells then.selves and ^ J^^J.^ j",^^^, ,, ,,„ epithelium. ,„,,„brane through which the V"^\' '"''.• , ,..i,i,u!ss of the "f-iJfsSii^^ f,.rwanl through '■''=';;•;•;:..' J ;^^^;Lv nerve, from which mav also be due In cnmpre,-.-nin ui Hu ."(^ 530 THE EYE. the corneal nerves are derived, af?aitist tlie luird, unyielding sclerolic, as they pa-^s forward on the outer surface of the choroid. The iia; . ss of the cornea wlieii present, ajjart from other causes, tends to .nake vision misty. It is also the cause of another very characteristic sym|)t()m of glaucoma, viz. : the appearance in the dark of halos of rainbow colors 'iround lights, the re<l color always Ixnng the outermost. A precisely similar appearance of halos of rainbow colors around lights is produced by drop|>ing a solution of the alkaloid erythroph- la'iiie, obtained from an African arrow poison, into the eye.' It causes also a slight steaminess of the surfiK c of the cornea, slif4,ht ana'sthesia, and .some blurring of vision, but <loes not increase the tension. One specimen dilated the pupil and another contracted it; with both the halos were .seen. lOviilently then they are not tlu" result of |)ressure on th(> retina or any altt>ration in the pupil. Halos may also be produced by the instilliit'.on of adroi)of erythrophla-ine in the eye of a patient who has undergone extraction of cataract, which excludes the lens from any participation in their production. We are led irresistibly to conclude that they are the result of the slight haze in the cornea. FlO. 314. Tlie angle ol i '.x aiUerior chamlKr iii a case of primary Blaiicoma, »lii)» liiu closiit* of the flltmtloii area at the periphery of the cornea, liy apposition with i' of the ro<Jt of the iris. In primary glaucoma which occurs late in life no ai'im'ciable altera- tion in the sliape or size of tlie cornea occurs, \\iien, however, in- crease of tension is met with in infancy or early life, the cornea, like the sclerotic, being still very elastic, enlarges and becomes globular in shaiie. Tlie condition is spoken of as keratoglobiis or buphtli tlmos. Anterior Chamber. The condition of the anterior chamber in glaucoma varies with the position at which the primary obstruction in the circulation of the iiitra-ocul.ar fluid takes jilace. In primary glaucoma it is shallow; as will be shown Liter, this is due to an increase of tension occurring iiist in the vitreou lianiber, and the lens with its suspensory ligament being forced forward. .\ continueil shallowing of 1 ophtlialmii' Keview, IS'.K), vol. Ix. p. 19ii, ULAUCOMA. 631 tlu- aiitmur fhaiiilKT. aiul prossure .,f tlic oiliary processes against the root of the iris, result in eontaet of th<' latter with the hack of the cornea and :i narrowiiiR of the angle of the chanitM'r. In xoiiK <'ases of secoiularv glaucoma ami in cases oi congenital .r|.,ui'oina the priniarv ol)struction to the circulation of the intra- ocular fluid is at the'aug.e of the anterior chninher, where it gams .■xit from the eve ; the anterior chanilx'r then iH'Coines .leeiK'iied. Iris. Pressure of the root of the iris against the hack of the cornea 1,.„1< to compression of both its bloodvessels and nerves. If the incn'ase(' tension is sudden in onset, the compression at first causes adeina and venous engorgement, which make the iris a;)lM>ar altered ill eol,.r Later on. its vessels become empty and its stroma atrophies ■iiid shrinks. The pigment epithelium on the ])osterior surface of the Fid. 315. ■n,e in, and .ili.ry body fn,m a ca«> of glaucoma of long «an,llnK, showing nmrked eetropkn. of .„ ,.i«,n.nt .,,i.h«lium a, .he ..upillary margin. The angle of the «"'^';;^»"f J^^J^^.^^^^th'y „,,,.«.,„„ or .he r,«,l of .he ir,, .o the back of .he cornea ; In the prei«r.t ion "' 'f 'l^ ™«" '^^^ have i«.on,e simi.'y ^,«ra.ed. There ,s an abrupt hen.l in the Ir.s where '' ™»» '^ »« '» ""'*'=' «iil, the cornea. The s.rcma of the ins is .nueh atrophied, »o that it a, ,an, very th>n. iris is ui.atTecte.1 bv the atrophy. It normally ends at the inipillary margin; but in cases of glaucoma of long standing, by the shrinking <,!• the stHMua. the |)igm<"nt epithelium becomes drawn around ont.. the anterior surface, a condition which is spoken of as ectropion o the pigment epithelium. Clinically it is seen as a dark ,.igmente.l .,n.;. on the surface of the iris at the pupillary margin, usually ex- fudiiig m..re in one direct ioi ihan another. It is most nuirked uli.'iv the iris has beciine most atrophied and when the tlilatation 111' the pupil is widest. , .. , • „,.♦„ The pressure of the nerves against the back of the cornea in acute ease., of glaucoma paialvzes the iritic muscles, ami the piipil becomes inactive and semidilate.'l. If the tension is relieved l«-fore atrophy has s,.t in, its activitv returns. In long-stamling cases of glaucoma ■nt dilatation" of the pupil may be brought about through iiiTinanei 532 rilE EYE. atrophy of the sphincter inusrh' and shrinking of the stroma. The amount of dilatation is sometimes not equal in all directions, so that the ])U|)il is often oval or im-gularly circular, and it may Ik- displaced away from the centre. When the cornea and root of the iris have he(>n in apposition for only a short while, their separation is easily effected. After a time, however, cell exudation takes ])lace and tiiey hecome adherent, and in long-standing' ases of glaucoma most intimately adherent. Ill chronic ca.si of glaucoma, wlu re the onset of tension is gradual, and there has been time for compen.satory changes to take place in vessels an<l nerves, the dilatation of the pupil and atrophy of the iris may be absent. Ciliary Body. Incrca.se of tension early causes disturbance in the acconnnodative action of the ciliary muscle, due probably to com- pression of the ciliary nerves against the sclerotic. It manifest.s itself by the a; parent rapid advance; of presbyopia, the patient requiring stronger and stronger gl;i.s.ses for near work. In the early stages of primary glaucoma, more especially in acute cases, the ciliary proc- esses are swollen and (udematoas. "their veins ar(> engorged, and they press forward against the root of the iris, .\fter increase of tension has lK>en established for some time, they Ix'come atrophied and shrink, as al ") does the ciliary muscle, so that in cases of glaucoma of long stanuing they are no longer in contact with tlie back of the iris, and a considerable s])ace is left between them and the margin of the lens. The ciliary body receives an extensive nerve .supply, from both the long and short ciliary nerves, which p(>rforate the sclerotic posteriorly and p;iss forward in the lamina suprachoroidea, until they break up into a net-work of fine branches, which is known as the ciliary plexus. It is the sudden onset of pressure of this plexvis against the unyielding sclerotic which is the cau.se of the excessive pain of acute glaucoma — pain which is not confined to the eye, but referred also to ether parts sujiplied by the fifth nerve, especially those receiving branches from its first division. Certain reflex disturbances may also be set up, which will Im- referred to in speaking of the different clinical ty])es of glaucoma. WhiMi increased tension comes on gradually and is ntit very intense, the nerves, like the bloodvessels, have the power of adapting them- selves to the changed conditions, and in the majority of chronic cases of glaucoma no pain is experienced by the |)atient from first to last. Choroid. The efTect of iner'ased tension on the choroid in acute cases of glaucoma, as on the otlu>r ])ortions of the uveal tract, the iris ,ind ciliary bodv. is first to jiroduce a condition of venous conges- tion and (vdema: later on, emptying of its vessels and a.rophy. In chronic glaucoma, o;. the other hand, no sudden disturbance of the circulation is set Up. but the compression of the choroid against the sclerotic tends to empty the blood out of the cajiillaries. The fundus ophthahnoscopically in such cases is seen to lo.se its uniform red hue, OLMCOMA. 5ua and ti. pri-seut a tessellated ap|.earance, due to exposure of the net- work of larger vessels in its outer layers. _ . Itroi.hvof the choroi,!, th.- result of mcreascni tension, is most .nirke. It the parts where it has the Hrniest attachments with the i r s .-x ernal to it, viz.: around the optic- disk and at the seats f?^it of the vortex veins. When increa.se of tension has exjste.l or i ne tinu-, the optic dish is usually seen to Ix- ccircl.-d by a ylunwiih-whit; ring, which is due to the atroplued choroul allowing tlic sclerotic to 1m' exposed to vi'.'W. Lens. The .lisplacen.ent forward of the lens in primary glaucoma wmU if the <'ye is emmetropic, to make it myopic, as do also e ching of the walls ami expansion of the glolK> in the antero- ; , wtV.-ior axis. .\ drag on the suspensory ligament from .l.splacement n rd of the lens or expansion of the glob- in the ciliary region !.;,,;.ld, on the other hand, lessen its refractive power, and te.ul to in'iki- an emmetropic eye hypermetropic. , . , , n g aucoma in llie adu.t hardly any expansion of the globe takes phui, hut it is stated that during attacks of glaucoma the refraction "'iTi' glaiic."mrin' earlv life, where considerable enlargement of the gl, . i i its mericlians is met with, the lengthening o the globe is r ,ei^ ted for in part by the flattening of the lens, and the amount ;;; ,;iyopia met with is not as much as might otherwise have been ex- '""ln"iiaucoma of long standing the nutrition of the lens sometimes suffers ami it becomes cataractous. The opacity of the lens occasioned !,v glaucoma usually pn-sents a bluish nietallic lustre ■ Aqueous and Vitreous Humors. Seeing, as already stated that u acute glaucoma there are at first venous c.ngestion and ^f^^^^J h.. iri> and ciliarv body, it might scn-m natural to suppose that theie V ul li«w.soxmlation into the aqueous and vitreous chambei^, 'that th.' intra-ocular fluid would be more albuminous han n,,r- , Whether this is so or not, has yet to be determined definitely^ Th,. haze of the cornea in acute glaucoma prevents it being seen h„ V much the obscuration of the fundus may !«» due to want ot clear- ; s h. the other nie.lia. That part of the increased onhiancy n the iris whieh is observed innnediately after opening the anterior cham- l"r in operations for acute glaucoma is due to escape of imperfectl) ,.l,.;ira.iueous humor, there can belittle doubt. Th. .'n'enish-grav reflex from the pupil sometimes seen in glaucoma is prohablv in in>rt"due to an incn>ased seros.ty of the me.luh Retina." The imme-liat" eftect of increa-sed tension on the retinal bloodvessels is to obstruct both the entrance of bloo ' by the arterie •Hwl its ,.xit bv the veins. ronse,,uently the latter become enlarge* and the forn.eV smaller than normal. The in^ra-ocular pressure and ,he pressur.. of the bloo<l in the r.>tin.al vessels are so balanced, uder Mornml con litions. that no pulsation is to be observed in the retinal arteries. V hen the intra-ocular pressure is much increased, or tne 534 TIIK EYK. artorial pn'ssure much (liiiiinishod, this balance is {liaturbod; blood then can force its way into the retinal art-r' only during contrac- tion of the heart, and pulsation in them l>ecot..es visible it) the vicinity of the optic disk. If the increased top'uon in a case of glaucoma is not sufficient to give rise to pulsation of the retinal arteries, it may readily Iw elicited by slight pressure on the glolx' with the finger. I'lKler normal conditions a considerable amount of pressun? on the glolx' is recjuired to jjmduce pul.satioii. Pulsation of the retinal arteries has tx-en observeil in cases of aortic regurgitation and of s'-ncope, without increa.sed tension of the eye and due to diminishe 'ood pressure. .\s the result of ' ontinued increa.sed tension the walls of the retinal arteries bee sclerosed. Hemorrhages into the retina from rupture of the sniaii vessels are met with fre()uently in glaucoma. .\ disturbance of the function of the retina, as the result of increased tension, may be due either to diminished blood supply i to atrophy of its nerve fibres. Loss of vision due solely to the first cause is recoverable; that due to the second is permanent. If the tension of a healthy eye lx» increased by pn'.ssurc from with- out, as with the finger upon the eyelid, vision may be completely abolished, it disappearing last in the region of the macula. This may be attributed to arrest of the circulation in the retinal vessels, and possibly also in the choroidal capillaries from which the outer layers of the retina receive their nutrient supply. Directly the press- ure is removed, the circulation is re-<>stablished and vision returns In the same way in acute glaucoma, vision may, in the course of a few hours, be reduced to mere perception of light or completely abolishe<l. If normal tension is re-established before sufficient ,. . has elapsed for organic changes in the nervous tissue to set in, ■ will be r(>store(l. The branches of the retinal artery which go to the periphery cf U retina on the temporal side have a longer course to i)Mrsiie than ili )so distributed to other parts, because the point of entrance of the oj)tic ner\e into the eye is situated to the na.sal side of the midille line. It is the capillaries, therefore, from the t(>mporal branch which are affected first by any increa.se of tension. The n(>rve iibres destined for the i)erii)hery of .ue retina, which lie in the outer portions of the optic nerve, are more liable to be exi)o.sed to pressure against the scl(>rotic iis they enter the eye, than those destined for the central region.-s. Thes<' two anatomical facts serve to explain the manner in which vision fails in cases of glaucoma. The process begins at the ()eriphery, producing a contraction of the field of vision. This contraction usually is noted first on the na.sal side. As the ciise progresses, the held gradually becomes reduced to a more or less oval-shaped area, extending chiefly to the outer side of the fixation point. I'ltitnatcly the fixation point becomes involved, a small area in the field to its OLA VCOMA. 536 „ut4T .uh- b.-i..K l«-ft until thp l:u.t. In somo chronic cases of glau- coma ;; rfect cmtral vision may Ik- rotaino.1 with extreme contract..,n Flo. SIC Right Eye Conrentric contraction u seen In gUucom» simplex. Kio. S17. 106 ^ Ti Concentric contr»cUon as «een la glaucoma .implex. 536 THE EYE. of the field. In otlirr cases, in asMiciation with a contracted tield, some l()s.f in the acuity (>f central vision is met with. Kl(i. 31H. Hight Eye iloncentric oonimctlon R!» peen in Rlauct . siraplox. Km. 319. Ijft Eye m-- '" '"'oncentric contraction rh Been m glaucoma simplex. tlLArcDMA. 637 TliouKli the above is th.- niusl tyi)ical way for tho Hold of vwioii to h, ((iiiH- alTopted in plauc.ma, cases occur when- it is contracted cou- iitrically, or wiiere liiere is a central or parairiitral scotoma. Wlicn the ♦ieid is tested l)V an "hject whidi sul)tends a snia'.ler visual I with tlie ordinal V |)erinletor^ s in tlie nietiiod crl angle than enii)loyed «)phth«lmo«cni.i.' appearonco of the opllc disk In absolute utaucoma. .l*KtiE«.l siifip'sted i)v Hierruni' ), it is found that in plaucoiiia, whatever 1m' tho situation of" the' defect in the fiel.l, it always starts from the blind spot. The fiel.is for color usually fail proportionately to the field for white ami to one another. In ey(>s blinded by Bhiucoma then> are found some atrophy of the Fig. SJ Seition of optic nerve heart of cane lU'pieled In Fig. 3a). (Jaeoer.) nervous elements of the retina and some increase of the fibrous tissue elements. Small cystic spaces in the tmtcrior portion of the retina, in 'he vicinitv of tlie ora serrata, are mot with v(>ry commonly. Optic Nerve. Tho delayed exit of venous blood from the retinal uxxl.-., and c.nM-.iuent venous o()i;::rstiun, probably jjive ri«o to 1 NordUk Ophthal. Tidsskrlft, il., S, and ophlhalmic Review, 180O, vol, U. p. IW. fiSM Tut: KYH. some (I'dcniatoiis swt'lliiijr nf tlii' (iptic |iapilla in tnatiy cases nf acute glaiiconia. Hy the time a clear view of tii(> details of the fiiiidiis can \m' (ihtaiiied, this swelliiij; has niveii way to cii|)|)iii>j and atrnpliy. S'Veial oltservers have, however, descrilx-d seeing ap|«'araiices like optic iieiiritis as an initial syniptnin in glaucoma. The position wiiere the nerve lihres enter the hIhIm- is a weak spot in its walls. There, instcid of having the three coats— sclerotic, choroid, and retina— there are only the fibres of the o|)tic nerve ami the laiiiin.'i crii)ro>a. The latter does not represent more than h.df the thickness of the sclerotic, and is compiM^il mainly of yellow elastic tissue. When the ten-ion of the eye hecomes increas«Ml, this weak spot soon begins to give and bulge outward. Tlie sclerotic surrounding the optic disk is very thick and unyield- iiij:. -o that, as the liimina cribrosa becomes curved backward, the ner\' fibres become compressed against the tough resistant edgi' of the -iclerotic at its niargi';. and conse(|uently atrophy. When they hecdine atrophied ilown to the lamina cribrosa, instead of, as in the healthy condition, there b<>ing an elevation in the region of tlii optic disk ( the optic I lapilla), a depression is formed. Clipping "fttit^ optK: disk IIS (he result of Klutiiuniit. lH."iiiU's (Icpresstoii tiut kwunl uf tbo lamitia crihros* there hiis Ipeeii N'lne Ititerul eximlisinti, so Ihat one siiJe nf the eup lins ttecume Koniewhat cxnivHteil. Ill ttu' pre[>aratioii of the siieclineii the retina hta become (lisplaceil lorwiird from r-oiitact with the rhoroid. The cupping nf the optic disk iii i^hitsconia is then the re';ii!t of tv.f. cau.ses: depression b.ickw.iril of the lamina cribro.sa and atrophy ot the nerve fibres down to it. liLAVCUMA. A" 111" .lc|>rcH>»ic"> biickwanl of llif 1 imiiia lilm.-a increase- the sides of liie cill) I ..il to iK'eollie .niite steep hey may Ix-eolii. ex- liainled laterally at the posterior part, so that on section it |)resents a tiask-shaped outlin<'. Oplithalnioseopieally. a riipiK-d .'onditoii of the optic nerve m rec<i>;riize<l. with the iiidirt ct inetho<l of examination, hy the parallax which is priHlueed on movement of the lens. The hottoin of the cup and the surromidinjr fun<lus seem to move at dilTerent rates, the former more slowly nan the latter, sr) that the siirroundiiift fundus appears to nio\' ver the d.'presse<l surface of the disk. Fio. S». I ,l,iiic,innlrm« oicavall..!! taking place in an o|.tii- nerve with a phyRiological cxcnvalinii. (Jakgeb.) ( »ii examination with the direct niethiMl it is found that a ditTereiit I. MS is necessarv to see clearly the liottom of the cup, from that which i- rciiuired for"the rest of tJie fundus. Thus supposiiift the patient t(v he enmietropic. a inimis lens would be needed to see distinctly tl,,. h,.f,to!H of the cup; or if the patient were myopic, a higher minus ■:1a <s than that used )r seeing the rest of the fundus. When the side ot the cup is steep or somewhat overhauftiug, the 540 77//; /•;>'/•;. rctiiiMl vessels as tliev curl arouiid it disappear from viinv fora portion ol' tiieir cdurse. or may l)e vieweil in a t'oresliorleiied maimer. If tiiey disappear from view for a portion of tiieir ('onrse, there seems III !)(' a i)reai< in tlie contiimit y of the vessel seen at tlie base of the cup and on the surface of the retina, it often reaiipeariiifi-at a slifjhtiy ditlerent position on tlie latter from what it disappeareil at on the former. If vicwe(l in a foreshortened maimer, the blood in the vessel appears very dark. riie margin of a cuppe(l disk in jilaueoma often throws a shadow on its surface. ,so that it appears lijilitest in tlie centre; th<' markinjis of the lamina crihrosa on its surface are usually well defined, and its color is sometimes altered to a Jin /ish or lihiish hue. Conditions which Predispose to Primary Glaucoma or Excite Acute Attacks. Age. There aic cases of i;laucoma that date from birth, or even before birth, which are not the result of some obvious prece(l(>nt disea.se, anil which mijiht be classed as oases of primary };laucoma. They .are. probably, the result of some con<reriital defect in de- velo|tmenl, and evidently have a different c;iusation to that of other cases of primary <;l;uicoma. They \\iM therefore, be dealt with separ.ately under the headinfr of conjcenital jrlaucoma or primary buphthalmos. i;\cl;idin<; these ca.ses, it may bi' stated that the li.abiliiy to primary ^huicoma increases with advance of life. PriestlcN' Smith' h;is shown, from a careful analysis of KMM) cases, that at the a^e of sixty-five years the chance of an attack of <ilaiicoma is at least one huiidrecl times {jreater than at Hfteen years, and more than twice as ji;reat ;is at forty-live years of aj;e. Primary glaue()ma under tiiirty years is very rare; in practice it is met with most commonly in the decade between sixty and seventy ye.irs. Sex. Women .are more liable to primary glaucoma than men. especially to acute attacks. Heredity. Several strikinj; instances are recorded in which prini.nv jrlaucoma has occurred in members of the same lamily, through two or three p;eiieratioiis. 'I'he number of c;ises where an hereditary tendency is met with comjiared with the number of cases of jjlauroma which occur .are. howi'ver. few. Race. Certain races are stateil to be more liable to primary jjlau- coma than others, viz.: the .lews, the I'.gyptians, and the ne.srro(>s of lirazil. More definite statistical evidence is re(|uired on these matters before it I'aii be said that they are i)roved. Errors of Refraction. Nearly .">() per cent, of eyes afTected with jirimary glaucoma are hyp<'rmetropic. .and it is generally believed that a liy[)crmclropic eye is pn-disposi'd to glaucoma. It should br borne in mind, however, that hypennetropia is the commonest re- ' Tmiisiictiipris nf Ult: OphtlmlmoInjfUMl Society of ttii' CiulO'l Killf^'lom. 18S0. V'.l vi. p. 2*'-. (ir.ALC'iMA. 541 fnictivo error, and that tlic pmijurtioii of casos of jilaiicoiiia occiir- riiii; ill association with hyiicniictropia is not very much iarftcr than tiiat of cases of liyiuTnii-troiiia to tlic popuhition at larfrc (ilauconia in cases of hi^li myopia is very uncommon. Accommodative Effort, 'hiere seems f;oo«l reason to Ix'lieve tliat prolonjietl near work teii.is to the |)roiiuction of jjrimary glau- coma. Sch i' lias published statistics to show that the oirur- reiice of glaucoma is often associated with nefjiect of the use of proper Smallness of Cornea. I'riesiley Smith- has proved conc!usiv( ly tiiat eves with small cornea' are iireilisposed to primary glaucoma. He sa\~ Iliat eyes in which the cornea measures only ten millimetres in the horizoiitar diameter seem seldom to escape the disease. He iias larthi'r shown that smallness of the cornea means smallness of the evchall. . . . Depressing Emotions. Among the more direct causes of primary iriaucoma. first and foremost is emotional excitement of a dejjressiug Th.-iracter. (irief connected with the death of a friend or relative, niixiety coniiecteil with business matters, or worry and trouble due lo other cause, very commonly precedes the onset of glaucoma. Widows seem especially liable to glaucoma. Thus out of 1 17 cases 7 J were females, 4;i males. Of the 74 females, .'iS were married, 27 widows. 7 single, 2 unrecorded. Of the U males, M wer(> married, S widowers, 1 single, ."i unrecorded. Loss of Sleep. .Associated with anxiety or trouble, very coiii- iiionly, is loss of sle<'p, and the two seem to act together in tending to bring on glaucoma. A by no means uncommon history is that t!ie first symptoms c:inie on after the jiatient had sat uj) at night tiMidiiig some dearlv loved sick relative or friend. Operation on One Eye. .VII that may be comprised under the term "shock," both mental iUid physical, which follows an oiK-ratioii lor glaucoma on one eye, is very liable to excite an acute attack in the other. The second eye wotiid no doubt be predisposed to glau- c.iiia. but mav not previously have evinced any symptoms of the di-'ase. Mydriatics. The use of a mydriatic such as atropine, to an eye pf.MJispo.sed to i)rimary glaucoma is very liable to caus(> increase of tnivioii. and its ai>plicatioii may excite acute attacks. II -used in cliroiiic cases, it may intensify the increased tension and cause acute <\ iiiptoms to set in. Local Injuries. A slight injury of the eye. an abrasion or ulcer ut the cornea, sometimes .seems to be the determining cause of the i.iiset o|' inimarv glaucoma. Constitutional Conditions. .\n attack of facial neuralgia is some- times the iirecursor of glaucoma. Other jiossible contributing con- 1 Ari'tilv r. Onhltintniiilielc, 11S7, Baiiil xxxvlii., i>l) 1. S. Hn - Tm..8Hflioiis of the 0|>lilhalnu,l,«icKl Safety ol tlio Initcd KinKJ..m. \fM. vol. x. p. fis. 542 Tin: i:ye. stitutiiiiial ciuiscs arc colil, fatijiiic, constipation, aiitl vascular or lun^ altcctioiis wiiicli produce venous congestion of tlic head and eyes. The Clinical Types of Primary Glaucoma. I'rom wliat lias l>een said (;f tlie elTects of increased tension on the dil't'erent sti-uctures of the eye. it will l)e seen that the syin|itonis of primary glaucoma \arv coasideralily according to its mode of onset. Different clinical types of tiie disease may cons<'c|'iently he described' acute congestive, subacute, and chronic or non-congestive. It must, however, be borne in mind that no hard-and-fast line can l)e drawn between these ditferent types. They merge iuio one another. .\n eye may be affected with one typi' of the disea.-;e at one time and a <lilTerent one at another; or the same individual may have one type in one eye and a different type in its fellow. Acute Congestive Glaucoma. .\n acute attack of glaucoma may occur in a person who has not previously had premonitory syni))- toms of the disease; it is then spoken of as jidmiimlinii (jUincoma. More frequently it conies on in those who have experienced one or more slight subacute attacks or in a patient w. .) has been suffering from the ciironic form of the diseaM'. The attack is ushered in by sudden aching |)ain in the eye and forehead, sometimes also of iIm whole side of tlie face. This pain is accompanied by a general feeling of nialai.se, repeated attacks of vomiting, and loss of appetit(>. So severe sometimes are these gen- eral symi)toms that they ;ire attributed to "a bilious attack," and their connection witii the affection of the eye is often overlooked, even by the medical attendant. The vision rapidly fails, going on in tlie course of a few hours or ilays, according to the severity of the attack, to b;u'e ])erception of light or complete blindness. The eyelids and conjunctiva become somewlial swullen from ledema. The ves-^els of the ocuhir conjunc- tiva and episcli'r.il lissue, especially the main trunks, become much congeste(l with venous blood. The cornea loses its natural brilliancy, |)resenting a dull, hazy api>earance, and after a short while it is less sen<itiv<' to the touch than norni;it. The anterior chamber is very >litll()w; the pupil is semidilatecl and immobile, it Mimonly assumes a somewhat oval shape, and may be 'ccetitric. . he iris viewed lliidujrh the ilull coine.i will be less briiihtly colored than tha* of thi' fellow eye. Turbidity of the media usually prevents any view of the details of ihe fundus being obtained ophthalmoscopically. On palp; tioii of the glolM' through the iids, the tension will be found considerably raised, usu.ally as much .as -}-'_' or +;{. If the case is left to itself without trealmi'iit. the symptoms of congestion will last some weeks, and then, as the iritr.a-ocul.ar vascular circulation adapts itself to the altered conditions, subside. The tension of the eye, how- ever, remains increased. The subsidence of the congestion is accom- panied by relii'f of pain ;ind some iinproveinent of sight. The cornea GLACCOM.l. 543 )< ■collies ■'>;il loss Iwzv ;iiul ;i view o if the fundus can he obtained oph- >;illlioSC()l)ll'allv vlu'ii, if tlie ease lias been of sutfieient duration the 1 •.laiaeterist'ie eupiiiiiR of the optie disk will be deteeted. The liar^ed and tiie pupil dilated, acting iiterior ciliarv vessels reiiiain en Is n verv slijilitly to light. Fresh subticuto attacks may follow, after each is recovered, absolute pennanent bliiid- )f which li'ss and less vision uitiniately resulting wil Sonietinies after tlie hrst acute attack the glaucomatous condition become chronic, and the held of vision gradually and steadily coiitiacls .vithout fresh onsets of congestion and pain. ite bhnd and the (liti :)f abf<o- heii the eye has become quite l)iin(l and ttie condition o lute glaucoma" is established, the iris will be much shrunken and discobred, the pupil dilated and immobile; at its margin on the surface of the iris there will bo a dark ring, often extending farther ill ,,ue direction than elsewhere— octroi mm of the pigment epithelium. 'I'iie cornea will bo dull, and vesicles may form on its surface. It will be verv liable to Iwconie ulcerated, a:id the ulcer will Ix' difficult to heal, often going on to perforation, with escape of .some of the contents of the globe. The anterior chamber will continue very shallow, and a (.uU grayish- ^iveii reflex often be seen from th<> pupil, or the lens may become cataractous. The anterior perforating ves.sels remain enlarged, and ;it any weak spots in the walls of the globe the sclerotic will give, iH'coming stai)hvlomatous aiul discolored. Subacute Glaucoma. Subacute attacks of glaucoma, as has been Miid. may precede or succeed an acute attack. Tiiey may also occur iiideiiendcntlv. . In a subacute attack the svmptoms are of a character similar to ih.ise in an acute attack, but "of less severity. The pahi is confined In the eve and is of the nature of a ciliary neuralgia. The jiatient .•niiiplains that during the attack there is an appearance as of a fog ur mist in front of the sight, and that around lamps at night-timo he sees rings of colors like those of a rainbow. The held of vision shows contraction, usually on the nasal side. The injection of the eve is not very intense: it has a dusky hue, .iiicl iisuallv is conhnod'to the anterior perforating and episcleral vr.scls. There is a s-light .steaminess of the cornea, especially about its (Tiitre, resembling ghiss which has boon breathed ujion. The ptiinl is semidil.-ited an<l sluggish in action: the anterior chamber is >li,illow. On oplitlialnu)scopic examination the optic disk will bo found cni.ped. In an early case the cui)i>ing may be very slight, amounting to only a slight aljru])! bending of the vessels at one margin. The tension will generally be found about +1 or +2. A sub- .iciile iittack may varv in duration from a few hours to a few days. In Mime pali.Mils I'iie .-vniptoms come on in the evr-nings. subsiding lifter a night's rest. In" the intervals, at hrst. jierh-ct visiim r.- <tored, or a slight contraction of the field may bo the only da ..ago 044 Tin: i:yk. that lias Ihvii (.ffcctcl. As tlic attacks 1ht(iiii(' rrpcatc.l. riioro and more iicrmaiiciit ilaiiiafr<- ciisiics, tlic aiiioiint dcpciuliiifr lai-'clv (.ri tlicir severity and ddralidii. " ' Some eases alter one ,.r two suhanite attaeks s.'ttle into a chronie state with a persistent stiiall amount of inerease of tension witlioiit Imtlier exaeerl.atioii of symptoms, except steady contrac- tion ot the tieid of vision. Chronic Non-congestive Glaucoma. A case of friaiicoma inav run a chronic cmi-e fn.in first to last. A cast" eommencin- as chronic ,!;laiiconia may become complicated witli an acut- or subacute attack A ca.se hejriimmjr with an ;>cute or subacute attack niav afterward pa.ss into a chroiiic condition. In chionic glaucoma there is no pain and the patient is unable to state dehnilelv. in a ca.se commencing as such, when the affection bcfian. Th,. <Iisea.se iiiav pro-rress to almost complete blindness in one eye in unobservant patieiUs witli- oiit their kiiowinji that anythiiif!; is the matter. An early .symptom often is the api)areiit rapid advance of pres- l'yo|)ia, the patients liavinj; „) keep on chan^rinjj and increasin"- tlie streiifith of their jilasses for readin-r. There is MO injection of the eye, or at most a sli-;ht iiicrea.se in the size of the anterior perforatin-; veins. To outward api)earances tio alteration m tlu" eye is to be observed. Th." cornea remains bri-iht, and ,he pupil of normal size .ind reacting; to light The anterior chamber is usually shallower than normal. The only Mibjective syniptoni is the lo.ss of si-ht, which coniiiioncos at the periphery of the field and extends inward. The failure in vision may be exceedingly slow, exteiidiiif; over maiiv vears Often periect central visi<,n is ivtained when tlu- fi,.|d has' ix^come con- tracted clos,. up to the central area in all directions. The degree of tension varies in amount and in dilTerent cases. TlKM-e -ire ca.ses in which the tension is hardly evr found to be appreciably increased by tlie finger-test, but in which th.- cupping ol the optic .hsk an.l l,,ss of vi.si,,n .Misue in tli.> same way as in cas.-s of chr.MUc glaucoma, wh.'iv th<> inciv;is,- .,f t.'iision is un.l.mbt.'d It I- possible that 111 .<.,m.- ..f thes.. .^s.-s th.' ti'iisi..!! b.Tomes rais,>d only m tiie .■veinrigs, at which tim.'s th.-y a.v not imd.'r .)b,>.ervation ot the .<urg.M)n: or it m;iy b.' tluit th.-re is abnormal elasticity of the lamma cnbm.si, which all.)ws it to be .lepresse.l back witli an cxcv.hngly slight incre.'ise of th.' normal amount of int'ra-ocul'ar pressure. In .)tlier c;iv,.s ,,f chronic glaucoma th.' t.'iision vari.'s in d.'gree from tim.' to time; "t may b.' as much as J •_'. •<||hthalmosc..pically.cliaract<'risti,. cupping .if th.' optic. lisk. with a w.'ll-m;irk.'.i scl.'fal ring .surr.Min.ling th.' .li.sk, is s.'.'ii. I'ulsati.ni ol th.' r.'tui;,! ..irt.'ries in the vicinity ..f th.' disk will be pivsent ..r r.'adiiv ..bt.'.m.'.l by sli-ht pr-'.-siire of \h- finger on the glob,' The ch.)r.)i.l will pr.'S('iit a t.'ss.'llate.l appearance. sr-watai ai.ArroMA. 545 Diagnosis of Primary Glaucoma. In cases (if acute frliiuoina the j;eiieral (listtirl)ance is often so frrcai lliat the fact tliat it is ail secondary to increased tension of llic eye is ii;'.l)le to h( overlooked. Cases of acute glaucoma not uiuMiiiinioiiiy are treated for sick head die, neuralgia, erysijieias, inlliieiiza, or toothache, and much valuable time is thereby lost. 'Ihe I ipid failure of vision sliould serve at once to distiiifiuish jriaucoma from such alTections. Fhe siiallow anterior chamber, dull coriK.i, semidiluied pupil, and hicroase of tension should determino tlie diajrnosis. A dlliiculty sometimes arises in distinjiuishinji cases of subacute primary fxl.aucoma from iritis. The difficulty is mi increased when. as occasionally happens, the iritis is a.ssociated with increase of Icnsiiiii. In both conditions the iris may be altered in brightness (ir coliii The presence of posterior s\T.('chia' should point at once lu irili-, bet it maj' be difficult to ilecide Wmther ir not any are lirescni without dilating tlie pujul; and if the case is one of [irimary jliaucoma. it is very desirable not to use a mydriatic. In glaucoma there will not Ix' so much ciliary injection and photophobia as in iritis. The anterior chamber will be shallow, while in 'ritis it will be of normal depth, or possibly deeper than normal, whh (l)ile(l opacities on the back of tlie cornea (kcmtilif: punctata). The history of the ca.se may assist in the diagnosis. In ])rimary glaucoma a history of previous attacks of diimiess of sight with an appe.'raiice of rainbow colors around lights ina\' be elicited; while in iritis there may have been a recent attack of sy])hilis or gnimriiKeal arthritis, or previous attacks -^f .similr.r inflaiinnation in the eye itself or the fellow eye. Differentiation between these two ;iffections is of imi)ortanc(> in deciding whether to presc.-ibc a myotic or a mydriatic. Confusion sometimes occms in distinguishing between cupping of tlie o|,tie disk due to glaucoma, cupjiing due to atrophy, and iii|)|iing the result of a |i!\vsi(ilogical ])eculii>rity. As already state<l, the glaucomatous cup is due to atrophy of the nerve librcs down to the I, nina cribros.-i and depression backward I'! tile lamina cribrosa. In an atrophic cup there is no dejin'ssion ba<'k\vanl of the lamina cril)rosa, only atrojjhy of the nerve Hbres i|ii\Mi to it. Hdtli the glaiK'om.atous cup. and the atrophic cup apy the '\li.i|r area of the optic disk. Th(> latter, however, h. j;radually -iiilving edges, while the former has steep si(l(>s or overhanging edges, .iKiuiiii wiiich the retinal vessels disapjiear for ;i jiortion of their lAtrlit. The physiologic,,] i'U|i is produced by divergence of the nerve fibres :!- ilicy eiiti'r the eye after piercing the 'aniina crii)rosa. This diver- 'jrnce occurs ,><ooneroris more marke(I in then a cup or depression is found in the some eyes thai) in others: head of the nerve. It is sp-s^sa/r^s^:. ^^^SS^S^S 54G riiK i:ye. (listiKgiiislicd from tlio other two forms of cui.pinjr l.y never orciipv- in« the whole area of the optie disk. I.ik." a {ilaiicomaloiis eup.'it sometimes has an overhaiif;iii>; eiljje, aroimd whieh tiie n'tinal vessels are seen to emi; tliis may at times lead iiiexperieiieed observers into making an erroneous diagnosis. whi< ii cap l.e avoided hv ohservinji that only a portion of the disk is invoiveo. The diatriiosis iM-tweeii eases of ehroiiie >;laiU'oma, where the tension IS not increased at the tirne the patient is s.>en, and cases of primary optic atrophy, is not always easy, liesjdes the diderences in tlie character of the cnppini: of the nerve just mentioned, pulsation of the retmal arteries in the vicinity of the disk should he looked for. Its presence should [loint at once to friaucoma. l! d.sent. a slijiht amount of pressure should he made on the <;lol)e with the hnfier, to see if it can easily he evoked. The character of the field of vision mav he of considerahle a.ssistance in distinjtuishmj,' hetween these two nfTections. A con- traction of the imier part of the (iel.l is a characteristic .svmptom ot filaucoina. The field in holh conditions mav Ik- conceiitrically eoi.'tracted or present .sector-shai)ed defects. Iii atrophv the fields tor color will he nmtracted out of proportion to that for white, or there may he complete color hlindness; while in jjlaucoma the contniction of the fields for color is always concentric with that for white, and color hlindne.s.^ is met with <!nlv in the latest sla-'cs of the disea.se. " '^ Varieties of Secondary Glaucoma. As the result of various different diseased conditions of the eye a deran-remen; of the circulation ,,f the intra-ocular fluid is liable to occur, result 'iiji in increased tension. The different dise;i.ses in connection with which secondary glau- coma occurs are dealt with in detail in other portions of tlii.i work: it is necessary here only to emimenite them, and to point out the maimer m which each iiiteneres with the circulation .so as to produce the<r|aucoinatouscoiidiii(in. Posterior Synechiae of Iris. As the result of iritis, the pnpillarv mar-:iii of the iris may l.econie adherent to the lens capsule in its entire circumference, a condition spoken of as annular posterior synechi.-t. The aqueous humor then is ohstructed in its pa.ssafje for- wanl throufrh the pujiil into the anterior cliamher. It accumulates hetween the iris and lens, l.owinj; the former forward and producin<' the condition teniKMJ iris homhe. At first this accumulation of lluid hehmd tlie ins is compeii.sated for hy escape of lluid from the anterior chamber, lllimately the root uf the iris comes into cont.act with the back of the cornea, so that not oiilv is pa.ss;i<;e of fhiid throufiii th- puijd (ibstnicted, but also any esc-ipe tlmiuKli the .space,- of Fon- tana. The tension then hecoines increa.sed. This is ;i form of secondary frlaucoma which is readilv relieved GIAL'VOMA. o47 l>v iriilcctoiiiy. When ;i i>(irti(iii nf tlic iris is ri'iiiovcd, lluid can a^aiii piiss I'uruani into lln' anterior ciiainiicr and tiic normal circulation will he re-<'sial)lislied. Sometimes as tiie result of iritis, not only the pupillary marfjin, l)ut a'<o the whole of the posterior surface of the iris becomes utiited to the lens cajjsule, a condition known as tutnl intslcnDr sunccliia. Where this is present, the secretion of the ciliary body is unable to tind its way forward between the iris and lens. It accuimilates in the vitieous ciiamber, increasinfi the pressure there, and forcinj; forw.ard the lens and iris. When the root of the latter conies into apposition with the periiihery of the cornea, farther escape of fluid from the anterior chainber throufih the filtration area is blocked, and fjlaucoma becomes established. The relief of tension in this condition by iridectomy is not an easy matter. It is very diilicult to remove a piece of ivh wliich will allow iliuiiiimii M'l'oiiilBry to iritis and tlie formution of aiimiliir ixieterior ^yiicohia. Flui'l fti-cumulating ill il.f |««tirior iliamlicr lias bowed the iris lorwanl into loiitact with the back of the cornea. lit the. satisfactory passage of fluiils forward, so firmly is it bound down and so frail (h.'s its (issue become. Anterior S3mechi8e of Irk liie formation of an extensive adhe- sicin of the iris to the scar tissue left after a perforatiiif; ulcer of tlie iiiriiea may prevent jias.sajre of fluid throuflh the i-upil, so that the whole anttuior chamber becomes obliterated. The at|UO()Us hmnor iiccumulates between the back of the iris and lens: none can piin exit from the eye tiiroufih the spaces of Fontaiia or throiifili the lymph spai'cs on the anterior surfare of the iris. The tciision then is iii- ereased. as the result of which tlie recently iiiHamed and softened corneal tissue jtives and iiecomes staphylomatous. .\ less extensive adh(>sion of the iris to the cornea, which does not involve tiie entire circumference of the pupil, may cause it to bo -o lirawn i'orwanl as to iiiinj; its idot into coiilacl with the l);ick of tlie lornea. \\\ an obstruction to the passage of fiui I throuph its nnin exit at the angle of '. 'Ulterior chamber, glaucoma is established. /.Ji-i'Jl 54» 77//:' rvi:. Siicli an ()l).-itriicti(Pii is especially liai)le to occur when a cornea hccotnes stapiiyloinalous, as an increase in the jiroininence of it tcmls to draw the iris still t'artlier I'nrwanl. Anterior Synechiae of Lens Capsule or Hyaloid Membrane of Vitreous. Alter the operations of extraction of cataract, or discission, or after woiimls of the eye, adhesions of liie capsule or portions of tile vitreous huinor to the cornea .are lialile to form. These struc- tures, norin:dly situated behind the level of the iris, when advanced in position in this w;iy. may so draw it forward as to hriiif; its root into contact with the hack of the corne;i. lilockinji the filtnition area.' (ilaucoma may tlius he produced, even when iridectomy has heen performed, the liltration area opposite the colohoma heiiiji lilocked by a small piece of the root of the iris, which has heen left, or hy the most anterior of the ciliary processes, (jlaucoina hu.s occurn . Ki(i. Hi '■'"'"■""'" ^' '"O' I" til.; fornmlimi of an anlerinr sjiiwhhi of ihe liMis caiwiili- afler I'xlniction cif cHiarart. .Vii irlilfii..my iia.l Iveii inTlormcl. Imt 111 thu ririipii of ilie culuU.nm Ihc liltration ar™ i.« iiloik.'.i Ijy the anterior of the i-iliary (.riK'esses, ilravvli forwar.l by the M.lherent eapsuie. Oh the opi.ijiie Mile Ihe angle of the anterior ehainher is bioeke.l hy a broad aiiliesion of the root of thi' iris. when tlie whole of the iris has escaped through a wound (traumatic aniridia-), the liltration area heiiijr hlockeil in its entire circum- ference hy the anterior of the ciliary jiroces.ses, dniwn forward hy re.i-ioii of adhesion of tiie lens capsule to the cornea. Wounds of the Lens. Increase nf tension sonietimes results from swelliiijr of the lens sulistaiice in its capsule, after some of the .•i(|ueous humor has heen ;iilinitted to it throujrh a wound. In such ca.ses the swollen lens seems directly to pnw forward the iris and close the filtration .irea. The tension c-iii usually he relieved hv making a freer o|ieninf; in the caiisule ;iiid allowiiij: .some of the lens matter to escape from the eye or into the .anterior chamher. 1 Transaction- of the (i|,lithMhn.iloi:ii'aI Sieiely of the L'liiteil Kinplom, I.swi. vol. s. p. li)8. -' 0|ihlhillniic Review, lv.)|. vol. x. p. Iu."i. ULMCDMA. 540 Iiicrciisc (if tonsion iimy also ncctir after wimiids of llic lens, wlicii tliirr lias twcii ;i free oii(>iiiiiK madi' in its cmiisuIc and sonic of tlic lens matter has conif forward and dissolved in the aqueous humor. Kio. 3X. r.lHucoma KCf oiiclsrv to dlslocBtion of the leiw Into (he luitcrior chamber. The lei.s wax In contact witli the Cornell. "O'l tlie iris closely i.rcn-cl foriviinl inUi c.nit»( t with the inTivhery of the cornea hikI hiuli of the lens In the iircpurution ol the s|iecinicn the •trnctnrcs h;ive fMllen ^liuhtly aiart. 1 ihrnpl iK'M.l In the iris, wlivre it ceawl to be in contact with the cornea and |Misse<l into conuct «i,h ihc lens, i» «ell shown. .\fter the operation of discission for lamellar rataraet iiiereased tension is of not uncommon occurrence. The aijueous humor liecomes loaded with the colloid substance fjloliulin, of which the lens is mainly Fi.i. K ^J^ ^^ ^ ^ 1 p ^ ^ w ^ 1 nirtiicoma secoiKliiry to traiunatic dislocation of the lens. The displaced lens has presseil forward the iris into conuiet with the back of the cornea. The iris and ciliary body where they were in iil.|>.sitinii with the lens are much atrophied. In the preparation of the specimen an oljvious sliclit alteration in the poKition of the lens has taken place. com[)o.sed: it is then much le.ss easy for it to hlter out of the eye than in its normal condition. It is possible also that bits of undis- y<-]\-<;\ liTis substance may Ix'oome entntfwled in the mesh of the li^amentum jiectinatum and fill up the sjiaces contained in it. In- creaseij tension broufiht about in this way is always readily relieved by a jiaracentesis and evacuation of the lens matter. 650 nit: i:Yt:. Dislocation of the Lens. (Ilauconin is a not iiifrc<|iii'tit jir-rom- paiiinicrit nf dislocatioii of tlic lens. Cases arc met with in wjiich tiif suspensory lipmierit is ilclicient in a portion of its cireinnfereiice, atiii the remain. ier so attachecj as to allow the lens to sway haekward" anil forwani will venii'iits of the head. In sotne of these, wiien the patient hanjis his head down and the lens falls forvvard, the oeiilar tension Imtoimcs inereased. returninji, however, to normal when he raises his hea<l and the lens falls hack. Siniilaii\ , permanent displacement forward of the lens into the anterior chamlHT. either completely or |>artially, caii.ses increa.so of tension. The displaced lens tills up tlie pupil and blocks the passage of fluid through it. The acjueous Km. s-.>H humor then accuiimlates in the vitreous chamlM'r. (I'ifj. :\2i\.) Wheti the lens is displaced backward or laterally and in- creased tension results, the angle of the ant<'rior chainlMT is always found do.sed. The relative altera- tion in position of the len.s and vitreous body seems to force directlv forward the root of the iris. lV\fr. ;j27.) Serous Cyclitis. Mhen the ciliary body is inflamed, the fluid secreted by it is in excess and altered in character; it is more serous than normal, an<l is mi.xed with a number of formed ele- ments, leucocytes, and cells which have desiiuainated from the secreting .surface. The increased amount of albumin in the fluid makes it m.)re dimcult for it to filt.r out of the eye. The formed elements in it. .'is they pa.-^s through .'le ligamentuiii pectinatum, pet caught in the mesh, and. accunmlating there, cause obstruction (Fig. .'il'S.) There are then these three factors v.hich combine to give rise to increased tension in serous cyclitis; ( li excess of secretion; (2l albu- minous characler of tiie aijueous humor; (.'}) accumulation of inflam- matory cells in the spaces of I'ontana. The obstruction to the circulation of the fluid being primarily at the outlets from the .anterior chamber, and ;he !ilbuminoiis character of the fluid making it diflicult for it to filter through the anterior hyidoid iiieiiil.ra!!.- iiito tlie vitrcuus, .-in ;iccutiiulati(Hi takes place in the ;intenor chamlier. which becomes deepened, the lens and iris being depressed backward. The glaucoma in such ca.ses is treated best by rejieated jiaracentesis, rather than iridectomy, Angle iifthc anterior rhambcTlnttiiiyi' which hjMl Klanc.Mnii Neeondary In semuH iriiiiK'ytiitis, !t flioHs wi.le !.e|iaraliiin of the root of the Iris from the \m\ of the cornea, hut an aci'iiinn. laticjn of intlii'ninatorycellson Die Inner !:nrlace of Jiescenie* 'lenibruiie and in the niesh of the liKanicnt. i>eclin»tiiin. OLA VCOMA. 6S1 Intra-ocular Tumors. A turnor niuwinn forward Intm the ri'tiiia, ,,r iHii.a'li iIk- ri'iiiia I'rntii tin- clu.rui.l, inuls to increase the pressure in tiie vilreuus eliaiiil«'r. This may I'nr a time l.e eompeiisated fur |,y an increase.l eseape of Ihiiil tn.iii the vitreous into liie ai. erior ciiamlier, iiiwi an increased es<'ape from the eyi-. Gradually the vitreous Ix'comessoeonipressed that fluid is less.uMl less.'asily j.resM'd out of it. Tlie tension tliati in IIk- anterior, .. then in tlie vitreous elia .er Iweomes greater tlie lens and iris are pushi-d forwMnl until the root of till' latter eon les in eontart with the filtration area in tin niriiea, :<nil a permanent stahlished. (KiH- ."Sl'JI.) hloek to the eseape of fluid from the eye IS ( In a eas( iiif-rease o tana contain cells similar in ( are, n liarv hoilv, which has caused ,-, of sarcoma of the iris or ci _ . f tension, it will nenerally In- found that the spaces of Kon haracter to those of the growth. They iiturallv, most numerou? in the part in the vicinity of the jrmwth, hut m.ay alsi Ih- met with in part." ani: c|Ult e reino te fr ■om it. Th. rui. 3.".), le of the anterior chamlHr may also he found closed, hy the root of the iris havinji heeii directly pushed laaiicniim sfiiiiiilary to melsncilic nar- cdiim of the cillHry l»-ly. The loos In >lio«ii illrt'CIly preswl f(ir»«r.l by the pn.Mlh The kukU' of ihc anterior eh«m- btr l« el iseil by coiilael of the root of the Iris anil cornea. fiirwaid hy the growth, or hy thick- ( ning of till- root of the iris Sy the jrrowth itself. Epithelial Cysts in the Anterior Chamber.' AVhen an oiM-ning has been made into the anteri 'r cham- ixr, either l>y an operation or acci- dentally, some t)f the surface epi- thelium may he imi)lanted or spread liliinj; the wound into Hie anterior cliamher. Tl"' epithelium, subse- .|uenllv forming a cyst which fills the wli.ile anterior chamber, obstruct * the passage of ai|iieous humor into it, and causes increase of tensio". Detachment of the Retina, (ila icoma sometimes comes on m eves with simple detachment of the retina. When this is the case, the |.Ve.-;ence of an intra-ocular growth is gem-rally suspecteil. and often ii is not imtil the removal of the eye that it is ascertained definitely tliat the condition is one of simple detachment. The extent of thn (iit.ichment is usuallv great, ami the vitreous much .shrunken. Some li'iiiorrhage or serous" etTusion into the subretinal sjjace forces forward tlie lens and iris, blocking the angle of the anterior chamber, much in till' same wav as in the case of an intra-ocular growth. Thrombosis of the Retinal Veins. The coiulition which is coin- :iHK:!v >\<nlrn of as " hemorrh'tgic retinitis" is probably m inost cases due to thrombosis of the central retinal vein; it may sometimes 1 rnnistifiinn'- of iho OphthBlmoU)«ical Scicicty of the Cnite*! Kinirdom, 1«92, vol. xU. p. 175. 552 Tilt: Kit: !><• the |.ri'ciir.s.ir nf an attack nf ulaiicmiia. The syiii|i|..iiis of tin- attack ri'scinhic th(.s<' of a caw of primary jilaiiconia. from which it can only U- (hsiiiiduishcd hy the [.rcscniT of numerous hcmor- rUaiiifi scaltcrt'd over the retina, an.l the enlarKement of the retinal Ni'ins. Thromliosis of the ntinai vein is mostly met with in elderly jM-ople, and may exist without any increas*' of ocular tension. It seems proljaiile that it is only in those i-yes which ar struc- turally predisposed that glaucoma is set u|), increase of pressiri' in the vitreous chamlier lieini; 'I"' excilin;; cause. The venous enfior^je- ment and serous elTusiou into the retina, together with the .serous effusion into the vitreous which follows throml)osis. cause this increas.' of pressure. In such c;i.ses the iris and lens an- pressed forward and the an>;le of the :inferior ehatnU'r closed. It is a con- dition which it is very necessary to dinerentiate from primary ulaii- eoma, iM'c-iuse operative procedures on such eyes are followed freijueiitly l)y extensive and ilisastrous heiiiorrhaci'. When- possible, ojMTations in such casi-s should he avoided, pref- erence heinn niveu to treatment with myotics. If an oin-ration Ix'comes urgently necessary, a paracentesis'or sclerotomy should he IMTformed. the esca|M' of fluid and lowering of tension iK'iuK effected as gradually as possible. Congenital Aniridia and Coloboma of the Iris, lint glaucoma can sufxTvene when there is ap|)arently entire congenital absence. Fill. a.10. eoliK.Miital aniridia in mIikIi Klani-onia Hilli »i-.l on a i^rl.TatiijK ulr.r nl th.; i.iriwa. The an^lt "I thennuriori-liumUTisshmni l.liH.-',t.i bv a very nHliriu-niury irs, wh:: ;i was «.,sniall as m.t lo U- visible vlinii'ally. It nas U«>nie ai.:.erent t() llie bai-li iif tlic fonrca. or ;icol(.h,,in;i r.f the iris, seem.- at first wholly (■ u of keepinji with till' fad libit an iridectomy is the most ofTective ,,eatm(>nt for the n iief of tension. Several cases of fil.mconia, both primary and seconil;iry, in association with the.se defects have been recorded.' •Fijj. ;!;!().;■ i'atliolo^ica! exainination of f■ye.■^ with these di-feets lias ' OphthalL io Heview. isin. [.. 101; Transactions of the Ophthalmological Society of the fnlted Kingdom, iwftj. vol. xiii. \> 12h. )1 LA I COMA. 5d3 slinwii tl.jit the ciliary Imdy really iuIh in a fTiiall nidiiiifntiirv iri^<, wiiicli, thiiiiuli (Hit (if siitlii'ir-iit li until ti. rciKlcr it visible heyond the scleriicdriieal margin, is of siitlicietit size wlieti pressed fiirwaril tn Idiiek the liltraliiiii area. In two case's where iiicreasfnl tension was |ireseiit the rudimentary iris was actually found bl(M-kinff the lilt rat ion area. There is rea.son to iM-lieve that ('a-ses with congenital d' : , 's of the iri> may Ih' |iredis|iosed to glaucoma. Strands of tissue have In-en liiinid .sirelchiM^ from the anterior surface of the defective iris to the li);amenlum peciiiialnni, showing a conjjenitally imperfect sepa- ration of these structures. Congenital Glaucoma, or Primary Buphthalmos. liiilarcement of the cornea, and the jiroduction of a condition rc- ilii semlimijT a hullock's eve, tnav occur as the ri-sult of increased int ra- ocular tension in children, in whatever way that increa.se is Wrougiit aliiiut. Then' is ;i form of buphthalmos that is not the result of any obvious precedent di.sease, and tiiat may In* termed prim.'iry. In many such cases a definite history of the .-^yinptoms dating from birth can Ik- obtained, and jirobably so in all, the symptoms in stime at first Immiik so slight jis to es"ai)e observation. The increase of tension is unaccompanied by injection or other ,'ic\ile sympt.iins. The enlargement of the glolw continues steadily without pain. It is not only the cornea th;it is increased in size, iiul the whole eyeball in all its meridians as well. The measurements of the '.'ve of a boy, aged four years, which was affected in this way, \ver»*: antero-posteriorly 2N mm., vertically '_'()..") mm., while the diameter ( ' the cornea was 14.5 mm. Besides liaving its diameters increased, :.i' cornea becomes more <'onvex and globular in sliai)e. The stretching of the cornea and sclerotic occasions thinning in tlie latter. This thinning allows of the pigment of the uveal tract being seen through, .so that it appears of a bluish-gray color. The anterior chamber becomes very deep, aid the iris is often Irciiiulou ■ ;in movements of the eye, from weiikeniiiiiuf the susjiensory liiiatiient or fluidity of the vitreous behiml it. ()phthalmoscoi)ically, the o|)lic disk is fiumd deeply cup|)ed. In some ca.ses the increa.sed tension pei"sists, and failure of sight .-leadily progresses until the eye becomes quite blind. In others, a spontaneous relief of tension occurs, and, altliough the eve rrmain.s l"Minanently enlarged, there is no further increa.se in size or deterio- rniiun of sight .\ congenital malformation' in the cliannels of e.\it of fluid fr> ui ' Triachor Coll ... Kesearchi-s Into the latomy and PatholngT of the Eye, p 104. F. R. C- Trunsactlons of the ophtbalmoluglcal So....y of the United Kingdom, vol. xvl. p. ;i04. 554 THE EYE. tlic <>yp is the |)r<)h:il)l(' cause of tin- iiicrcMsc of tension in these cases. Ill some a conjieiiital ailiiesion, or. ratlier. failure in separation of the peripiierv of tile iris ami l)aci< of tile cornea, lias been foiiiul. in some, strands of tissue about the ariftle of tiie anterior chamber, suji- pestive of ;iclliesi()iis which liad become stretched and broken down by the collection of fluid ill the anterior chamber, wliich forced hack- ward the iris and forward the corne;i. Such a breakiiifi down of conjreiiital adhesions which at one time existed, explains the cases ill which spontaneous relief of tension occurs. In other cases the canal of Schlemm was stated to be c(iiij;eiiitally absent. The o|)orations of iridectomy ami .sclerotomy in tliese cases fre- (jucntiy fail to relieve tension or to check the expansion of the globe. Kl(i. 331. Tin- atiKle of the anterior clmmlier iii a cat* ol euiiKenital KltiticDinii or primary bupbthalmo^. Showing a t'otigeiiital adhfsinn of ihu root uf the irl:* t-j thr hack of the (!oriica. The rest of the iris is vvitlfly K.'piirHle<l from tile cornt-a, the anterior chamber having been very <ieep. and ait attended with jireater risk than in cases of glaucoma in the adult. The expansion of the globe causes stretching and weakening of the suspensory ligament of the lens, wiiicli renders it very liable to rujiture on the escape of atjueous from the deepened anterior cliain- iier. Dislocation of the lens or loss of vitreous, which is usually of a fluid consist. 'iicy, are complications, therefore, likely to occur. Hepeated paracentesis and the u.se of myotics have Iweii ('inployed as altcriiatixc measures, and. although attended with less danger, are fre(|ueiitly ('(pially unsuccessful in checking the progress of the afl'ection. i he appe.ii.iiices of Mime ol (he eycN, wiiicli liavf been removed for this condition, suggest that the adherent tags of ti.ssue about t hi' root OLALXOMA. 655 of the iris iiiiplit bo (lisonfraRo I or incised l)y tho point of ii knife ]),(ssc(l into the cxlrcnic angle of tlie ('liiinii)er. Such an operation lias JK'cn practised i)y \'incenti' for jjlauconia in the eyes of older people. Pathogenesis of Primary Glaucoma. The whole scfuienoo of events whidi result in the production of increased tension in primary glaucoma is hy no means so obvious as in some of tlie secondary forms of the afTectiim. It is nee(lless here lo enter into the 'lumerous theorii's which liave been suggested as to the origin of this disease, many of which, with the growth of knowledge respecting the intra-ocular circulation, have beeti shown til be unten.able. Any increase of secretion into the eye is compensated for by an iiK rease(l outllow. so that no theory of the pathogenesis of glauci ina based on an incn^ased secretion alone cm be accepted. We must look to the channels of exit of (iuid from the eye for some obstruc- tion to account for the increased intra-ocular ]iri'ssure. As pointed out by Max Knies and Weber, the filtration area at the angle of the anterior chamber in primary glaucoma is found obstructed by ajiposition or adhesion of the root of the iris to the periplu'ry of the cornea, the iris apparently Iwing puslied forward l)y |iressure of the ciliary processes against its root. If a l)lock to the exit of fluids from the eye at the angle of the anterior chaml)er is the primary cause of glaucoma, we should expect to meet with an accumulation of acpieous humor and a deepen- ing of the anterior chamber. Instead of this, we find the anterior chamber shallowed, the shallowness often |)receding the onset of increased tension. I'riestley Smith has met this difficulty by suggesting that there is :il first .-m accumulation of fluid in the vitreous chamber, due to oi)sl ruction at the circumlental space, which causes the lens, iris, and ciliary )irocesses to be pressed forward. He luis shown that changes which pre(lis|)ose to narrowing of the circumlental space predisjiose to glaucoma. It will be well here to (piote his words in which he sums up his \iews on this mafter;- '' I'rim.iry glaucoma a|)iiears usu.ally to <l(>p(>n(l on some vascular disturbance which congests the uve:d tract, or upon a faulty relation nf the lens to the jiarts around it, or upon both. If the patient l)e elderly, we know that the lens is relatively large. If the cornea be small, we may infer that the whole eyeball is small, and that the rela- iiiin-i of the lens are such as to preilispose to compression of the liltration angle, es|H'cially during tlilatation of the pupil. An obstruc- tion in the region of the hyaloid and the circundental space, which checks the escape of surplus fluid from the vitreous and leads to an ' Revuf Ki'ih'Tiile <VO[>h., November 30, l*i'H. - Norriaand Oliver, System ol Diseaaes of the Kye, vol. 111. p. 6,'*. 556 Tin: ICYE. advance of the lens, appoars to W present in many rases. Slackness of llie zonular, witli eonsei|uenl instability of the lens, is prohalily a rontiihutory cause. 'rhrou;;li one or other of these causes, or several in conihination. tiie ciliary proce.s.ses are jiresseil ajjainst the iris, and the tiltration anjile is narrowed or closed." I'anas. .lonnesco, and others look for an ex|)lanation of the incr(>asetl tension in jrlauconia to .some disturbance in the controllinjr action of the nervous system on the intra-ocular prc-^sure. .-\s already stated, oui' knowledfre of this controllinj; action is at present incomplete. The reduction of tension in ,<;laucoma which .lonnesco has been able to effect by resection of the superior ccrvicnl sympathetic panjilion lias led h^m to formulate the theory that glaucoma is due to iieriplieral or central irritation, either peinianent or intermittent, of the ocular sympathetic fil)res which pass thniufih it. The effects on the eye of such irritation have been mentioned. The dilatation of the pupil, whi'ir is thereby produced, mifrlit alone, in an eye with ;i slialli : anterior chamber and predisposed to filaucoma, be sullicient to bncp on increase of tension, just as atropine mydriasis sometimes does. Th'' influence which emotional disturbances sometimes have in the production of jjlaucoma may po.ssibly in this way find an expl.-i nation. Treatment of Primary Glaucoma. Fifty years ajro jrlaucoma was an incurable dis(>ase. lentil von (iraefe introduced the treatment of it by iridectomy in l.S.JO, no means which would .afford permanent relief was known. In 1n7<) the next most valuable method for the reduction ot in- creased tension, viz.: the use of myotics, was suggested by Lat|ueur,of Strasburg. These two chief forms of treatment, together with otlii-r procedures for the reduction of tension, will now be individually described, and afterward their clinical .application. Iridectomy or Iridectomydialysis. The way in which an iridectomy relieves tension in jjrimary glaucoma has been the source of nuich discussion. The pathological examination and comparison of eyes in which it has proved succe.-isful, with those in which it has failed, have thrown nuicli light on this matter.' Several eyes have been examined in which an iridectomy suc- cessfully relieved the tension in glaucoma and subseijuently had to l)e removed for .some intercurrent malady. In these eves either the obstructed |)assage for the exit of Huid ;it the angle oi" the .anterior chamber was found o|)ened up. or ;i new channel of exit had Iwen established by the formation of what is termed a cvstoid cicatrix. (Fig. :«•_'.) The opening up of the tiltration .area at the angle of the anterior chami)er h.id in sonn' of the cases been etfecled bv removal of the ' Hoyal Liinilon 0|>hUmlmli' H(is|iitul l!i'i«)rl», IWJl. v(il. xli'i. p. (1 LA i COMA. 557 (ilistnirtiiip iris up to its point of juiictioii with tlif riliiiry body, in the vicinity of tlu' wouml. In otiicrs, aitiioufili a |)ortion of the root S4vii.>ii ihrDiiKh the penlri' cif the onlolH.ina in nn pyo which Imrt lia^l an iri.lcetoniy pfrformtHl l.,r flu'icnnm of two mnnlhs' stimciing. The tensidn wiix ruliuvi-ii hy tho .>iK>ratioli. The eye was ,xfi«fcl five wvki Inter fur ulceration of the cornea. The iris has been reinoveil up lo tlic ciliary l>i ly iiii'l tile Jinu'le of the anterior chamber therel>y opcneil np. .-. riioii throiieh a cystoid cicatrix, wliich lormcl at the aimle of a pololionia In an eye in wliicli :ch ■inm cuinc on alter extraction of cataract. It sliows a li'lilla in the sclenK'omeal tissue liuc'l ly a lol'i of atropliieil iris Tlic snlieonjunelival tissue anpund tlie listula is swollen. iii.l Ih'ch lifi. ii liccaiiic disliiilp'il fmiii it^ faulty ptisitit-n. l!vi- liiitiy in such cases sulhcicnt time iiad not elapsed for it to hecoiiie o.jH Till-: i:yi:. ailliciciit to tli<' <'i)riica. 'I'lic ilnifi on the iris. cscaiH- of a(|ii*'oiis. and roiis('(Hiciit rclicl' of iircsstirc in tin- vitreous cliainhcr. tofrctiicr witli tlic local escape of blood, liad sull'ced to restore tlie normal channels for the circulation of fluid, i I'ij;. .'{;>.'{.) When a cystoid cicatrix is present, .a fistula is estalilished in the fihrous tissue at the sclerocorneal Miarjrin, thiowjih which fluid inav pass from the anterior chamher into the suliconjunclival tissue and he alisorheil there liy the conimictival vessels. The tissue around tiie fistul.i is found usually in a l>o<;i;y condition. The hstula results from prola|)se of ;i fold of iris, which prevents the two sides of the wound in the fibrous tissue of the sclera and cornea from unitinjr, but over which the conjunctiva lieals. At first Flo. sa. Sfctinn tlir.'iiKh ti rystoiit ricatrix whioh lurined antTaii iTiileotmnv for olimnic Klancniim Tin- tiMi'iiim remaiiu'd nr>rmal lura yrar: thfi'Vf «a> llicMU'X(i«-il mi ncwuiil "f irilis an>l t«iii A li'liila ill llio sclfriKiininil tissue i«sh.nm, lini'.l iwrlly liy Ih.' alrnpliit'il rixit of llic iris, anil (artly liv the ciliary [)roce»M's. The sutK'onjiiiiriival tissue aroillld the tisttlla is swollen. the iris tissue liiiin}r such tract offers an iiiipeilimeiit to the pa.ssajje of fluid out of the eye: but beiiij; a weak spot in the jrlobe, it tends to bul<;e. and the iris liniiiji it atrojihies. until ultimately a fistula is e>t;iblislie(|. I I'if;. ;{;i4.) .\ cystoiil condition of a cicatrix after iridectomy appears most often at the an;rle of the coloboma /. c. the position where the |iro- lapse of a fold of iris is most likely to occur. .Mthoiijrh the production of such a condition may prove beneficial in relievinjr tension, it is one which is attemleil with a certain aniotml of risk. What is pr.actically an .adhesion between the coiiiunctiv.a and iris beiny; formed. ;inv inflamm.atioii of the former readily spreai's to tli( I; ,er, and is liable to start a iietieral uveitis. OL.liVoMA. 559 An iridtrtdtiiy (nils to relieve tension in primary jilaucoina win he lloriHMl |i; i<;es for tl'.e exit of (liiid from tiie eye remain unopened am I no new eliannei is formed. Fth. :»■■ SfoiKiii thriiiiKli the centre of tlu- railnbijinii in an eye with alwolute i;laucoina wtiicii had had an iii.liit'imy inrt.irnied. and in which the increased tensiDn snbseiinently returned. It shows the ciciitrix In lie Fi very inripheral one and fr ■• Irmn any entandeinent nf the Iris. The anijle of tlie iinterior chamber remains blockeil by a ix.rilDn of the root of the iris, intimately adherent to the corncu. Fiii. ;i:iii. Sec tion tlironnh the centre of the colobi>inii m an eye « liicli had had an Iridectomy performed for -iil«i,ine Kliiuconm. and in which tlic increa.sed tension Inicl snbsoqnently returned. It shows that » liirRc |«iriion of Ihc (leripliery of tlie iris liad t)eei. leil blocliint; the inUltration area. The cut end "t iliciris is adhorcnl to tlie corneal cicatrix II l.».k^ a» Ihongh the rcnitof the iris miitht have i»cn i..rn away nnich nearer up to the ciliary Ivuly. Probably a simple iridectomy wai perfornie.1, n't an iridectomydialysis. ■{'he normal passages for tlie exit of fluid at the angle of the anterior ' liaiiiher a'f iino])eried up: oGO THE EYE. 1 Uhcii flu> r..(.t of tlic iris has Ixroriu' s.. iiitiinatciv adhoront to tiK' hack ot the rornca that on L.-inK drauii upon. inst(-a<l of t<"annc at Its cxircnip r<.ot. it tears through ;■.( ih.- point whcr.. it ceases to l)e adherent, and the portion vauAw^ ..bstnictioi is left behind I r ij;. X\U. ) •2 When by reason of the way in whicii the iridecion.v has bo..n p."rfonne. a portion of its root is left behind, which, {iiouRh not adherent to the cornea, has failed to bec.ine .lisiodjr,,! »>,„;, its faulty position, f !• ijr. .'{.sr. ) .1 When by reason of delayed ref.n nionof the anterior chaiMb.-r til." lens l.eco,n,.s ,in,te,l to the posterior surface of the wound by phustic exudation thrown out from the latter. Then when the S. ,„ .hrongh the oenlre of ,hc clnlnnna m an , y. which had hart a„ iri.lectoray r..rf.r.nert for al«.„l»„. J. Hue,„nH A„ nrthi^i,,,, «, ,he Ion, .apsule to the pos,en.,r «„rf«ce nf the ^.meaTn th r... .,,,,, he c„.utr,x i« .how,,. The len, h,„ .«oo,ne s,„„ewh«t ,lis,.laee,l .«, k« an in thrC™ ,„ o, the .,,.,.„,,e„. The a„^.leor the , „erlor elm,„.,.r ,s olo-seU i.v the anterior oltLXn- |.rooe.«-.. whid, have Ikvii |.resa.l f„rw, A hy tl,e a-lherenl le„8. ' " anterior chan.ber .l.,es reform, the lens becomes .Iniwn f.,rw;,r.l its adherent marfrm [.ressinj: the anterior of the ciliary processes into <''»'tMel with the hitration area in ll„. n-ion of theVoloboma In the ,.,bs,.nce of prol..,pse of .■, fol,| of iris, no fistula and no new .•liMniie! o| exit lor fluid ;ire produced. Fro viously desirable in performini: to reinoye the „•,,,■ ... - - ■■ 1- •■!■■■ ■.•'■•',„• I, ,> „|, lo us poiiii otniiiction •the chary bo, iy. lort un.Mtely it is at this spot that the iris is thinnest, .•md it ,s l„,e ih.at it is most lik.-ly to tear through when drawn upi,!!. unless ;ibiiorm;illy adherent. In performinj: an iridectomv for d;iuco sciei-ocorne.al margin has been madt an rom the forefruirif;. it is ob- iridectomy for glaucoma to trv oni;i, (itfiT an incision of tlse ,. I . , , , .. . • ''"' "■'■' ^'"""Id be drawn out and snipped throu}rh from its pupillary to its ciliary margin at one OLA VCOMA. 5«1 Miifilc 1)1" the wound. It slidiild then lie drawn alimji the wliolf Iciijjtli lit' tlif wound, so as to tear it away, and, finally, cut tlirougli apain at its t'ln'tlif'!' cxtri'inity. This nictiiod of pcrforniinf; an iridectomy is very (litTcri'Mt from that adopted prehminary to the removal of a catanK'l or to form an artificial j)upil. For thi'se purposes a piece of iris is simply drawn out of the wound and snipped off. 'i"o distinguish the two methods of performing the operation, the one from the other, it is well to term the first an iridectomydialysis, and the latter simi)le iridectomy. Anterior Sclerotomy. Anterior sclerotomy of de WCcker is per- formed by enterinji a (iraefe knife 1 mm. external to the corneal marjiin, carrying it across the anterior chamber, and hringing it out ei|uidistart on the op|)osite side. The |)oiiits of entrance and exit are planned as if a flap 2^ mm. high were about to bo cut. After the StTtion throueb the angle of tlu' antorior chtinilH.'r of an e.ve with al>w>lute glaucomn. upon which :tii cxjierimenlal anterior scltTDiinuy was jieri'ornied, 'i mm distant l"rt»m the soterw<trneal margin, immediately aftor i'nucleati<jn. It shows that the periplicry uf the iris had been divided in two l>liiccs, the knife having pwsed through the adherent root ul iris into the iMisterior chamber. knife is inserted, it is drawn backward and forward with a sawing motion, but is taken out before a flap has been c(.ni|iletely cut. A liridge of tissue is left between the two cuts, composed of conjunctiva :md part of the .sclerotic. Prolapse of iris very fretpiently follows the operation, and it is recommiMided that any tendency to it should 1h' counteracted by the use of eserine before and after the operation. The operation is desigtied to form a cicatrix at the scleroconieal margin, without the removal of any iris. Its value in producing a |iennan«>nt relief of tension in primary glaucoma has proved to be lar inferior to iridectomy, and the results obtained by it are very uncertain. Isxperinientallv ami piithologicnllv it ha.s been shown th:it a mere liaiid of cicatricial tissue at the scleroconieal margin does not allow of filtration of fluid through it. 8(1 m o«2 rill-: HYt:. When |inilai>sc df :i fuM of iris IuIIdws ,i sclcrnlomy, a (istiila and rystoiil coiKliliim of llic <'icalrix may Im' fmiiicd, as after iriilrctoiiiy. Ill this way an artilicial clianncl for exit of fluid will l>c forincd and I lie iciisioii r<'iic\('d. In an rye wliicli had Im'cii iMiuclcatcd for alisohitc <tlaiiconia tiu> o|>t'iation was iicrfornicd iinnicdiatriy afterward. Sections snlise- iiucntiy inadi- thioii>;li tin seat of o|M'ratioii showed that at the points of |iiiiietureand coimter-ininctiire the root of the iris iiad iieeii divided in two places. ( Kijj. ;{;iS.) The knife had pas.sed from the sclerotic through the iris just where it cea.sed to he adherent to the cornea into the jiosterior chamher. ,iiid then throufjli the iris ajtaiii into the ante- rior cl.ainher. My cutting across the adherent root of the iris in this way the operation may pessihiy open up a passage for Huid from the Jiosterior chainlM-r into the spaces of Fontana. An oiM'iation termed iridosclerotomy or .scleroiritoiny, in which the adherent root of the iris is intentionally cut tlirouj;h, has Ih'cii I -M-ti.sed liy Knies and Nicati. Scleral Puncture of Posterior Sclerotomy. Posterior sclerotomy is not an operation from which alone permanent relief of t(>nsion Via. 339. >i'Cliiili .>f nil i\e ii|-'M »\ liicli H |H»(,.ri(ir Mlfi,,l..iiiy »,i« |,Tl..riiif.l liir uliiiiocnilH. iiii.l whlrli Mil.- ^i-.|UL-litly U-iMhif Tiiiuh i:ilhiiniil. Tin- i;:ip in Uu ,il-olthu lyi- l- >li.nni, williii ti.Kc.l vilrcim- liiiniijr, inui-li iiiliitiuli.i. wilh r.nin.l ivlls |iniiiii.Kirii; iIilhikIi h. Thi' |iri.lii|i!*il vilrc.,ii« iviilcntly tiirnicil lln' truck almiu which iiili ctioii kkiiicc! ciilmMcc In the eye. may Ih- expected. It may. however, in certain cases, Iw advanta- jieously ein|iloyed to produce a temporary effect, or as a iireliniinary procedure to iridectomy. The puncture is in;ide witli a (irai ''e knife, which is ie.serfe.l in such a way as to make an openinir meridiaiiiil to the corneal marjiin: for in such a wound there is less tendency to ftajie than in one made (ILMVitMA. .j(i;i |,ai:illcl to its inarjiiii, :iinl tlic cliuniidal vcwi'ls and nerves, whicli mil l'((i- the iiiiisl part aiiliTD-iiosleiiorly, are less likely to Im- divided. A s|M.I is chnseii lof llie operation on the sin'i'aee of llie jjl"'"'. iM'liiiid iIk' ciliary body and Ix'tween the r.'eti iiiusele>, iisiially up Mild out, <> mill, or more |iosterior to the eonu'al marniii. Het'ore iiisertinj? the knife the eonjunctiva is drawn with ti.xatioii foreeps a little to one side, so that on conelusioii of the operation the opening ill it and in the walls of the jjIoIm- .shall not coincide in position. In uiihdrawinn the knife it is niveii a half-turn, which makes the wound L'.ipe and allows of escape of the Huid. j'he hemorrhage which results, liotli intra-ocular and extiinicular, i-; usually iiisif;nitii'ant in amount. A |i'olapsed portion of the vitreous liiimor (Kig. XW in the wound has been known to form the track uloiin which septic infection jjained entrance into the eye. The escape of fluid from the vitreous, the immediate result of the operation, allows of diminui ii of pressure in the vitreous chamber and the recession of the h'l and iris, with increa.se in the depth of the anterior chamber. Kor a aort while after the operation fhml may continue to ooze from the wound. !^oon, however, it coinniences to heal, liirtherdrainafie is arrested, and the tension ajrain becomes increa.sed. In posterior sclerotomies performed exiierimeiitally on rabbits, llie wound was found to U' closed and any outflow of Huid clu'cked on the eighth day iTobler'). Paracentesis. Paracentesis of the anterior chamber is another upeiative measure which affords a t<'mjiorary relief of teii.sion, and wiiicli mav sometimes be employed in ca.ses of enierjj;ency. As .soon :i> sullicient time has elapsed for a fresh secretion of the intra-ocular thiid to accumulate, the tension becomes re-established. The amount 111 relief is fireatest. and lasts lonjjest, when the anterior chamber is .|(c|. and a larjje amount of fluid c;in be evacuated, as in cases ol •glaucoma secondary to serous iridocyclitis. Removal of the Superior Cervical Ganglion of the Sympathetic. liniioval of the superior cervical fjaiiplion of the sympathetic has iiivii shown iiv .loiiiiesco, of Hucharest. to be an operation capable of rnjuciiijt the' tension in filaueoma. The results of the operation ill eii;ht cases he summ.-irized as follows: I. Immediate and lastinp; reilnction of tension. _'. Markeil and permanent coiitraction of the pupil, oven in the raM's ill which iridectomy had bei'U previou.sly performed. :!. .\bseiice of frontal headache. (. Disappearance of the att.acks of irritative jrlaucoma. .'). ("onsiijirable iierinanent improvement in vision in all cases in uliich ciiinplete atrophy of the nerve had not set in. Ill other surfieons' "hands, thouf^h the oiieration has sometimes l.icii attended with success, disastrous results liavi' also occurred. Swinr palirtils have t!ii-d as the result of the operation. Tn others Archives of Ophthalmology, March, 1901. .■)(t4 tlicn THE t:YK. luivc Ihm-ii luarkcl tluslui.K of ll.c si-lc <.f the h.wl aiul fan- hikI M'vcrc pain ai tier ;ln' ojii ratitiii. Tlir iiuT(';i.s( I ifhsioii, althouffli liT tiiiif niluiM.l, lias rrtunu-d ni soiiw cii htlialiims liavr also (li'vrl(»|HMl iftcH. Syiiiptoiiis of tacliy- canlia and I'Vp Thf nannliiMi can 1m- icaclu'" anlciioi' or tin- posterior formiT is tlu" simpler aii.l eaiises less injury 1 (iilier liy an ineisioii iiiiulo uloiift tlie horder of tin- steinomastoitl muscle. The .loiinesco recoinmeiK 1 sheatli b (1, till vein separated from the that the carotid slieath ix- oiM-neii, tlu ,. ,■ , , , art.TV. and the Kanglion found i.-hin.l 't KmRhanl says he has ,„„„d i, ,„„eh simpler to exi.ose tl-.e oufr edge of the earotul sheath, and then, with a i.hmt hook, to pull the sheath aiul its c. iitents inward toward the median line, when the ganglion is at once .•x,K)sed. It is then <lrawn forward with forceps and cut out with sci.ssors. Myotics Neither invotics nor mydriatics dropp<'<l into a normal eve produce aiiv alteration in the teasion which is appreciul.le hy tl." linger test At'ropine dropped into an eye with a shallow chamlMT :u.d pre.lisp.w..,i to glauc.ma, as already stated, may bring on incr.'ased tension. ICserine in many cases of i)ninary glaucoma will reduce the tension to normal. These ilrugs influence tension appreci.ibly only when the anterior • hamber is shallow, where an increa.sed or ilimiiiished thickness ol the iris is capable of causing ai)position, or withdrawal of apposition, of its root with the back of the cornea. . In acute cases of glaucoma, wher.' the sphincter muscle of the ins, from pressure on the ciliary nerves, is paralyzed, myotics lail to cause contraction, and. conseciuently. are unable to relieve ten- sion In glaucoma of long standing, where tl.c Pot of the ins has become absolutelv adherent to the back of the coniea and diH's not siiiinly lie in apposition with it, myotics are unable to separate the adh<-sioii. ,ind in these cases fail also to reduce the abiKmnal tension. l';seriMe. besides contracting the pujnl, tends, especially in some iM'ople. ♦. cause a certain amount of hypera'inia and irritation or pain. It .sh. therefore, not 1m' used stronger or more often than is abso- lutely I |inred to produce tlie desired (>ffect on the pupil and tension. Solutions of (1.12") per cent, or (1.2.') per cent, of the sulphate are most tn(|uentlv emploved. One or two ai)plic,atioiu of a 1 i)i-r cent, solution will sometimes. howev<T. reduce tension wh"n the weaker ones havi' failed. W'liiii the use of eserine has to bo persisted in for some time, it is well to combine with it cocaine. Cocaine has the opposite effect to eserine; it dilates the i)Ui>il. diminishes the sensibility of the eye, and eontnicts the bloodvessels. If a solution be emj)loyed containing 0.2.') i»r rent, of .sulphate of eserine and 1 per cent, of hydrochloride orcocaine, the myotic effect of the eserine will predominate, but its irritatinir :v.u\ Iivpeneniie effects will be reduced. Pilocari)ine is a feebler myotic than eserini'. but causes less irrit on. 1 H.rlisl. These .If Pans. 190U. al.AVVOMA. Ut).> It may Im> uscI in the lorin < iitT CIMlt. il' till' nitrate in sululiittis of ().."> or 0.7") itIC Morpliiiir a(liiiiiiist.'r<-<l hypoii.iiuically. l)y ivasoii ol tlu" iiiyot (Itcct it |.ro.lu<-i-s and its sfdalive action, uftt-n prows a valuable KJilitioiial ail! to otli.T infasuivs in the n'duction of increased tt-n.-ion. OUnical Application of Treatment in Glaucoma. In cases ol acute .'laii.oina iridectoniv siiould he iMTlornied at tin- earliest pos.sil>le m..inent: a few liouis .lelay may make considerai)ie dillen'tice in the .iiriount of sijiiit which will U- repiinod. Kxrine should he dropped into the eye two or three tunes while the patient is heiiifj prepare.! for operation, so as to ohtain as much n.ntraetion of tlie pupil as possihle. It preatly hicilitates thegraspwig ,,l the iris with forceps and the withdrawal ot a iiortioii Irom the V,. The ( nestion of the eve and the increased tension prevent ;,caine producing anv marked anaesthetic efTcct, .so that a peneral uesthi-lic has to 1k' administered. Chloroform is much to H- pn-- ive. f(iTed"a't anv rate wliile the o|K'ration is U'lnp jHTformod, as with il thei'e are less venous congestion ami less heaviii); respiratory move- ments than with ether. Ill the performance of any intra-ocular operation, either tor acute ,,r chronic glaucoma, an endeavor should he made to lower the - iivased tension as jrradually as pos.sih!f, so as to avoid any in- sudden ni-h'.i til.iod into the intra-ocula"rl)loo< {vessels, causing their ruptuie ,11.1 h.'morrhage. In makhig an incision into the anterior chamher. tl„. M.,.ieous should he allowe.l t.. drain away, ami not to escape with a gush. , \tler an iridectomv a compress .should he api)liod and a bandage tirmlv a.ljwsted. 'IV tiatieiK shoul.l he ])Ut to bed and kept there uiitirthe ant( vior chamher has well reh.rm.'d. Care should be taken t,, prevent the patient rubbing or touching the eye when half asleep, l,v tethering the hand .m the si.le ojxTate.l on to the foot ot the IhM '^o that it cannot be moved Im-voiuI a certain safe di.«tance n„m the eye. T.. pnn-ent tl sh..ck of th.' operation exciting an i.ut.' attack of glaucoma in m.- feUow eye, eserme (Iroj)s should Ik- :i|,plie.l t.) the latter imme.liately after the operation, and twice a ,> ..ir the succeeding week. _ th.' prognosis in acute glaucoma, if the operation is jMTtormed .ullici.-ntiv earlv. is good. If it h.as iM^eii .lelaye.l fo.r some days, ,li hough "the oiM>ratii-.n mav relieve tension, the lost vision will not !„• r.-st..re.l In the most acute ca.ses vision may he reduce.l to no l„.n.,.nti..n of liglit for a few Imiirs, and then restored to almo.st its n,.rm.Ml acuitv. If, however, there has \m-n no perception of light tnr two or three days, tlie chances of restoration of vision aiv very ~iiiall. In subacute cases of glaucoma a greater reduction of tension can he .■flVcte.l bv eserine than in the acute cases- sometimes a compl.^tr nduction though bv the etTective u.se of .vserine in such cases the immcliate urgencv for iridectomv is not so great, .still there can he l;iv AiaA-fc.- . •&i'mFims^mi^mfm:mswrm^ : d«6 TIIF. EYE. little ijoiiht that tlir MMiinT it is iMTfiiriiird tin- iM'tti-r cliaiici' tlnTi' is i)f its itriiviti); siirci'ssliii. Ill JHitii ariitr ami siiliai'iiti' cases nf );laiU'i>iiia. slmiilil tlii> lens ainl iris 1m' iiiiicIi iiii'»>ci| lurwaiil ami lli^ aiili'iinr cliaiiilMT vitv sliallnw, it may Im' aihisalilc In |M'rl'nriii a pi'i'liiniiiary sclrral |iiiiicturi', iind. by cscaiM' n| lliiiil I'rom the vitri'oiis cIi'.iiiImt, allow uf some rcccMsiitii of till' It'iis. A knife can then Im' passeil more reailily into the ante- rior chainlMT and the risk avoided of splittiiifj the layiTs of the cornea instead. The recession of the lens also has the advantage of facilitatiiifj early reformation of the anterior chamlKT, and so preventing adhe- .sion U'twiH-n the lens and cornea, which adhesion has been shown to be one caus*' why iridectomy may fail to relieve tension. A scleral puncture pn'liniinary to iriilectomy is strongly nTommended by Priestley Smith, who has practised it extensively. In chronic ca.ses of <;lauconia experience has shown that iridectomy is not nearly such a reliable measure for the relief of ti'tision Jis in the more acute caw'8. It produces much the Iwst results in the cun; of the plaiicoinatous condition, if |H'rforiiied early in the diseitse. Many surgeons, however, hesitate to operate on jiatients with chronic plauconia when the symptoms are very slight, when the central vision is normal, and when there is only slight contractinii of the tjeld of vision. Vet it is in just such cases that the iridectomy is calculated Ix'st to arrest the disea.se. .\ very ilistinct objivtion to |M'rformiiig iridectomy in these c;i.ses is that the o|H'ration nearly always jiroduces a certain amount of cornejil astigmatism, so that the patient finds that thi' immediate effect of lif opi-tni'iii ':.^^ lieeii to reduce his acuity of vision uncoirected by gla.sses, although it may Im- just the .simo as Ix'fore with glas,ses. The alternative tn>atment to iridectomy in ca.'^es of chronic glmi- coma is the continued use of myotics; eitlier eserine or pilocarpine. .Many la.ses of chronic glauconu'. may by steady |K'rseverancp in this treatment be kept in .;rrest for an unlimited time. Some, w, spite of if, go on steailily losing sight. ( )thers, again, notwithstanding the myotic, as the result of some excejitional exciting or emotional circumstance, suffer an acute exacerbation of symptoms, when the surgeon is forced to op'rate. The choice of treatment in chronic glaucoma, in any individual case, is a matter calling for considerable judgment and exiK'rience, it b'ing necessary to tak(> into consideration the patient's circumstances, age, expectancy of life, general health, and other matters. Cases of .ihsoliife glaucoma are met with in which operative treat- ment of some form becomes necessary for the relief of pain. If the patient is old and feeble, or if the eye has in any w;iy become unsightly from st;ipltyloin;itoiis or other changes, it had best be excised. I'nder other circunisfances the effect of an iiidectomy may first \w tried. In such eyes iiidectomy fre(|iieiilly fails to ■ rodiice periiuinent relief of tension and the pain recurs. In some ot iliein severe infra-ocular OLAircOMA. M7 lii'im iH'tWf'Cll I i lens, I irrliiiK'' froi" ♦'i'" ^ hontitlul vessels ucciirs. Tlie I>1ihmI (•oIlectiiiK Mill 1„. elM,r..i.l aiul sclerotic luin-s f..rwar.l tl..' tvtii.a, vitrciis •iipiiiK from the eye, iiiul eiiu- this (lis)isir«)as form of liich is not ubs«)hite. tu two llllHT St met ires es« leatioti lx'comiii(j inevitable. In rare case; l„.inorrliane follows iriaectoiny for glaueoina w If all iriilectoinv >lioiilil Ih- exaiiiiiie( has failed in any <msi I carefully to see if the lens has Im'coii to relieve tension, the eye tilted lorwa rd throiijjh adhesion of it toti le wouiH 1. Where such an adhesion isists, the li-ii; mil i\ Ik- reiiiove( I. In making a fresh incisi<i tlie fe knife should In- made to sweep across the |K»sterior surfate 1.1 the old one, so as to dividi' anythiiifi adherent to it If the lens luis not Ik-coiik tilted forward, th, return of tension is inesiiina liitratioii area. ol tli hlvdue toa jMtrtion of the hk) t of the iris left lilockinj; up the \ sclerotomy should then he jM-rformed in the reRion '.lohorna. which will cut through the adherent r. it of ins, aiu possibly eslablish a pa.ssaRe ito the spaces of I'ontana tl Sometimes in the pertormance o for Huid from th<- ixwterior chaiiilMT if an iridectomy for plaucoma the leiitallv wounded and be<-omes ()|)a(|U( lens is accii to occur w -hallow, the anterior sii This is most likely the pU| hen a keratome is employed an.l the ant.-rior chamlH-r is rfuce of the lens iK-iiid pressed forward throiipti ilso to occur when the ojxTation has lit. It has been known a ,„.,.„■ ,H.rformed\viih a (ira<-fe knife, from the iris having been cut throiiirh in making the upward cut. t 1 ne cas,. The lens beconi.. catanictous after ^^<^ /Wf^^' ,,i,,, living lM.en woim.l.'d. In these it is generally f.mn. that :,;,,;. I,!..' prevLisly l.-en some peripheral stritr, an.l the manipulation .,|- the ('■.:• acts as a maturation oiH-ration. ■• ., op..rntion of removal of the superior cervical ganglion of the .V, I mtl etic is one which must In- regarded as .till, to a certain extent, .. tr • ivn in skilled han.ls it may \^ atte.ule.l by grave risks, ;:;;d there are probably few who would care to -commond it, unless the <.ther and simpler measures above indicated ha( laiKd. P i^ts utTeriig from glaucoma should be advised to adopt, ^s ,.,r ; .racti.-able. the following habit.s in lif<-: all worry. '^^^^^^^' f tiju > should Iv avoiiled. They should Ik- warmly clad and guard ..!, sf anything like a chill. Great importance shoul.l Ik- attache.. :',heir ..-btaining a regular and a.le-.uate a.noun o sleep AM .training .'fforts lik.-lv to lea.l to c.ng.'stion of th. hea.l an.l t,.c. s , 111 wluM, p..ssible, be prey.>nted. Where th.-re is a ten.lencv to : s ;ui ... ap.-ri..nts shouM be a.lminist..re.l. V.nors of n-fra^mn sh!liilll b.^ a.T!irately corrected an.l no very prolonge.l nenr work I'lisiagi'd ill- f# ^'•'ikwk™' CIIAPTEK XM. IHSmJIUNCKS OK VISION' WITIIOIT AITAUKXT LKSION. n\ i:i.mi;k (!. staui!, m.d. TiiK (•(iiiditioiis ilcscrilicil iiiulcr tlic licadiiit; of this chapter an' pi'dlM-rly ciiihraciMl hy tlic tiTiiis (iiiHinnisis il(iss(it'si};ht ) and niiihliiu- lild {dcti'<-tiv(' or chill sijilit i, Icriiis whicli arc used to iiuhcatc all cases I if defective \i>iiiii whicli d(i not result from visible disease of the eye -truciuii'.-. and whii'h cannot be rcnicilied by the correction of an exisiini; error in refraction. The diajinosis of this condition is often \cry ditlicult. a- it must be based chietly upon the evidence of suii- jective symptoms. The color sense may be lost or lessened, the lield of vision limited, and x'otomata found. In this class of diseases may be included the follow inji-named conditions: color amblyopia, amblyopia exanopsia, conjrenital, hysterical, and simulated, ura'mic, jjlycosuric, malarial, from liemorrha<re. from lif!;htnin}f flash, reflex, scintillatiufi scotoma, nyctalopia, liemeralopia, erythro|)sia, snow blindness, micropsia, mejialopsia, ami metainorphopsia. It is |)robablc that future increase in our knowledj;e will rr'niove from the catej;ory of amblyopia some of the conditions enumerated above i)y disclosing their real nature. In all amblyopic conditions careful Mplithalmosco|)ic examination should l>e made, as many cases of suppo.sed .amblyopia will, by careful ;ind lhoroui;h examination, be found to depend in reality U|)on .some disease of the retina or choroid in its extreme peripheral rofji'^'is. parts of the eye which are ilillicult to see, and which fre(|uently esc.ipc scrutiny in the routine ophtlialmosco|iic examination. ,\nother objective point in the examination is the macular legion. 'I'his should be closely irispe<'ted by the direct method, as not iiifre- i|ueiiily in low dc;;rees of amblyopiji slijiht chanjies are found in the rejrion of the macul;i, >uch as a jiraiuilar or stijipled iippearance. or the pn-eiice of mimile while, f^ray, or yellowish points -conditions whii'h in some cases inidoiibtedly have their orifjin in long existing refractive error eyestrain!, while in others the exciting cause seems to be .-I I'enal or inteslinal toxa-mia. Color Blindness. Perhaps the most wonderful of all our senses i~ that of ;id.;ipt;!tion or refinement of thf sens., nf sigiit. the perception of color. I'ure hues of red, yellow, and blue appear to the eycso positively unlike ,ind contrasted that it is remarkable that tlr'y are ."iti.H I nisTUJlBA.WKS OF VISIOX WITHOUT Al'PMiEST LESlOS. -jfl'.t causcil l)y Wiivcs (.1' I'tlicr, tliflViiiif; only in Icnjitli and rate of vil>ia- lioii, and that tliciv is a graduated scries of waves froiii()iie cuior lo another, linkinj; theiii together and iTiei-fjinK the colors of tiie spec- iru;. "'e into anotiier. ,Mi. ^ ri'. -ense of siftht was first deveioiMMl, it is prohahie tiiat n.-lhinft niu.-e \'.,, i lijiiit and dartiness was pereeived. As tiie visual Mi;Z,'is hecaine ...ore .leveloped. more delieate ehanfjes in lifiht and .'irdow would '«• seen, Imt color, except in so far as it modified the ..d.iui;;' ■■ ■ 'i'-t.t reachinj; the eye, wonid not he visible. A hifih state ,,r (leveloi)ment of the eye as an orf^an of vision is comp.atilile with the .'ihsence of all color sense, and may have existed loii}; l)efore the -ciise of color hcfian to develoj). The time at which tiie color sense appi'ared is imknown liv soiiu color it is helieveil to have had its orifrin. ■r'at least to have develo|>ed within historii' times. There :ire facts. liowe\er, which indicate that this sense existed in a hif:hiy developed ,-ondition in prehistoric man. Mirds ;ind many animals undoubtedly distinguish colors. liven in so low ;m order of animals as fishes a M'nse'^if color seems to I'xist, as is evidenced by their protective coloring. It is (|iiit<' possible, of course, tli.at the color sense of the lower animals may not be identical with that in man. but a fact which points to the early develoiiment of this sen.se is that babies have a well-develojM'd sense of color, whidi would hardly be the c:ise were this a recent ac(piirement of the human race. Color has no ob.iectiv(> I'xistence. but is an internal sensation, and iiiav be caused bv pressure on the eyeball or any means which stuiiu- l.ites or excites the retina of the eye. In the jircsent chapter it is loiisidered as duo to the action of lifilit waves. Objectively, then, color corresponds to lifiht waves or ether undu- latioi'is of certain length and rate of vibration, at least this will :,pply to such colors as have a known vibration for their cause. Tlu'fe ;,iv ('-olors. however, which have no objective definite ether waves tor ilicir production, and which serve to illustrate still further the tact ;liat color is purely a physiolofjicai sensation. Such colors are purple. which does not occur ill "the spectnmi, ami has no definite wave lenfith mr it< produ-'tion: and white, if this may be called a color. By ixperiment it has been determined that the sensation of red is caused Kv the loiifiest visible wave and slowest rate of vibration, while the -Imrtest wave and the most rapid vibration give the sensation ol \iolel. l{ed, then, gives us one en.l of the visible spectrum, and \inlet the other end. Between these limits there is a graduated -cries of wave lengths, all of which affect our visual apparatu.s and -ivc us the various colors of the siiectrum. The s|)ectral colors jiass iroiii one into .•mother by such slight gradations that, when examined ill a long spectrum, no sudden change from one color to another is louiid to occur, but one merges so gradually into another that it 1- dillicult to s;iv iust where one color ends and another U-gms. so I hat the spectrum is fouiui to be nmde up of an infinite number of -radutions of colors. If, however, the s|M'ctrum is made shorter, so ■•^s'arn. 'SSK' •SBTSWM:' .-sKLa:-.. "•;►•: 570 Tin: i:yi:. tlmt till' colors air more coiidciiscl. as it were, it appears as if ma.lr up of only tiucc or four colors-n-d, firccu. blue, ami viol.-t, and tiic transition from oiii' color to auoiiicr is more al)rupt. There are several theories to exi)lain the manner in which the dirt'ereiit colors alTect the eve. Without enterinK . ito a discussion of the subject Ihtc, it inav 1k> stated that in ^vwvA ihese theories sujipose the eve to hi' provide.! witli sets of sensitive elements wliK h are affected e'ither directly or secondarily l>y some three ()r more of the siM'ctral colors. For, while the decomposition of white hght by in(>ans of a prism pives seven i)nsmatic or spectral coh)rs, it is touiiil that all thes<' colors, as well as white, may be obtained by combining three colors, such as red, blue, and green. In the Voung-lielmholtz theory the retina is sujjposed to Ik- pro- vided with three sets of elements, one set of which resjKmds niost stronglv to red ravs, another to green, and a third is most aflected bv blue light. All" the elements are, however, affected to some e.vtent by each of the three colors mentioned. Thus, red light exerts its greatest action upon the red-sensitive elements, although it affects the given also, and to a less(>r degree the blue-percipient (>lenieiits. Simirarly with green and blue, all the elements are affected, but in "varying degrees. The sinmlt.'ineous action of red. blue, and gn'en gives the I'olor or effect of white light. Tb' effect of color waves u|)on the percipient elements is su])- posed to be due, not to the action of light waves directly, but t(v the ,. 'Composition which they cause of a i)hoto-cheniical sul)stance with which the .sen-itive retinal elements are sup- plie<l. That is, the red-sensitive retinal elements are affected by the ilecomiHisition of a photo-chemical substance which is ii'iost sensitive to the red rays of the spectrum. Similarly tli<> green-sensitive and blue-sensitive elements are affected by green and blue light waves. Inii)aired color sense, or color l)linduess, exists m :{ or 4 per cent, ol males and is less common in females. Color blindness may l)e total or partial. Totallv color-blind individuals see the spectrum in differ- <Mit shades of grav", and all objects ajij^'ar to them much as they do to normal eves iii stereoscopic ])hotographs. To the partially color blind the spi'ctrum apiwars in two colors only, with a gray or neutra band in it. The most common forms of color blindness are red- and "reen-blindness. Ti/,'se are .sometimes classed under one head, viz.; •"^red-green" blindness, from the fact that the red-blind do not see green correctiv, and tin- green-blind do not .see red correctly— in hict, an blind to both colors. There are two clas.ses of " red-green " blind- ness and tlK're is a clinical diffen'tice between them. In one class t he spi'ctnim is shortened .at one end (the red), while in the other the spectrum is not shortened, but has a neutral zone in it. Those having thw delect see some colors corivctU, olher colors iiuorrectly, and the rest , tho.se to which tiK'V are ■• blind." not as colors , 'It all, but as neutral gr.iys. Hearing this in mind, the following .schedule from Le ( onte i,i\Tri!i!\\ci:s or yistn\ wrniorr Ai'i'Ani:\T lkskis. ,j71 will hv\\> make iiitcllifiil)!'' wIimI the color l)liiiil sec, what mistakes ijicy aif apt to make in iiiati'liiiiK colors, and the means a.loplnl ui iletectin^r this delect . I'uuE Colors. I. >V> I'lurfCthf. n. While ami blKck ami all iiitermoliaiL- shades, or Knys, h. YiMow ami all shades of the sami'— i. ' ., hrowii. .•. Blue and all shades <if the same or slate blues. II, !><> Hilt Me tit all as cohrit. (I. Kcda are seen as ditlerciil shades of gray. (>. I Ireeiui are seen as ditTerent shades ul gray. Mixed Colors. HI. Srr ineorreftlu. n. Scarlet, whkh is a miiture of red an.i yellow light, is seen as (rray and yellow. whieh eciuals darli brown. b. Ornnite re<l • yellow, are seen as gray . yellow -lighter bniwii. c Purple - red f blue, are seen as gray <-■ blue - slate blue, rf. Yellowish green .yellow + green, un- seen as yel!.w + gray-bniwn. e. Illuish green blue . green, are se.n as blue .gray- slate blue. To Ih' clinicallv accurate, lliis table should be modified in some ways, inasmucli a.s it does not ihstiiiguish two chi.s.sos of red-green l,l'i,'„l',„.ss— one with and one without shortened spectrum. The tai)le serves its |>urpose. however, as an aid in eluciilatiiij: the subject. From this it will be ob.served that the red-j:ieen l)lind are very Uable to contuse or mistake all mixed colors, as well as reds and greens with cither browns or gray blues. Blue blindness is rare and of little i'lijwrtance ciimcally. Ihese I hiv.' t vjx's comprise practically all cast color blindness, although there are manv deviations from the geiu. yj)es. One curious result of color blindness i.^ that persons having tins ,i(.fect are able to discriminate between certain hues which to the normal eve ap])ear identical: c. r/., two complex solutions may have the .samtMM.lor to the normal eye, but to the color-blind eye some one or more of the chromatic constituents of the solutions may not be perceived, ;iiid ill consetiueiice the two solutions appear to differ in color. . , Color blindness is usually a congenital defect, but it may be an .iciiiiri'd coii.lition, de])ending on some disease process involving the retina, optic nerve, or visual centres, such as atrophy of the optic nerve, tobacco amblvopia, and cerebral injuri(>s or disease. In the ■niiuiicl form the color blindness may be limited to a part of the \ isual field, either [M^ripheral or central, .\notlier difierence betwwn tl, dijrenital and the .'ictiuired forms of this defect is that macfjuired ,olor blhidness the acuteiu'ss of vision usually is hiwere.l, while in the consienital form this is not the case. Tkst koh ("oi.oH Hi.iNDNKSS. Of all tests-aiid there are more than lid-ty ditTercnt onc^ -the wool test of Ilolmirren is jirobably the one s'l fretiiieiitlv used. The set of wools consists of a selection of uoisted varus lived with various colons. The skeins of test-colors •mm^''Fi^^ '«a&^fflit:5:-': "M P" ii^K?x^r >?T;s5S^"fe^iS 5v i : nirjilc. and ri'il. < M' ._, Tin: EYh:. Oil ;„v tl.ir.- ill mnnlxT, viz. nn-.'ii, rose pink .>r pn . . vMuiuiu^ ~k-iu>. so„u. I.av.- tl... san,;. n.l..; a> I ■- '-^;^ ; , !J;„' r of tlu. 'olor l.li.MlM.-ss. and is not to lu- us..! n. any ua> a>a .. M "'''Ct.-s.i<n.ad..in«uodli,l.t^dV if possihl. -and ,1.. -v.- . ,. il 11u-',os,-sk,.in of ,n..M. is pla.^d at un. s.d. s.>,.an. M Illation IS rc<|Ufstcil t(i scit ( 1 ; ,, ,. ,,ii„.l,.ss is to 1..' .U'ti-nniiu'd, .-xaniinations w.U. oti.c n>- k Js 1 .1 1... mad... Til. s.ru,.d ..xaniinatiu,, witli t i. l'un>l.' fs ■ k.i wil sl,..w that ••r..d-l.lindn.ss- .-xists ,t tl.c colors wind, a - :l:ic!;;.:V'o Inatdi -h.. pu,-pl.- in.-hul.. sha.h.s of l,lu. or. viol., : wlnl. ■ 1 ,rrc(Mi or -rav is s.-l.'Ctrd the sul.jfct is - jtre.-n-l.ln.d. ? V li;; Thomson Ints d..vis...l a vory .■onv-.m.-n, '-"I; ";;;'; ' ..f IH- Holm,n.n wools, whirl, .-msis.s .,r a stick will. >;'''- ;;'^'^,^ ; • Pl.t.. VIX Vs in Hoinsiicns method, tho tcst-skcm- as shown m I 'j'" -^ •); "^r ', , ' .Li^^i,,, ,,, t., hr matched in turn |r,:i,.!l!i colors, and which aiv mmil.crcd from one to twenty. Tf. 11 tints ari' to be selected. , Tl ,. id m.ml-ers heinfl the match coh.rs and the even numle. „j : „.t on colors, it isevident that the seleetion ma<l.- '>>■ tl-. <;' j- „.l ,v,. will inchule some of the even numbers, wliih- tli,. eve liu iniiii tliis defect will select onlv o.ld liuinliers. Th 1 , 1 has further improved his test by discarding the c. or- .tiek-u creasing the number of the coloi-skems to orty. each nt ieh s bangle attached bearing: a number. Hy 'his means ^^ kei, av be lu-aped together without any r..gulanty ot recui.iig .. s . 1 .s occuis on tlu. color-stick, thus obviating the poss.bih y iv'm^ L hint to the I.erson u.ul.'r ..xamination by the ivgular :;l.,.?:;;;Se;;t :" y!.rns,as'miglit occr aft..r repeated ..xanunation. if the individual. The Holnigivntest is very atisfactory in det(.cting congenita! color ,,,i i;;rimU.. a;; uinM conditio,. so,..e other niethod nn.. 11 ,1 of the fict t>"fore mentioned, that the bhndn.» ;;a;^^;,i;;;;te;rn:l^n;d^;.r;a,.., ha, the color ^ " orrectlv seen, and the defect in the eolor s.-nse is d.scm e, I '" > Sng a sn.all t..st-..bjeet, such as a distant signal light, whose ,etin..l ;#«^ }'L/vrt: XIX. ^^^ \:Skf^ /./.s7rA'y;.i.vciw of vi.sioy ninioirr ajtmu-.w Lt:>^i"y. 573 ■„„■,.',. i. sn sumll MS I.. ImII .-ntircly will.iii the (•.,lni-l.lii..l a.va. It is, ,l„.n.f,,n. •■via.'iit tliat sli.-ul-l tl.c wool-trst iii.licaK' no .l<'t<ft in tlu- ,,,|,,i -I'lisc wr rami..! l"' sniv witlioul a liiitlicr (■xaiiiiiiatu.ii that a ,Maoi- MM.i.inia-a t..l.a(-<-.. s(M.t..iMa. lur ('xainpli- .lurs not <"xist. Tl,.. existence ..r central color scotoma may !>»■ detectcl l)y tl>e use ,,, ,|„. ,„.jiineter. employing' small s(iuares of colored paper of tr(>m niir In tell millimetres size. n r . . \ innre satisfactory method is to use as test-ohjects small distant ,.,,i,,n,l lights the (litTeri'iit colors of which should he distmpmshed; ,„. , ,|Mrir-l.hie col.alt filass is placed over each eye separately and ,l,e vision is ihrected to a small distant lijiht. such as the tame of a ,..,„dle \ normal eve sees a li^lit of one color surrounded l)y a halo ,;, :,,iother .'olor, hut a color-blind eye sees but one color, blue, or a while lisiht surrounded bv a blue halo. Individuals who are blin-l to red are also blind to itscomplonientary ,..,!,„■ Application of this fact as a t<-st for color blmdne.s.s may be „,„!,'. in the followin<t way .\ sheet of white paper is illunnnated by uvo lisihls placed at a little distance, one lipht having a red glass m iV,,ni of it. Hetwe<-n tlu- lights and tin- pajier a small ol).|ect, such ,- -I pencil is placed so situated that two .shadows of it tall on the white I'lper One shadow, that formed by the rays from the wlute li.rlu will be red in color, while th<' other shadow will be its coin- piiin'entarv coloi, or green, A color-blind person will .see but one 'hidow under th.^s.- conditions; or at lea.st will disnnguish no ,litieivnc.' in their colors, but mereiy a difference m the density ot ~ Amblyopia ex Anopsia. .b/fWyc/"'" /'■'"" l^i"''-^''- I'' '" '"""'>' ^''''^'" 1„„„1 an evi' is disused, its visual power is diminished from im])erfect ,,li\si,,io.riVal development of the central visual centre. An active l„:t,,i ii? causing this condition is probably the act of suppressing ,h. viMon ill the .lisu.s.-d eve. Particularly is this true it, as usually ,„-,ius in stiabisiiius. the vision of the s(ivnntmg eye is suppressed l„.r:iiwe of the contusion of images otherwise seen. Tills suppression of vi.sioii, which really nu-ans an abeyance of the ,,l,v~iolo.rical processes in the visual centres, together with the youth ,,l ihe patient, is undoubtedly the important factor m the production ..! aiiiblvopiaexaliopsia. , , ,■ t \,.v ;,iso is im|.ortant in det.'rmining the result ot disuse, in ■i.hih life after the visual centres become phy.siologically developed, :,M,l,lvopia does not result from disus.-. It is in th." first years ol hie. tl„. years of ,leyelopmental activity, that disuse of this funeti'm. led with efforts to suppress it, exhibits its effect. Thus it will be .Md.nt that in all ca.s.'s of sciuint in chil.lren efTorts should be made ,,, u,aiiitain physiological activ.iv in the sipiinting eye by exercising i-- functions for a short or long time daily, while the other eye is . ,,,.!, ,j,,.| (•,.„,„ ,^.,,rk bv means of a bandage, patch, or opaciue g.ass. Ihe amblyopia accompanying .squint is, howev(>r, frequently, it not usually, a'coiiiri'iiilal condition, and in no way the n^svilt of disuse. ■{ Tin: i:yi:. liui in casi's nt' siiiiiiil, even in iIidsc liaviiis; normal visual ac'iilfni'?.> in cacii cvf. tlif |ii)\\cr nl iiindciilar tixatiim Ix'coini's M'iiiiii>ly ini- pain'tl. so thai true liinucuiar lixalion is lairly at'aiiM'd atlff ciiii-cctinji a stfaliisnuis. In ca-cs 1)1' liifjli I'cliactivc cii'nf. nut ii;lr<'i|urn!ly a i'iin~iilri;ilj|c (l('<;n'i' (it anihlyupia fcriains alter (•(irrcclidii ul' ilic retracticii l)y siiitalili' lenses. In a certain nunil)er ot these cases the aciitene>-- nl' visiiin ini|iriives when correct inj;-<;lasses are worn, at lirsi ra|iclly. then more slowly, mitil vision liecoines normal, or the concliti<in m.iy liecome stationary hel'orc normal vision is altaiiieil. Congenital Amblyopia. This is prohahly tiie result of arrested or imi)erlcct (levelo|iincnt of the central visual centre. It often escapes oliservation durinji chililhood, ainl. indeeil, not iiifre<|uenily is undiscovered till* ' adult ajre or middle lite, when hy chance, pi'ihaps, the patient discovers that one eye is hlind. When atTectinj; one eye, it is as.sociated fre(|uently with stiahismus. Nysta>:mus, also, sotiu'tinies accompanies hij;h dejirees of amlilyopia. The entire field of vis, on may he atl'ected. or scotoma may he present. No olijective conditions adei|uat(' to ai'couiit for the defective vision are found. The condition is not amenahle to treatment. Hysterical Amblyopia, .\monfi the ocular manifestations of hys- teria, aiiil>lyo])i:i is often pnseiit. It is .always associatcil with con- centric contraction of tin- tield of vision. .\ peculiarity of this form (if contracted tichl is that it may he moditied in size liy excit.ation of the skin. \ puncture of the skin hy a pin, for instance, will incicase the size of the lield, and hy successively irrilatinjr or e.\citinj; the skin, the lield may he increased to its normal size. Color sense is often disturhed, and there may he inversion of the normal color lield — i.e.. instead of the lield lorhhii' heinj; larp'st and tli.it for Krccii the smallest, the tield for f;ieen is foinid laifjest and tli.it for hhie smallest. There may he polyopia, monocular diplopi.i. micropsia, mefjalopsia, hemianopsia, or central scotoma. The aculeness of vision is often improxcd hy plain hliie j;la,sses. When hlin<lness is coiii]ilete. it is usuallv inonolateral. and the pupil reacts when the other eye is covered .and uncovered. < )ther disorders of sensation, particularly of the mucous menihranes and skin, anil especially of the |>liaryn\. almost always accompany liysti'rical amhlyopia. Simulated Amblyopia. Mlimlness. complete or p.irtial. afl'eciin^' one ir hoth eyes, is sometimes pretended !iy individuals who hope thereliy to escape the performance of some duty or t<i jrain com|ien- salioii in the way of a pension, or damafies. If the individual is intel- lifient and cle\-er, or. on the other hand is deii.sely stupid, it may he very dillicailt to co:i\ict him of deceit, and much care must he <rivcii to the examination of his condition. Coniplete lilindness of hoth eyes is not often simulateil. except in those cases where a colisiderahle defrree of amhlyopia ri'ally exists. Ill these ca~e- the action <if the pupil is. perhaps, the hcst iiulox uf the nlsrrnHAM 'i:s or yisii>.\ wiriinir Ari'Mn.sr i.esids. :,-:, ,.,,ii,|ili. !i. Ill al>s(.liil.' hliiidiicss in hdli <'.vcs tlir iMij.ils will imhIv ivsponcl In iinlil. Sliuul.i llir |>atii'iil iiavc iisnl atrniniic In Kiii. ;i4o. Jiiijfit Eye KfTprsHl of ficlit «« seen in iieuraslhenla. 576 77/ f; A.J/-;. ma: •k ll II' ii'al ndidhioii III till' pupils, this fact may Im- siis|M'fti'(l if ihi'iv is I'Xlii'ini' ililalalioii, as lln' my.lnasis arci.mpaiiyiiiK amaiiiusis is usually miMliTatc It is tnir. liuwi'ViT. tliat tiif pupils iiiay cnu- tract uiuliT till' stiiuulus nf linlit, nr thai tlic iippnsiti' cuiulitidii, llial of \vi(|i'ililatatii>ii "f tin' pupil, may I'itliiT of tlii-iu accompany liliiiil- ncss: so that it will Im- sicii that tlic unmasking of maliiip'riiin in ihi'sc cases mav Im' very ilitlicult. A dose watcli slioulil I"' kept on the actions of the iiuliviilual when he believes himself free Ironi ohservation. A prism of (1° or s° may Im> placed with its base out before one eye anil left in place for a" few miimtes. If on its smlilen removal tile eye is seen to ileviale outward, it may Im- sus|M'cted that the eye sees.' Should re|M'ated tests show that withdrawal of the prism is accompanied by this movement of the eye, the fact that the eye sees is establisiied. If blindness in one eye is claimed, a prism placed before the pre- tended blind eve will cause no chanue in the position of the eye if it be reallv bliiiil. If. however, the eye does participate in vision, a prism oi' tt° or S° placed with its base out before the eye causes the eye to move inward, and if the prism be suddenly removed while the vision is tixed on some near object, the eye can be seen to move out- ward. Prisms stroiij; eiioujrh to cause double vision may Im' put on the patient, and he be rei|uested to walk or to p' up and down u few- steps of a flight of stairs. The diplopia caused by a 5° or (1° prism w-ith base ui) or down, for example, is most coiifusiiif;. In makinji these tests, it is, of course, important to see to it that the patient does not close the "blind" eye. With a (>° or 7° prism with base down in front of one eye, and the vision directed to some distant object, the eyes will alter- nately move up and down if they be alternately covered and uncov- ered with a screen. .\ jjiism may be held with its thin edf;e op])osite the middle of the pujiil of the seeiii}! eye. thus causiiifi double vision in the single eye. When the i)atient's attention is directed to the fact that he can see double with one eye. the prism may be moved so as to cover the pupil, when if he still admits that double vision exists, he is seeing with both eyes. These tests show the existence of binocular vision, but do not indicate the acuteness of vision in the blind eye. .\moiig the quantitative test.s may be mentioned the following: A strong convex lens— c. </., U) 1).— is placed before the .seeing eye, and the test-type is held at such a distance that it can be read with this eye, which with an emmetroiiic eye is one-tenth metre: then with both eyes o])en the tyi)e is moved farther away, and if it is still read, it is being read by the '"blind" eyi The stereoscoiM" may be used with cards bearing various designs which differ on the tw'o sides, and which are combined by the vision of two eves to form a definite figure or letter. .'.'^•^fri.-ri^ msTUJiJlA.WHS OF VISIOS WITHOUT AVPARKST LF 'OS. 577 W'iuTv the scoinn cv" twn struiij: cyliinlcrs — e. ij., I '). aiiil i 4 1). — an- so airaiint'd sis In neutralize eai )i other, I. <"., with axes tojji-thei 111 til I" lion lliev (Ii> iitit afl'eet llie vision. Now. wliile the patient is re;iiliii>r ihstant ti'st-ty|H" one cvhnder is turned ll)° or l.'»°, thus entirely <•! ijlinn tiie relraetiun ol the eonihinatioii and lessening the visual aeiiily of the eye hefore wiiicli it is placed. This elianp- -hould U' niade'whili' the patient is readinR larfct- ty|K', as in reading -mall tyiK'. which demands of the patient close attention to detail, a compaialively small change in the lens before one eye is noticed at once, even though liotli eyes have normal visual acuteness and are Ihmiih used logether. When one eye has suluiormal vision, then .-ny chanp' in the refraction of the lens in front of the ljett«*reye ia, oiiviouslv, more (|Uicl;lv detected. of course, the '.■efpiction of the eye should Ik- det<'rmined, at Icasit appro.vimately, hy usiiifi the shadow test with the supposed blind eye. ami etTorts to imjirove vision l)y correcting lenses should be made. " Snellen's transparent red and green test-letters of ilitTerent sizes may enable one to detect simulation, and at the same time to determine the" amount of vision in each eye. The patient is re(iuested first to read the letters without anything before his eyes. Then a sjH'ctacle frame, holding a red g!ass iii one side and in the other a green gla.s8, is put on him. and he is asked to read the letters again, taking care that he kee])s both eyes o|)<'n. The green glass shuts otT from one eye all the light coming from the red letters, thus making them invisi- ble to the eve. Similarly the red glass makes the green letters in- vi>ible to the otlier eye. " By noting what letters are read, it is easy to determine wliet;ier one only or both eyes are used, and what acute- ne-s of vision is represented by the size of ty|M' read. Ursemic Amblyopia. Amblyoiiia from ura-mic poisoning Ls seen accompanying the albuminuria" of scarlet fever, variola, measles, and pregnancy, it is a.ssociated fre«iuently with symptoms of brain irri- tation, such as vomiting, convulsions, coma, and hemiplegia. Hoth eyes are affected, and blindness may lu' complete within a few hours Iron, its onset. A peculiarity of th'is condition is that the i)upillary reactions are not lost. The jirognosis so far as vision is concerned i- good, blindness usually di.sapi)ei'ring with subsidence of the .ilbiiminuria. Glycosuric Amblyopia. Diabetes sometimes causes amblyopm, :tiid it is characterizeil bv a central color scotoma. Central scotoma Inr white may al.so be present. The visual field may be normal or contracted, or may be hemianopic. The jirognosis is unfavorable, ■lit hough u.seful vision may long be retained. Ma/arial Amblyopia, \lalaria is another di.Mvise which, in addi- tion to those cases of impaired vision due to aiinarent lesion, causes • ilher disUirhances of vision in which the ophthalmoscopic findings .lie negative. The affection apjieai-s as a tr:Uisient lo== of virion, lasting from a few hours to several (la\ s. and disappears under treat- ment with (juinine. The amblyopia begins with the chill and ends :!7 578 /•///; /.»;. Willi tlir ..iisct ..I 111.- sw.'Mtinii -iM«i'. Aliliniijih l.liii.lii.ss may Im- ciilliplrlc. the pilliils rflU't llnlllially In li^lii. Amblyopia from Hemorrhage, l.nss ot I.IimmI U inllnw.'il ..crasi.iii- allv by imi.air.Ml vMnii or l.v hliii.liic^s. Tli.- .iHliirbaiic.- in visH.ri iiiav ii'ol iiiaiiil'.-si ilsi'lf until smiir tim<- after tlw lii'iiinniiajjc .'Vi-n •ill.T iIm- iK.niial vulmiK- ul" I.K.nd lias Im'.mi rt'-»'j-ial>lir.li<Ml ami llir I'tiuiiibrimii uf tlir riiciilali.ni ivslmrd. InstaiicM-s ni tins .■uii.liti..n havr Ixi'ii nl)s.TV.'.l lnll..\viMi: iii'iiioirliap's wliicli w.iv ii..t vrry seven' i>l- exliaiisliiin, so that a ciiiulilinn uf ana'ima rnul.l tiul i)e sai.l to exist, allliutiKli il ninre ufteii aer..iiii.aiiie> „v iuliuws an e\- sMiiciiiiiate.l edii.iilioii. It is seen afi.T nielh.iilia-;ia, lia luoptysis. pa^ric lienii.rrliatie, and post-part uin lieiiinrrliane. The anil.lvoi.ia sometimes aeeompanvinn ureal anaemia and extrem.- elilorosi- may 1m' considered llie same in kind as lliat iollowmy: liemovrliajre. A ease of this naUire. iindiT the nl.servalion of llie writer, oeemred m a frail, anainie woman, lliirtv-six years old, after a prolonged periud of laetati..n. \ isioii firadii.dlv failed for several days, when hlmd- i,c^«^ Ixrame ahsolute. The lijilit reaetion of the pupils was not lost, iMit was lessened, and the pupils wen- hut little larger than normal in size. Tonic tn-atiiient was ;it once instituted, and tlic child wa-; taken fn.m the hn-ast. The condition of vision leinanied michaniicd for llwee weeks, when si>;ht h-uaii ton-turn, and soon normal vision was n-ston-d. The loss of vision niav ix- trradual, or sud.len an.l complete, or |.;ntial. and is frcner.illy'biiateral. 'Iliere may l«- central scotoma. The aflectioii m;iv n-m.ii.' for a few hnui> nr days, or ey«-n for a tew weeks, and then' ^niduallv ,|i^appear ipletely, or it may ieavi- hehind il p<'rnianeiil defect>, Tlie iik.sI unfavorable cases appear to be those which an- late -a week or mo ■• -in followiiif; the liemor- rhap-. and thes(- cases usually <liow, at a later .stajie, aln)phy ol the opiic nerves. it should b(- n-m;irked that an impairint-nt of vision cominjr on ihirin;: an exhausted bodily coiidilinii may be dui- to a w(-akeiim^' or exhaustion of IIk- |«iw(-r of accommodation, and the state ot the n-fr:iction and accommodation should alw ys be examined in such conditions. It is, of coursi-. important to have some piidt' as to tlu- pn>frno.sis in these- condition-. The negative n-siilt of the ophlhalnioscopie c\;uiiinalioii is no index in makins; a projinosis, for we meet with cases of siiddi • blindness occurriiiji ilurin<i tli<- course of acute dis- ease, in which no clian};(- in the ey(- fuiulus is visible for w(-eks, d y<-t when- biindiK-ss is permanent and in which atnjphy of the ,,,tic n.ive eventually appears. Th(- behavior of the pupil may Slivc information of v.ilue, as when pupillary n-action is not lost m blindiK-ss in any of the fon-fjoinjl conditions the pnif!;iiosis is mon- lavoiable. . r i » ■ Amblyopia from Lightning Flash. Loss ot vision by liKlitnin^' stn)k(- has been n-iiorledin many instances, and may beaccoinpiuucl insiriiiiAyt IS in- yisii».\ wiriiorr .i/vi «/■;>/• lksih.s :,- !» I,v uIIht Irsioiis, such as Imrii nf the skin i.r ci.iiica. ptosis, or mjuiy u\ 111.- Ifiis. niasiMKfalanKt.ur iiittMimii.'Unrycoii.litiiiiisnf the .l<-<-|) MiMctuirs ..f tl vc. The -inlit in .-is.s iinconii.licatc.l l.y intliiin- mat.iry »r ..iIht visible diallers is usually fully rt'st.ir.'d. Reflex Amblyopia. Iniiation ..f the tifili n.-rvf, csptTially that f..rni arising fr.mi disrascl tc«-th, is said sonu-timcs to atT.rl visi.m. \inl.lv..|)ia in <.nf <'V.', n-sultiiiK fn.m irritation of the ciliary tu'rv.-s in Ih.'- other cvc, has Ix-en report.- 1, as have (-as.-s of anil)ly.i|.ia froiii intestinal irritation .hi.- t.) the pres.-nce of worms in the intestinal '"scintillating Scotoma. Ihis condition (Fin. a»2) is known also MS ••nn.aurosis fupax." an.l as "flicker sc.toina." The c.n.htion is chara.t.-riz.-.! hv th.- apiM-araiic- in th<- tiel.l of vision ot a clou. . ohscurinc uioiv or less c.inpl.-t.-ly ohject.s ui one imrt ..t the fi.-i.l. SciiitlllatliiK ncdtonm in migralue. (Revtki this clou.l increas.-s in size an.l may ..l.Iit.-rate completely on.'-half ,,f III.- hel.l. It is h..monvm..us-/. f., affects the nasal half ..f .me vHual ti.-l.l. an.l the l.-mp.".ral half ..f the ..th.-r. A.-cmpanymji this ,.l lin.-ss is a peculiar wavy or flickering visual sensati.m. Ott.n M>irk< ..f linht api).-ar. ..r the cl.m.l may he bor.l.-re.l by a biu'iit ,.'|.r,. The acuteness of vision is .listurb.'.l. bemji generally very ,|.-ri.i.-.llv .lecr(-as.-.l. Th.- scintillati.)ns linally cease, the clou.l (lis- aupears/and vision is again normal. A.-cmpanying the sensations iuit m..ntion.-,l. or imm.-.liut.-ly foll..wing their subsi.lence, h.-a.lache usuallv api)ears an.l is Umite.l to one si.le-migraine. These phenom- ,.„•, niav result from irritation, pn.bably of the brain cnex. in.m tuxi.- substanc.<s absorbed .luring gastric <.r intestinal m.hgesti..n. i;v.-s.rain fn.m .vfractivo rrrnrs is surrly a no? infre-pu-nt .-ansi-. .ither .liri-ctly by cau.sing brain irritati.m, or mdirectly by reHexly disturbing the functions of the stomach. 080 THE EYE. As tomiiorary ohscunitions of vision occur in glaucoma, tin- tension of the eyes slioiild always i)0 examined in this condition, in order to avoid niistai<inn tiie character of the affection. Nyctalopia.' Niflht hhrnhiess is a functional disease characterized l.y a diminished seiisiiulity of the retina to lif;ht. It usually occurs suddenly in spring or summer, after one or several days si)eiit in l)ri;rlit suiilijiht, a debilitated condition of the health often being a contributing cause. In the beginning the centre only of the retina is alTected, and a more or less sharjiiy define 1 cloud ai)i)ears in the ccnire of the field, whieh compels the patieni to look beyond or at the sidi' of an object in order to see it at all distinctly. Krciuently all of the field, or all but the jjcriphery. is cloudy. If the excitmg conditions continue, the density of the cloud becomes greater, aiid the blindness comes on earlier in the evening. In ea.ses of only moderate severitv the full light of a bright or even a cloudy ilay is sufficient to pi'rmit the patient to read or distinguish objects near at hand. In high degrees of night blindness, however, very bright illumination is necessary for normal vision. An unfavorable position of the object to the light, a cloudy <lay, shadows falling on objects, all materially les.sen the visual acuteness, and lessen the power of distinguishing colors. Sudden changes in illumination alTcct the visioirmuch more than is the ca>f with tiie normal eye. If the illu- mination is reduce(l, a point is i -ached beyond which the decrease ii vision is very rapid, so I' ' ,h very sm.alj decrea.se in illumination causes a profound effect ujitiii \ ision, often rendering objects instantly unrecognizable: evo perce|jtion of light may disapjiear. This particular iioiiit in decreased illumination varies with different indi- viduals. Diiuinislietl light at any hour of the day has the same effect, and the idea, at one time conmion. thai tin' disease was confined to certain hours of the day, is incorrect. The pupils are usually some- what ililated, but react "to light, and the iK-ld is often irregularly contracted. The color sense is fre<|uontly distmV)ed, and coloreil virion may exist A cure usually follows removal of the cause, but relapses are fic(|ueiit. rrotectioM of the eyes against brigh' light and the use of toiiii- mdlii'ines com|>rise the treatment of this atTectioti. Hemeralopia. Day blindness is a form of retinal hypera'sthesia ill wliicli vi.-ion is diminished during ordinary daylight, but is good ill ,1 dim light. It may be caused by exposure to bright light, espe- ci;il!\ liv light ivllected from glistening snow or ice. \\\ important coiiiriliutiiig 'MUse is eyc'.^lraiii from refrai'tive errors. Inteiist- photo- phuiii.i i< sometimes present, as will as tla- phenomena called phos- pheiies, which consist of subjective symptoms characterized by the appearance of highly luminous moving clouds, rings, or streaks, and dazzling sensations. The condition may exist fis one of other 1 Thetcrm iiycl*li)iiia i.^(.niniis.'.l toiii'liciitc'lay hliiiiliii*. nml heim-ralopU to Indicate night bllivlnts.s The tnie mc«innK "f Hie wopli'. lioHever, iieein- to !»■ a.« atnite unil. insruRiiAscEs OF visioy wrmoLT AVPAREyr tEsioy. 5hi (.«,ii<T,.|iit:il defects, such lus iilliinism or colobonui of the iris or The use of tinted glasses, hut especially the careful correction of refraction, will eventually cure the affection. Snow Blindness. This niav take the form either of day blindness or ni"ht blindness, and follows exposure to the sun's rays reHected from snow fields. It is accompanied often by mtlannnation ol the eonjunctiva or cornea, intense photophobia, and spasm of the lids, altliough it mav not be accomi)anied by intlamniatory conditions It bejrins bv a'ft^lual or rapid darkening of the visual field, and cmtinues as long as the eves are exposed to glaring light. Pro- tection of the eyes against tlie l>right light by means of smokeil-glasses, ur otherwise, relieves the condition. \ condition .somewhat similar to the foregoing is met with some- times in iHTsons who are employed in the care of the electric arc light, the intense light of which has an injurious effect on the eye structures. , . Micropsia, Megalopsia, Metamorphopsia. In iiiicroi)sia the con- dition of vision is such that objects look too small: m megalo|)sia thev look too large: and in metamorphopsia they appear distorted. ()ne or all of these conditions mav be present when the retinal rods aii.l cones are displaced by exudate or other cause. If the retinal elements are pushed asumler, so that the images which all ,,11 the retina cover fewer elem.-nts, the objects seen will appear smaller tlein thev are; if the retinal elements are j.ressed together, the opj.o- <ite cond'ition exi.sts, and it is evident that distortion of objects^may •nipcar from disturbance of the order of the rods and cones. These c.n.litions of vision are made out best by causing the patient to look ■It 1 -^et of parall(>l lines drawn on a surface and held near at hand, wlieii. if tlie central lines aj.pear bent toward .-acli other at the point ,,t fixation, micropsia with metamorphopsia appears, while it the iiiie< seem bent apart at this point, megalopsia exists. l'are^i< of. or weakened accommodation, whether resulting from ,liM-a<e or p'roduc<-d artificiallv bv drugs, has the etTect of causing n,:ir objects to apjx'ar smaller than is natural. Tin- psychic etlect ,,| the incre.-i.xed effort of accommodation re(|uired to see the object ,li>tiiietly is to give the hnpression of a much smaller object. In hv^teria'objects sometimes appear too large or too small. ■ M,'t,'imorphopsia m:.y be .■ansed by irregularities in the curvature or ilmsitv of the refracting media of the eye. Erythrbpsia. This is a coiulitioii char;icteri/ed by saturation (.1 t|„. |i,.!,l ,,f vi.<ion with a certain color, and may be due to coloring ■ Hitler in the dioptric media or anterior layers of the retma. It is M.metinies seen during the occurrence of icterus, and is then probably .111,, to the pre.-;enee in the eve structure and fluids ol bile pigments. (',,l,,red vi.Mon is often noted" after cataract extraction, in which case ■A.r color of III,- tiild i- comp-lemeniary to the coh-r of the light wl ich the eve saw through thi' cataractous lens. That is, the color of a I '-/sat Jiv. w':3^tf^ 5«2 Till-: EYE. (.■ataractous li'iis is usually yt'llowisli, and it transmits lifilit of lliis coliir. s(i that after the yi'llnwish It-iis is rciiiovcd the <'yc sees white liftht ;is l)luish in color. This condition disai)|iears in thi' course of time and demands no treatment. Red vision sometimes follows exposure of the eyes to stroiifi lif^ht. (iazinfi at the sun through a telescope having a colored plass behind the eve-piec(> is followed by colored vision iM-rsistinp for days, the color seen heiiig complementary to the color of the kI'I"*'* Ix'hind the eye-piece. The injjestion of c(>rtain druss. svich as cannabis indica. santonin, amvl nitrite, picric acid, osmic acid, and some others is often followed by colored vision. Coffee i.s said sometnues to cause red vision. "n f'EP»'" CHAPTER XIII. rilE EYE IN ITS RELATION TO GENERAL DISEASES.' By C. F. CLARK, M.D. CONSTITtJnONAL DISEASES. Anemia is s.c...ubry to s., ...any and such "livo--;; l>;|;ho>;;^cal ,.,ri,ions that, iu ,-<...si.l.-ring its rotation t-V'^^^'^ 'j;, '' ffe ,s , the •w .....■(.ss-irv to ol)s(-rvc caution to avoul confasing the ottctts oi iw ; n" ia n P T witl. tlu.se of tlu- .lisoase upon which it acpcnds; an. ; ; S wo .xchidc the pmnary ..r essent al a.ja.nua. (^'^l''^'^ « '^"^ ,.,• lie or i.rogressive pernicious ana'uua), there is, probably, no ': , it. i nal conditil.n wh..h n.ore fre.,u..ntly luus a part ... pro- .• ; .rious forn.sof .sthcopia. the cons.clerat.o,. of wh.ch "S..S so .nv.ch ..f the ti...e of tl..> "if '"''""' .•'^V''": ' '. K,.tween N , sul.urt pertaining to the con.plex relation wh.ch ex.sts b. t ^c ,lH .V • .ul general diseases can be of ftn-ater ..npoi'tance to the . i .,; t Ln that V hich co.u.er..s the functional n-tiex <!.stu,.lunKH.s i ' -ofle'. se..n i.. patic.ts who hav.> errors of refract.o.. a.ul are at the ''Z:;;::^'uZ'2ZZ':U. .ni...l of the wnter that the ,;arly .,„a ' h i^. use of those n.ea..s, hygienic. dietef,c a..d nK..hc.nal. "el to overdue a-.a-nia, coul.l. i.. a large number .. .ns^ e.> 1 .V for ,na..v vears the necessity for crn-ctinfi the .m giades ot ;lv;:.^nl ;!a ai.l'as,ig.natisn. which are so i.nporta... a leatur.. .n the „;, Hie e of ophthal.nology as we see .t .n America. ' Tl ,. ..'neral asthenia which acco.npan.es the a.ue.n.c state nu .- ,. J ..vlf as as.la.nopia. and this .nay be co.ijunct.val. c.l.a.-y mus- V e i.ial. It Lt infre.,,.e..tly happe.is that after a prolo.iged ; ;. ' . he pa.-t of th.- ophthahnic surgeon to correct proper • V .;. ..i' '.' i Jnatis.n. a..d nn.scular in.bala..ce by .neans of spher.- V ninir Hi weak pris.natic Icses. and to rel.eve ol,scure ;: i;,;i; n . s. su<.h as headache, etc., ap,.irently due to eyestra , ubii . ite photophobia a..d co..junctival irr.tat.on. by approp .at ■a e . s fou'nd that large doses of a ferrug..ions tun.c an. a ;, rlv .-g..lat...l hf.-, with an abu.ulan.-e ..f out-of-<l....r exerc.M-, 1 ;r ..lir'inple... reli..f fo... all th.> .listress.rj r^::'i;;i;;ri.:;d ,le,i,"f; f:lass.'s for tlu- ti.ne bei.ig uniuH-.-ssary. On the ..th. r ha.ul. , ■,,.,. K„.h„r wis,.« .„ Kckn,.w....Ke his >n..em»h.» to i>. J^ K. l^gcr, fur '.^r- ^.l.^M^ -.st- ,„„... ,.ttorl...l hM>. in clleotlng m..eri.l for the f,.llo«in« chapter. ^ _^^^ ^ r- •mms^.^v .J84 THE F.YE. it frc(|U('ntly liaiipoiis that all of the host diiwtod plans of ponoral inatincnt ("oniiilctcly tail when they aro not supplcinciitfil hy the most jiaiiistakinfi correction of all such errors of refraction and muscle inihalan UK) iiif. ... .leal life is seldom possible to our patients, ami the practical )l)lern wliicli faces the f;eneral practitioner, as well as the ophthalmic An i surjieon, m lealinji with such ca,ses is. How shall we afford relief to the^'symptoms of whicli they complain, and still allow them to con tinue to tliem? I'nder these circumstances it i correct a live the life ami follow the pursuits which seem necessary essential not only to 11 ftrorsof refraction antl imbalance, hut also to treat the anaemia which renders tiiem a more active source of disturbance. In simjile aiuemia. e\en when profound, the oplithalmoscopic ap- pearaiK disk |)rodui orbit. ,..,'es are often iiefiative. In some cases we find i)allor of th and under-tilled bloodvessels. When sufficiently ])rolonfied to stinj;, the eveball inav become somewhat sunken in the ■e wa Congestion of the coniunctiva accomi'amed bv d tmii'? no rvness is some- crience to find case; tliere I) ted, and it is not unconnnon in the writer's ex| if what would be classed as palpebral conjunctivitis, in w sensation of t le presei hich ice of dust i>articles in the eyes, yicM )iilv after the anaMuia has been relieved bv treatment. lere r if eve are accidental co symptoms m wi haracirr as to .justify the term |)erni( iiiditions that may fiive rise to a number l-marked cases, even when not of such a 10 us aiuemia — ledema of tl lids, eMr.ivasalioii <if bl 1 api)earin<; suddenly, generally at night, beneath the bulb.ir conjunctiva, and, at times, oven small retinal hcniorrliatres. I 1 s], (kinji of pernicious anarnia. Kmes. (|Uotmg l-raei ukel. men- tions p were pale renehvMiatous I'hanges in the external ocular muscles. They and clav-c<iliire(| .,,,. ,...,> ...... lith partial absence of the transverse striatioMs, .and the tiiires were filleil with :i yellow or brown pigment, or were linely granular, sniue tibres being ikimow an<l waxy. Occ.isionally in this cMndition we may ha\f even neuritis or retro- bnlb.ar neuritis. Idlloweil by atrophy of the ojitic nerves. In chlorosis eye svniptoms present lliemselves of a character similr.r to tho.se (>f anaiiiia: l>ut. unlike ]iernicious aiuemia, chlorosis is not accomi)anied bv retinal lieiiiDrrhage. Leukaemia. In this f.ital ilisease eye symptoms may or may not be present. Ill the acute stage hemorrhages into the lids or con- junctiva iii.i\ ajipe.ar. and they are seen also ;it limes .as n late maiii- fesialioii. Neii|ilasnis of leuk.emic origin may develop in the orbit, though llii- i- ;m extremely rare occurrence, and involvement of the lacrym:d glands .nid lids has been reporteil. Occasionally the iris and choroid are involved: in the former, circumscribed tumors soiiie- tiiiies ;ipin-;inilj:; u vt--!V tl lynij)li:itir and -plenic enhirg nients, and I It'iib^'lie Arch. f. kliu Mfl., xx. THE EYE IS ITS RELATION TO ilESERAL DISEASES. 5«o certain rases prosont tl.o appoaranco of chronic iritis with flocculcnt iipacitios of the vitreous (licrger). HcniorrliaRos and exudations into tho choroid and o|)tic nerve liave also been ()bser\-ed. althougli the most freciuent seat of sueli IcsioiLs is tlie retina, where one may sonietinies see hriglit areas ,,f defeneration. I'oiicet has shown how vjiscular degeneration malces lieinorrhage possiiile, and de Schweinitz describes tlie wliite ^|)ots with red iK)rders which m-dkc^ their apjiearance in the macuhir region and also near the c<iuator. TIh'sc spots are said to consist of leucocytes surrounded by red corpuscles. "In some ca.ses the ,,range-reil color of the fundus is masked by a fine, striated, grayish veil, due t<i opacity of the superficial covering of the retina " ( Berger). Although albuiiiin may be present in the urine in leuka-mia, the liiigiit white areas of infiltration need not mislead one who takes into ae(M)unt the other general manifestations of the disease, especially the iiiicroscoi)ic appearance of the blood. Ehachitis. Whether due to rhachitis or some other concomitant .Iv^crasia, interstitial keratitis and phlyctenular conjunctivitis and ki latitis are observed in rhachitic subjects. Lamellar or zonular cataracts, either congenital or forming in early childhood, in which ■ve liiid alti'rnalt' layers of opa(iue and transi)arent lens tissue, deiK'iid lui- their development ui)on constitutional disesuses which interfere iciporarily or periocUcallv with the nutrition of the lens, and their luiiuatioii is analogous to and at times associated with correspoiuhng mierrui)tiens in the formation of the enamel of the teeth. Hereditary sviihilis, scrofula, and rhachitis have all been assigned ,< causes of "this interference with the regular process of development. hilt it is to the i)rolonged and violent convulsions accompanying the I M-t-named disea.se, and occurring during the period of active develoi>- Miriil of th" lens cells, that the majority of authorities attribute this I, ,1111 of cataract. \Vhil(> (luite generally accepted, considerable doubt 1- tlin.wn uiK.ii this theory, so far as the convulsions are conciTiied. i.v tlie fact that prolonged infantile convulsions so fre(iuently occur viih.Mit the development of cataract, and the adchtional fact that 111 Ml large a proporti(m of cases no history of convulsions can be liicited. 1- f Hsemophilia This condition, so little understood, cause- disease ot i„. eve far h'ss frequently than would be exi)ecte<l. I'riesth'V Smith !,!< reported one case of orbital hemorrhage following an injury m , •bleeder," .and Haab states that retinal hemorrhage in the torm ■ 1 retinitis' proliferaiis has been olv~er\-ed. Surgical juocedures m -ucii cases are to be avoidi'd when it is possible, and especially those iiivniviiig the use of the knife. Tlie wiiter litis removed without accident a i)apilloma from tlie mjimcti'. >' s.ac bv means of a ligature in a pronounced ha'mo|)hiliac. Addison'i. Disease, .\side from the asthenopia which natural.y ac- li ,|,„,.M.^ .. ....^. .... .'haracterized by marked general weakness, the lids may share in the general bronzing of tiie skin of the face, and Miiiiames a diseasi .J86 Tl'E EYr. tlicic is apt tn 1)(> jatiiidici' of thr c i-iFutiva, while Schroottor' saw paiclics on lli(> sclera. . Myxoedema. Tliis disease may inaK-' its aiil>earaiice lirst 111 tile skin of the evelitls. .\ini)lyoi.ia has" been rei>oite(l. an<l Wadswortli suw one eas(' with atrojihv of the optic nerve iiivolviiij; l)otli eyes. With jieiieral alopecia here is falliiij; of the eyelashes, and this as well as the failure of acci-niniodation and concentric limitation ot tlie visual field, which may occur without apparent atrophy of the optic nerve, has been known to improve or disaiipear under treat- ment with thvroid extract. Diabetes. ' I)i(i})et<:-< Mcllihi-'. Probably no other constitutional disea.se ])rodiices a greater variety of ocular inanifestatioiw than (lialx'tes, and vet in its milder forms it may be |)resent for a loiijj time without evidence of its e\ist<-nce l)einf; api-arent in the eyes. In teiiip<irarv toxic and traumatic filycosuria. nctwithstaiKling the presence of large (|uaiitities of sug.ar in the urine, the eyes are not afiected (Knies). which would teiul to confirm the theory that the pn's<'iice of the sugar is not the direct cause of many of the .symptoms. Among those who sujiport the various theories <,f the etiology ot this interesting disease there seems to 1m> a general agreement on one point, and that is, that the underlying cause is some profound disorderof the nervous system. Tniloubtedly many of the ocular manifestations at times attributed to diabetes are accidental or indirect elTects; but when it is so far ;,<lvanced that assimilation is s<>nou.sly interfered with aiiil evid( nces of auto-intoxicatioii present themselves, we find, as in ;ill)uminuiia, the most profound changes in almost every portion ot tlie eye. and. while it is to the con.lition of the cry.stalline lens and retina that attention generally is directed, the external ocular muscles, the cornea, the iris and ciliary body, the lens, the vitreous and the choroid, retina, and optic nerve may all be alTected. In advanced cases we may have a somewhat intractable form of eczema of the eilges of the lids, and there is also a tendency at times to the formation of furuncles. Many instanci's have been recorded of diabetic paralysis ot the external ocular muscles, any of which may be affected; and Leber has jMiinteil out that such paralysis may l>e due directly or indirectly to diabetes or may result from the cerebral dista.se on which it depends. While some aulliorities state that i)aralysis more commonly affects the branches of the oculomotor, Hirschberg and Lawford agree that in their experience the sixth is affecteil more fre(iuently. Tnilateral ptosis, from paralysis of the third, and lagoplithaliiios from uivolve- nient of the facial, are .s<M'n occasionally. The paralysis may in the more advanced stages be permanent ;iir it may be slight and temporary in ciiaracter in those casi>s in which the constituMonal malady yield.s to treatment. Nuclear and peiiph- 1 Wien. miMl. BI»U , 18X6, No. 21. lilt: EYE jy rr^ helatios to uesehal diseases. 5«7 (■nil liciiinrrlKijics ami toxic ix^riphonil n.uritis liavc Ih'cii assijiiicil •1^ llic causes uf paralysis ..f the external (iciilur muscles, and to the latter cause K.'ies assi-ru-. the freciueiit ueuraljlias ami iK-casioiia! iiuestiiesias ami seiisurv disturbances which are seen in diabetic patients. He calls atten'tion also to the fact that a peripheral neuritis .,1 diabetic origin mav cause heriK's zoster ophthalmicus, ami that the aiucsthesia of the first branch of the trijjeniiiius may give rise to iiiiimparalvlic keratitis. .V- in otiier diseases causing marked impairment of nutrition, dia- lietes in its terminal stages sometimes cau.ses destructive keratitis. Diabetic iritis is by no means unconuuon, as was established by Leber, in 1SS.J, and has been confirmed by many writers .since that time. Hutchinson states that in his experience it generally occurred ill patients who were also the subjects of gout. .\s a complication of operations, such as cataract, diabetic iritis is not only very intract- ,l>le, but also not verv uncommon. Iritis in diabetes is generally of ilie plastic tvjK- but. with the exception of ca.ses following operations, i~ not usually severe. When there is exudation it is generally lil.riiious in character, and may entirely block the pupil, in^ .some instances being as.sociated with hypopyon and hypluemla. Cychtis 1. seen occasionally, an<l is followed by degenerative changes m the \itreoUS. . 1 I I II That cat'sract occurs as a result of dial)etps is conceded by all iuihorities. but there is some difference of opinion as to how it is i,,u,|uced. When occurring in elderly subjects of diabetes the pos- -i. ijitv of its being a mere coincidence should be borne in mind; but nl.ileit niav occur at almost any age, diabetic cataract is ()ften seen !i, (iiiile young jx-ople, several instances Iwing recorded in patients 1 iti"iii<' in age from eleven to fiftei-n years. Hu' proportion of individuals with diabetes who develop cataract ';,. been variously estimated at from t to 25 per cent., the latter i»iii<r t!ie result of von (Iraefe's observations. It'is (juestionable whetiier it is ever possible to distingui.sh by a . hv^ical examination between a cataract due to diabetes and one !,.,.• to other cau.ses. although, as they often appear in relatively young ,,1,. thi'v are apt to Im- soft, usually developing rapidly, and are at -nnes precnled bv almost visible swelling of the lens. They may pnear in cases in' which the general nutriticm has been only slightly 'riled as well as in those in whom there is great emaciation; and re is great diff.-rence of opinion as to the mode of develojHnent. 'i.inaioriiy of the elaborate theories advanced to account forthepro- ictioii of cataract in dialK'tes an> easily proved to 1«> imworthy of con- I.Tation and this applies especially to the theory that the opacity II some way due to the chemical effect of the .sugar which is found Mie substance .)f the lens. This theory proves too much, for sugar l«cn found in the lens in two-thirds of the ca.ses of diabetes, and 1 nioir freipientlv in the aqueous humor ami vitreon:- It is .bible that Knies'is correct when he states that diabetic cata-ict V(i-jif !^:»m .M:-:-^ r.. ^'l^M^^^T^ l^.itt^.r I HUH Tin: i:yi:. il('\r|n|) result '■ mi.lcr til" -iiiH- cDUilitiiins as spoiitaiicnu- rataract, as tin- Mist iiihaiifts III tin clKiniid. and pail'u'iilari. m the cHiary l,ri)(rss(- wliicli furiiisli tli.- luiliitivo supply to the lens. Toxic suhstaiuTs ciirulatiiiK ii. li«' 1)1'"mI. uii.l iK.t ••the liarinlcss supir. sot up tin- iliscas.Ml cDiKlitiDii ot the uveal tract, wliicli ni turn iin>- (luces the cataract. , • , , , • , Several wrKers liavi- cited cases of dialx'tes m which the lenticular ,,pa<'ities have disapp<'ared when the neiieral condition improve.! under trentnient, jmiviiij; that such opacities were not the result ot coini)leteilefreiieration of the lens fihres. liei-m' opi'i-atinj; for the extraction of cataract in the fas<« of a diahetic patient, it is well that some dietetic ami constitutional treat- ini'iit Ih' maufrurated to improve his general condition. After ohserv- inji this precaution and i.rovidinn the condition of the other struc- tures of the eye does not contraiiidicate it, the oiM-rator may proceed with reasonable assunuice of success. Limitation of the i)ower of accommodation is a well-recogmzed svniptom not infre(iuently met with in even mild cases of diabetes, aeil the earlv develo|)ment of presl)y()|)ia should always lead to examination of the urine. This, ;is well as the occasional mydriasis, is attrilnited hv some to the (icneral mu.scular weakness, hy others to a periphend neuritis or to lieinorrhages, while still others consider that it is tlue to toxic substances circulating in the blood. Diabetii- myoiiia has been reported from time to time, and while in pome instances it is api)arently due to other cau.ses, in a larpi- i)ro- portion of cases it is probably due to swelliiiu of the crystalline lens ill the eaiiv stafjes of a iliabetic cataract. Myopia deveh.piiifr in ]iatienls p:i"<t forty or fifty years of afje should always .suggest an examiiial! i of the urine. if aciiuired hypermetropia was reiiorted by Horner' in a iv-five years of age who had s<'vere diabetes. The liyper- ,i:i .iiminis'hed when the diabetic condition improve.! under This case seems to be unii|ue, and is difiicult to account One c; patient nii'tro ti-catment. for. f r 1 ■ (■ l{etinitis. while seldom .seen early in the course of diabetes, is ol fre.iiieiit occurrence in the terminal stages, presenting itself in an exudative or lieiiiorrhagic form, or aitli exudations and heniorrliages coniiiincd. .\ppearing at a period in tlie course of t!i<' disease wlicii degenerative ciianges in the vessel walls are present in other |iarts of 'the l>odv. as well as in tli<" eye. it is not strange that the glycosuric form is sometimes seen in association with albuminuric retinitis, lii the exudati^■e form there are ;ipt to be small, light, shining |iatches with minute heniorrliages. but swelling of the retina and involvement of the nerve are not characteristic, as in albuminuria. Hemorrhages, e'liher ill the small punct.-ite form or larger and of sufhcient extent to lead to the formation of vitreous op.acities, are fre.iuenlly seen. < Kliiiische M(>Imt^l)lillU•r fur Aiigtiiln'ilkiinile, 187.1. 8. 490. Tllh: KIK /.V /r.S- RELATIOS TO UESKliAL DISKASES. 5Hy ^..v.Ttl writ.-rs iK.v.- rcpurf.! casos ..f h.Mi...rrlmnic plauc..ina aiul , ,i„„. t„ trrat.M.M.t, .-xfiisiv.. irtinal l,.-.n..rrhap-s ..t .Ual.rtu ..npu. iiv (.1 tlif iiravci^t iirognostic sipiiticancc. i i. , i i; .i- V„H..i tl... ran-r n-sults ..f .lial..t.-s w s..n...t..n.-s l.av- du.knl .l.>k, n,..iriti< iiii<lii<'un.r.'tiiiitis, witlisi'CDn.laryaln.phy. I l.l'v .a a.ul amaurosis, wl.i.'h an- r.T,-m'.l to olscw UTO. an- also ,„.;';;il:;i:ii; <;'^' i.. ti... .•uu.-s,. ..f .liabot... whh such a.ui,iyop.u «(• iii'iv find ci'Utral scotoma for r<'<l. In' lns.i,i,lus. .Vs a r.-sult of or assoc.atc.l with .Imbctcs in "i I , . a n«.ul.c, of writers have rc,.ortc.l hcnua.u-psm. epi c,,^.u , ,ks optic n.-uritis. ami svinptonis of cerebral •uiuor but it is ; nhh. s Kuies has suKKeste.l. that in tlu'se cas..s the polyuria was :;;:,;'";:,:i„;!i,leMtal etT-ct of a lesio.. in the floor of the fourth vontnele. ul.i.-l. WIS the real cause of the sviiiptoiusrelerred to. ^^';;';„;::;,.hagicVeti.iitisis said -to liave b.-e.. fouiKl in diabetes in- 'oraies- or Basedow's Disease (Exophthalmic Goitre). I'alpi- ,.„iro. irregular action ..f the heart, enlargement of the thyrou i Md, and pmtrusion of the eyeballs are the ^^^''^X^^^^^^ rr,M.Ms,. although in the early stag.-s one or mon- o these s>"'Pt ""^ ,. ; 1,.: ibs..„t In well-mark..! cas.-s the diagnosis will force ,ts,-l ;;;■:,;,;.: „.ost unobserving, but it is in the early stages and atypical (■.,Ms that its recogniti<m is of the greatest vahie. c, :1 p.,trus^m <.f the eyballs in a.lvanced cases is a most „K,rl!" svmptom: but, as the writer has had occasion to veri >• l^ . ,. ' ueasurem.nt in a mimln'r of instances in mild cases this is ' r, ^parent. Stellwag lias described the pei-sistent shgh , ,; ..f'the upper lids, and von (Iraefe tl... '^/f^^^-f.-f T,"'? , r„i u„i,.hisoft..nI.bserv.Mi in i..oking .l..wnwar.l. Uns latt.T n. ( .\..f 's svmpt..m. wlm-h mav for a long tim.- be th- ..nly symptom 1 dis-J^e. w;s al.s..nt .wily tw.-lve times in six luiiulml and ,i ...„ ..as... inv..stigat.Ml bv Shark.-y.' The r.'tracti.m of tl..' 1 ds, XL to ..onstan. an ..tTeH ..f th.- instillation of <-«-.u^ and -; M,ic!Mv.ll.M- has (.all.Ml att.'nti...^ sugg.'sts th.M-arlv stag..s,. (.rau ^M...M. and appanmtlv is .In.- also to a .hr.rt stimulation ..f the Mn.ilhetii nerv.-s suiiitlving the orliital muscles. Th::^;;em.. pn.,n.ion of tl... ..y..balls seen m -lv.ince.1 cases , ,n.il.ut...l bv son... authoiiti.^s to spasm...li.. cm raction .. th. , , ... musclar fibr.'s fo.m.i in th.- orbit, but th.' maj..nty ot , : !. ,...f..r i. to dilatation of th.- ....bitai ar,..n,.s P-*-'"^,;- Ij;: - v..|op,n..nt of tl... fatty an.l conn.-ct.ve tissu... It is a > P «•"" ,., hMW,nvr.that tl....-x..phthaln...s..tt..n .Imm.ishesaft... '1«'-' ''■ 11,.. n,..st s,.ri..us .■.ms...iuen....s s.. far as th.. ..ye is conc..rn...l >om - ■Z ivsuit tVo... ..xp..sur.. ..f the (...m.-a du.- t.. this pn.trusu n ot .:i, .^..!■.a!l whi.-h ...av imt 1... clos.-.l .'v..!! .luring sleep, and those > Hritiih Meilioal Jmirnal. October 25. IS90. ill) THE EYE. \va to lie t'li' niniv serious llic iiioic nipiilly llii' cyi' is prc-scd tor il ui.cis. rcsiiitiiif: ill ncLiila- or fioiiiu on to sloii<;iiiiij; •Mr, , •mil vii'iil oiilv wlini ilicy :irc rcco<j;iiizi'(l i-;iriy aiK nl. ( OlUC soiiictniii's occi In 'a trd witli till- uri'alt'st cair hy llioroiij;lily ^^iitiuiii« tin- liils. and tliiis alTiirdiiif; |ifotrctioii. Uari'ly diplopia and rvcii niarixi'd paralysis of one or niorc of iiu (■xtiTiial ocular imiscics as iici'li o liscrvcd, and soini'tinics there is severe | •am in tl le eves. \v Tlie |i\l|iils respond \v ill) profuse scaliliii}; lacryination. ell lo direct iliuiiiinatioii ami contract on I'onverm'iice, a times observed. Itlioiijlli moderate dilatation and irrenularity are soiin .\i miirniu •ultati on over the orl>it sonu ■limes will elicit a distinct va.scular r. similar to the pi.icental hrui ilxophthalmos, while j;enerally sei '1 Unenlly unilatera Kni< ■s calls a n on i)()th sides. i.=; not very infre- iiid often varies In de};n'<' in the two eyes, and tiention to Hack's' interestinj; ohservation that tiie lie side has been known to ilisai)pear alter tl exoplitlialmos on o ■ ■ • i i mucous membrane of the nose on that side had been c:iuteri/.ed: and IJolose- has obtained tlie same result. .\ few other similar cases have been ivporteil, iiut.as Kiiies remarks, they are excejilional. Iritis is not uncommon in severe cases, and epi|iliori;i ()tten is marked. Nvstajimus and tremor of the eyelids .ire sometimes ob- served, and il di'firee of corneal insensibility is of fre(|uent occurrenci'. which, as Knies has remarked, accoimis for the infrequeiicy of the wiiikin;; movements in many cases of (Iraves' disease. .\tidpliy has at times been observed ill extreme (■:■ > s as a result of strelcliin;; of the optic nerves, but ophthalmoscopic tindinps are rare, coiisistiu}; of pulsation of the retinal veins and rarely of the arteries. .\s severe casi's of (ir;ives' disease are aj)! to be accompanied by anaiiiia and netnasilienia, il is natural that with headache and vertifto we should often hiid all of the dinrt and reflex symptoms which accompany muscular and ciliary asthi'iiopia due to other causes. esiH'ci.ally if there is a coexisting! error of refraction. In (iraves disea.se the visual fields are at times concentrically contracted, whih- the central vision and color sense may or may not be impaired. Goitre, owinjr t" pressure uiion the veins of tlie neck, at times causes disturbance in the vascular structures of tin- eyes by venous stasis. The author has seen one case in which he was convinced ot a caus-itive relation existiiifr between jjoitre and a central choroido- retinitis. General glandular enlargement, or jiolyadenitis. has, at least m one instance reported by KoiiifTstein. been accompanied by a number of small tumetactioiis alouj; the o|ttie nerve and the motor oculi. with extensive neiiroietinitis and total unilateral o])hth;ilmoiile<ria externa. 1 Doitsrlw lllf'l. VV.ich.. l'-S'>. N". J.'). : \\\\\. il-Uclli,. l»9fi. p. ■-'6(1. rut: EYE IS ITS REI.ATWS TO (lESEliM DISEASES. o'.ll DISEASES or THE DIGESTIVE SYSTEM. Diseases nf tlu> in iiilic(HU'iitly llic cause i iheir iiiiiMiitaiice in llii testiiiai traet and llie associated nrnaiis are not liseaseH of the eyes, aitliouuli und(iulitedi> •tioii lias at times Im-cii exanKcrated. conne( This is esiH'ciaily true of tiie disorders aplwariiic durinu the period of Durinjt tiie |M'riod ol erui if tiie permanent, teetii, arn i.f cari( •y an- 'trii)Uted so frec|uently, I of eruption 1- 'lie deciduous, and less frec|uentiy lentition, to wiiicii ail tiie ills of inlaiic id later as a result of the various forms uid other disejises producinji i rritati f the terminal tila- liien of the ev! ts of the fifth nerve, we may have most n:arked reflex symp (.ni> l)Ut. as sunjjested alM)ve, in their zeal for luidmj: a plaus- itionOf olvscure phenomena, hoth physicians and parents liiere is such a tiling as coincidence without 1 etTect. Nein-otic manifestations, such a ilile explan often seem to forfjet that then tiie relation of cause ai IIM titation, mvdnasis. inyo iis, relaxation, and, more fre(|uently, spasm 4 accommoi latioii, and even disturbances o if tlu! external ocular mus sucii as insuiliciency iil)tedlv n ■lieved at times hv the reiiu leading in some cases to diplopia, arc un- val or treatmiTit of a carious too III' til. Wliether these syinptonis a the result of a htck of sulhcieiit innervation iliiriii i-e (hie to a true fetlex irritation. th I'Xistence o lain m the tooth, must !«■ determiiK 1 l)v a studv of each case ria The writer was tioii l)y the n ciieral medicinal 'troiinly impressed with the importance of this assi ifter suit ohtained in the case of a patient who treatment extending: over a period of many inontlis was com pleteiy relieved of the most .listressiiifi sympt olll.- sia accompanied hy gaseous distention and insomnia uljustment of a 2° prism liase in (>ii <;;'ch ( iiiMilliciency of the internal recti. Th ! vear. when, without other cause w IS n the ve, fitr the correction of •lief continued for almost illeil to reveal ull^(•lllar halaii lie patient was a man (•lice, who s|)ent hi hich he could discover, lie found the most critical examination ■r the relr.ictioii. presbyopia, or it s('enied that we had exhausted our resourres. )f liftv vearsof aj;e, an attorney in active >ymptom< all returning. aiK [I change in eitlu iflice work and hiseveniiifrs in readint the failure to ol)taiii relief was ni.akiiif: iiim i st unii; ippy when fiiclid .|(fe( Uffsre ted to him that it would be well to give atteiilion to tive, 'ulcerated" tooth which was causi iir liim so little :iimi'V- .at inv attention had not lu'cn ca to it. This he did. and ti the reinovi )f tl le .source o 11- at once and iK'rmaiiently (lisai)l)eare( ist coin 'ia resu f the dental irritation the gastric symp- ■d. This case illustrate; id astheii pleteiy the general principle that dental tlisease ai itini: from muscular inibalani two absolutelv ditTerent iditioiis. but in both of which the terminal tilamen its of the lifth I i\(' a re involved, may produce the in a remote- orgsui .same group of rellex nervous Iritis, keratitis, plilyctenuke, and even glaucoma have \wn\ at t rib- to di.sease of the teeth; am I it is undoiibtedlv the case that an .V.»2 Tilt: r.Yi:. ■ Iv. ..lar i.Lsc ss, with -r witl...iil iiivulv.-iiirht lit- iii.tmiii ui IIiRh- ,.nr- iPMV CIV., risr to iiitVHmus |.,on.s...s ,,. ll rl.u, IlU, an.l . wl.aM, altli.-ujjli su.li a rflatioii is of /ar. •urnmv. ■ S-i-.rs iia.strir an.l p:i.stro-int«'stinal .t-.i.*' loa. - Mr,,urntl> t.. .,„,,,,„ ,au.l ..tlu.r>j.-iuT.I .lisra..-. wl.i.-l., m turn, <-uis<- must inarM-.l "u ;; vn.p, ^; bu. .iK-sc will I... .Irait with ..l-w ...r... In all t-mw ,.. K;.,!nMnf>t,.,al .lisunL-rs a( i-M'.-."i<-'l .v v.ol.nt v-nntiup th.. , , nh.i -tiva r.M un, o, rliorni.! .nay I..- thr -• i' -f h.M....rrl.a-(-. riu- ,. .■■ ., „-. f ivai aanp.r. .^IKriall) Mu.., „„!. .iHort.v,. v.'s^' .^.,r .„..• .,p.Tations invclviMK s.Tl„Hi ..f tho rv i.all :.M.l sh..u..1 h, a' , .„K rras.m f..r tlic avni.laiicf ■ I p-i.rai . M-ilM-sia, wlu i.i'irti mMc- in ucli casfs. .. , , . »». . \r rril .l.lr It.' nf !lH« luUHUis .• .^hr uc nl the .iii;.vtiv" tnu;t .SM ., . ft<>n m. iJ.lr.-n ni ass..<-iati..n vitli phlyctnuilar. mjiin mtis .„,.l k,.rui»i> ai.l th." c.-rroction ..l .-rr N„f .1, ..n.l n-pulati. t the .,li,„,,, ,.^ .■(•n.T.uns arr f..ll..wnl ».y such i.^, n.-.air nMi.r..vrn.rnt "thai MM. n.aralK - i...-lin.Ml to Jx-li-'v.. that th.MV is soin<- assocat ...ii lH.|w.-..n th. .lis..:ts.- of th.' .-yr. an.i that of ilu- al"«."'"tary ''!«• ,nor.. intiniat-- ^ .an w..ul.l »h« in.'i.-at.Ml by th-- ;;ra.h.al nnprovn,,, t in ihr mitrii^ pmc^^-. s f.,ll.,«in« - ., !, ,„:,najrcni.'Mt an.l tn-atin.' Vascular . ,it..rp'tn..nt !.i. u. co->li!.ati..n and the c.)ns«..,n straininp at >ti)ol may, in ili •-< witii wcak.ncl v.-^s.i wail- l.'a.i lioroiihi! hcniorriiaj:. -: ami, :• cordi Ills v.fll as ir.mic arrl: ■'- have .'laucoina. . i.- .-lis.' calls id ''!<>" ha I. as in . lvsi-n(. (•..njunctival. orhital, retinal, or ^ to H('r<''(r. proloiijj(>.l c.iiistii>a been a— i);mi ll as a cau.sc ol t.. the tact thai nrolonp'.i '^i.! ,„,,rk.Ml .•nfc.'l.l. nt of a. .'..niiii "btu.n. an.l Hi:,; .liarrli.ca of infaib v the a.Mitioii ..1 an elenu'iit y\ syst.ini.- .lepletioi! leu.ls af n.cs I.. k.'rat..nialacia, ' In.liseaseo! the liver ac. nipani.'.l \<} iaun.hi'c, of the cMijun.tiva is ol'i.'n n.>ie.l lulore 'li.- -^kin is ^ remain after "'i.. skin has lieare.l. HeiiK-raloi ;.i, ~ Ljective yellow vision tonin-i' 'i-^oning. n- v "f the ret ma. ai i result iroiii 'lepallc >!i-.'ase, an.l n acul. Iieni.>rrh;!>:es. .111.' t.) sept i.-sul)staiin- im ilr I Kiii.'si. l,:iii.|o|t li..lieves that we may ' relati.iii . . \istin.i; Letweon cirrhosis <■■ ivtim'i~, IS well as In iii.'ral.ipia without Sciiilillaliliir sc.uoliia ami ocula'- nii-'' -invh.'re, ar.' mii'ii a— oei.al. i '.vith ami a| , may n- tii ui in the chroni iifection i' 'ii- Me ilisc.. >ra 'in iii.'.l, ami mav ■II kel; 11... . H »l ! a ■ hver . i.'Utatioi: . wliir-h . ■ ireiitl\' .i.'p' f SM' nrpiii of 'lie lou.T l«) Th. jii'iailiar vell.iX' xaiithoin.-i palpebral- iivpr: ■■■'■•■■■\ r.^erster. n! a<'Conim.>ilal loii ;i cause. Intestinal p: of the put>il^ '"111 ■" . I, an.l oilier ilisonle i' th.- ilip'-ii -h plates in the skin li'' .•y.'li'l-. ;, .'ire ass.iciateil ficiu. !y witii i wMKaml Mlawat-''hek rep'.rt c. .•.|Uat' ial leliti.'uhit .i^ icit; ! -ites, a< is well ^ii. ■ ■ oft' ■■ reti»>X . iilar s ah 'final iiii i, rcii I .poll -Iflll. ■ sy known a- •ase .if 1h' .)f failur. . the sain. (lilatatLM Ttii: i-:> ^: '>■ > ^ nEnriox v <h:HAL />lSt:ASh:s ,-,!);{ DXSKitSIS or THE MSPIRATOilY RACT Diseases ol the DOBe and pharynr aro r.-.i •"i>'-l"'."">; |'';' ;;'"f;; ,,t .1'. iiii'i tiM n V I ,1111 .f thf ••vcs, :ti .1 linl - f:it-i is lK>rn(' in iimi'! iltrt tlMIl .11 w lili^ I II iiiau\ ill pHMluc-o rctli'X syiiipt (1 ■,i-i(- ii «iunM' dt' iiiitidi.iii 111 in H' fvc?' wliicli iiltlioiiKh )iiii)i' l'!l-i at' I>i ltl< „,,v-..t-i...it..oi.:a.ii-di>.....r. II ''''-' f''-;^'"';-';; ..,1 orfraiiic l('^*l<'l^^^ arc pru.lur. d, alttioiiftli ,,(curr> II •!• a woiiUl Ih' iiitVrnMl fioiii the ,, til ■ hu. ••ol 111 this, as ill many .ith.-r '. then- is a nil .s .liscrcpaiicy iM'tsvccii th<- iiitiiii-iitnl aii.l 1)V Anicricaii (il»s.iv.'rs. Tin- .liscmlil iiniiv <-f 'I " n'portcil ■ wrcs of cvf; lisl iticcs wcll-tlfti nci- "t' a- Irt'qiu t iiti-ratun- [(■pal 111''"' r. .f I! , f'llHK sources (• if ..Hex in ition by niHratioii aii<l ptuiii so (Iclti ijiiiiiiiij; turhii iifcrinr turtin ■iiity which n. i( iiihranc iif t 111. Mora iU- I till of „ ol . '• ">■ r.sll .1 iiC 111UC' plIlS -11 the (•> ,ia, iai viiiati.iii, jwrsist. tit or nTiirriiii: |, ctioii, l.icpharospasiii, a- c(.miiio.lativc uitioii of the visual lieKl. ainhlyopia, :■■ ,1, ,h.s«m1, iiiav even excite glaucoma. Ohe; have reiHine.1 cases of };laucoiiia in w».i' 111 xcitiiiK cause. The intimate associaiioii existing i s to have it- nnivex iMMJy, hypeitiophy • ,. ImkIv. or ans other y Ik" accompanied by it> nose, liia> proiluee 'Oiese niav cause |)ain .ml photi)- I'oiijunctival and ciliary r muscular astlienopii 1 in those who are pn- 111 uiii Ix-nnox Browji.' isa irritation serveil as Mi- ls ■ til I1S< Ki nasopharpipal cavi- inchidinfr the eye, '■owinRof the visual lown to follow the the nasal cavities. n\>teria. and mentions in.l the various structures withu II illustrated by the temporary con Ahich in a nuiiilx-r of instances lias ,f the jralvaiioc.iiitery in treating diM Kn - considers this as a form of traiinuit. ,, he I ict that similar symptoms may r.-snlt iron, otln r painful p. I, n s in tt neijjhlH.rhoo'd of the eye-, but this explanation is .■ .r.ely ;.; Xte"; with tiie results reported by Hack ami "^J--;;';, ^ „l,i..h Craves' disi^ase was cured by tlu application ..f the pab ui" .MUterv to the nas .: "iiicoiis menibrane. lUiinitis in itsva-! .as forms, especially thos< ;i.ssociated with umo ,n, .. i . ,,roce.s.ses, is anio.m the most fre.iueiit can .s of diseas.' o ;■: :::,,;nctiva ... eornea.u.d. w.u^ :!'::. r^^.s,^ :::::i 'hall ■ r means. iiel of communic atioii, it is by no means imjxiss their products to be conveye 1 fn.in the nose to the eyes by oiher That it is i ossibli on the other h.md. for Ihiids containiiifi I lull.- nialeriai to i)c :;!mmu!\;< IwiiliH-hi' i.ie.1. Wwh , 1*-*V N" -'•• ;|»f ,1 «. !!!! th.e eye to the nos(> I? ,l,lhr r .VUglMlhcllt., iwi.-.. I>. *Vi iiifi'C- wel :« 594 THE EYE. .•stal)lisli('(l. And, jilthotiKli, Iwcausc of tumefaction of the mvicous uuMiihranc in infectious iliscascw of the conjunctiva, the <iuct is often occlutled, it is prol)al)le that such material not infre(iuently passes into tlie nasal cavity with the tears, there to 1m- rendered less potent by the secretions from the nasal mucous memlirane. "The I'ase with which fluids may reach the nose and nasopharynx should alwavs he iiorne in mind when usinjj my<lriatics and other substances iii the conjunctival sac; and it should also be remeniln'red that solutions of atrojjine, as they must i're«|uently be used in the treatment of iritis, contain in the amount instilled far inon; than the usual iiharmaco|Meial dose of that remedy, and it is probalile that a larjier proportion is absorbed than is the case when adminis- tered bv the month in therapeutic doses. Transmission of disease throufih the nasal duct from tiie coiijiinc- tival sac to the nose is certainly extremely rare, but Knii'.s mentions lupus and epitiielioma as having heen so transn»itted. In acute catarrhal conjunctivitis the nasal nnicous membrane sel- aoin becomes secondarily involved; but, on the other hand, the con- junctiva seldom escapes in an acute coryza, while in the chronic forms of rhinitis {\w lacrymal sac or conjunctiva is very prone to 1m' affected at some perio<l, es]>ecially during acute exacerbatioiLS anil in the atrophic st:if:e, when crusts form near the nasal orifice of the duct. Syphilitic coryza is seldom transmitted by this chamiei, but I\nap|) has descrilxMl a case of lupus of the na.sal ('avity which produced tubercular conjunctivitis. In many of the infectious dis- eases which afl'ect both the conjmictiva and the nasal mucous mem- brane there .seems to exi.st no evidence that there has been trans- mission from one to the otinT. liven in the ca.se of diphtheria and croup ill which the na.sal and, much more rarely, the conjunctival muci>us membrane are involved, there seems to exist no proof tiiat the path of the infection has been throufih the nasal duct. .\denoid vegetations in the vault of the jjliarynx, and hypertrophy of the ph.tryii^eal toiisiU, are, especially in children. frei|ueiitly found bearinj; a causative rel.ition to diseases of the eyes. There seems to I'xist a somewh.at intimate relation between these jcrowths with their a.-sociated conditions, and plilyctemihir conjunctivitis and keratitis. Disease of the frontal, ethmoidal, and sphenoidal sinuses dm' to jnllamn, iiioii of tiicir liiiinji membrane or occlusion of their outlet, accompanied bv the accumulation of serous, mucous, or piinileiit tluitl, or llie formation of ):ranulatioii tissue or various forms of tuini'irs, may all iiio>t profoundly a ITect the eyes, and for loiij? periods the nature of tin- trouble may escapi' iletection. Supra-orbital or, more r.irely, infra-orbit.'il neuralfjia, pressure symp- toms, and rell<-x i)henomeiia,ilisplaceiiient of the eyeballs witli ptosis, and disturbed relations of the extrinsic ocular muscles, may occur; and in the e.irly r-tap^s, Ix-fon- the developie.i'iit of marked protrusion, the writer has in two instances seen on oiihthalmoscopic examination a peculiar parallel striation of the retina. THE EYE ly ITfi HELATIUS TO (lESERAL DISEASES. o'JS Wlicn erosion or niiirk.'d irifliiininatioii of the bony walls of the orbit is i)n's<-iit, wr iiuiv luivc an orbital (•clhilitis or abscess accom- panied by cheinosis ami inU-rference with corneal nutrition, and con- HMiueiit sloURhinR. II' tli(> sphenoidal sinus is involved to such a .lejjree •1^ to cause necrosis of its walls, we are apt to have first disturbance i,f the visual field, and later paralysis "f the external ocular nniscles, and blindness, from disease of the optic nerve, chiasm, or tract. Diseases of the ear, which may i>roi)erly Ix' considered in connec- t . M with the superior respiratory tract, may in rare instances j)roduce .'ve symptoms. .\s illustnitions of n>P.ex nervous phenomena niay be mentioned bleiiharosiiasm, which sometimes occurs on irritation of the external auditory meatus, and the nystiigmus which Pfluger observed on compressing a i)olyi)Us. Mastoid disease or operations for its relief may cause lagophthal- iiios by i)artial or complete paralysis of the facial nerve, although the otM-rative form often recovers. When meningitis or cerebral abscess occurs, we inav have the usual results in i)aralysis of the external ocular musch-s', optic neuritis, etc.: and Kipp' and Pomeroy' have repo.K'd thrw> cases of metastatic panophthalmitis in i)urulent otitis Diseases of the larynx, trachea, and bronchial tubes are not often i^sociateil with disease of the eves, although a number of curious reflex phenomena ire often observed, such as dilatation of the left pui)il •iccompanving infiltration of the apex of the left lung, and the sneezing produced "by opening <!i<' <\es. especially in cases of c<mjunctivitis .ind keratitis. . , , ■ t t\ Bronchitis and pneumonia mav !»• accompamed by her)K's ot tne .ornea: and the dvspna-a of emphysema is, as Knies has pointed out ,.•(•< .mpanied l.v sta.sis in th«' retinal veins, and at times conjunctival ■ui.l retinal hemorrhag.-s. Schmall has often seen injection of the fundus and reports five ca.ses of visible arterial pulsation m phthisis NiMiroretinitis has been reported in association with i.nemnonia: and <;,,w.'rs d.'scribes a ca.se of intense febrile bronchial catarrh with in-.ik.Ml evanosis, which was jiccompanied by lu'un.retmitis with enor- ,n,mv extiava.sitions, manv of which were r.'gularly arrange, and Miualed upon the smaller vi-ins. The writer has, on the other hand, -ivii a fatal api.arenlly metastatic pneumonia di'veloi) in the course ni panophthalmitis following gonorrlueal ophthalmia. DISEASES OF THE CIRCULATORY SYSTEM. Diseases of the circulatory system manifest themselves m the rye by hypera-mia, aiuemia. ledema, hemorrhage, and the results of lumorrhage in the conjunctiva, uveal tract, nerve, and retina: aiu ulicn the blood is modified by disease or is the bearer of effete material 1 Amcri™ii .liiunial of tlii' Mi'<llcal .Sciences. Aviil, 1W4. 8 .Sew Eii|{l»nil Me<lli'«l Moiilhly, J«iiu»ry, 1W9. iti 5'JtJ Tilt: i:yi:. or tdxiiis frciicratctl in other portions of tiic body, we may havo also (•inl)olisiii, throiiilHisis, ami various forms of cxuiiatc witliiii tiic ciio- roii 1 and retina. Tiie peenii itomital arraiiftement ot the eneu- lation witliin tiie eve sliouid 1)0 home in mind, its supply of hlood is derivoii from both the internal anc 1 external earotid arterie.- Th tree ana: itomosis of tiiese two systems and the eommunieatioii with theoi)i)ositesi(leof tiie brain are su<'h as to jirovide well for its milri- lion. even when serious obstruetiou exists in some of th<' larjje vessels, attention should be directed to the larf;e, freely anasto- i: ;pecia mosing arterial and venous trunks of the tuniea vaseulosa of tl 1, overlaid by the ehoriocapillaris, which alTo'-ds niitritioii t( chorou., the layer of rods and cones, or epithelial layer, while the terminal .systein made up of the central retinal artery and vein with their brandies supplies the imier or "brain layer" of the retina. While there has been in the past a tendency to expect too much of the ophthalmoscopic ajipearaiici' of the va.scular systein of the eye in interi)retins the iihenomena of the general va.scular system, and es|)ecially the conditions exislinji within the cranial cavity, and while its limitations as an index of tli<>se conditions should constantly be borne "i n.ind, the !:ict remains that when jiroperly iiiter|ireted they are of the utmost value. In estimating the va'ue of ocular manifestations, a sharp distinction should be drawn between those conditions observed in the retina v.hich are a.ssociated with evidences of disease of the blood itself, with the accompanying degeneration of the vessel walls, and those due merely to ;ilterations in blood vohmie and blood i)re.ssure. The |)ecu- liar conditio! ~ of the circulation within the eyeball, in()difi<'d as they are by the non-elastic sclerotic coat, and by the admirable arrangement by which under on linary circumstances the large trunks of lh<' choroid serve to regulati' the pressure Upon the visible retinal circulation,' renders it impracticable, as has been attempted, to use the retinal circulati(.n as a means of gauging the blood jjressure in the vascular system genendly, or "ven in that of the brain. (!eneral anaemia may be accompanied by more or less hyjienemia of th<' eyes, and it is mIv in extreme cases that variations of blood pressure, .so easily recognized in other iiortions of tiie vascular system, can be properly interpreted by means of the ophthalmoscope. iiyperainia of the conjunctiva may be present ;»s a Iik'.mI manifes- tation where there is a corresponding coiidiiion of the general circu- lation due to various diseases, but it is not a very consistent sign, as many cases of most obstinate c.mjunctival hypera'inia accompany geiienil aiuemia. Hyperainia ot the retina and optic nerve is not apt to be found as the result of general i>letliora, but is more fre- cjueiitlv of the pa.ssive form, and accomjianies such obstructive con- ditions as asthma and emidiy.senia, and such heart lesions ius induce venous stasis, ' It i« pmhHiily Id » i)i«tiirl«niTiif Ihin 'li'lir li' Imlnncv itmt many of the phenomena of glaucoma TJIi: KYK IS ITS liKLATIOS TO OESERAL DlbEASES. 597 The eve i< far l>cttcr iil)lc to i)r()toot itself iigainst th(> ill effects of a su.hleii increase of l)loo.l pressure tliaii af,'aiiist sudden dinunu- ti„n of pressure, iiltlioujil. it is an extremely rare (.eeurrenee t.. have retinal hemorrhage or other permanent retinal disease as a result of either unless there is some disease of the walls of the bloodvessels. The' acute anaemia due to ext<-nsive hemorrhage is only in rar(> instances followed, hv .liseuse of the eyes. Fries' \vu.s able to hnd ,l,e recor.1 of <.nlv KKi cases that have occurred durinj: the past two h„ndre.l and thirtv-five year^ : and of th.s.>, it is probable that many occurred am..ns those having some iorm of (hsease ol the bloodvessels. Sixtv |)cr cent, were from gastric, intestinal, and uterine hemorrhage, •'.-, per cent, from artificial abstracti<.n of bloo.l. 7 per cent, from epislaxis, 5 per cent, from wounds, and only 1 per cent, from pul- monic hemorrhage. , . , ^ ■ . That serious di.sease of the eves results only m the rares instances from extensive hemorrhage in indivi.luals with healthy bloodvessel.s i. ini.arent when we recall the enormous number of instances ot ,,r,',fuse h<>morrhage occurring as the n-sult of traumatism, especially .luring militarv ••ngagements, and note the extreme infre<iuency of di^eaM' of the eves as a r.'sult . Not a single ca.se is .ecorded as having .,.:,„nv.l during the Franco-Prussian War of 1S7()-71. ^\ lu-n amau- r,,Ms and amblvopia do occur as the r.-sult ol extensive loss ot blood, it is u<iiallv after several davs have intervened, and it seems to l)e ,h.e to hemorrhage into the optic nerve, resulting from fatty degen- ,,,„•,„„ of the vessel walls conse<iuent upon disturbance of nutrition Irom insuilicient supply of blood (Knies). From the above statistics it is apparent that extensiv.. hemorrhage in.m the stomach. Innvels, an.l uterus is •. real source of danger to virion- and. having in mind this .langer and the weakened state ot ,1,.. bloo.lv<'ss<.ls. the phvsician will naturally insist upon the recuni- |„.nt i-ostur.", an.l will luactis.. intravenous injections or a. loot such other m.'asures as may tend to restore the e.|uihbrium of the vascular '■ br'nortic insiifhciencv the rhvthmical redd,.niiig and bleaching sometimes observed in the tinger-nails may be appaivnt in the op'ic ,M< (.laeger), and i)ulsalion of the arteri.-s m harmony with the ridi il liulse is also generallv seen (Haab). . ' (.,h,!r cardiac diseases <;c<'asionally affecting the eye are mitral in.ullici.-ncv, dilatation of the heart, and fattv degeneration. The Inter disea'se is often onlv one manifestation of a general i.rocess. ot wliich one of the features is disease of the ocular vess(-ls. \mon.' th"disea.ses of the vascular system which s.mietmies although riivlv affect the eves mav be mentioned aneurism ot the aorta, uteriovnous aneurism of 'the internal caroti.l an.l the cavernous .imis. pnulucing a i.ulsating exophthalnu.s, and, very rarely, aneurism i.f the ophthalmic artery. 1 Klin. Mon»l« f. A.igeuheilli., l«76. Wm'^ifmK.^^it ^f..'« 5tlH THE KYE. Til iiiu'urisin of the aorta we may liavo paralysis of the sympathetic nerve, wiiieii leads to coiitraetioii of the pupil and also of tiie pal- pebral tissure of the affected side. A local, temporary slowiiif; of the l)h)()d current, due to traumatism or other cause, producing a thrombus from which small masses may break away, foreign sui)staMces in the bloodvessels, and endarteritis iti its various forms, eiuisinf; fibrinous de|)osits on the vessel walls or the valves of the heart, may result in the develo|)ment of embolism of the central artery of the retina or one of its branches. In somt' si.\- toen cases which have been studied anatomically the obstruction was, in most instances, found in the region of the lamina cribrosa (Haab). In those portions of the general vascular system in which there is free ana.stomosis, such emboli, even if they find lodgement, may cau.se only very slight and temporary disturbance, and this is in large measure true of tl-.e ves.sels of the choroid; but in the retina. a.s ia many portiois of the cerebral cortex, \\i' have one of the termiiril systems of Cohnheim, in which more or less complete cutting; otT of mitrition occurs in the area sui)plied by the obstructed vessel. Thrombosis of the retinal vessels may occur as a complication of intiammatory and especially of infectious i)rocesses in the orbit, whether they are c,ause<l by erysipelas, meningitis, thrombosis of the cerebral sinuses, or in any other manner (Ilaab). They may involve both the arteries and veins, and are apt to Im> the inunediate effect of stooping or straining in people having disease of the bloodvessels. I'nless the p.atient is seen soon after the accident has occurred ami the case is st\idied with great care, it is in many instances by no means easy to make a clear distinction betw(en embolism, throm- bosis, and enilarteritis obliterans. Tlu* presence of j)erivascular infil- tration and degeneration accompanying endarteritis, and visible to the ophthalmoscope, is indicative of thrombosis, and an existing valvular lesion of the heart is characteristic of embolism. In some ca.ses, however, as in sever.il which have bc-n observed by the writer, the sudden occurrence of the .syini)toms and the oph- thalmoscopic pictur(> are such as to leave no room for doubt as to the existence of an embolism. DISEASES or THE UBINART ORGANS. Albuminuria, .\mong the diseases usually grouped umler this head, albutniruiria (Hright's disease) in its various forms is by far the most imi>ortant, and the one in which eye IcnIous are found most fre- quently. (K<lema of the integument of the eyelids of a temporary character may occur at a very early fwriod in nephritis; but |K'r- manent (edema, when present, usually accompanies (X'dema in the ankles and other parts of the body as ;i late manifestation. Chemosis or irdema of the conjunctiva is rare. ^ -rrx— ffS?^ rilK EYE Y.V ITS HKLATIOS T" (IESEHAL DISEASES. .j!)<» \iiunic tl.c iiitra-ocular atTcctioiis (lu<- to iiUniinimiria \v«> hav<' liviM-raniia ..f tli.- papilla an.l ivtiiia. retinitis witl. the characteristi.- white ^pots arranjicd in ra.liatii.R lin.'s alxmt tlu- macula, u<'»ntis, nriiiorctinitis, and cvi-n choivcd disk with henu.rrliaKcs, especially, n. tlif iierve-fii)re layer. , . i i Detaclinient of the reti-ia, iritis, and honiorrhaRic glaucoma have 1,,-eu described as rare conditions, and chorouhtis as of not mfre- ouent occurrenc.-. Chans.'s du.- to tlie latter disease have often U'on I'.u.ul o„ aut<.psv: hut the lesions, which seldom are rei.orted. are ,„ol.al)ly ren.h'r..d invisible at the ophthalmoscopic exammation by the pimnent ei.ith.'limn (Knies). Whitish patches, generally m the macular region, but not infr(>(iuently in other i>ortions of the contra retina, accompanied bv swelling of the nerve-hbre layer and, at times bv small, often Hame-shaiM-d hemorrhages, are the charac- teristic retinal manifestations of albuminuria on ophthalmoscopic examination. . . . , .. Intensive hemorrhage into the vitreous is seen sometimes, but it is of rare occurrence. , .• • :„ Complete blindnes> is very rare, seklom occurring, excepting in coin- cident ura>mic amaurosis or in atrophy of the optic nerve and detach- leent of th(> retina. Retinitis is not an early symptom, but it is not hlfreonentlv the first svmptom which leads to a correct diagnosis. II has occiusionallv been Uie exiH-rience of the writer, m patients having Mhnost normal vision and asing their eyes (,uite constantly, to hnd „„ mikhig an ophthalmosc()i)ic examination that the centra fundus w.s the seat of extensive retinal infiltration. In these cases the fovea hM< ..scai.ed, and the conducting power of the ax.is-cylmders seemed to 1„. tulimpaired. The <rdema may bo marked and yet the rods :md cones mav for a long time remain umhsturlx-d. Tlu. .lis(>ase with which we are dealing affects the b o.kIvossoIs n.a.nlv as a scl(Tosis; and Knies has pointed out that all the other |,.<i„n"s including the hemorrluiges. <e(h-ma, the formation of folds, .,,,.1 .le'taclunent of the retina, and fatty degeneration are ^«-ondar>- ,„ these changes in the l,loodvess..ls. He calls attention also to tlu l,,t that whil.- disease of the ch..n.idal ves.sels may be very extensiv.- without giving -iso to such nutritive disturbances as are seen m th.- ,.,ina it is because in the choroi.l we have a collateral supi.ly while in the retina the arteri.s are cud artories, and circulatory disturbances ;ire not compensatwl. ,.,■.• c .k„ ^,,,.,11 There is marke.l thickening, especially of the intima, of the .s u U arteri.-s and capillaries; and while in the latter we often hnd dilatation, in the former small dissecting aneurisms are not ""''""^">""- ^„ •„„ W eeks r..ports a ctuse of hemorrluige and acu e glaucoma occurnng with albuminuric retinitis, ami other ciises have been roconU-d proving thMt acute glaucoma is one of the occasional comphcations of this ,li-.' .>o Hull has puinteil out that dise:ise of the walls of the bU,od- vessels is probably the connecting link botwwn these two c.nditions^ and GowJrs stated that in some cases of chrome renal disease there wv^mF ()(I0 77/ A' /;■ )•/■;. is (liiiiiimtioii in size of tin- retinal artriics iiKlciM-iidciilly of tin- t'Xistciici' of otlicr f'vidciicc of special renal disease. Albuniinuric disease of the retina is to Im- found in all forms of nei)hritis: but it is rare in the larjie white kidney of parencliynialous nephritis, in the sta^e of fatty de};eneratioii, and also in the form characterized as waxy kidney. In this latter form liull has jjointed out that t is seen only when the waxy dejreneratioii occurs in a contracted kidney. Although not uncommon in the albuminuria of l)re<inancy, and sometimes seen in th ■ acute forms of nephritis, such as ap) ar as a coiMi)iic;itioii of scarlatina, all observers sei lu to aj;ree tiiat cnaufies in the retina ar(> fomid most fre(|uently in the late stages of tiiat form of nephritis wliich is accompanied by contracted kidneys. Tln'V make their appc .ranee when, after ;i |)eriod of hifih v.-iscuiar tension, elimination is be^innin^; to fail, but are by no means always found under the.se conditions. U'hile jH'rhaps somewhat less serious, if the nephritis is of the form which is often .seen in acute exanthemalous diseases and in prcfinancy, the |)rojinosis is always j;rave. or at least doubtful, the patients often dying within u few months after the discovery of the retinitis. Knies, in s|)eaking of the more chronic forms of nephritis, states that lifi' is rarely prolonjjed more tliiin one, or at most two years after the discovery of retinal infiltration: but when seen anioUR those who will carefully observe the hy<;ienic and other rcfjulat ions neces.sary under such circumstances, it has not, in the writer's experience, been uncommon to see that jieriod jrreatly extended. In the albuminuria of pregnancy, threateneil loss of sijihl from neuroretinitis is a strong indication for the induction of jiremature labor. Though generally affecting both eyes, unilatend albumimiria is observed occasionally. Hull has described ten cases. Lesions of the retina which resemble those of true alhuminiu'ic retinitis, undoubtedly occur as .-i result of profound aiueiuia, leu- ka'inia. .'ind diabetes, and in some forms of organic disease of the br.iin. as well as in a certain projiortion of cases of what is termed cyclical albuminuria; but it is well in these cases to make freiiuent t<'sts of the urine, for, as is well ktmwn, nephritis may coexist with these conditions, and albumin be absent from the urine for a con- sitlerable period. While rare, paralyses of the external ocular mus- cles are .seen sometimes in this dise;ise, occurring as the result of a hemorrhage in the region of the n<'r\-e roots or miclei (Knies"). \\"i\\\ ura'iriic aniblyopi;i or .-unaurosis, nmscular paralysis may :it times be seen ill t lie last st.ages. These are not necessarily accompanied by changes in the retina. When ura^mic poisoning occurs in acute nephritis, as in that of pregnancy, it is not uncommon to find that the retina h:!s und.ergone no ciiani^e whjitever^ astd, in fact it hfts been pointed out that the combination of ura-mic amblvopia and reiin.i! di.sea.se is comparatively nire. In eclamjisia the pupils are generally dilated, and the external ocular muscles often take part in TJIf: KYE IS ITS RELATloy TO GEM: HAL DISEASE:^. (,<': tlH' c)nvulsi.)n.s. ("atsinict may h<' the result of vascular changes .li'iifiiilont uiioii lU'pliritis. ijxaluria, uric acid diathesis, and phosphatuna have each ui rare instances Ix'cn assigned as the cause of eye lesu.ns. hut it may well 1„. doiihted whether the changes ohserved in the eyes wen- properly to he attrihuled to these conditions or to some other unrecoginze.l • lisease on which thev in turn were dependent. Hansell' recorded a" case in which the retinal chai , hough not uuite characteristic, resembled thus.' of alhummurK t.s. 1 here was failure of vision, hut there were no subjective >y onis. he Ml.norinallv abundant urine contained an <'xc.'ss ot phosphates, but lepeateil examination reveuled no albumin or sugar. DISEASES OF THE SEXUAL ORGANS. Much has been written on the etTects of sexual excesses, esi)e- <iallv masturbation, in producing diseas<- of the eyes, .iiid, if we were u: be influenced bv the extreme views of many otherwise high -.uthorities, we would conclude that there exists some peculiarly iniimat.' relation between the eves and the sexual organs. If siK'h a irlition exists, its importance has certainly been vastly overe.<tiniated. ,S-xual excesses have been !i.><signed as a cause of atrophy ot the ,,,,iie nerve, but it is doubtful if the relation of cause and effect has Lccn established. ... . , Conjunctival livpera'mia, catarrhal inflammation, impairment of .„.,.un,modation, nuiscular a.sthenopia, and even serious disease of the optic nerve, have all been attributed to habitual masturbation, liiitli in male and female patients. , • r. It i- undoubtedlv the case that a degree of neurasthenia often ivMilt- from the direct and indirect effects of this morbid habit, which in its turn serves to aggravate asthenopic con.litions <hie to other ciuM's In common with other conditions leading to vascular .Mi-'cgement. excessiv<> m.Msturbation :i,^ well as vonercjil <>xces.ses Invr been known in numbers of instances to .serve as the exciting raiise of various forms of intra-ocular and subconjunctival hemorrliages when the ves,sel walls have been weakened by disea.se. Coi.orrluea. which might for some reascms be chissed more prol)or y with the infectious di.sea.ses. is treated here because it is so essentially , ,li-ea-.' of the g(>nital mucous membrane. ( )phthalmia neoiit.torum ,nd sronorrh.eal ophthalmia in the adult, with the resulting destruc- tive keratitis, siro the well-known eve comi)lications of this disea.se. Metastatic disease of the eve is also sometimes seen ni association with .ronorrlxra. especiallv with gonorrlueal rheumatism of the larger oiiits aii.l iritis not infre.iuentlv acconijianies the rheumatism duo I., this dlsea.se Well-tiuthenticiited cases of ineta-static gonorrhoeal I FhlladelphlaPol.vcllule, January 21, 1S97. !i G02 riih: h:YK. n.iijunctiviti>. wiiti iiitciisr cliciuosis and scanty non-puriilont st-crc- tiiin, Init witlumt (Ifstructivc (•(Hiical (•iiin|)lirations. have Imh-ii rc- port*"*!. To tlif varicuis fnrins of (listurhanoc in the viuscular ami nt-rvoiis systems whicli arc excited by al)iu)iinal iiieiistniatiou are properly attrilnited a lar^e ^jroiip of ocular alTcctions. and in a still larger nnniher of instances diseases of the eyes due to other causes are anjrravated i)y such disorders. I'atients who are ana-niic, chlorotic, or "scrofulous, ■' especially, and soinetinies those free from such con- ditions, show a marked tendency to disea.se of the eyes durinp or immediately jirior to menstruation. This may Im' insipiihcant.and manifest itself as a slight (iMlema of the lids, or by the up|M'arance of dark rings under the eyes, or it may 1h' that conjunctival hyper- a'lnia will develop or well-d<>tined a.sthenopic syin{)t<)ms prestMit thein- .selves. (jiven a tendency to hor|)etic eruptions of the lids or cornea, to marginal blepharitis, .styes, phlyctenular conjunctivitis or keratitis, oi even iritis, the approach of the menstrual period, especially if there he dysmenorrlKva, is apt to he accompanied by an outbreak. In nervously susce|)tible patients a variety of .symptoms of an hysterical character may i)re.sent themselves at the menstrual period, su<'h as limitation of the visual fields or nuMlitication of the color ti.'Ids. Leber' calls attention to the |)o.ssibility of hemorrhages into the optic ni'rve during menstruation in ca.ses in which the vesst'ls are diseased, and Knies mentions cases of hemorrhages into the con- jiniitiva, vitreous, and anterior chamber. .\ttacks of anterior uveitis and dis.s<>minated choroiditis and cho- roidori'tinitis are frecpiently due to menstrual disorders, and sudden snpitressioii of the menses is said, in some instances, to have produced hemorrhages into the o|)tic nerve and Ms .sheath. Hemorrhagic glaucoma is sometimes seen at the time of the meno- pause. . . It is doubtful whether normal pregnancy and normal parturition in ii lealthy woman ever are accompanied by di.>-,eases of the eyes: but. as in menstruation, ' pnwxisting di.sea.se of the eyes, a systemic c<»n- dition, such as ana-mia, which seriously interferes with the nornmi course of ])regnancy. or any of the numerous accidents which may befall the patient during this critical jx-riod, • >• convert what should be a normal physiological process into a i)r i e source of disease of the eyes. In a nervously susceptible woman, especially if she is anaemic or is the .subject of any form of disea.se which impairs her vitality, mus- cular or acconmiodative asthenopia may iM'conie a source of great disc fort, and if, u.- We frfqurntly find, thiTc e.xist.s a latent error ni refraction or imbalance of the external ocular nmscles, the symptoms I Handb v. Gnefp-Sainilnrh, Bd. v. p. «19. THK EYE IS ITS RELATION TO OE^iERAL DISEASES. ^(r.i •lie aKCnivat.'.! an.l are soinrtiincs most (listr.'ssiiiK. In thcs.- casos •,< in llmw ..f -M hysterical i.ature. sucli as t(Mn|.(.rary l.lin.ln.'ss unam)iMi.aiii.'.l l)V organic lesion, and contraction of the visual helds. we should attribute the disturlmnce to the ana-rnia or other systemic condition u|.on which it really de|K'n.ls, and look upon the pregnant -tate as merely an exciting cause. The eves »M'ar their part in the altered facial expression sometimes .een during pregnancy, and are n..t infn-ciuently the seat ot pigmen- tation. l»hlyctenular conjunctivitis and ev«'n keratitis sometimes are rncountered. , , , , The occurrence of alhuminuria during the lat«'r months of pregnane) i^ apt to 1h- --companied by retinitis, choroiditis, optic neuritis, etc., which are considered in their resi)Octive chai.ters. In proj^Tly elected cases th<' induction of jiremature labor may check the progres.s ,,r the di.s»'iise, and, while not infallible, has in many iiLstanccs served t,, ,,r.-vent blindneas. .\.s, however, the .same accident is apt t(. occur ill future pregnancies, patients should be warned of their danger. Detachment of the retina and retinal hemorrhage may occur even when not associated with albuminuria. U is natural that i)arturition, especially when painful or prolonged should in cases in which albuminuria or other diseas*' has weakened ,li,. walls of the vessels, lead to h<Mnorrhage into th<> retina and nerve. \maur()sis niav make its a[)iH'arance during parturition as a result ol the ura'inia of eclampsia, or when there has be<'n profuse uterine hemorrhage it may r(>sult. as in cases of great loss of bloo<l from other ..orlions of the body. Hemorrhages intJ) the retina and optic nerve occurring during rhiMlx'd without api>arent cause are attributed by Knies to emboli ni the c<Mitral retinal artery, such as have been observed after phleg- MiMsia alba dolens. . , »• i I'ueriHTal septica-mia mav lead to nieta.stiises in the retina an. |,oroi<l and in severe ciuses septic embolism may readily be followed l.v i)anoi.hthalmitis. It is j-robable that, as in other forms of se))- Mca'inia an<l i.vaMnia, this occurs f.ir more fre<|uently than is reported. ,- .ittention is" directed to other symptoms and the patients so seldom Vhortion accompanied bv infection, an.l .sei)tic processes in the A,, Mil) ..ccurritvT !>.< the result of disease, .)r f.)ll.)Wing the various urgical proc-dures involving the womb, may, in a similar manner, ad to disease ot the choroid, retina, and optic nerve. To lactation and the ana-mia and exhaustion which at times accom- nanv it an- fre<iuently due phlvctenular and other forms of keratitis, ,!i.r even choroiditis accompanied by vitreous oj)acities has been uun.l t.> be due to this cause. , . • ^u tu,- TIk' eves .)f infants are often injured at the time of birth. 1 tus Kiy occur in a variety of wava in prolonged but otherwise norma ibors, but is especially apt to occur in cases in which instrumental l.'livcry becomes necessary. Here almost every form of traumatism t)i)4 Tin: EYi: II ■ \\n^ Ihm'ii rt'C(<nli'il. lici-liyiiuisis iiitu tin- coiijuiicliva, l»'iiii)rrli:iK<' within tlic eye ur nriiit. mill t'r:iclwri' nf ilir l'riiiit;ii Imhk' or at tlicliasc (if tlic skull, wiili icsiiitiiin iifiiiitis, I'lilldwcil liy |>aralysis of flic optic nerve, may 1h' ciicdunicicd, and \\i' may have pafalysi^ uf any ln'aiicli nf till- tliinl nerve, the sixth, or the facial. Niimcnnis c.ises in which paralyses have ncciirieij have been |inl)lishei| hy Miulin. Mloch, Merger, and iitheis. Hut when we cuiisider the nuinei'oiis instances in which inslnnnelital delivery is resorted to. serious ;iccidents to the eyes are seen to he of relatixely infre(|ucnt ((ccurretice. ( tphlhainioscopic I'xaininaiioiis of the newborn have in many instances revealed i-etin;il lieinorrhasies, and while such eyes often recover with jjood vision, there is imich rea.son to believe that many of the cases of amlilyojiia so frequently seen in strabismus are due to such lesions, the j;ross <'haii>;es, such .as coiilil be seen by means of the ophlli.alnioscope, having; lonji since disappeared. There is room for further investigation of this subject. ()phlhainiia neonatorum, almost alw.ays due tn the irmiococcus of Xeisser, but sometimes tf.'tceable to other sources of infection, is >ii conunon as to rei|uire little cominem. As in fionoriiui'a. it may be associated with atfectioiis of the joints. POISONS AND INFECTIOUS DISEASES I Poisons. The direct and indirect effects of the introduction into the system of chemic.il poisons and livinji jji'rms and their morbific products are so varied fh.at it is extremely ditiicult to arraii};*' a sysf<'m of classification which will be thofoujihly scientilic ;ind satisfy all of the coiKlitions. Indeed, for our present purpose no such classification is necessary, as our object will be attained if. byftroupiii^ similar forms of jioisons on the one hand and the infectious processes on the other, we ;ire able to [iresent .a coin|ir(>liensive view of the manner in uiiich thi- eye is affected directly by the substances beloiiflinir to the v.arious groups, or indirectly by the disea.sed con- ditions which they excite in othei parts of the bod v. .\ lai'tre .and most important jrroup of jioisonous substances afTecl the eyes by producins; some form of retrobiilbar neuritis, at times including; .1 lesion of the fj.injtiion cells, resiiltint: in what is fjenerally termed toxic amblyopia, chiiracferizeil by form and color scotoinata. To this {Tioup belonji alcohol, tobacco, lead, .arsenic, the silver salts, mercury, phosphorus, the salts of potiissiuin, iodoform, ioduret and tliiuret, essence of .lamaica jrinper and essence of pep])ermint. bisul- phide of carbon and chloride of sulphur, nitrobenzol ;ind dinitro- l)enzol, the various ciial-tar products, opium and its alkaloids, chloral, cannabis indica, te.a. cotl'ee and chocolate, ercot. vanilla, and stramo- fuum. carbon dioxide, osmic acid, i|uiniiie and the various pr()duct> of cii!'lion.a bark, s.alicvlic acid, and aspidium or filix mas. lOach of these substances, it luis i)een claimed, lias pro<luccd true toxic am- nn: )>; l\ lis HEI.ATKiS TO liF.SEHM. l>ISt:.\NES. (j()5 !,lyr;>i;i "!>> ;iii action nn the nannlmii ( iicrv>. "I tln'ir va; :;inri:il clTcct ii|hi|i t cll- nrrv( til lit': am I (iptic ocular supply" (tU- S-liwrinitz). and wliilr tlu-ir he eves will !)(• (•(ilisidiTcil ilftv, the sviiiptollia- MjiN and I I i.atlinluiiv ut rcir<.l>ulliar iii-uiilis will lie Inatcil ..I in the liapiiTim Diseases of the Optic Ncivi As llic trrni poison is applicc ill. .■tti'cl of all clHMMlca to lliosr sulisiancfs which, if intro- Ih'IWI •fd into tlic svstcni, prodiici- disease, we here consider not tl I >iil>stances n| the eye, lint such cITects as are I ,1 jjiven poison is introduceil into the ve, and we should make a distinction ite attack and those which iiiiduced in that <»r;:an when ,i \-.|ein or direellv into the c n those ellects which follow an acl hi; Mv make their appearance in cases of chronic poi>oninn. In Fniih arine and chronic poisoninjr. however, the more proinnniced ften the indirect etTect of till- action of the poi.son rvi' symptoms are o upon some o Iher part of the hody, Hich as the vascular system the ral or pi'ripheral nervon- system, o r the ki<lnev: idirect etTects Ul>o ri thi' eve of acute svsleinic poisoniiiK are i|it to mam fi'sl themselves in the action of the iris and ciliary hody, ydriasis, myosis. cycloph'fiia. etc.. and .soinetiiiH^s in the ext I- in iicular muscles and I in chaiiijes in the vessels of the fundus. Colnn-d \i-ion and illusions are W hile intoxication am (tip ilso sometimes noted. •iilistancr^ nami' hlvopia is the most noteworthy etTect of the 1 in the ahove list, a numlierof them produce other k-mptoms of which we must not lose sijjht li'iiil-imisiiiiiiiii produces a varii irijiheral lesions, re: 1v of both central and hich iiltini: in disturhaiices of vision which are geii- illv traceable to .sclerosis and periarleri lis, the evidence of which iinetime^- be se( n with the ophthalmoscopo. Disturbances of I he external ocular muscles may follow multiple neuritis due to this and we may have the ciiaracteristic picture of albumiiiuri( uria may result from lead-poisoning. Th nioretinitis, as albumin [iplicalioii of lead lotions is fre(|uently folioweil by itu lelibi le dci'osils |e;i il in the l'l,i,sjilii>riis'^m is sometimes accom))ani<'tl by hemorrliap< ihe retina, and later by fatty depiieration. -oinewhat r ibling i.it of albni linuric retiniib The frei|uent occurri' '(' of hemor- iixes in th' !>tic nerve and brain produces characti'ristic eye symp- i/((V seldom produces eye symptoms, although hemorrhages and tatty degeneration, as in have Imm'Ii noted. Tii. eye symptoms in lc/(/i' nitrriiri/-ii<>i--iii severe cases n tinal i-phorus-poisoiiing liriiMic c.'ises resemble those due to chronic lead-poisoning. 'II ^(111 III r 'iiniis (/ jrom the silver salts, aside from rare cases c Ihi manifests itself in the eye coniunctiva, which not iiifre(|uen )f retrobulbar onlv in the (hirk indelible stain tlv is .seen as the result of rii-ijril iiiCa! ::pi)!i ication:- liiilinc-i>oi.-(>,iln(i. chieflv when it is administered in the form of lide of potassium, induces at times catarrhal conjunctivitis, but ^1 l« «jO<i THE HYK nidii Irr |Ui'iitl.\- pains in the cvcm anil larrvniatiuM in aswwiation with ilic tvpii'al cory/a. Wv sDinctitncs mt illustration.'^ of ihc cxiri'Mii' iiri! iiion |ifoilufcii hy the ilcvt'lojinicnt of iiidjilf of iniTniry when ii'\ ijiati'il i"t'' ' ' is liiislcd into tlic t'M's while iodide of potas-inin is Im in^ ,1. ..;... II "red internally; Imt, although these drills are not inf!e(|iienily used at tii;- same tune, this is an extremely lari- occiir- renee. limiiiiih iij juiUissiinii in exees.sivc anioiiiits has Iwen known in SO! '• instances lo proiliiee retrohulliar neiiritis, Imt e\('ii when not in MiliieiiMil dose to eanse the eha'aeti'rislie skin eruption, it may exeite eotijiUK'tivitis with phlyetenular foci of intlamtuation (Kniesi. Alfohiil, which prolialily produces more cases of chronic poi.sonin^ than all other sulistances topether, causes a variety of eye symptoms in addition to retrohulliar neuritis, .\ liich latter disease will Im- con- sidered elx'where. In acute alcoholism we have at times as an early manifestation, fai'tire of accoiMiriodation. inco-4)rdination of the ocular muscles, causing diplopia, and later, ab.siMu'c of normal pupillary reaction. With noniial ophthalmos('o|)ic appearances wo may, in delirium tremens, havi a well-marked concentric limii.itioii of the visual field which -ioinetinies cniitimies for several days. What is known as retro- hulhar I axial ojitic neuritis is only one manifestation of the inter- stitial aiil parenchymatous changes and Viuscul;ir disease due t" chronic alcoholism, and the conse<|uent lesions which develop in the 111 lin. spinal cord, kidneys, etc., are accompanied l>y such changes in the 'ves as are found in a.s.-!ociatioii with t!>e same lesions due t^ other <-,iuses. S'\erc ilisease of the centr.al nervous y>tem, si.'li as ofti-n su|K'r- venes in ca.-es of chronic alcoholism, i-- .iccompaiiied liy a variety of ey lesions. .'in>l anionji them, in rare in--i:i!ices, <>|ihthalmopl( i;ia externa, which is due generally to hemorrlKinii- intlaimnatiou of 'he floor of liie fourth ventricle. Mrtlnil nirii'itii and (DuijI iiln>hiil may hoth cause sudden lilmdiiess — iadei'd. some authors have claimed that to tlicM' suhstance.-^, rathei than to pure ethyl hydrate, is due the retrohulh.ar neuritis which often follows the use of the more conunon forms of alcoholic drinks. AfiiU •tj)iin)i-j'iiisitnini; causes well-markeil myosis ,ind. at times, cloiidinf; of \i-^ion. In clunnic cases accomp.anied by marasmus there is also apt to he corneal softeuinj;. Actilv cliloriil-jtii'^iiiuHii produces myosis. althouirh .after large doses liave lieen .idMiinislered f.ir .1 Ioiil' time I'lydri.asis s(,mctimes is noted The cutaneous eruption ;uid iirticari.". of the li.ls. whicli are .seen after prolonged use of thedrug. are apt to he accompanied by conjunctivitis. S\i!ph(it'iil-jii -luiiiiti may jiroduce ptosis, .•md has Ik'cu known to cau.se anasthesia <if the c<iniunctiva. ('iirhi)ii i!:<iru!i -!:!!isi>>!!>!!; !i;is in a numher s-.f ca^es iu'cf! known '■■■■■ produce jianilxsis of the ixternal ocular iTiuscles, which may disapiwar after a few weeks. It is attributed to hemorrhagic procosst^ in the rut: h:YH is its rhi irms ro ueskhm diseases. mi lifii iil)Mtru('tiuii iliiiii (»f r-arli(iii ii'trlia>ri'>. •11. wliicli, aci-'ird- ■iiii-iia, iM'diiis li'ii Iruu, uiiil is pri' iicrvc iiucli'i i>r in the pfriplirrai non-rs ( Kimpp In rcr<|iiraii(in or cirfulation results in 'In- anaiti illiixidc in tlir liliind, rtc arr apt to liavi- n'tiiial ; Stiiiliiiiiii-iH>i.-oninii is cliarac'tcri/.tMl liy vfilnw \ i> la^ to Kiiics, who has . arcfully investigated its phei i.r tilleeii iiiiimles after tiie adiniiii-tration ol the ceiU'd l)y transient vioh-t vision. 'Ihe pupillary riiietion »snorinni. is in the appearanee of the fuiiihis, and eetilral vision remains undistiirlied Kri/ol has l>een known to jirodiiee i irrowinK of the retinal hlood- \essel.s and tetnptinay disturiiance of \ision. with sliii;;:ish |uipiliary react!' . but in chronic poisoinnn the prolonged nutritive distiirh- aiices ut'i urring tis the rtMilt of spasm of the \es.s<'ls of the <'iliary iiody are ustiJilly :u<sij;ned as the cause of tin- cataract which some- times follows withiti a few year- of such an attack. Fiutijits-jDiixiinitiij varies in its etTiM'l upon the eye aceordi'ijt to the uriiuie of the alkaloid jiroduced: inuscarin- <■ausin^r spasm of accom- iiioiiation and inyosis, whili' other varieties, such as inorchella, pro- duce mydriasis i Knies). The profound systemic disturiiance prixluced liy these deadly alkaloids sometimes results in fatty de>:eneration .iiid heiiiorrhap' of the retina. Almpine may he taken :is the t>pe of tin- mydriatics, and its elTects upon the eye when Used internally in a poisonou- dose aie well imder- >tiHii|. It luiiy cause hypera'inia of the fundus as well as cyclopleKia iiid mydriasis, and in those who an- predispo.sed may excite >:lau- i,Mn:t \'ot infre(|uently we find in<lividuids in whom the smallest iiiiount of .itrn.ine acts as a local poison in the conjunctival sac. (•roducinjr a n, !,-i -r form of conjunct ival cat.irrh aiul a so-called ec/eiii:i of the '■ ' • i sometitues stated that this is due to impure dilutions; hut v lij, 'i 'i rlli/.ation and the oli-'t-ance of every I'Msonahle prec. ^ ;■)■■ tin viriter litis convincetl himseli tl.at thi- is iMil the cas«'. ■ • ..:.r\ oi iiie or duhoisine will usuali l-<- tolerated \'\ those patieti- . wi ■ :;i'e susceptible to this :.r'i.>t. oi atropine. II ilit^riinnnm'. diihoisinr. iliilurinc. hin/ialr.ti '■•-, ■ ■■i,'>liimini\ etc., • :ive mydriatic and cycloplefiic ett'ects similai .^« l.'iose of atropine. lid any of them may, umler favorable coiiilitioiis. induce ulam-oma. I'ulioisine is inore prone to ctiuse rleliri'.im. and also, at times, pro- iires ii.irrowiiifr of the vi;t,al field; and I'loley i;is inted temportiry iiiblyopi.'i !is a result (•;' lit" iiistilliition ol -copolamiia'. ('iiiiiini-imisitnitiij if 'xnite. may cause transient amblyopia witli •lUtr.ii-tion of the retinal arteries, or it may produce syncope with Mic .itteiidaiit temporary blindness. In chronic cocaine-poisotiiii}' we ' ..ly have visual hallucination ehromatopsi;!, hemia.iopsiji, iniiTop- i.i. diplopiii. daiiciiiir of objec , and ainblyo])i!i. In ti numlwr of ■i-t.mces iilaucomatous symptoms ' >e develo|M'd after the instilla- ■ "ti of cocaine into the coiijunctiv; . sac or after its use on the nasal '\i-.:\;< ineinl-rati'-. I'.orinc instilled into the conjurictiviil .sjic has, in a few in- tiices, 'iroduced temporary complete blindness and a dopree ti08 riit: EYE. i '. of tiaiisiciit aiiil)lyi)pi:i soim'tiiiics follows tlio injootinn of pilocarjjiiic. l)ut it is a curious fact tl- U wlicu adiuiiiistcrcd internally hoth pliy- sostijiininc and pilocarpint often produce mydriasis. i^andeshur;; lias r.'ported live cases in which opacity of the crys- tMlliiie lens followed treatment with jalxirandi. I'lonininis and Inxdlhinnin.'- found in certain annuals, or as the n'sult of the action of microbes u|>on certain articles of food, such as meat, sausage, oysters, hsh, ice-cream, etc., |>roduce a varii'ty of diseases of the eyes." Many of the ptomaines in their phy.sical proper- ties resemble certain of the vejietahle alkaloids, which accounts for the fact that i)ilateral paralysis or paresis of accommochition and mytlriasis are often observed after poisoniiifi from decomposed meats or tish. Muscarine and neurine produce spasm of acconunodation, while lyrotoxicon r-uises paralysis. Ptosis and paralysis of the extrin- sic ocuiar imisdes have also Ixrn observed. nn(l have iH'cn considered as of miclear orifrin, or possibly due to a basilar neuritis. Infectious Diseases. Infectious diseases, their coiiii)lications and seqnehe. are the cause of numerous eye lesions. Such diseases may 1m' due to siiifile micro-orpuiixms producing wellnhlined clinical manifestations, such as are seen in ftlanders, tetaims, and splenic fever, and are in each instance peculiar to the s|M'citic ap<>ncy which pro- (hices them, or they may result from the more complicated pn)ees.ses by which ditT(>rent !nicr()bes may In- the cau.>*e of the .same group of clinical svmi)toms, as is the case in ery.sijjelas and pya'inia. In either instance the resulting eye l(>sioii.s may be a direct effect of the primary infection, or an indirect result of the mimeroas complicating condi- tions which arise in tin- course of the disciise. The involved aiid intricate naliwe of the subject under discussion will 1k" appreciated when it is reniemlMTed that with many of the infectious proces.ses which are supposed to have a specific cause we may have in various stages of the disease coinplicaticms arising from secondary inleclioiis. This is esix-cially true of those accompanied by abscesses and pnruh'nt proc(>sses, the mixed infection In-ieg due to the addition of one or more of the common forms, such as Staphy- lococcus pyogenes aureus and albus, Sfeptococcus pyogenes, Diplo- coccus pneumonia', etc. Indeed, the clinical picture wliih Is made up of a grouj) of signs and symptoms to which we give a s|)ecial name, is in many instances de|M'ndent for its existence upon the combined action of two or more of these inicre-organis>ns and their morbific products. It is often to these secondary infections, which are so common that we look upon them as a necessary part of the disease, that are due many of the complications which make their apjiearance in the eyes. Knies has made the following smninary f)f the atTecti<ms of the eyes which may occur in connection with infectious discjuses: 1. Hemorrhages in all parts of the iH<ripheral and central visual apparatus, from the most varied causes in all stagi-sof the disease, and conse((uently ev<'ry jMLSsible disorder of vi.sion, motion, and seusation. Tilt: Ali' 7.V /7-.S' RELATIOS TO UESERAL DISEASES. 609 2. Foci of fiilty dcRt'iicration and softoniiiR in tin* central divans and the eye, visiltlc in the retina witli the ophtliainio.scope, and often associated witii iieniorrlianes. .{. InHannnatory dianpes in tiie vessels in all localities, with the aliove-nientioned conse(iuences. 4. More or less ditfusi' inflammations of the tissues of tin- eye, es|K'ci:illy of the uvea and retina, iritis, cyclitis, choroiditis, retinitis, ditTuse interstitial keratitis, etc. Meningitis with its various eye symptoms also devel(.i)s in the s.ame way. " 5. C'han>;es (chronic and acute hemorrhaRic forms) in the ojitic nerve, ciuasni, tractus, motor and sensory ner\-es (multi|)le neuritis). (). Pure atrophy of the nerve tissues (central organs and optic nerve), occurring? after the lapse of years, and jjrohal^ly tiie final outcome of the vessel lesions. 7. Focal hyjx-ra'mias and inllammations (meta.stases) in various dejrrees, from a chronic to an acute hemorrhagic ami jiurulent process, or even terminatinj; in acu:<' fjanp-i-ne. These are foutid in the int<'fiument of the lids (eruptions sometimes leadiufi to };an>;rene), the sclera (sclerotic foci), uvea (disseminated choroiditis and choroido- relinitis, and emholic sup] )urat ions), retina (iM-nign, but usually .sejjtic emholi), orlnt (metastatic suppurations), lacrymal glands (embolic abscesses and dacryoadenitis), optic ner\-e, and brain, etc. S, Specilic neoplasms (syphilis, tulierde, leprosy) in almost every part of the eye ami surrounding structures, and in the central nervous system. The functional result.s of these lesions are: 1. \isual disorders of all kinds, of peripheral, intermediate, ami central origin. ■_'. I'aralysis and si>asm,'« of a ceiitral, nuclear, and |)eriplu ral char- acter, and even due to dinct di-ease of the muscles. ;{. Neuralgias, ana'sth(sia.s, i'lid para-sthesias of every po.ssible mode of origin. I. ( (tlier affections, such as adhesions of the lids in conjunctival catarrh, disorders of lacrymal secretion and conduction in aifections of the hicrymal glands and canal, etc. In infectious diseases which are attended with high fever and cimgestiun of the meninges and cortex, visual hallucinations and illusions also are encountered. These dis- eases may terminate in more or less .severe forms of in.sanity. The eye is in nire instances the seat of the primary infection, and not infriMiu-ntly presents the earliest manifestations of di.sease which attract the attention of t!ie physician or attendant, as in the photo- pliubia and conjunctivitis often seen during the period of i""abation ol measles: but more generally eye lesions, when found in association uiili infectious diseases, are a direct ••tTect of the disease itself or of s.iiiie of its complications or sei,uela'. In studving the great v.ariety of eye lesions produced by infectious diseases, it is well to bear in mind ihe marked ditVerence which is often to l)i' -loted between tnose toUowing an acut(> disea.se and those resul.- tJlO nil: i: > ;;. ini; t'niin tlic iiKirc cliniiiic iiniccssc.-.. An intVclioii iii;iy \iv so inti-iisc tliMl, MS ill acnii' |it(piii,;iii<'-i»ii^niiiii}:. llic system is uvcrwhi'iiiicil. and we tin'l at till' aiitn|>sy, in assDciMliini witli llic ntlicr lesions, exten- sive retinal lienioiiliaf^e as tlie only (•■iilar manifestation of a disease wliicli. liad its onset l>e<ii less rapid, would have ii'siilted in fatty de<;enei:ition in tlie |>aieneliynia of the liver, kidiu-ysand otlii'r organs, ;ind the assoeia'ed ehaM<ies in tlie vascular system. These in turn would, in the more <rradu;il [iiocess of infection, lie accoin|);imed hy fattv de,t;eneratioii in the choroid and retina and secondary heinor- rlia"'es in these str;ictnre,- simil.ir to those found in the hraiii and otiier or}jans. Th- profound infections wiiicli we often ohserve iii such diseases as typhoid, tyjihus, and yellow fever, aid in intense malarial poi- soiiiiiz. are accoinp;'iiied hy alterations in the hlood. and at times tiy cha'ii^es in the choroid, retina, and optic nerve, the exact nature o' whicii cannot he said to Ix- entirely understood, althoujih they sed'i in many inst.-inces to iiear :i somewhat direct relation to the special poisoM c;uisin;i the disease with which they are associated. The con- ditions attendiiifj; tlu' late war with .'^p.iin atforded many illustrations of the elTects of these diseases in eausinj; chaiiiies in the fundus of the eye, and a minilwrof observers have made valuable contributions to our information on this interesting subject.' It remains to Im- demonstrated, however, whether the lesions noted cat! l)e classed as part of the morbid anatomy of the diseases nien- tioi.ed, or siioiild Im- ascribed to intermediate changes de]M'ndent i'.pon tiiem. ami possibly common to other maladies. in the niof' chronic processes of infection in which the interstitial coniu I'tive tissues are largely alTected, or the vessel walls have umler- gone grailual degenerative changes, we have thrombosis and retinal heinorrhag's, and as later manifestations, sometimes making their a|)pe:iraiice years after the original lesion, atrophy of theo|)tic nerve ami retina associated with "videiic's of similar sclerotic changes in tlie brain and spinal cord. A- the general powers of resistance of the patient who is subjected to an infective ]iroce<s givatlv modify the systemic etTects produceil. Ml the condition of the eye may inlhience the course of the disease in that oiiiaii. An old iritis with a jiosterior synechia, or an old |H'iie- trating wound v>itli entangled iris or I'lis capsule, mav iniike the eye far more vuiiieiaiile than d otherwise would be, and lead to most -erioiis conseciuelices when it is subjei-ted to the dangiTs of an infec- tious ill-i :i-e, .\ >ubiect of <:reat iiili'rest in comiection with inlretious diseases m their reliitioii to il yes is th.it which concern- the route by which the eve i- invailed bv the micro-organism^ or their niorbitic prodi; •!•;. In such dise;i^es .'i- mpus of the <kin of the lids, infection may take pl;ice bv direct transmission of die iiiiiiobes or their products irom Ko(!iTv. OplitliHlmic KfiHPl. Oilnli. r, \'W. 77//; /v)/; /.V ITS RELATIOS To CESKUAl. li'SEAsK-S. Oil Is to til tlw ll ii'iiti' iii;iv mjiiiictiv;!, \vliil( n siicii diseases as erysipeias tiie )V wav c't' the orliital cellular tissue ami untie iierv :i- \v :is (il)serve(l liv llie writer ill a w i: ell-iiiarkeil case in a man -ixciity years of ajje, who diet! of iiieiiiii>iitis as tiu' n'sult of facial erysipelas which jiroduced orliital cellulitis. In iiieiiiufiitis the route iiiM\', as ill the above case, he by the optic nerve, or in some instances ll I'liUfth the spheliol lal <inus and orliita! ti>sui 111 <lis pf the respiratory tract the coiiiiiiunication may b (jiiectly by means of the nasolacrymal canal to the conjunctival sac. or indirectly throupii tl rbit by involvement of the frontal, ethmoidal, maxillary, or sphenoidal sinus. ll till diici) III cases ol serious );eneral mleetioii, ami es|M'cially m those m whicl; there is ulcerative endocarditis, the vessels are tlie usual means of ii.iiismission. and either the enormous vascular expansion of the choroid or tiie terminal system of the retina becomes the seat of ,111 infectious process. In svplirniiiid. wliicli is often only the early stajie of an infective process terminatinj; in pya'inia, we have areas of fatty defreneratiim ■ iiid heiiiorrhap's into the retina. The.se are of J^^a^■e inii)ort, as iiidicatinji the exti'Ut of the systemic invasion. I'jiaiiiiii. luiving its orijiin in an inHainmatory or necrotic jiiocess, liKiduciiiK infective emboli, thrombi, or liemorrhafie-;, may result in 'lie dcvelo|)ment of a new focus of infection in any va.scular portion 111 the eye oi orbit, the choroid au'' retina beiiij; most fre(|uently the -I ,ii of this inelastatie process, which may orifrinate in ;ui ulcerative ' iidocarditis or an active phlebitis. \\ liili- Hotli ims anatomically p'-oved that it is possible to have \\liat mipht Ik' termed a benifrri form of metastatic jiurulent retinitis which does not extend to the clioroid or vitreous, it will readily be understood that a rapidly exteiidiiifr destructi\e imrulent intlam- iii.itiiiii of all the structures of the eyeball is the usual result of metas- i.iiic ini'ectioii of the eye in pyaemia. In the l;ite stag's of pya mia, even wiien no septic thrombus has i'luiid its way into the eye. we may iiave numerous retinal hemor- ih.iires occurring immediately before de.itii. Miilii/niiiil puxhile or splmir jcrir. Ienne(| also ;inrhrax. malijriiani ideiii.i, ch;i'-!)on. etc., is somewliat proni" to atTeet the <k'w of the iid- and l.i c.iiise entropion, ectropion, and infiltration of the 'inii'.i. [t may even produce an orbit.al abscess, and severe cases ll ilnii' i.ite stafii's tend to cause retinal hemorrhajics. Enisijuhis. classed iiy some writers as an .atTection of the skin, 'u:w properly be considered amoiiji the infectious diseases. It is ni iiifir(|uently seen ill the lids, thouirh it };''ii'''':il'.v originates else- \li"ti'. ;iiid extends to the delic;ite skill ,'llld loose comiecli\(' tissue I' ihese structures, where it causes marked ledenia, and, in rare iii- '.inces. .abscess and necrosis, which may lead toeetro])ion. Mrvsipelas ! ilie lids is often accompanied by slifiht c.atarrh.-il conjunctivitis and '\\\v cheiiiosis, but oiilv in n-ire instances bv ulceration of the cfirnea. G12 Tin: i:yi:. Acute (hicryopystitis may Ix- causcil liy crysiiK^las, hut is ii(.t()l' fiiMiuiMit occunvi'icf. whilt an I'xafcrhalinii of a clironic iutlarniiiatidii (.1" till' lacrynial sac, or tlic .l('Vclo|)incnt of au cry ii»clatnus iullatn- ination as a coniplicatioii of a iic>;lcctcil (iacryoi'ystitls, is uot very uiicoiMiuoM. and iu such cases tiic innlcrlyiuf; cause soiuct; u 's escapes detection, or the diafrnosis of erysipelas is made wiieii W( aave only an a-ifiravateil case of cellulitis due to retention in a siini)le purulent inllannnation of the lacrymal sac. An extension of the .-ellulilis of erysipelas to ih<" tissues ol the orliit is seen occasionally, sometimes takiuf: the form of an orbital al)sces< and sometimes of a serous infiltration, c.-iusinj; eviilence ot pressure on the optic nerv<' and motor oculi. In the more severe <-aM- there may he extension from iheorhit to the hiain, with resultiiif; menimiitis or simi- thromho>is. and in others exo]>hthalmos with evi- ,h-wv of comi.ressioii in optic nenriti-. with defective vision, narrowinj; of the visual liclds, i^tc. >ometimes terminatin.n in atrophy of the nervi' and narmwinj: of iln' retinal vessels. Throinho.sis of the central vein with retinal heinorrlia',re has heen reporteil in several casi-s, and ptosis and pan-is of the (Xtern.al ocular ,nus"le-, and i ve:-, of theciliary mu<cle, may result. Opacity of the vitreou- and ;jlaucom;i li.ive also l)een seen after ery-ipel;i-.' .\ numtx'r of case- lia\r i.cr ?i recorded in which ;in attack of ery- .-ipelas lias S(>rved to ll.a-leii leeiivei'y in I r.aelli .ma and diseases ot tlie uv al tract. ,and tiii> is in keepini: with wli.at h.as hecn oh- served occasionallv ii; patli-p|oL;ic;tl proce-M< in other poitioiisof the h^.dy. Whethei- we classify rlieuniatisiu as an infect ion-ilisease, or aiihere to one of the other iiiiineiMU> theories .a- to its origin, it is certain that in -oiiie of the nianife^talions of the acute articular form we are dealing with an i?ifeitious proci'ss. and it is |)rol)ahle that in many inst.ince- tin' din :i~es ..f the eye- which ociair ihiriiifj; an attack <if rheumatism are trace.ihle to this cause, it is not clillicult to recofr- ui/.e the action of ,an acute infection in the associateil eye lesions ot ponorrhna! rheumatism, tmr in the lanholi-m of the central artery of the retin.i which i- so Imiuenlly the rcMilt of ulcerative endocar- • lili<, hut there are m;ih\ ci-es of diseases of the e\es associated with ;thno>l imperceptihie rheumatic m.anifestation- in wliii li the operation of ,all infectious pt'oce-- is Hot so apparent. lierurrinf; attacks nf iiiti-. sometimes allernalin>i with the disturh- ;ince in the joints, c^-cliti-. seleiitis, episcleritis, tenonitis, inflam- mation of the hulhar poMii.n ot the ocailo-orhital fascia, petechi.il coniu!ieti\ itis. ;ind iven p.ii:il\-is of the motor ocaili, may follow attack- of .acuii ;irti(ailaf rheiim.atism. (ilauconia, -omelimes uiiforlun.ately associ:ited with chronic iritis, is vt time- seen in the snjijects of chronic rheum.alistM not necessarily ;irlicular in ch:iracter, atid in these cases it is ditiicult to avoid the I ,.^^t■I^ Mid. opl-. !• -■"«■ wm Tl[]: HYi: IS ITS HELATKjS to (iHSERAL DISEASES. 613 inclusion tliat thoro is stmif o tiler cicincnt in addition to tlic infir- timi wiiicii we rt'ciifinizc in tiic more acute forms of the disease M, \i\ I iiial am ts prodromal stajre is apt to be accompanied i)y well- .ked catarrhal coiijmictivitis, with the accompanying pliotophohia 1 lacrymation, and throujihout the course of the disease and often lonji time after the fever has suhsided, asthenojHc symj)toms. uilh weakness of aci(imm< )dation, a tendency to niarj;inal i)leph arilis, superficial vascular keratitis, and obstinate phlyctemilar con- iunctivitis and keratitis are observed. This is esiM-cially apt to be in cases of hyperopia or asti>;matisin, and in such patients local 1 1 IK am 1 constitutional treatment fienerally fail to afford relief, unless tlu (•fraction error is first corrected. These manif<'stations are seen most . ..tly amoiif? those who are strumous or tubercular, though they t times observed in patients in whom it is difhcult to di.^coyer lences of tuberculosis, (i.-mprene of tlu; lids, tcrminatiuK Irequen are ;i nilier evH in ('ctnipioii, h sult«'d in a few instances. • ■ra lia- riiere have been reconli'd several well-authenticated cases of bilat- 1 optic neuritis with resulting blindness, which hi some instances been Dermanent. Thev have occasionally been the result of uasilar meniiifiitis following mea.sles, and hi a few rare instances tlcv h.ive been secondary to purulent otitis media. .Ubumimiric retinitis after mea.slos is extreniely rare. SidHdlitiit is at times accompanied by conjunctivitis, but this is nut so f-ecpiently a complication as in measles, and is not so valuable as an ai I to early diaj;nosis. In the course of an attack of scarlatina, c-pecially when" it is .severe, active phlyctenular conjunctivitis ami kiiatitis niay occur, sometimes n'sulting in extensive corneal ulcers. Dacryocys'titis is not vi'ry uncommon, and in rare instances we have orbital cellulitis with its usual conseiiuenees, even resulting in aiiophy of the optic nerve, and in a few ca.-es purulent inflammation ..1 the lacrviiial pland has lieeii reixirtod. When we consider the fre<iuency of renal comi)lications, eye lesions iiic to this cause are relatively rare, though then' are many recorded .■a<es of ura'iiiii' amaurosis and amblyopia. After describing a number of well-observed ca.ses, J. H. Storey, innliiig Koerster, maki's an admirable summny which seems to be ■'.: keeping with the views of other careful observers. In all of the :,-cs reviewed by the last-named authority " albuminuria was present. II. I tjie amimiosis i.ccurred in the destiuamation stage after a lu'riod I Lreiieraiiy favorable symptoms. The amaurosis was ushered in by . i-.liral symptoms, headache, convulsions, vomiting, and stupor. It ' mic nil sudiienlv. was bilateral, and for a time was complete. No ; liili.almoscopic'lesions were detected, and the blindness gradually rared otT. There cim be iio doubt that these cases must be da.ssed - ur.i'iiiic." W iici, ciiroiiie iiephrilis re- uHs from scarlatina, we may. of cotii-se. : I lati r period have liie '!sual retinal and nerve h'sions of albu- •iinitria. Meningitis following .scarlatina may result in paralysis of G14 rut: icYi:. tilt' dptii' iHTvc and. rarely, in partial or niinplctc paralysis of out' or niort' of tlif ticular iimsflfs. lAfM whfii iiti rt'iial dist-asi' lias f:;istt'il ami im alljiiiiiiii lia> lufii ft)iintl ill till- uriiif, iii'iiforctinitis lias bffii ohst'rvt'il. Puriilfiit otitis iiifdia, wliicli occurs so tiv(|iifiitly afttT scarlatina, may. hy fxtt-nsioii of tlif inllainiiiation to tlic incninfii's or tin- tlfVclo|)- inciit (if a sinus tlironilxois. lead to |iaraiysis of tiic ojitic ncrvf or of tlif fxtt-rnal ocular imi.scli's, to secondary infection of the retina or clioroiil, or to ahscess of tlie orbit. Acconimoilative astlienopi.a is not uneoinmon after scarlatina, as after all of the exantheiiiala. and is iiuicli intire prone to reciu- if, as is often the case, there is a pre-exislinj; error of refraction. Dililithrriii may l>e accompanied hy ;i most ileslructive form of conjunctivitis with a ch.-tracliristic densi' intiit ration in the siihcoii- junctioil tissue; hut this ccimplication is, fortunately, of extremely rare ticcurreiice in this country. The ocular lesion most frei|Uently met with, and one of extreme clinical interest, is the p.artial or, nirely. complete paralysis of accom- modation, which comes oi rapidly, and at times sudileiily, from three to six weeks after the a|),)earain f the pharyii<;eal lesion. ;ind from two to three weeks after apparent recovery. It is much more fre- «lU('iit ill children than in adults, and often apjx'ars after ca.ses of diphtheritic infection in any part of the hoily, and which may 1m' .so mild as to have entirely escajM'tl detection. The paralysis is almost always liilateral, thoufih there are excei)- tioiis. and it rarely ;ifTects the iris. It lasts sometimes for months, disai>pearin<;};radually, even when not treated, thoUf;h the correct .on of refraction errors which impo.se an lidi lit ional Imnlen upon thecili.iry iiiasch', an.i the internal administration of stryclmine and iron, exert a favorahle influence and shorten the ])eriod of its duratitiii. Complete or. more freijueiitly. jiartial jiaralysis of the external ocular muscles, indicated hy tropi.a and ptosis, is not very uncommon. Neurojiaralytic keratitis from involvement of the fifth nerve has been reported, and .also ;i nuinher ()f cases of concentric contraction of the visual field, with defective color visitin, which latter Koeni^ h.as attributed to retinal aiia'sthesia. \\ hile in r.are instances henioniiajies ha\(' been observed post-mor- tem, near and even in the nucleus of the third nerve, it seems more p-ob:ibie that, as Voelckers has jxiint. d out, the se;it of the lesion is in the nerve terminations in the affected niu.scles. Knies has foind it dillicult to account for the plieiitiinena of diphtheritic |)aralysis of accommodation, exceptiiij; on the theory that "a definite i)tomaiiie is produced. ;ind th;it thishns a paralytic action upon accommodation, while it has no influence upon the movements of the pupil." N'ariola before the introijuction of vacciiuition u.is a most prolilic cause of blindness, it h.ivin^ been estimated that in (iermany .T) per cent, of all cas(>s of blindness were due to this tliseiise. This per- centajre has now been trnatly reducctl, raiiffins, acconhnji to ruclis, ■■■■H mmm Tin: i:yi-: is its helatios to oeseral diseases. 01.-) Inim 2 IMT cent, to .■{.(■) jxt ci'iit. The same iiiithorily states that llic eyes arc atTcctol in frniii 1 per cent, tn 11 per eent. of all eases 111 variola, aeeor<lin>!; to the statislies of various ohservers. Altliou^th MJniost every portion of the eye may be affi'Cted, vision is most tn'(|iieiitly lost by extension of the inHamniatory jmu-ess from the ccinjuiietiva to the cornea. Tiie skin of the litis is a fre(|uent seat of tlie eruptioii, and it may cause (edeiiiatoiis swellinft, hi-morrhafiic intiltration, ah.-ces.ses, phlep- nions. and furuncles or h.calized loss of tissue, which latter is especially -erious if the pustules form on the lid margins, where Ihey are i\\\X lo l( ad to trichiasis and ectropion After the eruption has subsided Hicre is a tendency to the formation of abscesses, boils, and disturb- ance of the filanduiar structures of tlie skin in other portions of id tills is seen also in the lids, where we have iiiarpinal ■ilyes. obstruction of the .Meibomian frlaiids. fctropion, nd permanent thickening of the lids, or, if the destructive llie tiicl body, ihariti liasis, a proce: in some c has iM-en extc'isiv(>. gr real distortion or loss of lid ti.ssue, and, ases. even p'riostitis and caries of the rim of tlie orbit have been repnrteil. \s in mi-asies and scarlatina, the conjunctiva is a|it to be congested, not and there is not iiifre(|ueiitly iiillammation ;ind we may havi- catarrhal conjunctivitis even when the eye die seat of the erupti( the miicou> membrane of the lacrymal i>a,'<saf:os The pustules of smallpox iray form on any portion of the bulbar jimctiva, and rarely on the palpebral mucous membrane: but their '■III'.. favorite location is near the corneal maiftin, when I th 'V are sm i Her iiaii when seen on the skin, .and jiresent the appearance of cor.junctiyal tenules. There is s<'vere inflammation, with chemosis and aciive lily( seen ■tion, as in pundent conjunctivitis, and secondary corneal infeo lion is very apt to follow ([uickly, v.itli hypopyon and all that such a destructiv- priK-es.' means. Some authorities deny that tiie primary erujjtion is over seen upt cornea, and occurring, as it u.su the appearance ol !dlv d( nianv davs after til. f the cutaneous eruption, or even during corivalescencf s probable that the corneal infection is a secondary jirocess w It IS] a- Kl hich has suggested, may be held in check by the diligent use of ase]itic and antiseptic treatment. JA-eii when there is no conjimctivii: nor evidence of eruption on the eveball, we may htive corneal involvement, due ap])arently to In.a! infection by morbid material circulating in the blood. Indeed, this is bv some authorities said to Iw the most fre(|uent type of cor- nt (Sturvl. It occurs usually as a late manifestatinn. Ileal mvolvemi .an I is aj)t to be :iss( iciated with or followed by ,';uch serious comi lii- ilions in otlier organ that a fatal termination is not imcommon. Iritis, u.sually as ;i part of an anterior uveitis involving a low grade of t is. vitreous opacities, and more or less involvement of the choroid rvcll 1- not an uniisua IHl! 1 nianifestii'''in during the lute stages of variola, and ated areas of choroiditis an- sometimes, althougli rarely, observed. ' (Jl(i THE EYK. \ few cases (>f iiiMirorclinilis ami lii-iiinrrliafics iiitu tlir (iplic iicrvo liavt IxM'ii ili'sciil It'll, ami imin> wuiiiil prniialily lie n |>iiil('il if u|)liilial- ni()>('i>|m' ('\aniiiiatinii~ wvyv iiior*' ciiiiiiiuin. Sccniidary ii('|p|iiiiis is (•uiiipaialivfly rare, hut is sdinrtiim's iiicscnt, ami may Im- a('C(tiii|i,irii('il by uia-iiiic aiiiaiiiosis ainl alhiiiiiimiric iftiiiilis. ViKvlnutiitH. like ntluT iiii'i'ctiitiis pniccsscs, may cause ilisease of llie I'yes. llczema ul' the lace and plilycteliular discas.' ol tlu- cdIi- juiK'liva aiul curnea. wiiicii sdnieti'iies follow or accoiii|iany va<'ciiia- lioii. are of comparativi'ly sli;;lit importance in healthy jiatients, hut in children and others of feeble tonstitiiiion ihi-y may puisne a tedious course. Accidental vaccitiaiioii of the lids, conjunctiv.a, and rted man*" times, and. whether from a vaccine coiiiea has heeii rep I'ustule or from a lymph tu!i<'. produces a most serious inf.'clioii. If the cornea is .Mliecied. it is a|it tolwcomethe seat of active infiltration, stroiijzly resemblinir a vaccine pustule. W hile the tr.'iiismissiou of other <liseases by vaccinaiion is not so I'oniinon as is jienerally suppoM'd, it is by no lueaiis impossible for such a result to follow when the conditions are favorable, and when syphilis is transmitted we may have iritis and the other usual luani- fesl.itious of thai disease Ml the eve. V iiririlld nsrelv can ics (>\-e complications, but on(> instance is recorded of iritis accoiiipaiiieil !)y hy))opy((n. TiipliDhI Fivrr. \ dcfiree of hypera'inia or conjunctivitis may occur in typhoid as in other fevers, and phlyctemilar conjimctiviti.s and keratitis are not uucotninon dnriii!; convalescence. Kerato- malaci.'i may result in serious cases, and, with the profound and pro- loni;i'c| <onniolence which is sometimes a characteristic of the late stages, we often have xerosis of the cornea accompanied by infection from exposure. .\ ;;anjiren(ius iiiflatmnation of the lid which rarely makes its appearance is apt, if the patient survives, to lend to I'ctro- pi<in. While noT very common, v.arious afTections if the laeal tract an s.imetinies pn-seiit. as anterior u\'eiti>. pl.islic iiiti- i\clitis. choroi- dilis. ;ind choroidoretinitis, with their :iccompan\in!.; changes iti the vitreous .III 1 later in the lens. The ireneral nuis<'ular weakness wiiich often char.acterizos the |>eriod of convalescence after tyjihoid IVvcr manifests itself in the eyes as proloiiireil .and sometimes extreme v.e.ikness of accominod.i- tioii, produciu}: much more marked symptoms if i^iijxm.itisni orhvper- metropi/i is present. In addition to accon.nioil.itive we often have muscular asthenopia, esjiecially if a manifest or latent imbalance of the external ocular muscles is jiresent. 'I'm,' i aralysis of the external muscles, with deviation or ptosis, is rarely, th,.u!ih 'onuMimes seen .is a conse(|uence of typhoid feviT, juid, as Knies has well said, sh(iuld siiirtrest a careful study of the urine. The \-;iiious diseases of the br;iin .Hid spinal cord which are <\fi-\- sionally seen ,is seipiela' of typhoid fever iMa> be accompanied i)y Tin: HYt: IS ITS iu:l \tios to hhskral diseases. «i7 cliaiaclcrislic Www of tin- "I'tic i»i'rv<- anil retina. I'.ithiT dnriii); or after tlie attack w-- may liave retro!, illiar neuritis, followed ill some instanci-s hy atrophy: and neuroretinitis with macular li( iiinrrhane has lieeii reiiorted, as have also cases of amaurosis and hriiiianopsia, ap|iarently due to cortical disease. T'liilni^ jcrrr is known sometimes to cause catarrhal conjunctivitis, iiillammation of the rveal tia<-t, and oth<r lesions similar to th.x- ,.i.-.( ived in typhoid fever, hut few instances of such complications 1ki\c liei'll ]iul)lislied. Tfii'liKs nri(rri'i,.< or rilniisiini frnr, like typhoi<l and olher fevers, (MUses more or less catarrhal conjunct ivitis, and may he .•iccom- paiiied hv phlvctenular conjunctivitis and keratitis. It lead- also lu def^r'nerat'ou .and wi-akness of the nnis. iilar system, which result in accommodiuive .■'iii muscular asthenopia, especially noticeahlo durinj: convalescence. Directly or iitdirecliy. the poison of this irver^may so alfecl the vi.-ual centres, the tract, or the optic mrve. a< to cause temp.rary or per!iiaiieni hiindne-s; hut this i~ of rare occurrence when compared wiiii the le-ions of the uveal tract which often make their ap|)e;irance as la!i' manitVsta- lions or, more properly, as .se(|uehe of lyphus recurrL'ii.s. _ A ditfuse iiillammalit.n of the uvea, and especially of th.' ciliary hody, varying in intensity from little more than a mild hypera'tiiia i(. an active purulent cyclitis. may he found, and tiiis complication in:iv result in only a slight clouding of the anterior portion of the Mireous. which will clear away comi)l«'tely in the course of a h-w weeks, or it may lead to an active choroiditis anil retinitis, with puru- hnt inhltration" of the vitreous and suhsequent phthisis liull)i. It nv.|iientlv assumes the form of an anterior uveitis (serous iritisi, 111 1 sometimes is accompanied hy hypopyon. < >ne or both eyes niay ..■ iffected, .and while its occurrence as a complication is not iioces- irily dependent ui'oii the severity of the general di^easi-, ocular ie-o'iis are of far more frociuont occurrence in some e])iilcmics than in ethers, Kiiies, who has written quite fully on this sul)ject, [.omts out the ' IV import.iiit fact that analogous clianges jinihahly take i)lace in he pia mater, hut those appearing in the uveal tract, owing to its inti- !i .i|.' lel.ition with the retina .ind vitreous, are much more apparent, W liile occlusion of the pupil hy the exudate from the ciliary lM)dy iihl in- and den-i upacitie- of thV vitreous, oi even secondary detuch- Ill ,,r the retina, may re-ult in severe eases and lead to blindness, ■'le prognosis is not generally utifavoraiiie, as 'lu' ring of faint vitreous iMiities is. in a large proportion of cases, sulii^ 'ciitly ai)sorl)ed to ■iiiiit of good vision. Miiliu-nt may modily various disi-is-s of the eyes which are due to ■ ihi'r causes and giv"- a p-ri idicity ti) their manifestations whic!i .Ids to 111" action of quinine, [t may produ'" disease- of other ri,',iiis wiiich indirectly affect till eye-, or it may ho the directcau.se ! di-;'ase of the eves. 1 1" HI 1 } ' lii i; i g <{I8 J III. j:i /:. l*cTi,Mli<- iii«(iiiiaal M-'iiral;;iu, p arnillynf the siipra-urhital liraiich, i> '|i ■•'• <'"iiiiiinii. aii.l .M-, .i,i,,ii.illy inic ciliarv ii.MiraIi;ia i-. .Im- I,, llii.^ caii-c. ( 'iijuncMviiis an. I |.laMic iritis havi- Ix't-u ilc ■ ■ ' i',|. hut ari' rare, Wliilr k.-|;,!iti, is ,,|- .otupaMtiwIv ilv. |ll.-lll . . ill'lvilc,. \..||rn- paralylic :,>A nil.T,|iii; ' k.Talilis arc scfii at liii.o !.m, ,., „„„.,, !"""".""" '"'"' '■■ "li' : '- ''11 1 .l.'ii.lritio k.'ralilis. w|,i-h prcsnilv itsi-ll as a MiiM-rticial iiililtralic.n with iiarr-' v irrrj;iiiar >lr.'aks ra.lialirii.' Irm,, it, soturtiiiii- a-iin.iii>r lli." jnriii „i a s..r|.i.n,„',„s Hirer. Ulirli l|,|s |,,rir ..t ...rural illtiltralioll is IuuimI ;,>-c„i ilr.l with trn,lrr..rs,s HI, |.rr»u.r .,vrr tl,r sii|,ra-url.ital tirrvs, nuii.i;i<. HI hill ilos.s is ii„l„;,lr,|, in a.|.iili,,i, t(. siirh ..thcr h.ral aii.l Kriirral tn'aim.'iit a-< ip iv !..• luiin.i a|.|.r,.pria<r. l|,i,,rti<- coriiral r-ii|.tiuiis arr aIsM <.itn<.|i,M,w srrii alirr |.r<)l..iif;r,l attacks of malarial Icvrr Muscular paralysis has ranly |,r,.|i tM,tr,|. au-l trmpnrarv aii.i rvrn pcrniaiicnf ainl.jyupia aihl aiiiaiiruM-. arc „( i,„| vcrv ■iiilfrnii,.|it occiirrci.c.-. Ihr ainl.|y,>pia may i.r arr„i>ipaMir,| |,v ,;•„!, -mata ..r cyt<trarltnll n| ihr prriph.Ty „i thr visual lirl.l. I'rrmailct.t (IcIVcK <'l the vi-.ual hrM arr ,!,|c U, partial atruphv of th.' optic iktvi- ati.l occur imly m ihr morr srvrrc cases of malarial |.oisoiiiiij;. As Kiiirs has poititr.l out, a hirjj;.- proportion of r ^rs'^of malarial iiml)lyopi.i ,111.1 amaurosis arr prol.ahlv ..f .•riitn,! j.^i,, .„i,| when OccuiTMlj; at tl,.. o„.s,.t of tl„. attack he co„si.|,,s thrui to h- thr rrsult ..f pt..in,am.-pois,.i,ii,}:. .\ f,.w i„staiir.s of malarial hrmian- oi.sia havr I, „ n.p..rt.Ml. T..rporof thr rrtina .•im.,ui.tiiifr t.. iii.rht l.lm.liirss occurs (lot mfiv,|uci.ily iu chronic malarial poisonii..- fm.l Haas has ol.scrv.i a cas.. of hluc visi..i, apprarii.j; with a n-uulir prrio,!., ity, with ..th.r ovi.lciiccs of iiifrmittcnt frvr au.l .lis^o,. pcaniiK .ait.'r thr a.lmiiistrati.m of <|uiiiiii.'. ' The pr.,!rn,,>is ,,f ,n;,larial aml.ly.ipia ati.i amaur-.sis 'is cf-ncrillv not v.Tv irravr, ali!,.,uuh in rare instanc... serious ,1,-fccts of vision may na.i.m. My inr thr most imp..rlant h'sions rrsultiuR from nialaiial mt.rtion app,.,,r m thr uvral tract, n-tina, an.l optic nerve (.i-av.' cas.'s .,1 malarial p.,is.,iiiiijr arc son„.titnrs accompatiir.l hv mtra-ocularl„.m..rrli.i!:es\vhi.htnayappearattl uset of the .lis,,,s; Mit ar.' moiv .•,,,,Hn,,u it> tl,.- lat.T sta..:.s: au.l l>,.nc..t has estal.lishci tl.r act that tiie accomp,auyin^r ehaiijr,.s in the choroi.l an.l retina •"'■ ''"'■ !" <'''^"'icti.,M of thr c: larirs an.l smalirr ves.sels l.v i.iir- ■"•■>it tiak.'s an. oth.r ahnormal eLmietits in the l.loo.l. Me f..un.| .m aut..psy •■,,., Irma. h.in..rrhajr.'>. I.'si.,ns „f th.- walls of tli.' v.'s.cl-. an.l thr.„„l,..s,s ,.,,.i stnall inllan.matorv fori with an.l without pi.- Thr "iircus opaciti.w. ..xu.lativ retinitis an.l c!,..roi.litis an.l hemor, ha-.' or .Au.latiot. int.. il„ ,,,,tic n.Tv.. mav r.sult iti seri,„,s •1^ t..<.ts ot visi.,n, hut f,.rt.mat..|y s„rh r,-,;h. ar- ..f infrciuent occur- rence, ' Injhionza. whi.'h mav h,. an imp. vumi f.-ctor in ti,e causation ..f .lis.-ases .,f alm,,s! ,.v..,v .„•-„, in t|., h.,.ly, makes no e-'eptior, of TUK KYK I.\ JTS IIKLATIOS To HESEIt.lL DISEASES ,jij, ilic f'vc; Itiil wliilf ill its iTnilif cmirsc it niMy pnnlncr an tiliiutst inliiiiti' varii'ty i>f ryi' ^ymiildiii', tlnTi- is liiilc iiiiil'nrmily in tlicir •liaraclcr. ami U'W nf tlirni a|iiH':ir wilii ^w\\ tictnifn<y as to make ilicni txpical inaiiilrstati<iti>- uf this disfasc ill i| |iliiiti ('iiiijiiiictival li,\'|i< lairna, with iiinri' nr less lacryiiiatKni am |ili<>liia, is (if rxtrfiiicly tfciiiicnt ncciirrciicf as an early niaiiilisiatiun, and, <'s|M-cially when tin- lia^al iniiciiiis incnililaiii' is acti\''iy iiivcihcd, M' may have an a:aitc catarrlial or iiiiicciptirnlciil i-iuijiiiictivitis. I'l '•-existing; ciinjiinciiv itis in its varnnis lornis is apt ti> ni' acirra- vatctl, u'ljcnia nl the cnnjunctiNa may !"• |irrsciit. aiiil sniiictimfs we have a niimlicr of minute extra vasal inns nf hlood intn the con- jniictiva as a re>iilt of the attaeks nf severe (•iinjriiinfr. (ICdenia nf the ii|)|)er lid- is sumetiines iireseni in the |ieriud (if eiinvalescence, and rarely intlammalimi (if the lacrymal fjlaiid has lieeli kiKiWn til de\('l(ip. A deep aliscess (if the lids is seen at limes ;is a late inanifestatinn, and has lieeii atlriluiieil tu inxdivement of the frontal ^imis; and Imrdcdla are of not infr((|iient (lectirrence. while enilmlie nrliital swp- pnratidii has lieen recd^nizeil in rare cases. Dacrvdcyslitis is apt td develop if a stenosis has already existed. I'aresis df aecdiiiniddatidn as a se(|uela nf inlhienza is not very luieommon, Imt true paralysis is rare, and nuclear or peripheral paralysis df the extrinsic ocular muscles, allhouftli sdinetimes seen, is df very iiifre(|uent dccurrence. resulting; in trdpia orjitosis. Hle|ih- aii /s]ia.sm is found iiKire fre(|uenlly. The iienraljric pain and ten- derness of till" <'ye and its surrmindinjis are proli.-ilily due in lar>;i! part, as Knies lias suf;j;'''^t''<l- t" i' '"W form of orhital periostitis, resultinji from disease of the mucous lining; of the frontal sinus and other periorbital cavities. Phlyctenular keratitis, at times associated with phlyctenular ron- junctivitis. has occasion.ally Im-cii reported: and alsd iiiinctatesuper- ticial keratitis and herpes df the lid .■iiid cornea, in the latter situation Sdinetimes a.ssuiniiis the form to which the term dendritic has lieeii ipi ilied. Varidiis affections of the uveal tnict have lieen reported, althoiisili il is not so fre(|ii<'ntly involved as we would exjiect when we remeni- lier how often influenza occurs in those of such ap" us to have vul- neralile lildodvssels. .I'.idjliiiK liy his persdn:'! experirtu"', the autliiir Wduld say that ;i low jrrade of hytilitis is the most fre(|uent iii;inifest;ition of involve- t of the uveal tract as a s''i|url;i of itiflueii!!;i, altliouftli liyperinnia men if the plastic iritis, omholic liilocyclitis. purulent uveitis with lypojiyon. and even paiiophtl lann tis. h lave iM-en n ported, and cases ve heen descrilied which result(>d in thi> development of !i purulent lenomlis Non-se|itic einhdlism of the central retinal artery has lu-en reported in ;i lew cases, hut in so rare a complication we slioutd hear in mind the possibility of a coincident cau.se. Although not of fre(iuent occur- MICROCOPY RESOLUTION TEST CHART ANSI ond ISO TfST CHART No 2! 1.0 I 2.8 12.5 Si ^ ^ r_ la 112.2 I.I ■- ■■■■ 2.0 1.8 1.25 1.4 1.6 .= APPLIED ItVHGE Inc G20 THE EYE. 'W i ! iviii-c, :i imiiihcr (if instaiicos of o) w neuritis li;ivc he('i\ recorded, sdiiie n'sultiiifi ill pailiai. and otiieis in cdniplete atropiiy of tiie optic nTve: and B.T<;er menlions several cases of temporary amaurosis wliieh were proliahly due to tlie toxic effect of tiie ptomaines devel- oped diirinj; an attactc of inllueiiza. (ilaucoma lias been known to l)e p.recipitated liy an attaci< of iii- lluenza, i)Ut it is prol)al)le tliat defective bloodvessels and other nnravorai)le condition^ contributed to this result. Wliniipiirl-c'iiifili. (\injuiictival iiije('tions, photophol)ia, and lacry- niatiiiii are not iincominon in the early stages of pertussis, and phlyc- tenular disi-ase of the conjunctiva and cornea, sometimes occurs as a sei|iii'la. . . . But while we occasionally meet with evidences of disease ni the eyes which may be -^aid to result from indirect action of the in- fective agiMit, i)V far the larp;er proportion of the ocular mani- festations are of" purely mechanical origin, and result from the in- creaseil iiilravascular tension due to the si)asinoiiic cough. Hemor- rhages in the con,iuiictiva and lids are absorbed within a few weeks, leaving no trace, ami small hemorrhages in the orbit may escape notice? while large ones, which fortunately are rare, may cause e.voph- thalmos. I'aralysis of the ocular mr.sc!'. s may occur, with couseiiueut stra- bismus or jitosis. and is due to hemorrhages. Convergent siiiiint. the earliest aiipearauce of which so frequently follows the various infectious dise-ises of childhood, seems to occur with great frequency after whooping-cough, though it is seldom due to paralysis, and is" associated usually with, and in a large niea.sure depi ndent upon, hyi)ermetroi)ia. Mkidjix. In adilitiou to o'di'ma of the lids, conjunctivitis, kera- titis, and rarely iritis, mumps may, like other infectious (Mseases. occasionally be the cause of serious congestion or even iiiflaii'matioii of the optic nerve and retina, or primary optic nerve atrophy. Par(>sis of the ocular muscles and of accommodation may result, and metas- tatic iriilocvclitis has been reported. Liki' the testiel(>, the lacrvinal gland may be the seat of an inflani- malioii ajiparently due to the same -ources of mfection as that which produces the parotitis, or at least secondary to inliammation of the parotid gland. ('Iinhrii. With the sudden onsi-t of emaciation and great lo.ss (li blood serum which are characteristic of it. cholera produces a striking •iiaiige in the expression of the eyes, and often is accomiianied by pn.founil lesions in the deeper structures which, to a limited degree, m:iy be seen in severe ca-^es ,,f other forms <if diseas" of the gastro inti'siinnl tract, -udi as choleni inf.uitum ami ordinary choli-ra nmr- biis. The cyanosis ami shrinking of the eyeballs into the orbit, with shrink.ige of the lids due to tibsorp'ion of fluid, and the weakness ot the orbicularis palpebrarum muscle, uilh il> resulting inipirfect closure nf the palpebral fissure, give to these cases a most striking rut: EYE IS ITS RELATIOS TO OESEIiAl. DISEASEX. G21 ami alarmiiijj; ("xprcssio-. Tlicrc is a lack of secrotum, result iu« in <;r('at drviicss of tlir coiijuiictiva and cornea, and it is said liiat niMllicr tlic fircat pain imr the i-ontact of irritatin;^ suiistanccs is sntlicicnt to provoke laeryniation. Wliile by a great effort tlie i)atient can elose the lids, they habitually remain i)artially open, exposing thi' inferior bulbar eonjunetiva and lower i)ortioii (if the a|)turned eornea, which often beconies the seat of an 111 -IT and, if the patient recovers, of a leucoina. The exposed conjunctiva niav be merely injected or in more severe cases inHained and xerotic. A peculiar "form of irregular grayish patches, some- times isolated and sometimes conHuent, is seen about the corneal border in severe cases. They are attributed by Knies to choi(ii<lal hemorrhages shining through the thinned sclera, and are of grave prognostic significance, as are also the spontaneous hemorrhages which at tinu's ai)iiear beneath the conjunctiva. .Myosis seems mor" common than mydriasis, thougii the latter is sometimes observed. Active reaction to light is a favorable prog- nostic sign, while even in apparently mild ca.ses innnovalile pupils almost certainlv indicate a fatal termination. Owing to the weakness of the cardiac imisrle and the marked lowering of the general intra- vascular |)ressure when the disease is in the algid stage, great varia- tions in the appearance of the fundus are to be noted on light digital press\n-e <luring an oi)hthalmoscopic examination. An interrui)tion ,,f the blood current and intermittent circulation is someliin.'< ob- served res(>ml)ling that which accompanies restoration of the . rmal movemiMit after an einlxilism of the central retinal artery has been displaced. Ydloir Fever. While many cases of yellow fever exhibit no char- acteristic eye lesions, we may have intra-ocular hemorrhage with its serious consefiuenct-s in unpaired vision, or ura'inic amaurosis asso- ciated with cerebral symptoms, and in either case the prognosis is "■I'.'IX'C. "" S!ii)!iilis in all of its stages may atTect the eyes, and while the course it jnirsues in this organ depends much upon the virulence and the stage of the general infective process at the time the eye is in- volved, and upon the part affected, no portion entirely escapes its ravages, although the uveal tract, because of its great vascularity, sei'ins to be its more usual jjoint of selection in the ac((uired form, .•md iritis, eyclitis, choroiditis', and hyalitis are its more common ocular manifi'stations. Sy])hilis does not very frecjuently pmihice absolute loss of sight, Mangus having found 2.2 per cent, of blindness (hie to this cause; but, especially in large cities, where syphilis is more or less common, it is a freciuent cause of marked impairment of vision. Alexander, from ,1 studv of the statistics of eight (Jerman oi)hthalmological clinics, has estimated that L'.K) per cent, of diseases of the eye are the result ,..f svpliilis This would probably ho a high estimate if it applied to botii hospital and private practice, at least in America. (i2-2 Tin: i:yi:. Our attention will iirst 1)0 diir.-tcl to acMjuircd syphilis m its varicms forms, the suhjirt of conf^fiiital or liciv.litary sypliilis hciiif; consid- ered later. The initial lesion may be fonnd uiion some portion ot the eye or its appi-iidaires.and, if we except the <;enital orfians and tiie mouth, this is relaiivelv a frciiuent iioiut of jjrimary infection. Hard ciiancres have Ikhmi foimd upon the lids, especially at the fre(> maifini whi-re the cutaneous and mucous surfaces join, upon the iialjiehral conjunctiva, the plica semilunaris, the caruncle, in the retrotarsal fujiis. very rarelv upon the bulbar coiijum liva, and even upon the corne the most common locations seem to 1k' the caruncle and free margin at tiie inner canthus and along the lower lid. Infection may l>e tlie result of a kiss from an individual with a mucous patch on "the mouth, or from contact of infected fingers. Instances liave been recorded ill which attendants and physicians were infected in tlie latter manner while treating syi)hilitic patient.'^. The characteristic hard sore (level -, first jiresenting the ai)i)earancc of a pimple, which later breaks wn into a sliallow ulcer with rounded edges and an indurated liase. Th;' enlargement of the lymphatic glmids :it the angle of tlie jaw and in front of the ear, which is ([uite diaracteristic and sometimes extensive, should aid in distin- guishing a chancre from simple ulcerations due to other causes. Though recovery mav be (|uite complete, the induration often con- tinues for nianv niuiiths, which is ajit to be mislead ng, unless the ca.se is carefully observed. Hard chancre of the lids may b(> confused witii epitlieliai cancer, and chancroid may be found in the same locations, making it necessary at times to await the dcvelopniont of secoiidarv manifestations to determine the cause. Secondary manifi'stations in the form of roseola or acne-like eruptions liiav aflect the skin of the lids and cause loss of the lashes, and characteristic ulcerations of the tertiary .stage nun- appear later. Rarely there are mucous patclies on the pali)ebral and even upon the bulbar conjunctiva, and gummy tumors of the ocular conjunc- tiva have been seen, ile Schweinitz mentions an inflammation of the conjunctiva assuming the form of a catarrhal conjunctivitis (ir fc.Uicular trachoma, develojiiiig "in an •Muemic and rather colloid- looking conjunctiva," which yielded only to antisypliilitic treat- ment. .\n interstitial or gummatous inflammation of the lacrymal gland has been seen in rare instances, and syphilitic disease of the perios- teum and secondarily of the bony walls and orbital c(mtents is of relatively frei|uent occurrence, causing protrusion or fixation of the globe and 'ill of the evidences of exudative disease or tumor in this region, sometimes going on to sujipuration .and the formation of fi.'^t.uhe. A careful stmly of the history and other manifestations of svjihihs is necessary to determine the true nature of sucii cases, and a po.sitive rilK EYE IS ITS UELATIOS TO HESERAL DISEASES. 62:3 iliiilliiosis is sonictiini's made only after tin- syinptonis liavc yielded to alterative treatment. >y|ihilitic disease of i nose not infre(|uently li'ads to disease (if the inneous linin<;. periosteutn, and Ixmy walls of the lacryinal liassap';*. liroduein};; dacryocystitis, and later firm stenosis or hony ufclusioii. The uveal tract, as has been stated, is the point of selection lor syi)hilis of the eye, especially in the seeonchiry stafi'". and. owinji III the inthnate relation of the choroid and retina, and the deix'ii- dence of the vitremis humor upon the uveal tract for its nutrition, we are apt to find an extensive inilammat ion of one luirtion. inyolv- \n<i the others to a j;reater or less dcfiree. This is more especially true of chronic disea.ses, in which prolonfjed impairment of nutrition plays an important i)art : but it is jirobable that the ditTerence is only one of defrree, and even in an acute i)lastic iritis wo have, to -lime exte'.ii, a secondary involvement of the whole uveal trad and incipient chanjies in the retina and vitreous. Triedenwald' has demonstratf^l that in every case of iritis a prop- erly conducted examination will reveal deposits upon Descemet's iiK^mbrane, which is the only j)art of the uveal tract, in addition to die iris, in which .such an investigation can be satisfactorily made duiing the active stage of iritis. Plastic iritis as an early manifestation of general syphilis com- monly makes its appearance between the second and ninth month after the initial lesion, though it may appear many months later. Hoth eyes may be attacked simultaneously, though it often liai)pens iliat pVomjit and vigorous treatment will jirevent involyenient (if the second eve. Authorities differ as to the fretjuency of iritis in -yphilis, some placing it as low as 0.42, while others state that 5.37 |ier cent, of sv])hilitic patients have iritis. Alexander, who has made all extensive"researcli into the statistics-, of sy])hilis, i)laces the pro- portion of cii.ses of iritis in which syiihilis can be assigned as the can.sf It from ;«) to m per cent. Simple, plastic iritis of syphilitic origin !.as no characti'ristics which of them.selves prove its etiology, and the iamiosis of syiihilis nnist be ba,se<l upon other evidence: but in a rtain proportion of cases, variously estimated at b') to 20 per cent., ■\i' hiive "iritis gummosa, papulosa, or condyhimatosa, which is illicientlv tvpic.al to afTord a fair basis for a diagnosis." Often asso- iateil with a small hypopyon, we find in these cases a yellow or dull I ;mge-colored nodule, generally situated near the lower margin of he pupil ami surrounded by a narrow zone of red. In the later asres of severe svphilitic infection, we sometimes hav(> large giuniiiy ;mors, almost tilling the anterior chamber. With the exception the cryst: Mine lens, any ])ortion of the eye may bo the seat of a philitic \i->. .;. taking tlie form of a gumma or interstitial inflam- lation accompanied by atheromatous thickening of the intima of ' Arch. ilOiihtalmiil., vol. xxv. p. 191. 624 77/ A' /.TA'. i the l)l<H)(lvcss(<ls, vvhicli rUm ivsults in occlusion: and as those vas- cular lesions .In not entirely (lisai)|)ear un.ler treatment, tl.<-y some- times lea.l in the eve, as they .lo in the hrain, t.. the nni.ancl nutri- tion, h.'inorrhases.'etc, whidi account for many ot the m.lirect late manit'estations of .syphilis. . It is of "i-eat imi-ortance to hear in muul that antisyi.iuhtic treat- ment can have little elTect upon such late lesions, and it l)y no means follows that a lesi<.n of lonj; standing is not of syphilitic on^'in because it fails to respond to aiitisvi)hilitic treatment, .\nterior uveitis ol the form sometimes si-oken of as serous iritis or descemetitis may l.e fomid as a result of syphilitic infection of an asthenic ty|)e, Dut .<ucli <'ases are of rare occurrence. Svi)hilitic cvditis and choroiditis of almost every decree of seven y npp'ear with relative fre-iuency, and the latter is associat.;d usually with r Mnitis and hvalitis. While a lar^c proportion ol ca- -^ ol choroiunis have their orifjin in syphilis, it is the opinion ot the writer tint thi' t(>xt-l>ooks on ophlhalmolofiy have pven undue weifilit to this disease as an etiological factor; and thoufih stress has heeii laul upon n'l-tain ''laracteristics as in.licatinfi such a caus(-, there are no infallil)le ophthalmoscopic app.-arances which, t.iken alone, will war- rant a diaiinosis of svphilis. In deference to the opinion of some lii-h authorities, it should, how.'ver, he stated that d.^ •miuate.l choroiditis, and especiallv svmmetrical choroiditis areolata, and the ,-xisteiKv of large (luantiiies oi" line, dust-like vuivous opacitu's are „f not infre(iuent occurrence, an. 1 are by many reffir.led as pathog- nomonic of syphilis. . , , i „ lutlammation of the clioroi.l, which may he .hssemmate.l ..! areolar ill tvi).- is s.)in.-tinies mil.l, hut more fre.iuently severe m character W h.'r. it apiH'ars in tli.> earlier stag.-s .)f the infection an. I is treate.l un.miitlv an.l thoroughlv. svi>hititic chor.nditis often yiel.ls readily; l)Ut as "in other structures, in the later stages of the .liseasc, when extensive changes havt> taken place in the vessel walls, wo cannot expi'ct prompt responso t.) alterative^ treatment, however active it '"'in ass,)ciati.)n with svphilitic cvclilis and iritis, syphilitic choroid- itis ii,,t infre.iu.iitly results m entire l.-ss of sight, .letachment of the retina s„iteinng, and phthisis bullii. It is alm.ist invariably accom- pani.-.i bv more or less extensive ivtinitis, an.l is i)roi)crly .l<>signateil •IS ch.)roi.lor<'tinitis. Unless the m.icular rogi.m is involved or vit- ro.)Us ..pa.itii's are present, ch.iroi.litis an.l cli.)roi.l..rotmitis. oven tliongh >iuit.> extensive, air apt t.i escape the attention of the patient; but when .•eiitnd. the earlier stay:es are nianifeste.1 by a variety .>f more or l.'ss pronouiKv.l subjectiw symi)t.)ms, .wi.lently .lue to irri- tation an.l .listurbance . f the outer layers of the retina by the .lisease.l .•li..r.,i.l l'h..l.. phobia, sparks !)ef..r.- the eyes, micropsia, metam..r- ,|,„,,v,-i -abjective colore.l vision, etc.. s'.on give j.lace to diininish.'.l visual acnitv. torjuir of the o,..er layers of the retina, an.l often a positive scotoma, f.)llowe.l bv g.Mieral cl.ui.Ung .lue to vitreous dust THE EYE IS ITS RELATIOS TO QENERAL DISEASES. 625 or larger opacities. As the disease progresses and produces more and more disturbance of the pigment ej)ithelium, we liave a variety of opiithahnoscopic pictures of retinitis, some to a degree resembling retinitis pigmentosa, in which at the point of ailhesion between the choroid and retina the pigment of the former emigrates into the latter, some due to areas of dense retinal opacity, and others in which the characteristic specific exuilation has producetl changes in the appearance of the retinal vessels. The dast-like opacities of the vit- reous, sometimes spoken of as pathognomonic of syphilis, the writer has found in many cases which were undoubtedly due to other causes. While .sometimes appearing as early as six months after the pri- mary infection, syphilitic choroidoretinitis is asually a late mani- testation. The prognosis as to vision must depend largely upon the stage at which treatment is undertaken and the jjart of the retina ii volved. If the macular region is the seat of the disease, we almost invariably iiave serious iinj)airment of vision. The cornea, sclera, and oculo-orbital fascia may be the seat of acquired syphilis, but involvement of these structures is of rare uccurrence, and is generally secondary to disea.se of other parts of the eve. .Syphilitic optic neuritis, not secondary to disease at the base of the i)iaia or in the other structures of the eye, though of rare occurrence, has been ob.-*erveil, and simple ilouble atrophy of the optic nerves is said to occur at times unaccompanied by spinal symptoms. .\n almost infinite variety of lesions in the cortex, at the base, and, indeed, in every [)ortion of'the brain, may result from syphilis, mani- festing themselves in the production of cortical symptoms, such as licmianopsia, etc., and by their effect upon the optic nerve and retina and the motor and sensory nerves of the eyes. This subject is more properly dealt with in the i<ectio-i on disea.ses of the nervous sy.«tem, hut a brief review will here be given of the mo > important considera- tions in connection with svphilitic i)aralysis of t.e ocular nniscl(>s. The paralysis is usuafly peripheral. Th ■ muscle itself may be the seat of the diseitse, or" a gununatous growth may develop in the iieifrhborhood of the nerve as it piusse^i through the orbit or at the base of the brain, or a siiecific lesion may affect the nuclei or the i)oiiit of origin of the nerve in the third or fourth ventricle or in the a(|U('duct of Svlvius. According to .\lexiinder, 59.4 per cent, of paralyses of the ocular imiscles are due to svphilis. They are usually late manifestations, rarely appearing iluring the first six months, and while they may ieveiop rai)idlv or come on very gradually, they usually respond to tieatment nither slowly in those ca.ses whicli prove to be curable. Naunvn, cpiotcd by Knies, reports 70 per cent, ^f recoveries, but states that if improvement does not manifest itself within two weeks under vigoroas treatment there is no hope of rei- vi i\ . Other aiithoiiiies, !io\vever, encourage perseverance for a nm- .i longer period. Relapses •Itt 026 arc unconimon of lime niE eyl: if tlie troatment is inaintaintMl for a .suffificiit IciiKtli While ill soiuo instances it may be tiic first symptoin of sypiiilis, and tiicrt'f<)r(> of (^.n'lit diagnostic iniportaiicc, paralysis of an <)cular iiuisdc is found more frcciucntly in association with other evidences of this disease. AccoidiiiK to Kiiies, the isolated paralyses "are duo either to neuritis and perineuriti f the nerve mots and at the Ikuso )f the brain, or thev are nuclear in origin; other causes are excej^ tioiia rnil.i •al ih )f the b dies of the third supplying nerve the sphincter of the iris and the ciliary muscle is not unconimon. I'aralvsis of the fourth and facial nerves is rare, represent iiij; about 1 to 2 yivr cent, each of all Ciuses due to syphilis, while the .sixth is affected in about 25 per cent., and the oculomotor in 75 per cent. I'aralysis of the fourth and seventh nerves when present is apt to be associated with paralysis of the third or sixth. In considering the question of the presence of syphilis in a jjiven ca.se of di.sea.se of the eye, it should b(( remembered tiiat we are largely dependent upon collateral evidence, as the cases are very rare in which the ocular lesions taken alone are ])athogiiom(mie. Thera- peutic measures as a means of diaf^nosis are at times of f^reat value; but while, on the one hand, many non-,syi)hilitic lesions are favorably influenced by the use of the so-cajled alterative treatment, it is a well- recofjnized fact, which has already been referred to. that there are certain late manifestations or results of syjjhilis, esi)ecially in the nervous system and eye, upon which, owing to sectindary changes in the vessel walls or the non-Vii.scular nature of the tissues affected, the iodides ami .salts of mercury appear t(r exercise no influence. Patients whos<' tissues have undergone such changes, though no longer, properly speaking, the subjects of active syphilis, may develop erratic attacks of various forms of ocular paralysis somewhat resem- bling true syphilitic i)araly.sis, but more like those seen in multiiile sclerosis. These diymptoms will not yield to anti.syphilitic treat- ment. Cont/enilal Suphilis. Owing possibly to attenuation of the specific poison in transmission through the tissues of the mother, or to a lirocess of selection by which only the less s(>ri(ms cases survive, con- genital sy],>hilis is usually a milder disease in its effects u|)on the eyes than is the ac(|uired form, and it runs ([uite a different course, althcmgh it is often far more obstinate and unyielding to treatment. Intra- uterine sy])hilis, on the other hand, is said to run its course much more rajtidly, the f(etus in many instances dying of tertiary syphilis. ,\s in the ac(|uired form, it is the uveal tract that is the point of .selection in congenital sy|>liilis, and while diffuse interstitial or "par- eiicliymat(»us" keratitis is its most common and easily observed manifestation, this is what has been termeil an emigration keratitis, and is .secondary to and in association with other lesions of the uveal tract. nii: EYE IS ITU UELATloy TO OE.\L'KAL DISEASES. 027 Clioroiililis ill its viirious forms, ami mild or most sovcrc plastic iritis, iridocyclitis, and iridoclioroiditis develop in some iristaiici's, and .irc accomp.uii' i oy softeniiij; of the eyeball. As the various structures of the eye may he jirimarily or secondarily allVcted, either in ulcro or in early childhood, it will be readily under- stood that opacities of th.e cornea, occlusion of the i)upil, cataract, opacities of (he vitreous, and atrophy of the choroid, retina and optic ve are not infre<iueiitly met with in congenital sy])liilis. Con- ncri ;;cnital atro|)hy of the oi)tic nerve or neuritis is not infreciuently the result of intra-uterine meningitis of sy])hilitic orifiin. .Vs in actjuired syphilis, wo sometimes find in the congenital form liiat periostitis or caries of the walls of the orbit leads to most troul)l( - some sym|)toms, among which persist.-nt occlusion of the nasal duct is of not infre(|uent occurrence. Paralyses of the ocular nmsdes may also occur, but arc rare. By tar the most fre(|uent ocular manifestation of congenital syphilis, ;is has been stated abovi , is (hffuse interstitial keratitis, and while I his may Iw due to other causes, its presence should always lead to a caiiful investigation. The evidences of the inheritance of a syphilitic taint are too well known to re(|uire consideration here; but while nrtain Continental writers have been inclined to accejit with many • |iialihcations the indications pointed out by Hutchinson in the peculi.ar formation of the incisor teeth, and while other di.seases ■ liMibtless may, in rare instance-, prodvice shnilar changes, the writer |],is foutid them so frequently associated with congenital syphilis tlial when present he regards them as of the greatest diagnostic value. As in all late manifestations of .syj hilis. many of the symi)toms of the hereditary form of the disease, esix-cially those a]>pearing after re due to secondarv ch-'' "« ■> ot the innnediate result of iiilancv, a the infection, and it is a nustr tiratment, such as inav be obt t results from alterative earlier years of ac(|uired .1" of the iodides and mer- ipiiilis. Too great persistence i. uials ill such cases may <lo gred h..n:!; but, on the other hand, the tcr is convinced by liis own expeiience that judgment and dis- nation should be exercised in this as in all (luestions of therapeu- Al'l mill iiid the above principle mu; it not be too slavishlv adhered to it not infre(iuently hapi)ens that brilliant results are obtained by !■ discreet use of these remedies even in subjects of congenital philis who are no longer young. l.iproKji often has a very long period of incubation, and the jirimary -loll IS apt to escajie attention It is very prone to affect the lids 1 brows; the former, according to Lopez, being involved at some line in the course of almost every case of this disease. Mkluiul has 'aled that infection often occurs in the conji.nctival sac from the I the bacilli of leprosy, resembling those of tuber- if t( a IK ilosis, have been found in the tears. The eyebrows and lids may be the seat of ana'sthetic patches or idules," which lead to loss of the hair of the brows and the eyelashes, . i i 1 11 «28 THE EYE. and when ulciTation takes place we are apt to hav ectropion or en- tropion. Lopez calls attention to the occurrenn ot lagophthahnos due to involvement of the terminal motor nerve elements ilistrihuted to the orbicularis nmscle. In the conjunctiva leprosy produces aniesthesia, followed liy chronic conjunctivitis: ami pterygia and tubercles may develop, which fre- (luently lead to keratitis and pannus, especially of the lower half of the cornea'. The tulx-rcles of tli' conjunctiva may terminate abru])tly at thi" corneal margin and li'ad to secondary clouding and other degen- erative changes, or the deeper layers of the cornea may be the seat of the le[)rous tubercles. In a later period of the (hsease we may have distinct involvement of the cornea, resembling interstitial keratitis, and ulcers are not uncommon. Involvement of the iris may be secondary to keratitis, but is some- times an early manifestation, and may take the form of an acute iritis or the develo|)meut of grayish nodules or tubercles, esi)ecially near the periphery in tli • lower half. If the disea.'^e reaches the iris, we are apt to Hud vitreous n|)acities, cyclitis, and choroiditis, with secondary cataract; and in the late stages there may also Im' involvement of the choroid and retina. The progress of le])rosy is slow, and the fact that small nodules in the iris have been known to disapjH'ar under treat- ment is r-ferred to by Knies. TuiHTCulosis. While primary tubercular infection of tlie eye is sometimes observed, it is of not very frequent occurrence, but second- ary involvement is far mon? connuon. Lupus, which is generally conceded to be of tul>ercular origin, may ai)pear ui)iin the lid as an ulcerated area, with red granular i)atches, and later may extend to the conjunctiva, and finally to the eyeball, causing its destruction. The conjunctiva, if the surface is broken, may be the seal of primary infection. This, although uimsual, has been well estaiiiished in a small number of cases. In some instances we iiave tubei. ular infection of the conjunctiva, which in ap]«'arance for a time resembles trachoma, althcmgh its later course, the fact that it will not yield to ordinary treatment, and its frfvpient association with nasal and laryngeal tuberculosis will determine its char- acter. More fre(|ucntly we find "caseating" ulcers with irregular raised edges, sonietimes covered with grayish nodules, showing a tendemy to slough. This m;iy l)e associated with considerable swell- ih't of tiie lids: there is enlargetneiit of the lymphatic glands of the cnrrespondiiig side, and the patients are apt to sliow other evidences of tuberculosis. Tli(> diagnosis may be made more certai.. in- the microscoi)ic examination of small pieces of tissue or particles of tiie cheesy con- tents of the nodules or by inoculation. Tubercles of the iris containing the characteristic l)acilli, and also giant cells, an- fwuiiil riceasionally a- an ai>parei-t!!y 'Titntiry manifcs- tati(m of the disease, .\ccording to Kyre. it does not usually imi)licate the cornea until lute in the course of the disease, and the iris still later. THE EYE /.V ITS RELATIOS TO OESERAL DISEASES. 629 Iindlvcmoiit of tlic iris, as wfll ;is otiu-r tubercular dispiuscs of tin; eyes, i- iiinrc (•oiiimon in chililrcii tliim in lulults. In cases of >;eiieral tul)ereulosis the uveal tract ami the choroid es|iecially is soiuetiiiies involved, the o|)iithalinosco|)e revealinK yel- lowish-whito spots, often appearing to he not more than ■)ne or two niillinietres in diameter, and difhcult to detect. Large tubercular mmors resenil)iiriR sarcomata are seen also at times. ('hon>'dal tubercles visible with the ophthalmoscope, if .seen at all, so o.ien appear in the late stages of the di.si use that they are of only sligiit diafinostic value. riie development of tubercles within the eye is ofti-ii associated with reduced iiitra-ocular tension, but in a few instances increased K'lisioii has been noted, and Lubowski has reported one case of iibsolute glaucoma. DISEASES OF THE 3KIN. The conjunctiva and superficial layrs of the cornea being con- timious with and anatomically and embryologically closely related I. the skin, it is only natural to infer that many of the disea.ses of ihe latter should present themselves in a modified form in these |)ortioiis of the eye and often lead to comitlications in the deeper structures. This "inference is found to be correct, especially in the case of such diseases as eczema and herpes: while diseases such as lupus and ei-uhelioma frwiuently extend from the lids into the eye: lid the i)arasitic and other cutaneous affections a.ssume a slightly modified form in the lids, owing to the fact that the skin here differs ill some respects from other portions of the integument. Eczema, which assumes such a variety of forms in various portions of tiie cutaneous .-urface, freciuently affects the eyes; and here, as .■Isewhere, it presents itself in forms that differ so widely as to be somewhat confusing to (me of limited clinical experience. It may artect the lids, conjunctiva, or cornea, and while of very freiiuent occun-eiice in childhood, is more rare in patients of advanced years, although in those subject to gout and rheumatism it is sometimes associated with conjunctivitis, and proves most obstinate and dis- tressing. In adults it is apt to present it.self (m the surface of the lid in the form of eczema s(|Uamosum, but it is among children that we meet with large numbers of cases of this di.sease, and here, while the Miiface of the lids often is affected, it is the conjunctiva and cornea which deserve most carefi ' study. Owing prubablv to the ease with which the conjun. ival and cor- ii.al epmielium is roken, we seldom meet with true vesicles, but pnints of infiltration assuming the form of i>inkish-y<'llow elevitions ill tli<> bulbar conjunctiva, and grayish or grayisli-yellow infiltrations ill tlie cornea, are verv comnion. These are gt-nerally sjK>kpn of as phlvcteimla.', and often are found in association with eczematous O.'li) THE EYE. ■■ I dis«'iisc of tho inucoufl inc>inl)r!iiic uf tin' iioko, ami ospcpi.-illy in IuImtcu- Idus or "scrofulous" cliililri'ii with (•(•/.cniiitouf* erupt inns about tin- tiosc aixl mouth, and adi-noids, liy|«rtro|>hicd tonsils, and fulargcd postcfrvical jjlaiids. Herpes lOSter of tin- integument of the lids may oeeur under eon- ditions favorinn its (levelopmcnt elsewhi-rc on tin- faee, esiM'eially when vesicles are found on the side of the nose, and herpes of the cornea is not very uncommon. 'I'he latter assumes the form of herpes zoster ophthalmicus, sometimes eorresixindinn to what is termed neuroparalytic keniiitis, :mii l>y seeonilary infection may lead to extensive and dangerous ulceration. The rieuraljjie and hurninn pain induced by herpes zoster may precede and contirme for a lonj; time after the ei' iitioii has dis;ippeared. Herpes vulgaris or (ebrilis, which is a more connnon di-^c.i-e of the cornea than herpes zoster, is often found in assix'ialion wiili ritarrhal diseases of the digestive or respiratory tract, and is ch.irai terized l>y the formation of one or more small vesicles which often are broken before their character is reco>;nizi'd. The surface of these ulcers may b" ana'sthetic. but not the surroundinn |iortions of the cornea, ami while ilcy often pursue a sluj;>lisi» course, infection from the con- junctival sac fr('i|iiently occurs, and r.'iay lead to the development of a destructive serpi>;inous ulcer. What is termi'il k-irnlilis tlnulrilirn or ktnititis nimijiirmis, is by some authorities cl;issilied as a varii'ty of herpes cornea', althoufth it is more probable that it is dependent for its characteristic form upon a special inicro-orKanism. Seborrhoea, which is characterizi-il by the development of .acne in other |)ortions of the face, when it involves the sel)a<'eous jjlands of the bonlers of thi' lids produces hordeolum or stye. The larjre size of the filandr-' in this re>;ion. the nature of the si.. -omidinji tissues, and the ea.se with which infection may take pl.ace, account for the ilitTer- ence between hordeolum and acne as it a|)pears in othi'r jiortioiis of the integument. Favus, lichen ruber, acne rosacea, milium, and erjrthema multi- forme, all may ajipe.-ir on tlie skin of the lids, but they |)re.sent few characteristics difTerinji from those seen when they are foimd in other portions of the face. Furuncle is <K'casionally .-ieen in th' uttper lid, causin<; marked tumefaction ;md redness. MoUuscum contagiosom may appear o le lids, ni d Mittendorf has oi iservei I two epidemics occurrinj; in a n( |»ital. Elephantiasis arabum is sometimes confine<| to the lids, though jrenerally appearinj; with a similar condition in other parts of the body. Pemphigus of the conjuiy tiva is occasionally observed, ami ichthyosis, in addition to cansinj; shorteiiin<; of the lids, may extend to the conjunctiva ;inil eyeball. PhthiriaSiS "f the edire< nf th.e lids m.av sometimes be reeoCIlized by the presence of nits upon the eyelashes, anil sycosis and other ]iarasitic affections are occasionally found in this rejiion. TUE EYE IS ITS HELATIOS TO OllSEHAL ttnEASES. 6;U Purpura may provoke snmll licinorrliaRfs in tlic skin of tlif lid ami iiiidcr till- coiij'unftiva and into tho n-tina, as well -is in (ttluT portionM of till' l)ody. Impetigo and psoriasis somi'tinios invade the skin of the lids, tlio (•uiiiniictiva and conjunctival portions of the con -a. Urticaria is fouml occasionally on the lids, and iritis and paralysis of acconinKMlation may Ih" present as a result of the toxic I'lenicnt caiisinji the skin eruption. Alopecia of the hrows and lashes, often complete, may i)e found ciilicr with or without manirestatiohs dsewhiTe. Lupus as ii local manifestation of tulmculosis is more ])roperly triiited under the head of infectious diseases, where erysii>elas is also con-idered. Pellagra, dui' to ingestion of a fundus of maize by poorly nourished iiiilividiials, accordinj; to Hampoldi, pnxhices tor|)oi of the retina. iiiinitis pifrmentosa, atrophy of tlu- optic nerve, di-aiipear! "-e of the cliiiididal pifrment, marantic ulcers and necrosis of the i' ' ica, and opacities of the lens and vitreous. DISEASES OF THE BRAIN AND SPINAL COKD. Cerebral Hyperaemia and Ansemia. With the exception of cer- t;iiii condiiinns acconi|)anied hy jirolonjjjed venous hyperaemia or (•(iii>:estion of till' brain, as is sometimes seen in epih'psy of long ^landiu};, we look in vain to the ophthalmoscoix' for information as tn the condition of the cerebral circulation, although it is of the utniost value in studying di.seases of the bloodvessels, as in such conditions as arterio-capillary sclerosis, etc.. pronounced hyper- emia or ana-mia of the brain may coexist with a normal fundus, ,iiid the exist.'iU' of hypera'i lia of the retina may not be accepted .1^ proof that a corres|M)nding condition will be fimnd in the liniin. Those unfamiliar with the ]>!iy,siological variations in the ■i|i|pearance of tlie nornuil fundus not infre(|Uently fall into serious ■ rnir in the inferences they dr.aw as to the condition of the cerebral <irculation. Indeed, the author has known high authorities on di.s- r:is ■> of the nervous system, but with limited experience in the use of tiie ophthalinoscoi>e, to be entirely misled, and tn base a most grave prognosis upon the apparent congestion of the retinal vessels familiar t(, v\i'Y\ experienced ophthalmologi.st as one of the characteristics of high degrees of hypermetroi)ia. While, if taken ah>ne, 1; .pera'inia or aiuemia of the retina is not to be relied ui)on as evidence of a simil.ar condition of the brain, if found associated with otiier symptoms, it may be of considerable \ :ilue. .\n;eniia of the brain is often accomjjanied by inactivity of the i'upillary reflex with lilatation. wiiile contraction of tlie pupils is cliaracteristic of cerebral congestiim. »>' g;j2 THE EYE. \v si i t if Cerebral Hemorrhage. In ."stiniatiuR tlio rolativo nnportanco aiul si.r,ntin,ncc ..f the vuri-us ..cular n.anitVstatu.ns ..t (•..rcl.ra hcmor- ;.; 1!. or a,.o,.l..xv. tlu- nm,,.l.-x uatun- ..f tho H.na.t.nus vv.tl. wind .;,r .lealins slu.uia cmstantly Ik- k^.t in. nun. . llu- l-^tum u ,1,. l„.,uonl.af:.>. the ."Xtn.t ..f th.- ..xtravasation ,h.' su.l. on.. ■>^ u wl.i.l, it ...ak.-s its appearance. a..,l the t..ne that has elaps.M suce ' oecn.Te,u-e sl.oul.l iJl he tak.-., into a.-eou..t, a...! we ,..us re.ne.,|ber that «.n.e ..f the eve sv.ni.t.....s ...ay be .hie t.) ahsokite .lestruc- ti.m .,f e.-rtai.. porti.u.s .-.f the hrai.. tissue, while ..thers are tlje result of paralysis .1. .- t.. te...i...rary p.vssure in a zone su.;r..u...ln.>r th el, a.-i ..the.-s ajjah. are P. he attrilmte.l t„ the .rntat..m wh.eh ;,eeu.s \n a z.u.e still fartiter re,.,..vea fro.n the seat ut actual lu>.u<jr- ''"f s.i.I.len an.l ..v.-rwhelniinff hen...rrhage ...ay at first abolish the fu.*,rti,... ..!• both he...ispheres. wluTe.vs the later .level..p...e..ts, . .l,.ath <lo..s n..t e..su.'. will show .... which si.l the l.'s ..u is to be toun.l an.l f..r a sl...rt ti.ne we may have l,oni..ny.....us h.-nuanops.a in the visual tiel.l on the si.le <.pp..site the luMnorrhaRe Co.ijugate ,lev.ati..n of the hea.l an.! ey.-s t.nvar.l the si.le of th.- lesi..n is also „f frcpient ...'currence. This is attributed by Knies t.) irntal.on occur.-iiis in the opposite hon.isphere. Hc.orrhaso into the visual cortex may in some instances cause very few ..f the svmptonis usually associate.l with apoplexy- ll^^re niaV be only te,np..rary vertip. with a su.l.l.Mi attack of homony- mous he..iianoi.sia. If "the hemia.ioi^sia is per..ianent we may inter that the heniorrha-.- has been of such a character as to .lestroy the entire visual c(>..t.'e. . „,,.+„ Shoul.l the hem..rrl.age be not t.,o extensive, a fairly accurate .liagn.xis niav <om..tinu-s be ma.le at the bepnnniS of an attack. hef..re the ...on- or less confusi.ip: secon.lary an.l remote symi)toms hive .l.-veloi,e.l, .,r after thes.- symptoms have run their course: but a.irin.' their pn-sence it is .lifficult accurately to differentiate th.-m f.-...i. the syinpt..i..s which are the essential an.l permanent results of the lesion. , , , - t i^ Hemorrhase into th.' subarach.ioMl or sub.lural sj.ace is .apt to nro.luc<- symi.t.)n.s whi.-h i-.-s.-mbl.' th..se ..f ...emnsitis. Mydnasis. I,ccasi..nai'lv as th.> r.'sult of in-itatio.i ..f the sympathetic, but >:eiier- allv .lue t.M)r<'ssure up..n an.l i-aralysis of the .....tor .,cul.. .s n., mtre- „ue..tlv s,-,-n. Mv..sisis..f rare occurr.M.ce ; it r.-s..lts t.-(m. h.-m...-- ■,-h,-.-'.-"i..t.. th.' v.-nt.-icl<-s. an.l in s..m.- instancs. pr..bably fro... irritation p.-.Hluc.-d liv hein..!-rl.a-.-. causing pn>ssure upon the nuclei of th.' ...ular ..ms.-l.-s." If a li."m..r.-l.a<je is of such extent as to .lestroy the ! .in.a.-v ..ptic fian-lia. th.- chiasm, or optic tracts, we may hav.' partial or ciupiet.' atr.iphv .if the oj.tic nerv.-s. Optic .i.Mi.-itis, cl...k.-.l .lisk. a.i.l partial ..r .-.m.pl.'te atr.)phy o th.- ..ptic n.TV.'s an- seen ,-eca:^ion:.lly in <-ere!,r:i! h.-morrhaffe: hut evi.l.-.ice supplie.l by the opl.thal..i..sc..pe is .if far less value in this .lisease than in the case of tumors or i.iemi.Kit.s. THE EYE /-V ITS KELATIOS TO UESEBAL DISEASES. 633 It should lie rcmciiibcrcd tliat disoasos such as albuniimiria, dia- l)ctcs, atlicroma of tlic bloodvessels, etc., which may predispose to (•(■rei)ia! hemorrhage often i)roduce hemorrhajies and other character- i~lic lesions of the retina and oi)tic nerve, independently . th()se which mav n^sult from extravasations into the tissues of the brain, and in old people the condition of the bloodvessels which favors cvtravasation into the Imiin is indicated not infre<iuently by recurring attacks of coTijunctival hemorrhajje. Embolism and Thrombosis of the Cerebral Vessels. A cerebral embolism, if not infectious, leads to dcfteiieratioii or softenin;: and necrosis of the brain tissue sujiijlied by the vessel whose cour- it ..hstru -, and a non-infectious thrombosis or a circumscribed hemor- ihMfie will produce similar effects, though the clear-cut and well- d(tine<l lesion i)roduced by an embolus often renders it pos.sible to determine (juite accurately its location by the resulting focal symp- toms; and if it is situated in the visual cortex, in the occipital lobe, ill the ])riinary optic ganglia, or in the course of the optic tracts, in the cortical centres or primary ganglia of the motor nerves of the eye. the characteristic jjaralytic symptoms will develop promi)tly after a brief period of reaction. Symmetrical, bilateral softening of the optic centres has been reported in a mnnlM-r of instances, and Wilbrand mentions one case in which double choked disk occurred I Knies). .\n infectious embolus or thrombosis leads to the formation of a cerebral abscess with its characteristic symi)toms, while an infectious thrombosis of the cavernous sinus may, in additi(m to the other symptoms of an abscess at the base of the l)rain, result in ori)ital sMpi)uration with its long train of disastrous etTects. The eyeball is protruiled and fixed by infiltration of the orbital tissues, the conjunc- tiva becomes chemotic, the lids swollen, and there follows blindness with a widelv (hlated and iimnovable pui)il. M the thrombotic process inclui'les the ophtlialmic vein, the ophthalmoscope reveals distended retinal veins, with injection of the nerv(> head and retinal iiiiiiorrhages. b.ater, as the infectious process extends, we have npacity and ulceration of the cornea, und finally i)anoplithalmitis. In the early stages of the infectious pr ss. and during the progress Ml' a non-infective or marantic ihnimbosis of the cavernous sinus. I he o])hthalmoscope renders most valuable assistance, especially in li-iinguisiiing the latter condition from meningitis. In both m<'nin- miis and non-infectious thrombosis of the cavernous sinus there may lie p.aralysisof the motor nerves, insensibility of the trigemiims. with. its eonseiiuences in conjunctival and corneal ana'sthesia. i)artial or 'omplete paralysis of the optic nerve, and more or less o'dema of the lid^. and protrusion of the eyeball from involvement of the orbit. Ill meningitis we may have congestion and even jminounced optic neuritis: "but the m.arkecl stasis of the retinal veins which is found 111 throml)osis ,if the sinus with thrombosis of the ophthalmic vein is never observed" (Kniesi. If III H 634 THE i:yk. Abscess of the Brain. Tli(> ocular syinptonis pnKliicod by ahspcss of tlu' biaiii may hv tlic same as those about to be ciiunuTatcd as rcsultiiifr Ironi tumor: but, in addition, there is tiie S'-nerai evideii,-e of an infiTtive proeess aetinji as a eause: an<l it should l)e borne in mind that some of the oeular manifestations, sueh as septie ehoroid- itis, embolism, and tiirombosis, may result direetly from this infective jjrocess rather ilian from the coincident cerebral al)scess. As in tumor, we may find diiTuse and local etTeets nlanifested in choked disk and obstructive neuritis, which latter is apt to be bilat- eral, and is the most chara-'teristic oi)hthalmoscopic manifestation. There mav be iiaralysis of llie motor and sensory nerves, ])receded 1)V spastic contractions of muscles and other evidences of theexi-'tence of a zone of irritation near the abscess. As the .absce.ss may be prac- tically stationary or rapidly jjrofiressixc, the various ocular manifes- tations may be of proh)nfied duration or follow one another in (juick succession, and in the event of a rujiture we may have a fatal ter- miTiation preceded by the ocular and <;eneral eviilences of purulent meniufiitis. with jiaralysis of the fifth nerve, neuroparalytic keratitis, etc. Perforation into the ventricles may be attended by marked mvosis, which is attributed by Knies to direct irritation of llie .sphincter nuclei. The projinosis after operation, so far as the eye is concerned, <lei>ends upon the location and extent of the dama<;e to the brain tissue. The irritativ<' symptoms may subside. ;is may the oi)tic neinitis, and to some extent vision may be restored: but if the visual cortex has been seriously involved, we are apt to have not only im- ])aired vision and limit.-ition of the visual helds, but also defective color sense ( IvniesK Tumors of the Brain. .Minost all forms of neopl;ism are found in the crani.'il cavily, alth()U<j;h some, such as lipoma, which are common in other localities, very rarely ajijiear in the brain. Tubercular tumors ai'e inoi-e conuuon in the br.ain than elsewhere, and sarcomata and syphilitic tumors aie of frecpient occurrence, the latter beinj: often associated with fiunun.itous meninfritis. (ilioma is almost ex- clusi\-elv a cei'ebral tumor, beiufr found in the brain and spinal cord, and in no other jiart of the bod>', exceptinir the retina, from which it often exli'iids to the brain. 'I'lie symptoms produi'i'd in the eye, as in other parts of the perijih- eral nervous system, dilVer };r<'atly in accordance with the siz(>, period of firowth, and location of the tumor; and it sometimes hitpjiens that a firowth whi<-h later causes irritation, and fin.ally destruction of the |)arts with which it lies in contact, may in the earlier stapes of its di'velopment produce only jreiieral symptoms of dit'fusi' inli'acranial pressure, 'i'lmiors of the .'interior and middle fossa may invadi' the orbit and (••■mse exophthalmos. Chokeu disi^ or ,.|)lic lil■initi^. usu;i!ly dou!)!!-. ;nitl .'ittaoks (if teiii- )iorary total loss of sijihl due to {leiieral intracrani.il pressure, indicate the ]iresence of a tumor of the br.iiii. althoujrh other evidence is ne('<'s- IvT, THE EYE IS ITS RELATIOS TO llESERAL DISEASES. 635 saiy to cuahlc lis to form ;ui ()i)inion as to its location, i;.^" size of a tiiiiior seems to have little influence, and the choked disk oi . ,)tic neuritis which appears is not merely the result of mechanical pressure. Ill addition to the g(>neral symptoms of cerebral coni|.ression accom- panyiiifi brain tumor, such as headache, hebetude, drowsiness, voniit- iiifi." a .slow pulse, and dilatation of the pupils, there is sometimes c\-id( !ice of pressure on jjarts far removed from the seat of the growth, which is apt to be very mish-adiiig in our attemjjts at localization. ( IwiiiK to its long course, the sixth nerve is especially apt to be affected by such indirect jH-essure, producing paraly.sis of tl " external rectus. If the tumor is of .such a nature as to jirovoke irritation as well as pressure, we may have conjugate deviation of tli(> eyes and head, coiiceiitric narrowing of the visual iields, and paroxy.smal attacks of liilatcial blindness. Wiiile choked disk is not always one of the early symptoms of l)niiii tumor, it is one of the most important, appearing at some st.ige in about SO per cent, of the ca.ses: and if this symptom is not fnuTid in some stage, the otiier evidence on which the diagnosis of I'livbral neoplasm ' based .sjioiild be very convincing. It is said to br iiii.r,' fre(|uent in tumors of the cerebellum than in those of the t'lmtal lobes, and may be |)roduced l)y a tumor in any i)art of the I ! iiri, although, if the neoplasm is in the membranes on the convexity .ml iiuiviv comjiresses the brain, it is less ai)t to produce choked .li-^k or optic neuritis than when it invades the cerebral tissues (Ciiwers). Choked disk is sometimes found even in tumorof the spinal i'diil. Some eminent writers on nervous diseases ignore the distinc- tion between choked disk and obstructive neuritis, but it is. neverthe- l('-<, an important one, for. while undoubtedly some degree of neuritis liiialiv (levelojis in almost every ciise of choked disk. ther<> often exists ill the early stages a true ledema of the nerve head in which ilie tissues are (luite translucent and do not present the ai)i)earance ol vascularity and inllaniniation seen in optic neuritis. This (cdema i- iioi necessarily accomi>aiiied by marked imi)ainiieiit of vision. Clidked disk with' tumorof the liraiii is usually, altliimgh not always, l.ilateral, and it does not necessarily indicate tliat the growth is large 'ir is located near tli' '• parts of the brain which are especially con- iciiied with vision. "eil, while rajiidly growing and large tumors :iiv apt to produce it, small growths by causing, as they often do, • Inipsy of the ventricles, are accompanied not infrecjuently by marked u'dema of the nerve head. Choked disk and optic neuritis, if maintained for a sufficient length nt time, will almost inevitably hnid to contraction of the visual field, with extension of the l)lind sjxit, and sometimes central scotoma, i.'lldwed by atrophy of the ojitic nerve and blindness. Kxceptions •<> tills are found in those rare cases in which a cure is effected by :.pii;;ti\'- "r otiier measures, ;(nd especi.ally in neophi-^ms of syphilitic •ligiii. when in the proper stage active treatment with mercurials iiid iodides succeeds in bringing about absorpticm. ••v'«J _..IL - (J.JG TIl£ EYE. |1 s III :i nunibor of instances' wlioro operative interference has been unsuccessful so far as removal of the tumor was concerned, marked freedom from ; lin and restoration of vision have followed the relief from i)ressurc on the cerebral tissue. While choked disk is one of the most positive indications of the presence of an intracranial growth, it s-hould be borne in mind that it is simi)lv an cedema of the nerve head accompanied by distention of the sheath of the nerve, and that there are other conditions as well as tumor which may produce it occasionally, .\mong these may be mentioned abscess of the brain and cerebral hemorrhage. It has also been seen after profuse hemorrhag.' in other |)ortions of the body and in cases of leuka'mia. albuminuria, and diabetes; but there is u-uallv other evidence to aid in establishing the diagnosis. Tuniors of the brain in a certain proportion of cases cause optic neuritis, followed by atrophy without choked disk "Oppenhcim observed tyi)ical chdked disk"fourt(>en times, neuritis five times, and hyperainia of the pajnlla once " ( Kni(>s). .Vnd we may in some cases have atroi)hy of the nerve without either choked disk or neuritis. Taken with other evidence, choked disk, obstructive neuritis, simple' optic neuritis, and [irogressive atr()i)hy of the optic nerve are (jf great value in determining the character of a brain lesiim: but alone they should not be considered as a sufficient ba.sis on which to make a positive diagp.o.sis. Aneurism, ')y pressure and irritation, produces effect.s upon the eyes similar to tho.se resulting from other tumors, and in very rare and exceptional instances a tumor may be .so situated as to produce a group of h.cal eye symptoms almost a.s clearly defined as those some- times observed in ca.ses of embolism and softening. These symi)toni.s ii.ay present themselves in the form of cortical blindness or hemian- op.sia, mind blindness, alexia, visual ai)hii.sia, dyslexia, amnesic color blindness, and visual hallucinations, or cortical disturbance of the ocular movements, such as conjugate deviation of the eyes, often accom])anied by deviation of the head in the .sai.ie diri'ction. If the tumor happens to press u]ion the gray matter around the aqueduct of Sylvius or in the floor of the fourth ventricle, it produces nuclear ocular palsy or ophthalmoplegia — external if affectitig the orbital muscles, as the recti and oblicpie muscles; or internal if affecting the iris and ciliary muscle. If the tumor lies in such a jMisition as to alfect the efferent fibres of tin- dcular nerves in the cms cerebri it j)ons, between the nuclei and theii' point of emergence at the ba.se of the brain, we have what is termed fitscirular jKirnljisix of the third, fifth, sixth, or seventh nerve, which is sometimes spoken of as crossed <ir alternate i)aialysis. Anil when situated a* the ba.se, in addition to its ctTect upon the optic tract. !i tumor may cause paralysis of any or all of the nerves sujiplying thi' external and internal ocular muscles, as well as the fifth nerve. 1 Svrniizy. in Niirris ami Oliver's S.v»tt'in of l>Ut'ns<"« iif ihe Eyi', vi>l. iv. p. .'il.'). ly-J. •i^Vt.'A-.-tJfM rili: KYE IS ITS RELATTry TO GENERAL JJlHEASEH. 037 If found in the corpora (luadripeniina, a tumor may produce oculo- motor paralysis, a reeling sait, with possibly blindness and deafness. The differential diagnosis between tumor and abscess of the brain is not always easily made. They may have in eonnnon headache vomiting, choked disk, or optic neuritis (generally double), and mental disturbance; while tumor is ai)t to cause m addition the well- marked focal svmptoms enumerated above, with, at times, hemiph ;ia. \\-\oT and rigor favor abscess. The cau.'se of abscess is often v\-ry clear, being freciuentlv traceable to a focus of suppuration, sm-i as uuruien* otitis media.'while that of tumor is obscure. Meningitis in its various forms gives rise to a variety of ocular 1,'sions of the mo.^t serious character. In general they are the direct result of the action of the exudate upon the visual c(>ntres, ganglia, ,.r oi)tic tracts, and ui)on the iioints of origin or trunks of the motor and sensory nerves; or they may be due to secondary inf<>ction of the ,. •(. from the septic material which is characteristic of the mening.al inflammation. If the process is extensive, we may find the eye congest<>d hvpera'sthetic, and sensitive to lijiht in the early stages; .,11,1 soon svmi>toms will develop which indicat.' whether the inflam- mitorv pnicess affects the convexity of the bram or the base. It the formei- we mav have in the earlv stages an homonymous hemianopsia with the pupiliarv reaction to light preserved, or both cortical centres mav be involve(i,"affecting both halves of the retina of each eye. In acute cases th(> inflammatory i)rocesS usually ext-'iids rapidly, s„ tiiat conjugate deviation and other symjjtoms pointing to a cor- tical lesion are transitory in character; and as in a large proportu-.. ot cases of meningitis there is an exudate at the base of the brain the ocular manifestations are apt to be i)erii)heral and the result o cither irritation or paralysis of the n(«rv<' trunks which are embedded ill the exudate and reach the eye through the apex of the orbit. The abducens is attacked most fre(|uently, the motor oculi rarely; and the presence of hypera-sthesia, para-sthesia, and amesthesia in tlw cutaneous surface of the face, with neuroparalytic keratitis, indicates involvement of the trigeminus. \mong the symptoms .)f irritation we may have contraction ot the ocular uuisdes", producing various forms of strabismus, and rarely iivstagnuis. , , 1 t • 1 ' I'lralvsisofthe facial nerve, leading to lagophthalmos. which ma\ !„. accompanied bv deafness from involvement of the auditory nerve, i~ one of the iK.ssii)le results when the exudate is found in the middle inssa In basilar lu-ningitis vision may be affected by involvenu'iit of the tractus, bv optic neuritis, extension to the orbits, genera ly 'ong the veins, producing chemosis, and perhai)s later orbita ceMu- litis Hxation. ami protrusion of the eyeballs, etc., or Dy the j-roductum of a seroplastic or purulent choroiditis sonu-times, though rarely, iiiiiiiiiaiing in panoiihthahiiitis. \ d(<gm> of optic neuritis presents itself in some stage of the i::a.iorityof cases of cerebral meningitis, and although, unfortunately, 638 rUK EYE. ! it somotiinos liapixTis that it caniK it 1)0 (Ictrctcil sulficioiitly early to 1^ m\ he the lucaiis of cstahlishiiiK the diajtiiosis, in many instances it is of the utmost value. When fully developed, it is generally bilateral. Doubt as to the ditferential diagnosis between typhoid fever or pneumonia on the one hand, and meningitis on the other, may isoine- times be deeidetl by means of the oi)htlialmoseope. Optie ni-uritis, as seen wi.h the ophthalmoscope, may vary in degree from simple hypera-mia to a decided pajjillitis. although great swelling of the (Usk is not often seen, as in cerebnd tumor and soint^ cases of ab-cess. There is u.sually an absence of jmniounced exudation and hemorrhage: but :' certain cloudiness of the tissues . the nerve head, with blurring and indistinctness of its outlines, is in keeping with the fact that the micro.scope reveals infiltration of tiie jnal sheath and coimective tissue, especially toward the jK'riphery (Knies). A dense, chalky-white disk with sharp outlines and marked nar- rowing of the bloodvessels, is seen in the atrophic stage, with often complete blindness, though in some Cii-ses the amount of vision re- maining seems entirely oi t of ])roportion to the evidences of atrophy as seen with the oi)hthalmoscoi)e. When some vision remains, how- ever, we are apt to have irregular narrowing of the visual fields, scotoinata, and defective color sense. A septic ("metastatic") exudative choroiditis sometimes develoi)s in the early stages of simple meningitis, especially in young children, although il may also appear at a lat(> period and in other forms of tlie disease: or it may be disc;)vered after the active symptoms have ubsided. It is generally unilateral, although both eyes may bo affected: and it is said to be of embolic origin, sometimes being found in cases of ulcerative endocanhtis, in puerperal fever, recurrent fever, tyi)hoid fever, scarlatina, mumps, erysipelas, etc. (\oyes). This condition of the eye not infnviuently escapes the attention of the attending physician during the active period of the disease to wnieli it owes its origin, but usually presents w:'ll-marked and easily discoverable local sympton.s of a low grade of irido-cyelo-choroiditis, sometimes accomijanied by markeil ciliary injection, iritic exudation and adhesions, parenchymatous keratitis, and even hypopyon. If the above symi)toms of iritis and keratitis are abse.a, the ophthalmo- scoiie. or sometimes ol)li(iue illumination, will reveal the purulent exudate in the choroid .and retina, which often extends so f.ar forwanl in the vitreous chamber as to lie in contact with the posterior surface of the lens. atid. especially when bloodvessels develop on its surface, it clo.sely resembles glioma of the retin.i -psciidixiliomn. Such eyes are usuallv soft and easily irritated, but sometimes r(>tain their normal exter-ial apiiearance. although often in later years they undergo degen- erative changes, becoming (piadrate und'r the pressure of the recti tmisdes, and developing (legenerative keratitis and calcihcation of the crystalline lens. Instances hav been recorded in which, after the formation of a moderate amount of exuilate, absorption has taken place and vision THE EYE IS ITS RELATION TO UESERAL DlHEASEii. «a<> liMs Im'cii riistorcil, thoufili sucli cases must Im- cxtrciui'ly rare. We iiiiiy also liave in iiieiiiiij^itis, as in certain otlier diseases i.c-cunipanied liy tyi)lu)i(l syiMptoiiis, mild jrrades of cyciitis and choroiditis, wiiicli -niiietiines n"cov< witliout leaving serious impairment of vision. Aviitr hihcrciiltii mininnitiy is in about 15 per cent, of the cases accomiianied l)y miliary tnhercles in the choroid, which may 1 ■ made (lilt with the ophthahn<i.scope as pale yehowish s|)ots which are s«me- \\ii:it prominent and vary in size from O.o nun. to 2.5 mm. They all unaccom|)anied by i)i};mentation. and seem to be more connnon ill I lie neigliborhood of the macula lutea and disk. More are often liiiiiid i)ost-m.)rtem. I'andyses of the ocular nmsdes are often seen in tubercular menin- j;ilis, asit is prone to attack the bas(> of the brain, and optic iKMuitis i> more common in this than in atiy other form, especially if the Uii)ercular exudate at any point api)ears as a tumor. ('enhro-spinal mcniiKji'ti'^ is very apt at some stage to be the cause III most serious involvement of the eyes. In the early stages we may have swelling of the lids, conjunctivitis with (edema, and photoiil'.ibia with contracted or dilated pupils which are often une(|ual. Keratitis i- not uiiconmion, and iridochoroiditis and retinitis with optic neu- ritis, or paralysis of the optic nerve without apparent neuritis, are 111 Irciju-'ut occurrence. What has been said under the head of septic <.r metastatic choroiditis as occurring in meningitis in general, applies especially to this form of the di.sease. Whether or not the ])neumococci r(>ach the eye through the lymph |i,ices of the optic nerve has not as yet been proved (.\xenfeld); liut that, in <5oino instances, they reach it by way of the circulation ihiougii general systemic embolic poisoning has been estab''shed.' The prognosis as to life, and especially as to s sjlit. is most grave. l'ii<-hi/mcnin(iilis produces eye syni|)toms which vary with its loca- lidii. .Vs it is most fretpiently found on the convexity of the brain. I he eye symptoms are a\)\. to be cortical in nature, tiiough when i-s(iciateil with hemorrhage the more dittuse symptoms usually seen vith the tumor may be addeil. A circumscribed meningitis presenting few of the other synii)toms I Miiiid with more general inflannnation of the membranes may be nriimpaiiied in the early stages by color phantasms, nyctalopia, etc., lid ;it a later jieriod cause impaired vision, scotomata, limitation of 'lie visual lields, and disturbance of color sense. The ophthalmoscojie ii.iy at first reveal neuritis, which is followed by more or less com- ' I'tr atroi)iiy of the optic nerve (Knie.-;). Mitd^tnlic piiriilcnl incninqitiK may result from purulent inflamma- !iin of the eye, es|)ecially from traumatic |)aiiophthalmitis. A number of instances have been recorded, some of wiiich have "•iiiire(| after enucleation, and this has been used as an argmnent j::iiii>;t enucleation in j-anophthalm'tis; hut both logic and expe- Swanzy. In N'onis and Oliver's System of Diseases of the I-ye. Hi ». I I! ili 640 TUE EYE. rii'iu-c teach us that thocasc must he an unusual one. in.lood, in which removal of sucli a source of infection will not mcrease the i)atient s chalice of escaping iiieiiin>;itis. _ Insanity. While the insomnia and excitement incident to many forms of insanitv mav lead to marked injection of tiie bulhar con- junctiva and vvliile variations in th." iiupil may be noted, and atrophic and degenerative disease of the nerve, retina, and choroid l)e tound ks the result of a di:<ease wliicii is a direct or indirect cause of menta thsorders, it cannot properly be said that there is any affection ol the eve which can b(> directiv attributed to insanity. Hallucinations of sight which are visual perceptions not founded on an obective realitv. and visual illusions which are misinterpre- tations of sensory images, when they cease to be recognized by the subject iis hallucinations and illusions, are among the nion- common manifestations of insanity. Fo<t-operative delirium, and even insanity are by no means uncom- mon after iridectomv and the extraction of cataract: and when we consider tiie prolonged suspense, the state of mental excitement witli phvsical inav'»ivitv incident to the operation and after-tr.>atment. •iiid the fact that all light is generallv excluded, it is not strange that judgment sometimes cea.ses to hold sway over the hallucinations excited bv such an ordeal. It is a fact, however, that such mental disturbances seldom manifest themselves excepting among those p|•('di^•^()sed to such affections. It sometimes happens after oi)eration upon the eye that the ten- dency to delirium is greatly iiicreas(>d by the eft'ect of atropine, used to prevent the formation oi" iritie ailhesions, and caution in its admin- istration may prevent the development of most troublesome symp- toms. . • 1 1- -i »• General Paralysis of the Insane. In view ( )f th(> wu le < hst nliution and character of the cerel)ral lesions in iiaretic dementia, it is not strangi- that we should have a variety of eye symi)ioms which, owing to the fact that they often make their appearance at an early i)enod, are of the greatest diagnostic ami jjrognostic value. Trophic and vasomotor disorders occur in tlic eye as elsewhere: but it is to tiie cortical visual disturbances, mind blindness, and hi .liaiiopsia. paroxvsmal or ix-rmanent, and to atrophy of the optic nerve, and especially disturbances of innervation of the intrinsic and extrinsic ocular muscles, that our attention will be directed. Paralysis of the orbital muscles, cyclo|)legia. ai';i i)ui>illary anoni- ali . suVh as mvdriasis. myosis, irregularity of shape, inequality m tlie two eves, ainl disturbance of the pupillary ivllex often appear in the pnidromal stage: but, as a great variety of cerebral lesion- due to widelv dilTerent causes may proiluce similar symptoms, tlir largest ex!)erii'nce and the utiiust cauti<in and judgment are often nr'cessary to enable tiie observer to interpret tiu'in correclly. Then V 'ue shoulil carefully be estim.ateil when taken in connection with the evidence derived from other sources. TllK EYE IS ITS RELATION TO OESEIi.iL VIHEAHES. (JJl Many striking caM-s arc on record in which some coinpiiratively t*linht pupillary anonwlv has served as the warning note of :ip|)roach- iiig insanity; but every ophthalmologist of wide experience sees numerous cu^es of pupillary anomalies and unaccountable paralysis of the extrinsic ocular muscles which are nevi>r followed by such dire conse«|uences: and while these symptoms are undoubtedly of great significance, the necessarily complicateil nature of the subject and the Hniitations of our knowledge of the brain should warn us to exercise caution in our attempts to interpret them. Mind blindness when present in dem.uitia is generally, though not always, found in the later stages. Schweigger reports a most remark- able "ca-e treated bv Wernicke in which, "with gooil acuteness of vision anil without "any absolute def t in the field, there were dis- tributed over a great portion of the tield a number of relative scoto- mata, within the area of any one of which, although objects could be seen by the patient, y-t he could not tell what they were.'" Mind blindness mav be paroxysmal, continuing for .several days and then disaiijiearing. Though it is always tentporary, it is ai)t to !>(■ followeil by actual blindness iis the disease progresses. Hallucina- tions of sight, in some cases unilateral, are very common, and some- times appear as earlv symptoms. .\trophy of the o])t\c nerve may occur in the early stages or even precede mental disturbance, but is usually a late symi)tom. It appears merely as an incident in the course of the organic cerebral lesions, of which the general paralysis and insanity are symiKoms, and is not of very freijuent occurrence, being found, according to Cudden, in about 4.9 jier cent, of a series of l.'iS() cases. Ilypera-mia of the i)apilla, and even a slight degr(>e of oi)tic neuntis, liav("' i)een observed in a verv small jjercentage of ca.«es. I'lipillarv anomalies and disturbances of the ciliar>' and orbital iimsries are the most significant ocular symi)toms in general paralysis <il the insane. The pupils are usually contracted in the early stages, .ilthough later thev are often more or less dilated; but what is termed ivHex rigiditvof the pupils, in which response to light stnnulus may Ih' diminishcil or absent, and lat.T reaction to convergence and aceom- inndation mav fail, or in which the pupils are eciual. or one or both n^suiue an irregular shape, is one of the most valuable of the early ^vmptoms. .\mong m) ca.ses Moeli found reflex rigidity present in 17 pel' cent , doubtful reaction in 4 per c(>nt., and sluggish reaction in 10 iKT cent. ; and among 20,-) i)atients witii reflex pui)illary rigidity Thonis'-n found S,3 per cent, of general paresis (Knies). It should be .rniembereii. however, that although other diseases rarely produce this -\inptom, absence of puinllary reaction to light and reflex rigidity .if the i)upil are among the more common ear symiitoms of tabes dorsalis as well as of general i)aralysis nf the in.sine. The studv of pupillary reactions in i rvous diseases is necessarily 1 9vf«aiy, m Norrto and Oliver's System of Dtaeaaes of the Eye. 41 (>4^ TUK km:. intricate am iiiiirc coiiiDli I inviilvcd, liiit it lias liv sdiiir writers Wecii rciiilered still iitteutiou to uiiii'-portaiit details. ■dl) •oriaiii (I i'aralvsis of accoiiiiiiodatioii is of far less fret|ueiit oeeurreiice than pupillary anomalies, heiiij; found by Mi>eli in aiiout 1.') per cent, of all oases (Knies). Altiiounii not so cominon a syinptoiii as iiiydri!i.sis. nuclear paralysis or paralysis of the orbital niuscies is occasionally seen. It may result in loss of power in the third, fonrtli, or more fretiuently the sixth nerve, with the accompanying diploina and strabismus or pt().sis. While usimllv temporary, it" is not always so, and is prone to relai)se. .\ccordinR toSchutz. SiemerinK, and Hoediker, the al)ove oculomotor paralyses are "caused by .h'K«'"<'i"!itive chanjies in the central gray matter of the aqueduct of Sylvius and fourth ventricle."' Ptosis, twitchiii}; of the eyeli.ls, and transii'iit uystanmus may all be found in a limited numl)i'r of ca.ses, and among other motor dis- turbances of cortical origin we not iiifn'«iuenlly have conjugate deviation of the head ami I'ves. Several writers have mentioned ocular migraine or scintillating scotoma as a not infrei|uent premonitory symptom of paretic demen- tia, but this is of such friMiuent occurrence in other conditions that it is certainly not a symptom of great diagnostic value. Diffuse cerebral sclerosis is apt to be accompanietl by impaired pupillary re.iction. and cases of paralysis of the sixth nerve and nystagmus, as well as optic ni'uritis, have been reported. " In paralysis agitans, or Wilkinson s disease, a bilateral or rarely a unilateral tremor may solnetiims be noticed in the muscles (tf the margin of the upper lid. This is more marked when the lids are closed, and is accoin])anied by a degree of rigidity on attempting to ojM'ii them. Nystagmus is a rare symptom. .Vcording to Gowers, the slowm - of motion which is notice- ble in other portions of the muscular sy.stem rarely atTects the (.;. al muscles. The patient will turn the eyes instantly i.: any desired direction, and follow them slowly with the heiwl by the action of the inu-sdes of the m^ck. Si)asm of iicconunodation lias been noted in several cases by Koenig. and gray atr()])hy and bilateral ptosis have occasionally been reported. Disseminated sclerosis in a large proportion of ca.ses is accom- panied by very significant and characteristic eye symptoms which may be of great diagnostic value. They manifest theniselves in d( fec- tive vision, a variety of forms of limitation of the visual and color fields, color, and, in rare instances, absolute scotomata, variations in th<' ophtlialmosco])ic appearance of th(> disk, and disturbances of the ocular and orbital muscles. The onset of these symijtoms may be gradual, but more often they come on suddenly. They niay atTect one or both eyes, and they Vary in degree, sometimes disappearing entirely, and in other instances relap,sing after an interval of many ' 9w«iizy, in Norrir' and Ol'ver's System of Diseases of the Eye. TliK EYE IS ITS RELATlOS To tlKSEHAL DISEASES. (j t;{ wiiks. Aiii.iiinisis, which i;* rarely complete and |MTmaiii-iit, may Kiiitinuc for r^cvoral months, and, after prolonged remission. a|)iK'ar i,'.iiii (Charcot). It is apt to lie accompanied hy the sensation of a mi-t before the eyes, and even when scotomata are present these are iMiily alisolute. hire cases of disseminated sclerosis jire not accom- pMiiied hy hemianojisia. and this tends to prove that tin- lesions, like those of retrohulhar neuritis, are not in the chiasm or optic tracts. Wilt in till' o|)tic nerve itself. \isiial <lefects and changes in the appearance of the optic disk may imcede the other symjitoms of disserninated .sclerosis hy months or yiiirs, or they may make their appi-arance in the early stap's; Imt ihiy are usually found only after the general symjjtoms are well iliveloped.' Anion}! the most striking ocular manifestations of di.s.s(>minated -cliio^is are the disorders of the ocular and orbital mu.scles. and of ilicse the mo.st important are the nystagmus, ataxic nystagmic iwiichiiigs, and tremors attributed by Knies to insudicieiit cortical iiiiiiTvation of the nuclei, which he believes to be due in the main to I'liimidear foci in the fibres of the corona radiata. Nystagmus, which is very rare in other forms of nervous disease, I- s.iid to occur in about one-half of the cases of dis,seminated .sclerosis. Hither with or without nystagmus we may have disonlers of the ;i-s()ciated nioveineiits of the eyes. This was observed by rtlioff in iliree out of KK) ca.ses. Isolated jiaralysis of the external ocular muscles and nuclear paralysis may occur, an "xample of the l.-itter liiing defective conjugate motion to the right or left and paresis of ihe ])ower of convergence (Swanzy). The peripheral n(>rves have been I lUiid in a number of instances to be the seat of sclerotic foci, I'thofT li.iviiig noted four ca.ses of unilateral abducena paralysis and three ■ tises of partial paraly.sis of the motor oculi. Moderate degrees of impairment of motility are very common. As in the ca.se of jiaralysis nl the optic nerv '. the motor affections are much more freciuently -'•111 after the other symptoms are well developed, but they may occur III the e.'riy stages, or even l)ofore any other evidences of the di.sea.se Ikivc ap] cared. Abiioriiial pu|)illary reaction is uncommon in dis.seininated sch-rosis, '>n\ a few ca.ses have been ob.served including reflex rigidity of the i'ii|)ils. myosis in the advaiiced stiiges, impaired light and conyer- iT'iice reaction, inecjuality of size, and hippus. Uthoff found sight li'viations from the normal in 16 jxr cent, of the cases .studied hy ^ini. As Swanzy has pointed out, the fact that ophthalmo.ieoi)ic clianges I the disk may be ob-served in alx)ut 50 \)0t cent, of the cases is I value m establishing the diagnosis between disseminated sclerosis Hid hysteria, in which wo sometimes find symptoms resembling those : tiie earlier stage of the former diseiisi'. And we are also tussislt-d 1 Swanzy. la Norrm and OllTer'i System of Diseaaes of the Eye. 644 TIIK EYE. f I f 1)V till- rarity of central -coloiiia ami tin- irregular and erratic cliar- actvr of the visual ami color tirl.ls in hysteria, as compared with tints*' of liisseiiiinated sclerosis which. altlioU(tli narrow, follow the regular |)hvsiolonical order. In amaurosis, sc lomata, and impairment ol the visual nelds the symptoms indicate retrohulhar disease of the ojitic nerve, and granular d"en<-neration of the me<hillary sheaths, with intact axis-cylinders, inuy he found with other evidence of interstitial neuritis. l)«'Renerutive foci are undouhte.llv some times found in the primary optic tjanglion, and rarely in the rhiu.sin and traetus, but they are of far more fre<|uent occurrence in th<' optic nerves. Accoriling to Kriies. the pathological p.. in the optic nerve •'.stands midway iM-tween pronounced optic .leurltis and simple t'trophv." Wliile the medullary slwaths are destroyed, a large pro|)ortion of the axis-cylindors esca"pe. although from time to time in tlu' progress of the dis<'iv.se th'.r conductivity may he impainMl. This accounts for the fact that the -.isturhance" .i vision or the defect in the visual field may he very pronounced, while the oi)tic disk appears normal, and that vision mav var- from time to time, or he in a meiusure restored so long as the !\xis-cylinders wliich pa.ss through the sderose.l patches are not actuahy destroyed. Optic neuritis, according to rthoff, is found in about 5 per cent, of the cjuses, hut the ophthal- moscope reveals no retinaratrophy, and there may he no visible evi- deiKv whatever of a defect of tin- optic nerve. Decided atrophy occurs in only about A per cent, of the cases, and evim |)artial atrophy- in only 1!> jxT cent. In a considerable luimlMT of cases (about l.S |)er cent.) an uphthalmuscopic picture is observed closely resembling that of toxic ainblyoi)i i. 'I'liis, however, i- not in every case accom- ]ianied bv tiie characteristic central scotoma. When 111'' ntrin>ic and extrinsic ocular muscles !ire affected, the lesions are in the main nuclear, although in a luimber of instances sclerotic foci have been found in th<' iieripheial nerves. I, cube saw- both motor oculi nerves converted into thick gray bands (Knies). Deformities of the skull following chronic meningitis in infaiits. producing premature ossification of the crani.-il bones and narroving of tlieoi)7ic foramina, rc.'^ult first in ojitic neuritis and laler in atrophy of the opt'c nerve. Hydrocephalus .-is seen in infancy may be accom|):mied by optir- neuritis or atrojihy i>f the optic nerves, but this is not (if fi-c(|uent occurrence: while" hydrocephalus appearing lat.r in life, when th< sutures are more firmly united, is as a rule accompanied by such symptoms ami by evidences of jiressure closely resembling tiuise of tumor of the brain. S\v:in7.v, in Xorris and Oliver's Sjisloii <>j Disease.^- oj Ihr Eye, calls attention to the occurrence of bitemporal henuaiiopsia in hydro- cephalus, due to pressure on the optic commi.ssure by the disteiidei! floor of the third veiii.icle. riiK KYt: IS ITS HEirruis ra oeskhm- DistcAsK.s. m:, In th.' v.ui.ais furiiis of iiirniiinitis as wrll as in liy.ln...-|.lialus, iImiv is ..Itfii such a lower.-.! stall' of vitality an to U-ml to tin .l.v<-l..|.- iiiriit of ixcialilisaiid (•oiijm><'''vitis. . Porencephalus (cvsts orcavitics inth.TortfX) may lM'a<T..m|miiicil l,v .v.- svin|.t..inrt s.',iii what siinlar to tiios • whi.'h a|.|K-ar in soll.-ii- iiit: ■ Nystagmus, ptosis, r.'llcx ri -i.lity of tlu- I'Upil, and Kiay atr.i|.hy ,.| the ojiti.' IHTV.' have all Im- .1 < .-"rv.'.!. Bulbar paralysU in its typicai form is not acooinpanuMJ »)y oyi- -yniptonis. l.iit ilii.'.as it is. "to patiiol..p.-al pnurss.'s in ih.- ni.'.lulla ,,'l,l(,iij;ata, it sonii'liin.'s lias jissociat.-.l with it l.-sioiis ot tin- visual ;,ii<| I'^sp.riallv tli<- motor (•.■ntr.'s of the vyr. Opii.' iicrvo atrophy l,a> Im'.ii ohscrvi'.!. and sfv.'ial writers have reported .as.r of paralysis ,,f the o.'iilar and orhital imis<-l.-s, with n-stiltiiiK dilatation and tixa- iiMii of the imiiils, nvstanmns. .i-ular d.-viation .ir fixation, ami even ;, ,|.%'r f .•xophthalm.is. ("o.ijnuate .levialioii and paralysis of ihiMiciilar hraiieh of the facial have Ite.-n noted, and while th.Mlis<'ase I- al its hei;;ht coiic'ritri.- limitation of the visual field and slijiht iin|i:iiriHeiil of vision inav o.Tiir. Straininski, of Wiina. reports a , :,>e .if this kin.l followini; iiillueiiza, ami terininatinj: in re.-overy in nine iiioiitlis . Progressive ophthalmoplegia, or what in rontradistinction to pure l.iill.ar paralvsis has Ix'eii .lesignati'd as snperi.)r poliencei.hahtis in lis acute for.il, is due to hemorrhagic intlainination of ih.' gray matter in the floor of ih.' fourth ventriel aii.l the a<|ue(liict of Sylvius (Knies). In a.l.lition to the somnolence, which is characteristic, th.-re is pro- _'i.s>iv.' paralysis of the ocular muscl.'s. and this may in a short tiiiie !..■ .|uite complete. Ill the chroni'' form there is dejieiieratioii, which may all.'ct the nuclei, nerves. ■ muscles, |)ro(lucinn proRrofive paralyses, which are Msiiallv hilat.Tal. although irr<'j;ular. and may Im- complet.- ..r inconi- |.lete." Thes.- paralvses, with the resultiiift convergenc.-, divergence, nvstafrmiis. refli'X rigidity of the pupil, -t.'.. may disappei-r in whole ,1 in p;ut,onlvt.)ap|iearafiainHiuli'ontimieti. advance (K les). Syringomyelia is accompanied somclimes hy concentric contrac- iiun of tli(> visual fields and raHy l)y optio neuritis. Abduccns jiiiralysis aii'l nystaginu: have also been reported. disea^:eis cf the spinal coed. Myelitis is .iccon.,.ani<^d sometimes hy optic neuritis, which may vc.veror jio on to cmplete l)liii.lnesp;"and Swanzy points out that 1 the cervical portion of the cord is involve.l wo may have my.lria-sis lin- to irritation, or pavalvtic niyosis. Tabes dorsalis is in a large proportion of cases accompanied or iT.T.l.,! l)v eve svmntoms which :ire nf Mie i;re.ntest importance in.l often supplv the 'first positive indication of the nature of this rious disease. " These consist of atrophy of the optic ncr\-e, par- (J4(> THE EYE. i\\\i^\fi and ataxy "f the ocular iuuspIos, pupillary alterations, and jiansis or paralysis of accoininodatiiiii. Assooiatt'd, as tabes often is, with other ditTuso cerebral and spinal vlisease, the ocular symptoms afford important assistance in estab- lishiui; the diaf^nosis. Atrophy of the optic nerve is found in about 20 per cent, of the cases, and, when fully develojied, the disk is s^iiy. is often slifthtly cupped, revealing the delicate fibres of the lamina <'ribrosa, ainl. especially in cases with a deep physiological depression, is dilhcult to distinguish from glaucoma siin|)lex. In the earlier stages the grayish discoloration of the disk is more noticeable on the temporal side than on tlie nasal, which is normally nioH' jiink than the outer half, but as the disease ailvaiices tht^ whole .surface becomes uniformly gi'ay, and the arteries and veins are reduced to narrow threads. Whatever may be the cause of tabes, it is evident that the atrophic process in tiie optic nerve is not a direct extension of the disease in the brain ;ind cord, but a se|)arate manifestation of the same process. The fibres in the centre of the nerve are affected last, and LeIxT has shown that it liegins in the peri|)hery of the retrobulbar p'ortion and extends toward tiie axis. The gray atrojihy may also sometimes be d(>tected in the chiasm, tiie tractus, and even as far as the primary ()|)tic ganglia ( Knies). Some writers claim that in the very early stages hypcra'mia of the ilisk precedes .atrophy of tin- optic nerve, but this is not established, and on theoretical grounds it would seem improbable, as the i)rocess is a primary atrophy of the nervous elements. Both histologic.-illv and with the ophth.almoscope, tabetic atro])hy is easily distinguislieil from ]i(istiieuritic wiiite atroi)hy, in which a den.se white or yellowish- white disk is seen utirely obscuri ig the fibres of the lamin;i cribrosa. Atrophy of the i)]iti(' nerve, while sometimes ap))e;iring in the later stages of locomotor ataxia, may antedate the aiijiearance of ataxia or even i)recede the lightning pains, loss of knee-jerk, and other spinal .symptoms from two to twenty years.' Ophth.'dmoscopic evidence of atrophy generally precedes distm'b- ance of vision, but thi' visual disttu'bance may in >ome cases be much more mat' cd than would Ix' indicated by the ajipeanmce of the disk. Strange as it may .seem, many writers maintain that the progr(>ss of the general disea.se is checked and there is an ab.'itement of the spinal «iympto!us on the development of optic atro|)hy if it appears in the |)re;itaxic stage.' In regard to this, Knies very iirojierly rem.-uks that ;i mistaken diagnosis may account for the improvement, as the prognosis is often much more favorable in some of the n<'urotic .•ind selenitic processes which may be mistaken for tabes. Authorities ditTer greatly as to tlu' fnvjuency of the occurrence of optic atro|)liy in tabes, (lowers pl;icing it at l.'J.o per cent., while swan/y, in Nnrris ati-I Oliver's System of IHReif.es nf the Eye. Beneiiiet, Wieii lucl I're»-e. ISHl, Nob. 1. 2, 3. 4, 5. THE EYK IS irs RELATWy TO GEXEIIAL inSEASEH. «47 ,Vr.n.r dvos :5:U per ont.. an.l rtl.off 20 per .-.nt. Altlx.ugh both ' \;Z'::^^iu..t^'^ that two-thinls of all optic ..rvc- atn.phu. J. t2ti.. origin ; l.t.t wlu-th.-r this 1... n.rrc.t or "<;J>-- ,; f^ „., ,..nuin.- ...y atrophy of tho^.t^ llX tS .i^^ S^i^ alt'; "";;';;"" '.'•X''att..ntion to tho fact, which i. on>itt..l by .onu- w,^;'^.: a to l.cKinni,.s vv .nay havo such ^ubjoc'tivc phc.om- 'as'potophobia, J sensation of sparks an. f-^^J'^^' f^ tnt the patients con.plain ..f a fog or sn.<.ke before the f'><s- "^ . ,Lts out th'it the interval between the :ippearance of optic -lill :il)le to set> TIk' op!'"- atropliv oi ^:"'f> i> avi...... ......■■ . - t4,.i,u- .,,„i ,„, ,.,,,.1. vision 'an,l narrowin, of th.- v.su:^;uul color helj-^and 1 The contraction r v,.i,.„ 'a,;.i „»r.™vi:,f of ,i„. -'-■'";;;;;';,, .t;, ;:;;;,;;:;:::-i;i::™;rr;;:t;:l.]i;:;:.i^^»;V'^,s i:;,,.-::r:;;;;;,:;;H::t;^,:"i;'ir';s;;,,!v:;;; ^■;^: n":,;ir:,.;;;;,::";:"':r,K'::» S';:,. a. ve.^ - ..; .»*>. :;:;;■ ™;ll"';;;,;«™i;;r!.u.^ "ill «,« ,.. » .;;;;*;;;;;;;, ;,. nc.v r.v n.avke.1 in.i.ainnent of central visu.n ^^^\^ a norma :.n :Srana-l,l: hut usnallV in.pairn.ent of the --a^ i^; < an. Moj. ;^ l,L\ visi..n as they pr.^sress b.-ar a -l.-tunt.' n-latu n ''" ' ^^'^^'^^j Sw.n.v r..f..rs to the fact that a <<'"M'.'rary funct o a . n^^^^ ,„c narr....n. ..f the visual "e;^ .->;-;■ t --n .;:;>; -;. ^^^^ ,l;;":,.;tr'7tS.':"bu; t^:^^t.. r....^y in direct !S5!5^^" •rrsr T^S^^^S^. r?s^ ^nsrr II 'i\ (J4.S THE mi:. |)r.)li.)rti(iM to till" visual disturbiincp mr to tho liiiiitatioii of tlic visual ticlil. Ill some instances it may oven !)(> (Ictcctcd Ix-forc ojitic atrophy <'tin he (liscovorcd with the ophthalinoscopc. An ('xaniiiiatioii of the color fields is very important, as those cases in which their narrowiiifi; is much more niarke(l than the field for white are ajit to be rapidly profiressive : and Kiiies has ixiinted out that a re-enteriii>; aiijile in the boundary of the color field is the forerunner of a similar riarrowiii<; of the held for white. As rare visual disorders, we may in the later stajjes have sym- metrical defects of the visual fields or liomonymous hemianopsia. Disorders of the ocular muscles are of fre(iueiit occurrence in talx"-. and their iinportanci" is jireatly increased by the fact that in a larpe projiortion of cases they aiipear in the early stages, my.lriasis, diplopia, or ptosis often bein<; the hrst symptom to attract the attention ot the patient. Acc<irdin<; to I'thoff. Ii.ry are found in •_'() per ."eiit., and according to Heifier in '{S per cent, of all cases. Thi'y usually ilevelop suddenly, and while they may be i)ennaiieiit, more freciueiitly disa|ipear after ;i period varyiiif!; from a few hours to a year or more; but they are prone to rehipse, aiicl they are more ajtt to hi' iiermanent if occurriiifi in the later stall's of the di.sease. The sudden ajiix-ar- aiice (if paralvsis of an ocular muscle in an apparently h(>altliy person, especially if it recovers in a short time or subscvpieiitly relapses, should ahvavs arouse the suspicion of tabes (Knies). .\ny one or more of the orbital nerves may be atfected, but paralysis and paresis of the abdueeus and motor oculi are of most freciuent occurrence. The lesion in paralysis of tabetic orifiin, while it may lx> perinuclear (,. internuclear, is generally ixTijiheral or nuch <r, and therefore we never have associated or conjujiate paralysis ' • t'ii's). While true nvstafimus is of very rare occurrence in tabes, we not infre(iuently iiiav observe ataxic dscillations or what are sometimes termed nys- tagmic twitchiiifis, which may be (h'monstrated by cau.siiif; tho eye tcTfollow ;in object in motion anil fix it when the motion ceases. Paralysis of the ocular branch of the facial nerve is of rare occur- rence, but jiaresis accompanied by tremor on etTort to clos(> the lid is fre<iuently ob-erved. Pupillary" alterations arc of the greatest diagnostic importance in tabes. Tlie pupils may be of une<iiial size in the two eyes, and are very often of irregular shape. Mydriasis, due to oculomotor paralysis, but not necessai-ily accompanied by cycloplegia, is sometimes observed, though it is rare! Myosis, on the other hand, is very common, and may be looked ui)on as characteristic of tabes dorsalis. The contrac- tion iiiav be extreme C'lnn-hole iiupil") or of only moderate degree: but whether normal in size or contracted, our attention in this disea.se is es])ecially directecl to the absence of reaction to light, accommo- dali\i- etTort, cuiivfTgrnce, ;nid cutaiu-Diis i; lilittiuii. wliich ap-jwar ill the various stages as the tabetic changes progress. These puiiil chan"es are due to disease of the ciliospinal centre. THE EVE IS ITS RELATWS TO GESERAL DISEASES. (J4D Tlio ArKvll-U..l.(Mts..n pupil, wliilo it is als.. <.cca.«i..nally obseryctl in other nn-v..us .lis.-ases, is a i.u.st i.npurtaiit sy.npt..ii. -t tat.os ,l..r«ali>^ It consists in the absence of contraction <.n exposure to ILrlit of a pupil wliid. still retains the power to contract ui conyer- ..;«•.- or acconnn.Mlation. Th<> pupil may be- normal or even .hlate.l ^ithoUKli it is penerallv .(uite narrow, and it shou .1 be born., in n.in<l ,l'Tt later, win the- .lis..as.. is sutti.-iently a.lvance.l. a.ul aft.-r r„.ht stimulus has ceas.'.l to cause contraction, the reflex to sensitive -tlmuli, such as cutaneous irritati..n. is lost, an.l hnally convergence ,ils<. fails to be accompanied by contraction Whil.- occasionallv .-ntin-lv wanting, th.^ Argyll-Robertson pupil is ,„„. of the most cmstant of all the symrtoms of tabes, and, owing ,., the fact that it is often an initial symi-tom. its value can scarcly I,., overestimated. Dillman f.mnd it in 7f> per c(-nt. of his cases. In :;i (i per cent, the pupils responded lu^ither to light nor c.nyerg.-nce. V.id th.- iK.rinal condition of both r »'il« was tomu by Herger in „nlv 4 among 109 cases (Knies). The latter writer has als.. called .,tt;.nti<m to the fact that in myosis of si.inal origin mydriatics are !,..< ..ffective. while in s,.inal mydriasis the action ot myopics is .r„ni„ish.-d. In examining for the presence of th.- light r..flex. Swanzy ...mHs attention to the importance of avoiding such cutan.-ous irn- i.tion as is apt to result from touching the skm of the face or luls, ;„h1 rec.mmen.ls that the t.-st be made in a darkened room. I'nalvsis of accommodation is rare. AVhen touiid, it is g<-nerally in Mssoc'iation with mvdriasis and in the late stages ..f tlu; disease. What is sometimes termed sympathetic ptosis but is really a ~!i-ht drooping of the upper lids not due to paraiy.sis of the third nrrve is occasionallv observed in a.ssociatiou with myosis. M.other somewhat rare sympathetic syini)tom, but which Borger ,.l;,i,„s to have s<.en in half of his cases, is ei.iphora. It is attributed ,,, disturb.-d lacrymal secn^tion an.l imperfect actum of the ..rbicu- l.uis paliM-braruin. B.'rg.-r also calls att.mtion to impert<.ct cL.sure uf the .'v.-lids. with tilmllarv twitchings of the orbicularis muscle, :,n.l t<. rivluced intra-ocular fension. which h.- attributes t.. paralysis , ,1 til., sympathetic. ( )th.T writers s.>ldom mention these symi)toms. TROPHONEUROSES. .\crom.-alv s.mietimes causes great thick.-ning of the bor.l.-rs .)f th.^nrhitsraiid tiiis mav be incr.>as.Hl by .lilatat.on ol the frot.tal .inus..s. Th.- lids mav'b<>com.- hypertroi-hi.'.! and brown in color. Tho .•onjun.-tivM. fat," an.l orbital muscles an- at times hypcr- irMphi.-.!, an.l the .>x.M'hthalm..s whica occasi.mally develops ma> 1m :icc.impani.>d by atr.)pliv of the oi)tic n.TV.'s. ., , llvpertr-iphv of the !,ituitarv bo.ly is by s..m<- writers cnnsi,ler<-.l :,< a .-ause. but Marie looks upon it as one ol the r<.suits ..1 acr..m.-gat>-^ ll„w..v.-r this mav be. the resulting pressure upon the chiasm and ~W. •T"wiTri¥- iiii~~ iii-TirM — iri i nw- ^^i i imr ri a iffT rfi- Ti'^T ..;'^ ^aii«.i: tJ50 THE EYE. optic tract may lead to optic neuritis or ciioivcd disk, or to Ijitcm- porai l)(>iiiiauoi)sia, or narrowing of tiic visual fields, defective vision, and sonu'tinies even to complete blindness. Hemifacial h3rpertrophy is a rare affection in which the eye neces- sarily hears an im])ortant part. The orbit, lids, and eyeball are often greatly enlarged, leading, when the hall is hypertrophied, to exj)osure of the cornea from dithculty in closing the lids. Knies and Ziehl have each reported a case in" which the eyeball took part, proilucing a high degree of myopia and, in tiie case of the former observer, extensive choroidal changes. Progressive facial hemiatrophy, which Ix'gins with unilateral irri- tati<in of the cervical symi)athetic ant! later i)a.sses into paralysis, involving also a h^sion of the trigeminus, ])roduces pto.si.s, myosis, and enoi)hthalmos, with oculoi)upillary irritation and paralysis. There is progressive thiiming of the skin of the eyelids, and the brows and lashes turn gray and fall out. Retraction of the lids often leads to exposure and disease of the cornea. Kalt observed choroiditis and myopia, and Ruhemann reported i)tosis. divergent .strabismus, cataract, impaired mobility of the eye and contracted pupil (Kniesj. i INJUKIES TO THE BKAIN AND SPINAL CORD. Injuries to the brain produce a variety of eye symptoms which may he classified as io) those which are the direct effect of trauma- tism of the cortex, nuclei, tracts, chiasm, or o|)tic nerves, and (7/) those whirl; result from hemorrhage, meningitis, and abscesses of traumatic origin. I'nder their respective heads the eye symptoms wliich follow th<" conditions mentioned in the latter grouj) (r) have alreadv receive(l consideration. Well-de'ined and clear-cut localizing symptoms may occa.sionally be observed in gunshot and punctureil wounds. \ wound of the cortex, if in the occi|)ital region, may be followed by cortical blind- ness or hemianopsia witii conjugate deviation and nystagnuis; hut fractures. esiH'cially fractures of the ba.se, are aji* soon to be compli- cated bv hemorrhage and m<'ningitis which obscure the symjjtoms. Not infre(iuentlv. however, in fracture at the base which does not necessarily rcMjuire a blow of great force, if in thr- iiroper direction, one or both of the ol)tic foramina are involved, lacerating the optic nerve, and we have innnediate blindness with loss of i)U))illary reaction, <'ven before iiillammatory symptoms have develojjed. This is. of eoiuse. soon followed by atrophy. Both Kna])]> and Knies have reported such casi's, and the latter author records one reported by Taflier in which fracture of the frontal bone was followed by nasal hemianopsia evidently, so he states, due to involvement of the anterior angle <ii' I lie chiaMri. Such traumatisms may also involve the niotor nerves, esjx'ciallv the facial, proilucing lagophthalmos and the ab (lucens, causing "paralytic convergence. I THE EYE IS /!>■ RELATIOS TO OESEUAL DISEASES. (J-,1 ('uiii])i('ssioii of tlio hraiii and (•oncu><si()ii hotli cause |m|iillary <'liaiiji('s. Ill the lornifr we liavc mydriasis witlioiit reaction ti) lijjlit ami, ill rare instances, coiiftcstion and (edema of tiie pajiiila. while ill tiie latter Hutcliinson describes a decree of sluftftisliness in the luipillary movements, and Knies refers to the not infreiiuent occur- rence of nystajinius, which he attributes to "cortical inactivity or interference witii the conduction of the innervation impulse which starts from the cortex." Concussion of the brain is followed by no oi>lithahnoscoiiic change, althoujili, as (iowers has siifjpested, .simple concussion of the nerve and retina nuiy probably cause loss of sight and slow atrophy. Contusions and lacerations of the brain antl hernia cerebri may be accompanied liy neuritis. Injuries of the spinal cord rarely cause organic disease of the eyes. No changes in tiie fundus were found in 17 rajiidly fatal cashes observed l)v .Xllbutt, although among i;^ chronic cases he reports 8 as having exhibited more or less hypera-mia of the papilla. He never found inie ojitic neuritis (Knies), When the injury is in the lower cervical (H ujijier dorsal re};; •;. a lesion of the sympathetic may lead to vaso- motor and trophic -listurbances and inequality or contraction of the |iii|>ils. U'hile in rare instances o])tic neuritis and atropliy of the optic nerve have been reported, in considering them we sliould bear in iiiiiid the fact that sj^inal injury may be complicated with injury of the brain, and thus account for the symptoms observed in the eyes. \ arioiis ocular symjitoms are of fre(|uent occurrence in concussion nt tiie spine, but it is n<i, usually easy to establish the existence of a real organic lesion in such cases. This is especially true of railway -pine, or what by some writers has been termed concu.^s'on of the -^pinc: but even where this is the case it is difhcult to find records nl well-authenticated instances in which it has led to organic disease (if tlie eyes. The neurotic symptoms are often very marked, and, as we iiiav even sometimes find hysterical contraction of the visual liclds. it is important, as Swanzy has ])ointed out. that in our oplithal- mciscopic ex.'iminatioiis we carefully avoid interjireting what may be a iiliysiological variation in the color of the aisk as indicating an organic lesion of the optic nerve. DISEASES OF THE NERVES. Multiple neuritis, which is a not infre(|uent effect of poi.sonous and infectious diseases, may affect the optic nerve, producing axial neuritis, central .scotoma, disturblinces of color perception, etc., such a- .are described in the section devoted to t«)xic amblyopia. It may al-o affect the motor nerves, producing partial or complete paralysis. Knies calls attention to tlie fact that in :iniyotrophic paralysis of I he arm, when the nerve roots or spinal ord .ire involved, if the oculoimpillary fib'-es from the cin' he sympathetic become im- •«:.■- ■»'-Jv,^VA \..3(P¥!E ().J2 THE EVE. periHcablc %vp may havo ptosis, myosis, and cnoplithulnios on the '"^InHaniniation ot tlic first branch of the uifii-niinus may lead to licriios, wliicli is considinMl clscwlicro. In trigeminal neuralgia th(> ocular branches are sonietnnes scarcely involved, but thev often do take part, leading to injection, lacry- mation, phot ophobi:-, and pain in the eye. Inflammation of the ocular brancb.es if severe is (luite constantly reflected to the other biaiiclio of the trifieminus. I'aralvsis of the trigeminus is apt to lead to neuroparalytic kera- titis if an abnisioe of the cornea occurs and the element of uifectiori is added. , ... \ iarjje proportion of the nervous i.henoinena which appeal as reflex expressions of the acc.iinmodative and muscul.'U- strain, made necessary by errors of refraction and muscle imbalanc(>, manifest themselves in the sui)erior branch of the trisi-minus. And m every case of obstinate trifieminal neuralgia a careful attempt should l)e made to discover and correct all such errors. Paralysis of the ocular branch of the facial nerve is followed by liKoi)iithalmos. which mav be present in any degree, and. if marked, is apt to b<> the cause of secondary conjunctivitis and keratitis as the result of exposure. Tonic and clonic spasm of the orbicularis muscU may be cortical or nucU ir in origin, or a reflex symptom of peripheral irritation. ij i i s CHAPTER XIV. (iENERAL PREPARATION FOR OPERATIONS UPON THE EYE. By CLARENCK A. VlvVSEY, A.M., M.D. Thk Renoral princii)lcs of aseptic and antiseptic surgery shoultl be (■in|)I()V('d in operations on the eye, as well a.s in ()i)enitions uj)on ntlier portions of the body, with the exception that the strong gernii- cidal solutions which may be used elsewhere are here, as a rule, not permissible. PREPARATION OP THE PATIENT. If time permits, it is important that the patient's general health !)(■ place<l in the best possible condition jjrior to the performance (if any of the major ojK>rations. Naturally, this does not ajjply in those emergency ca.ses demanding immediate attention: but m (ither cases the surgeon will be well rewarded for attending to .iiiv of the details that will improv< the physical or mental con- dition of the patient. Should diabetes or albumiimria be present, tlicy are grave comi)lications, to be sure, but by no means contra- iiidicatc o])erative jjrocedure, as was formerly thought to be the '■;i.<e. If, however, a course of medicinal and dietetic treatment will improve materiallv the ne])hritic condition, the chances for ulti- mate success in anv operation upon the eye will thereby be mark- edly increased. If anv acuto pulmonary disease is present, it is wiser to postpone operation until after its subsidence; aiK^ again, if liiei-e is any chronic pulmonary affection it is not only necessary to imi)rove the condition as much as possible, esix-cially if the re is any cxaciTbation, but it is also of the utmost importance to allay any cough tliat might give rise to complications during or following the operative procedure. For the latter purpose, in addition to the ohler remedies, heroin hiis been much employed of late, and in doses of one-sixteenth to one-twelfth of a grain, fre<iuenily repeated, has proved of value, as ha.s also the following spray: Menthol crystalu, !>u!v. camphnm! U gr. xxx. Li,), pctrolati, Sj. M. To be UBed loc«lljr In »loinlier or nebuliJer. (653) I 1)04 THE EVE. i vulur canliiif :in Dpcrsitiitii Ix' il T\w c-(.iuliti..ii (.f tlic licart and Lloodvi'sscls slioiil.l also !.<• (•arcfully iuv.'^tiuat.Ml If art.Ti(,-scl(Tosis is present, siicli .Inijrsas will reduce arterial teiisu.a, and therein- less.Mi the i)r.)i)al.ihty ct heiiH.rrhaKe. intfa-ueiilar (.r extra-ueiilar, sht.uld he administered. \i,l,n.|.riat<> r.'inedies and exercises shculd he employed h.r val- ■ •• atYeelions: and if the patient he a ■•hleeder aii.l determined uiM.ii. all possihle means for h-sseninjt the jiihiiit V to excessive hemorrhage should l)e adopted. For this purpose the a.iministrati.m ..f the calchm. salts and of gelatin has prove. 1 of vilue The latter is not oiilv employed hypodermically. but the eating of laifie .luaiitities is highly recommendi <l in the conditK.n of ha'niophilia.' .• >■ e It is especiallv important that there he no suppurative .lisease ot the coniuuetiva'or lacrvmal sac in those cases requiring the opening of till- evel.all. These 'conditions should be treated as l(.ng as it is ,„.re<s4rv to rid the pali.'iit of them, both by topical applications •lud hitranasal m.Mlication. and. in persistent .lacryocystitis resisting prolonged treatment, it is sometimes even advisable to close the lacry- iiial pimctum by means of the actual ciuterv. bath. II any exposure powder, or a iU ; ; ( )n the day preceding the operation the i>atient should take a warm th, including a shampoo for the head and beard, guarding against t'^) ilraughtsof air. .V l<'aspoonful of comiiound licorice dose of^some other laxative, to be followed the next morning liy a saline or enema, will i)lace the palii'iit's bowels Til the l-.st condition for rest and (luiet niter tiie operation. Preparation of the Region of Operation. .Vii hour, or two preceding the operation the skin of the eye- liils and surrounding parts is thoroughly cleansed with soap and water, followed by alcohol, and then by a solution of mercuric chloride ( 1 : TrfHW)). Par- ticular attention should be given to the eyebrows and ciliary margins, and at the same time care shouhl be exercis(-d not to irritate the conjunctiva by jht- mitting the soap or alcohol to come in contact with it. The conjunctival cul-de-sac is next fn>ely irri- gated, either with a sterile boric acid solution fgr. \ to .")j>, sti-rile saline solution (normal strength), or with a solution of mercuric chloride d: .t()0()). The eyela.shes should be rubbed (juite hard, as it is here that many micro-organisms lurk, after which the eye and surrounding parts are coven'd with a st<'rile dressing until "the surgeon is ready to proceed with the opera- tion. It is also advisable, as a<lvocated by Lippincott, to spray the nares three or four times a day for a coui)le of days prec(>ding any Sottic mill irriga lor for boric gtii Mtliition. 1 For a w'nm(' of thu lit.Talim' and ilirections ».« U) the iwc of gelatin, coiwiill a paper by Dr. Joseph Sailer, Theruitutii- (iazftte, August. IWl. 1'i:ei'Miat[o.\ for opkratioss rrox the eye. tiiV) niicration iipDii the cyclnill vvitli ii soldtinn <il' pcrmaiijianiitc itf |Mitassiuiii (1; ^(KK)), ius :mi|ilc cxpcrifiu't' luiw sliown that the pri)- (■(•iliiic iiiatrrially lessens tlu> lialiility to infection of tiie wound or Ik intianmiatory processes after operation. liacterioloRical investipitions liave shown that pathogenic inicni- ornanisnis are present in every conjunctival cul-(l('-sac and on the lid niarftins, and that germicidal solutions sutficientiy strong to destroy them also produce injury to the delicate epithelial layer of the cornea, sometimes resulting in permanent loss of a portion of the visual acuity, as well as nivinp rise to considerable irritation of the conjunctiva itself. We are, therefore, ohlipeil to content (.urselyes witii the removal of as many bacteria as possible, and the diminution of the vitality of those remaining, by forcibly flushing the conjmictiva. anil scrubbiiij; the lid marpns with some of the .solutions described. bnmediately preceding the operation the conjunctiva is agiiin Hushed with the boric acid or itiercuric chloride solution, the liil exerted, and the conjimctival surface wi|)ed with a pledget of ab- -orbc'it cotton moistetied witli the .same solution. It is also well to wipe very gently that portion of the surface of the cornea in which I he puncture is to be made in those ojK'rations in which the eyeball i- to be entered. In all office operations in which the surgeon is re.tdy to proceed at once the tem]iorary dressing is dispensed with. PREPARATION OF THE SURGEON AND ASSISTANTS. The hands of the surgeon and all assisting him in the ojieration iiv scrubbed with soaj) and warm water, the finger-nails receiving particular attention. After immersing the hands in alcohol for a iiinineiit they are dipped in a solution of mercuric chloride {1 : KKK)), .liter which nothing should be touched that has not previously been leiidet-ed asejnic. If the assistant is one with whom the surgeon i- unaccustomed to work, he slumld be advised of the details of the iperatioii and the orde in which the instruments will probably be required. In operations upon the bulb, the a.ssistant should be in- structed as to the method of removing pressure from the eyeball by lifting the speculum, and also as t^> tlie probable i)roce(lurps in ciuse .if complications. The nurse should be |)repar(>d to render any is-istance re(iuin>d, and neither surgeon nor assistants should have handled sei)tic cases for some hovirs before operating. If several cases have to be operated upon iit the same time, and some of them lie septic, these should be taken last. PREPARATION OF THE INSTRUMENTS, SPONGES, SUTURES, LIGATURES, AND DRESSINGS. Instnunents. .\ll the instruments to be employed, with the exeep- tion of the cutting instruments with very fine points (cataract knives ¥'whmm^--Ttwwa. :•».— x)««r f f 'i IfS ii «5«i allll IHMM I . ....^ l» w Ix'ttiT to t II t US iminrduitfly alter, a« \m ii :;"'U;;:?'. ,..--ti;:. '" ti:.; an. ti..... phu..i m a ^tp... .t.r li.. for . mi. ut..s or .-Is.' l.oil<-'l from thr.r to tiv.- muu.t.;s n. a I [.t .M. . i. . f .-arlKmat.- of sodium, tl... iatt.-r ,m.v.M,t.ns tl.ov ♦" Kki. 344. I yttlLftOCHS.WlU, j Vfttscy's tmrtabli; sterilizer. ,l,nn from tlx- alcoi.ol. whicl. is irritatinp to tlu- .-v-. In tl.' op.-r- ;;r:;;;: • ini.;^ 1 -■ <•" i" t;i;.sf..rn..i t.. ti... ai^hoi a,,,! th... .. thl^valor or salin.' solution. ..o instrun.ont l.-in. tourho.i unt.l th- ''7t:i^Z. sho.VM tl.at tl,.- .l.li<-at.- n.tti.., i,.strun>.nts .-am.o. J^Z^uX' sa„... manner as tlu- <--;:--'" :,;7£! .lestroyin, to a jar,.- extent thnr -«>.-. MU^^ht..^ .],':.^,;::' ■w.!;;;!!. for.. tir-;t wped Wit 1 >I(Tllc cotton liiolrt(I!"<l will, .lo.i.i , ..^ The'e ttins e,l«es and points having been can-fully mspected fo Ju^t :.r hill 'i.ts, are Ihen wrapped with sterile cotton and held } i ::mmsr^^smnp fi;i:rM:ATi<>.\ for (H't:nATi<>ys ri'n.s nii: i:yi: «.j7 f,,r a iiioiiii'iil in l)uiliii>; water, after wliieli they mav Ix- placed in ■il.Miliite alcnluil <.!• wrapped in sterile alisnrhent eott il required i,,r ii^e. Iniiiiediately heft.re iisinn tlieiii tl-y shoiilil a>;ain he dipped ill liiiiliiij; water fur an instant. Manv ditleri'nt n.etlidils to (ilttain the sjune results are employed l,y liillerent ophtl'.alinie surjjeiMis. For example, some do not em|»l<»y .lii-ohite alcohol, hut phu e the instruments after lioilinj; in a :{ per iiiii. .(ihitioii of i-arholic acid, or a 1 : KMH) solution of formaldi'hyde. (iilins transfer them at once from the sterilizer to sterih- water. Still oihers sterilize hy means of formaldehyde >ias, employinf; spe- ri:illy devised steriliz("rs for the puri)ose. The one here illustrated ilU'. ;{4.')) was devised hy Heik, of Baltimore, and is a very .•\c7ileiit one for this method. Before iK-pnninn an opiTation, it is F!(i. 315. Ktik'n foriimlin Btcrlli/ur. Mwavs a pxiil jwocedure to arransje the iistruments in the order ni 'Aliicii Ihev will iirol.ahlv l)e reipiircd. Tiiis can he d..ne when plaeinji tiietn ill thi' sterilizing: tray, and any one can then he picked out more ■klv should complications arise diirinj: this operation. oi 'pill Sponges. Ill nphlhalmic operations ordinary sponges may he -cl pn-pared hv the usual methods in vopue anion« >;eneral siir- ■..ns hut small" pieces of sterile gauze, or small i.ledfjets of sterile Hon. are prefcrahle. In deep-seated oiicratioiis in the orhit it is '.'.vv satisfj'a; irv to have the gauze wrapped on the ends of st(>nlp i.ks or prohes," so that, in sponging, the parts may he more readily kIiimI and the assistant's hand will not ohscure the field of o|)erati()n. Sutures and Ligatures. Catgut, either plain or chromicized, and ,. .-ilk .uv cmplovr.l as sutures an 'igatun-^^ in ophthalmic opera- • Ills and the iiietliods of their jjreparation do not differ from those i use in general surgery. The silk may be either white or black, 42 i I I n t i H 111 if: (J.'iS r///; rrt: hut thf latter is U< l.c i.ivf.Tic.l if it is t.. r.-main in positK-ii for soii.r time as it is incrr rra.lilv l.-cal.-.l fur r.-inuval. Aftrr \Uv iitiir.'s ar-' n-iM.iv.Ml frni.i the soluli.ms in wliicl. liiry „M.aily arr k.-|.t they an- ,,lac.'.l ill al.s.,liit.- ain.hul until rc.|iiii.il. «i.-'n they an- nns.',l ni sK'r'i' water. Tlie same prueedure applies tn litjanires. DreBBingS. Tiie .IresMnjIs f. l.e plaee.l npnli an eye alter an ,„„.ralinn neeessarilv .liller aec-niin}: in ti.e natnr.- nl tite ..|KTatiun •Hul the exip'ii.'ies of Hie ease. In extensive n|«.rati.ms aliuut tlir r„ls tii.'v .1(1 n.it .lilTer fn.in those einployeil in surgery el.sewh.'te viz.: a I'.ruteetive, pads of sterile «aiize, alisorlwiit cotton liaiiclaire. The ;raiize may have in a solution of niercuric ehlorii ciile, anil (hieil 1.1 anil a roller sterile l>y heal, or soaked ,1- 1: -.'(MKI) or other jierini- ■;|erile. and trauze is to 1„. ..referred in prepaniif: it. as it r.-tains its i-u.-iti-.n inueli Letter The li;inila;:e I mail. i I : IIHN) iiiiilil also li 1" thaii if made of llaiinel. The dressinj; may he either ry or wet. the litter instanee it is s..ake.i in some solution hel. re plaemn iii itiun, iisuallv menairie eliLnide : 1 : .VMM)), l.oric an.l (>rr. x to .,j) or sterile normal saline .snlutioii, and till- exeesssiiuei'zeil out with the haml. In the majority .if ophlhalmie op.'i- ations the followinj: melho.i ot dn-s- iii}: the eye will i>rove satisfactory . .\ few layers of sterile fiaiize twii ami one-half inches in diameter are moist- en.'il with a s.iluti.ni of mi'icuii.' .,^^^^^^^^^^^ chlori.le ll: ")(MKI), aii.l placed ov.'r yir^^^^^^^^Sc^l sutiiiient sterile ah.-^oil.ent cotton t.. VJ-X^ L04§J till ill th.'.lepressi.m ma.le liy the or- ^ " liital ridfje and the no.se. These are fasteii.'d .si'curely in position by a tew strips of isiiijrlass plast.'r. If the p.i- ti.'iit is .|uiet, this ts sullicieiit; if in' is restle.ss, however, or untrustworthy as to I ■ -sinji his lin<;ers beneath tlu' an atteni|it to s.'.'. it is saler to add ihe ^. . Indee.l, in many cas.s. as after cataract •i.l.rtomies, it is an excellent iih''. to jilace over tli.' above dressing a protective mask such as that shown in Fip. -.W which was ilevised bv the late Dr. Frank W. HiiifT, of New \ ork. an.l is ma.l.' of iiapiiT-mach.'. Other masks ma.le of wire or aluniinu:n areempiove.1 bv some surjre.ais. In place of the fisure-of-eifiht ban.l- a.re in some cases, and especiallv in those who are contimmit! th.'ir vocations, a m..ilih.Ml Ijrtnrich hand,,,,,; which is knit of black zephyr an.l fastened in p.isition bv a tape at each end, will be very acceptabl.v It is maiie either sinirte or .l..ul.le, accnlinp to wh.therit is n-^iuiv.- for one or for both eves. .\ prc^sur,' hnuhutc is not apjilied .liHerently from that .lescribe.l.' except that sullicieiit cotton is so plaee.l ovc- RiiiK ■ lilrt.-k. ilressin<;s, or lifting it in tizure-of-ei;;ht banda;^.'. extractions or iri. fUEl'AUATIOS h'olt <H'EH.iTI»SS ll'nS Till: h.YK. (i.",!) (1,.'H!UIZ(> pti.ls tliiit.wlifii tlif l)Mii<laK<' is appliid. linn picxsun' upon il,.. cyrhall is niatlf. A rimj ilnxstiiii. mucIi as is cniplnyfil S(.nu- Kl.i. ;U7. Mixliiiiil UcbrciL-b buiiilagu liiiirs after skin--:raftiiif;, is inadf by siim>nii(lin<r tin" wiu'ii' field ni nprialini; witli a liiiji of sterile paiize siillieiently lliick to pre- \riii I lie (liessiiijis from coiiiiiin in contact uiih it. /',''/«■ xltiuUs are sometimes em- pldveil after the dressings have been ilis- riiijed. and should lie firm, lifilit, and so -li:i|ied thit MiHii'ient air can enter behiml !,„,n tM Kcrp ti, ■ ye cool and dry. (I'itr. :\\\.\ \ Hiiller shield may he employed 111 lertain I'ases as a protective dressiiif;. I •(■(•Msidiially. a- in tuberculous (lis(>ase of the nrliilal bones, it is neces.^ary to eni|)loy iM,|,,|,,!-m dressing's about the eye, but these do not differ in any I' MKTt from similar dre.-isinj;s employed elsewhere. Kyu islmtle. ANAESTHESIA. General Anaesthesia, (n the proat majority nf ophthalmic opera- ■i..iis local anasthesia is sullicieiit ; l)ut ill a few. such as enucleation il the eyeb.all, ojierations upon .severely inflamed eyes, removal of .ihit.al -irowths, jilastie operations upon tht> lids, and in most of the ■peratioiis upon children or very nervous individuals, general anus- esiaisre<iuired. Mther is jm'ferable to chloroform, except, perhaps, patients alTected with chronic bronchial diseases, in whom it is i;ilile to dive rise to MM attack of pneumonia, liroinide of ethyl is ■Hietimes emnloyed. and at the jm-sent time is attracting consid- nible attent; "in among French surgeons, but by most ojierators it is considei d to posse.ss no advantage over ether or chloroform. mo Tin: i:ye. Nitrous oxiilo gas may be (Miiploycil :ulvnntaf;ooiisly in short opera- tions in very nervous patients, as in tlie ililatalion of strictures of tiie lacrynial duct or in tiie ri'inoval of a cjialazion. Local Anaesthesia, lor the purpose of local ana'stjiesia in opera- tions upon the eye, the hydrochlorate of cocaine is employed proha- l)lv more generally than any other dru}:, although witiiin recent years a number of new local ana'sthetics have been introduced, each of wiiicli has its ailvocat<'s. The Iiydrochloratt! of cocaine is employed ordinarily in a 1 to 4 jier cent, solution, anil even as stronjz; as 10 percent, by some surjreons, and, a.s it ])ro<luces some softeninj; of tin' corneal epithelium, the eyelids should remain closed after its instilla- tion. For superficial operations, one instillation usually sutiices, the operation being performed five minutes later: but in deeper opera- tions, for example, iridectomy, extraction of the cataractous lens, and tenotomy, three instillations should be omi)loyed at tive-niinute intervals, and the o])erati(,n begun fifteen miiuites after the first instill.ition has been made. Uy following this method, the cocaine has sufiicient time to reach the deejier structiu-es of the eye, and much less i)ain will follow th(> seizure of the iris or tendon than otherwise. Operations should be completed either within twenty minutes from the time of the last instillation, or other instillations made to |)rolong the effect. For the removal of a Meibomian cyst, the hypodermic injection of a drop or two of a 2 jut cent, solulioa in the immediate neighborhood of the cyst will render the operation far less painful than will several instillations. Hydrochlorate of eucainc ".\" and hydrochlorate of eucaine " IV' are sometimes used as local ana'sthetics, abluuigh the first is em- ployed by no means so fre(|uently as formerly, as the latter is less irritating and li'ss toxic. The advantages claimed for eucaine "H " are that it is one-fourth as toxic as cocaine, does not affect the heart, d(M>s not produce mydriasis, nor affect the accommodation. The disadvantages are nuich more congestion and bleeding during and after ojieration, and freipient slougliing of the tissues when em- ployed hypoderinically. For producing local anasthesia about the eve. 2 per cent, solutions are recommended. Tropacocaine in .'i jier cent, solution is employeil by some surgeons (Si liweigger. Silex), who claim more rapid ana'sthesia than with other ilrugs of this class. The elTeet also we.ars otT more rpiickly. Holocaine is one of the 'lewest memliers of this grou]). and is usi'd in from 1 to 2 per ci-nt. solution. It is chiimed that it does not atTect the corneal epithelium, produce mydriasis, nor impair the .accom- modation, and that it produces ana'sthesia more quickly than cocaine: the ana'sthesia, however, does not last so long. It is preferred to cocaine by some surgeons (Knapji. Derby) in all o|)erations in which local ana'sthesia is used. As it ]io.<sesses some bactericidal action a?id d'"'- U'-t afVecf tlie cnftie;'.! epithi'limil, it should be given tlie preference in corneal ;il'fections in which local ana'sthesia i.s reiiuired. and in the removal of foreign bodies. BJl" uiL'L.- rrcr i n ' n i \9m\ \ PHEI'MIATIOS FOH nfEHAVlOSS Ul'OS I'llE EYE. ()(jl Siroseliciu's Husk. f „f tl.o^c -solutions, as well as other alkaloidal nasnu.ch as •"- fj' . ^ ! ! " •,ello.,t n.o.lia fur the finnytl. ~':'''^''"'''';iS 1 V ium-i'^' "■rili.e.l thon-ughly h.-ro.e l.ein, ;:;;;;• ;:'r'::h;;;::;:'i;;:i.."'an;;;;:pt. ,...,1.,;: .. exan,,.. ':i;!o';u..,eurie chloride, .-r ^-^ ^^^^^^^ 1 \ ,le Sehwemit/.). The us<> of a saturate 1 -,auUoM of l.orie aei.l will nut pre^i.t t^he p^-owth „l ,u„jri, hut will prolong s.miewhat the P.T10. ,i,.r t^ their appearance. For stenhzat.on by l,„iliM^r, the Stroscheiu flask is very convenient. ' ' iifiliration Anesthesia. 'This metlu>.l of pr- Mu.inj: local anuvstlu>sia. as suggestea l.y he leicl^ ..,m.-ists of the intmmtanvoux injection ot tht following solution: Ciicaina hydtochlorat., K'' J- S-Hli ihlori.lli. ^[ J- A'liia' ,k-MillttlB, Sj-M- Uv means of a hyi-nlerniic syringe a <lrop or , w„ of the solution is injecte,l into the ^^in resu - „„ in the proauction of a small wh.'al. A not u ,.|,|itliahiuc practice. POSITION OF PATIENT AND OPERATOR. :,J i„ i,i,Vcton.y ana in extraction ot I'^V = \' .f^'^,,' :,.. ,Uvavs seen.ea to the writer -^'-^^ ;--^;^^:;^.S} ^^^.^ 2u\^ ::•:;l;;;•::^•7;;:i■:aSru;:;^V•'r^^ U„.K. hi. hoaa resting upon one or two 'l^''''' I^"-; ';,';",, t::;;;:;7u;;:';;t:r;l;rst^lv:M'-,£;;t;. ,.-.- :;;:^;i;;';:;;:i'Ii;'^:r",:i::=T:J;.rp,.™- .h.n.v.r a.sin..l.aua the jar of transternng the patient tio.n iiii 662 Tin: KYi:. talilf or chair to the 1)0(1 is tiicrcliy avoiilod. Sliould :i chair l)c ciniildvcd. till' mil' nroiiiiui'nili'ii by Kiiapp is very satisfactory (Fij;. ;{.■)()); i)ut tor iiiiuoriipcratioiis in tiicoliicc an ordinary arni-ciiair witli li' IT Kiifli'|''s o]K'n»tiii(?-i'lm.r. a low iiack. over wiiicii is placed a sinall pil- low for the i)ati('nt's neck and head to rest uiion, will he found to answer the purpose fairly well. The position of the operator may he either hi'hiiid or beside and somewhat in front of the |>ntient. If he is ainliidextrous, he may stand behind in all o]ierations: if not, he will be obli<;ed to stand behind in certain opei'aiions ii]ion the ri<;ht eye, and beside the patient in the same operation upon the left eye; for examjile, in making corneal sections in the extraction of cataract. If he will accustom himself to stand behind the patient in as many operations as pos- sible, however, it will be fi.nnd much more convi'iiient, as he may operate upon either eye without shiftinji his position. Knapp has truly said th.at ambidexterity is not a .-ift of nature, but must be acijuired. This can be done only by freijuent practice. To most of us it is '|nite natural to manipulate the instruments with one hai'd only: the other must, therefore, be educated. This can best Im' done by jiractice upon the eye< of ;inimals in oper.atinj; masks (Fii:. ;{.')1). those of the pi<r beins: the best, as sullicient i|uanlity can always Im" obtained, '{'he methods of practice ha\e been given elsewhere.' ' Set? the writer's buok, ophtliuliiiic 0(K,'rati'iiis hs rrat'tiso<l oti .tiiiiutils' Kyes. OftLTiii.'iK iniisk for (inu'tising (»n niiimiils" fvt's. KA' *. .,.■ , I'REl'Ml.iri'tS lOli UI'IUIATIOSS Vl'oS Till: EYE. (J63 ILLUMINATION. Ill in,Nt..f th.' (iiicnitiniis upnii til.- <'>■<■ it is iiupcrativc tlmt the ,ih,n,iMati.m 1..- ..f tl.r l.cst. It .imtt.-rs nut wl„-tluT u is unlmary ,|,vli-h1 nr artiticial li-ht from an Arjianl l)urii<'r or <'l(>('tric Ixilt. I, ;houM come Irnin tli.' i.l<" of th.> .-y." to 1)<> oporatc.l i- ami -liouM lie th.- hriirlii.st p..ssil)lo, l):.rriii>r 'lir.'ct sunliglit. I hat „l,„i„,„l from a small spa.v is tl..> m..st satisfart,.ry. as anm.yinK ,,.il,.,.liot.s :hv th.Mvl.v av<.i.!.'.l. If nrtifi<-ial li-ht from a.i Ariia.i.l l,„ni.r is .■mplov.xl, t'lu- assistant thr.Avs it up.ui tlv- .-y hy m.-ans ,,, :, ,.„n.l.Misin- lens, tlnis in.Mvasi.ijr its hrillian.-y : il from an .-l.Ttne 1,„1!, the liirht shoul.l 1..- ('..v.-nMl with a r.'fl.rt.-r. T .<• lat .-r is a vny'cu.v.'nicnt nu-tho.l of illiiminati.)n in ras.-s in which tlio arti- Electric bulb with rcflfotor. • ,i,l li-rht is omplov.-.l. as it mav !>.• attacho.l to any outlet from the -nvrt rurn-nt, aii.l with suilicicnt win- .-an l)_c carricl to th.- most :.Mn,,li' parts of the .)i)<'ratinfl-ro.)m. ( Fift. .•{.■)2.) It i< aJM) .if KH'iit importance that th.- vision of the op.-rat.ir be , 1 Th.- eye is a vcrv small .irpm. an.l many of the operations ■^qiiiiT .ielical.- mani|iulatioii in small spac.-s. so that good vision „,| ill,„„i„,,iion are ii.,lisp.-iisal.le. Operators havnifi refractive ■iMiv n-niiiin-; orrecti.ni for .listiiict near visi.m shoul.l wear ■i,:,t (.nrivcti.m whil.- operating. Various niapnfyinp; glasses : ,ve iMrii suggested from time to time l.y diflerent surgeoiis- i ..10,^. Herg.r. an.l ..th.-i-s (Fig. 4. Thaiiter I.)-to in.pn.ve the -ion in .ip.-rative w.nk. .-veii in those who have no refractive '.■,„■ hut th.'s.- have not se.-ni.-.i t.. the writer to possess any Ivaiitag.- ov.-r th.- .mlinary correcting lenses in those whose media ■ II' perfectly clear. 'S'JsmfssM^^m.'ikT'.^ ',' L-^ST^VT^BKl. ^. ■&«. JBti d; 6G4 ' !i I i 11 I! }i "111: EYE. TIME OF PERFORMANCE. Operations may he iicrtoniicil at any lioiir of tlic day or nijilit. or at any season of tlie year. W itli iirojM'r illumination, just (lescrii)cii, (Vises first seen at ni^iit or on very cloudy days, and re(|uirinf; iin- tnediate operative intert'erence. need not he post|)()ned. Tiie .season of the year intluenees results in those o|H'rations re(|uinnf; more or lew proloiif^ed conhnenieiit in bed only in so far ;is it may increas' tlie debilitated cnndition nf th<' patient. Obviously, therefore, if avoidable, very s'out ])ersons sjiould not be operated upon in ex- cessively hot weather, nor those alTected with ni'phritic or ])ulmoii- ary disea.ses in extremely cold weather. In most cases it is probai)ly l)etler to operate, if ])ossil)le, early in the morninji. whih' fresli ami before other cases have been handled. In the o|)eraf ion for cataract, how(>ver, it is thou<;ht by some surjreoiis to be, better too])erate in the afternoon, as the few hours nf smartiufj; which usually follow thi> op(>ratioii will be succeedeil by a nijiht's sleep and rest, so necessary for the earlv union of the corneid wound. AFTER-TREATMENT. It is manifestly impossible to jjive any hard-and-fast rules con- cerning; till' after-treatment of operative cases ap|)licable to all alike. The special re<|uirement-< of the more important operations have been {liveii elsewhere when the techni(|iie of the o))erative procedures lias been described. In general, however, if there is much pain followin}; an operation or the jiatient is restless. ;iii anodvne should be administered, .^^leei) and rest can usually be obtained, if pain is not jireseiit, by the administration of 1.') <Traii!< of trioii.il. If ]i;iin is ,i iiromiiient symptom, a hypodermic injection of morphine may be <:iveii. The patient should not be |'.; rmitted to lie ill one |iositioii any longer than .ibsolutely necessary, especially upi>ii the back, for tear of hyixistatic coiifrestion of the lunjts. If there is any history of hemoirlia<;e haviiifr followed a former opera- tion, the head of the p.atient >liould be kejjt hii;h by means of se\-eral pillows in adililidU to elevation of the head of the bed. l*atieiit< .■iccu-^tiimed to the habit iial use of considerable ipiantities of s|)irit- uotis lii|Uors should not have these entirely withilrawn, l)ut should be served in moderation. In operations recjuirini; the eyeball to be opened 111 in e\tensi\e operati\i' procedures, it is better to kec]) the patient on sdft diet for the siiccee<litii: twenty-four to forty-<'i!ilit liours. .\s a rule, the dressin<;s should be clianijed daily, and the eyes e.irefully ins|)ected an<l cleaiisecl with warm boric :ieid lotion until they are no loiiirer rei|uired: and eyes that have been bandaj;eil for some time shoiilil jiradu.'illy be accustomecl to the liirht. if the bowr'- di) not mo\-'. nf th''i!!-e!\-i'-; in three "r fiuir days, a !:i\a!i\-'' <lii>ti!d be administered, and in all operations upon the bulb straining 'i' stool should earefullv be jinan!' d ;u:ainst. .% ISMVJl ^.J*- TlBTTrWRRMf CHAPTER XV. .p,.r xErnXIQUR OF THE PATHOLOGICAL AND BACTEUlOLOtilCAL EXAMINATIONS OF THE EYE. Hv KDWARI) A. SHIMWAY. B.S., M.D. TiiF stu.ly of the piitholofiv of the oyc, in certain sections, has not kept pace with that of Kcnerul i)ath(>l()Sy, u fact that is .Uie jx-rhaps to tlie ahnost entire silence upon this subject of worlison genera! path- olo.rv and patiiological teclurKpie. In no i)art of the l)0(iy, how- ev.T are so nianv .litTerent tissues hitiinateiy related m a small -.paci- ami the additional interest which the niicn.scoiiic study of thi' varied pathological conditions hrinfis to our chnical observations, well rei)avs the etTorts niadi' to master th(> techni.iue that is required. \n elaborate outfit is :iot necessary. A good niicroscoi)e, with an oil- iimiiersion lens, if bacteriolojjical examinations are to be made, aiui a microtome, for holding the knife hi making sections <it the embedded Mcilluin lal«rati)ry inii-ri>luiiiL- tissue, are the first essentials. .\n expensive microtome may be dis- .rnse.1 with. The Schanz.> mo-l.'l (Kig. -^'^-^U nwide by the Hauscli it l.,,mb Optical Tompanv, is an excellent instrument. (Jood secti.m- iMittitiL' depends more uix.n the success in ( nb. dding and upon the ••on.lition of the knife than ujion c.stly mic< tomes. Thv best kiu\. s luv mad( by Walb, in i'eidelberg, ami a lairly heavy one. with a ( ti«5 ) wmmn IJ(J(i THE EYE. ■ i ciiltiti^ odfic fniiii K) to 20 ciii. long, sliould he selected. n"i<;. .'?.")4.) Aside t'niiii tliese l;ir<;er iiistniiiieiils, we need a pair ct' fine t'(iicei)s (prel'eraljly cuiahmIi. iieediedidlilers, spatulas (one hroad and <>ne narrow), staining dislies. cover-classes, slides, etc. For many sec- tions the onlinary slide, 1 x ;? inches, is suiiiciently large, Imt for sections of the entire eyeliall, slides \\ x .'{ inches, or the (iernian size, 70 X .■>") mm. ( 1 '.; X !'■; inches), may he ordered. Convenient sizes for covor-jrla.sses are IS mm. s(|iiare: 121 x •_'() nnn. for .sections of Fio. 3.' Ktiife fur microtoino one-half of the oyel>all. and 2S mm. square for the entire ball. Larger ones, 2S x '.\2 nnn., are occasionally useful, and when still larger forms are nece>sary isinglass may be obtained in sheets and cut to the proper siz(>. Obtaining Material, Normal eyes are difficult to obtain, but may be secured occasionally in resections of the upi)er jaw, and very sat- isfactory s|)i'cimens are furnished when the eye is enucleated for small malignant growths of the anterior i)art of the eyeball or of the optic nerv(>. Many interesting conditions require emicleation, and l)athological alterations of the conjuiu'-va m.ay be studie(l by re- moving small bits of the tissue after cocaine ana'sthesia. In po.st- mortem examinati(ms the removal of the eyes is rarely permitted: but if the skull has been o])ened, the |)osterior halves of the eyes may be secured by breaking through the roof of the orliit. dissecting away till' fat. iind carefully cutting through the sclera in the ('((uatorial diicction with a sharji jiair of scissors. .\fter the material has been obtained, it slioulil Ix^ placed in a fixir.g fluid as soon as possible, in order that the fine changes, which take place in the nervous structures of the eye, may be |)reveiited, and the tissues pr<'ser\('d in api)roxim.'itely the same comlition as in life. The exact time for the earliest appearance of post-mortem cha.nges in the retinal ganglion cells h;is not been determined for the hum.'iM e\e. I^irch-Ilirschfeld, IxAvever. found d.'cideil changes in rabbits' e\es iwo hours after di',;lh,and it is fair to assum(> that if a nmch longer time has elM|),sed. the human eyeliail can l)e of little value for a study of the g.'inglion cells, Mllhough it may still be us(>ful in ileterjnining changes in other li'ss susce])tible ])ortion,s. j:xAMiyArw.\s or rni: j:yi-:. G(j7 Preparation of the EyebaU. ( )n removal of the .>>(• the iiu't.suro- incnHofits.liaM.ctcrsslu.ul.llH-niuk and any pcciiliaritics iii its ,.M,.rnal apiM-aran.-.- .•aivlully i.nt,..l. Th." iu.-asur.M,u.Mts may cm- )taiiuMl hv iiicaiis of an iiistruniiMit like tlit one i\>\y vciiiciitiv 1)1' ohtainiMl by means ot an ~li,,Nvn in V\ii. ;}.V). wliieli was .lesijined for measimnjr interpuin,- l-iiv (lislmees Tli<-v sliouM incliKle the antero-i)ostenor diameter .i„;i tl„. 'vei-tieal ana'l.oii/ontal .liam.'ters at tlu- e<iuator. The snle ,,l 111.' liead from wliicli th.- .-ye was removed should also I... noted. ■ ■■ on the nasal side of the jiosterior The o|)tie nerve enters the ( yehail pole.s.) that if the long axis of the eornea is held in a 1. 'nzontal Instrument tor oMaiuing meHsuanii'nlsnf IheeyetBll. .lireetion. an.l th.< opti.- n.Tve dweeted toward the n.japnurv fell w ,.v,. the problem of orientation later should be a snnple one. It this ,.■„.; is not reeorded. w.> must rely on the ai.pearanee and insertion ..f ,|„,„bli.,u.-museles.provid..d that they are still II'-''^^'^^- . ^ ''''"- iHior obli-iue tendon is more tl,.shy and is =\'1''<-1"" f'"-^'",; " U;nn th<- eornea than the superior, lioth are inserted o t m- l„„.alsideof the c,>m>spondin« reetus musele. /•""•;'■ '^ ^'"'^'^ Uis of the eornea is h.<l.l apiin m the hon/on al plane xMth tl<> M.perior reetus up, the attaehments of the obupies ^.'1 '";;'»;;^ <" ,l,;.,o,nporalsideof the eyeball, and the side from whieh it \uis ,,, Moved The position of any ulceration or opacity ot the cornea -huuKl In. sketched, and the jm-sence of a coloboma or other i-ecu- li.ritv of the iris noted. If an intra-ocular tumor is sus];ected. it ,„,.,v be lo..ate,i by noticing a difference in ""■ '•■^';'7;;'V':'"f I';.'; "; Lvlooking through the pupil while the oye is hel.l be o.e a b ig t li.h, Ordinarilv, sections are made of the antero-p..sterior .liam- ,.t'.r of tlie eveliall, so that the eve should be divided m this direction. I'his. however, should i)e done after the fixation and hanlenmg, in Mider to avoiii distortion of tlie halves. ■ .• • Fixation and Hardening. Unl<>ss some special exanima i.m is ro- ,,ui,vd (see nu'thod for the retinal ganglion eel s, page O.M we may ,..,nli,„. ours(>lves to the use of two solutions-formalin and MuUer s ' "Mailer's flui.l consists of: potassium dichromate, 2.o gm.: sodium <ulohate 1 zm.; <listille.l wat<>r. 1(K) gm. The s.^lution shoul. 1... used in considerable (,uantity. and tlu- bottom of the jar nAon-d with cotton, so that the fluid may have ready access to all por- lions of the eveball and the eye not injured m transportation. It -s- ZtJiKlij^ ":?sr I.,- i" \_ ■ffaflpMMI (iOH nil: LYE. I is iimii'ci'ssiirv to iiutkc an npcniiii; in liic ('y('i):ill. as tlic tUiitI pene- trates rapidly. The specimen slKuiid he i<ept in the ilark ti> prevent llie r')nnatii)ii of pre<'ipitates, ami tlie lluid should l)e cliarifted daily until it no loiifier hecumes cloudy. At the end of six weeks, at ordinary room temperature, or after two weeks in tiie incubator (oT' K)° I'.) the eye should he washed thoroufihly in runninj: water for twenty-four hours, and then hardened in firailually ascendiiifistrenjrths of .ilcoiiol. .Mii'.ier's fluid is of s])ecial value when it is (h'siral)le to employ the \Veii;ert stain for the nerve sheaths, and even when other methods for fixation are used, it is well, if the lenjtth of the nerve permits, to cut off a piece and place it in Miiller's fluid for cross- .sections. It is also the best medium for the examination of the lens, as formalin causes this structure to shrink. Its disadvaiitajies, however, are that it disturbs the chi'omatiu chMuents of the cells, and is not, therefore, suitable for the study of nuclear structures ; it, moreover, does not at once check the post-mortem fjrowlh of or- >;anisins, and makes the subseipjent staining for bacteria, especially for tui)ercle bacilli, very dilficult. Formalin is a 40 per i-ent. solution of formaldehydt^ Ras, and should be diluted with !) jjarts of water for onlinary use. Stronger solutions are a|)t to cau.se black pre<-ipitates in the sections, jjarticu- larly in thi^ presence of blood. The eyeball should not remain in the solution lousier than forty-ei'j;ht hours. The penetration ami fixation are \ery rajjid. ami the sclera ami lens soon become so hard that they are dillicult to cut. Subse(|Uenl washinj; with water is desirable, but not absolutely necessary, ami the fjlobe is then liardeiie(l with alcohol. This should be done slowly, in order to avoiil shrinkin<; of the ti.ssues and di'tacliment of the retina as far as possible. Hefiinninji with a .■{.'! per cent, solution, the eye remains for a day e.ich in 'X^. 40, oO, (iO, 70. and SO pt'r cent, solutions. It is left in SO ju'r cent. al''ohol for several days, and is then ready to divide. .Mcohol should not be used as a fixing a^ent, as for this pui'pose it must be of absolute strength, and the rapid withdrawal of water from the tissues, which accompanii's tlu> fixation, produces so much shrinkinjj that llii' eye is very much distorteil. It is of considerable value if the sections are to be ev uuined for tubercle bacilli, <ir in ex- amination of the retinal ii;anj;lion cells by the Xissl method, but for- malin is almost ('(jually serviceable in these cases. The conibin.ation of .Miillei''s fluid and formalin in the proportion of 10 parts of Miiller's lluid and 1 part of strong formalin, as sujij^ested by Orth, is a very <;ood one; thi' swelling of the ti.ssue c.. used by the one offsets the shrinking; produced by the other. Cutting the Eyeball. If a part of the eyeball is to be [Jreserved as a microscopic specimen, it will usually be cut in a horizontal or ver- tical plane, which passes through the corne.a and < i\A\r nerve. If an intra-ocular tumor is present, the eye should be so divided as tosliow the connection of the growtii with the tissue from which it has sprung. Tumors of the anterior segment of the eye can readily be 7..V.I.1//.V.1770.V.S nr THE I.Yi:. 609 n: „,os.- of th. <-hnroi,l ..>.. usually Lolm-at.-.l ^^'r^J^^.^ , , ,r flu-cl.T. If thisi>nT;uiti..n isnot()l)scrv.Ml the xctiniiit \ . .: 1 ,i„„l Til ■ n.ai-r.is.>..|.i<- n»»n'ts may. Ii.'Utv.t, l«- mi ,.onu'a ana imxlucos ha.l artcfac s. 1 h tr. . '-"'K '" , ^ ,„„vil of tl.' al.-ol.ol. hv iinin.Tsion of the eye m ^^^Ur tor at . a.t i::r:ir'';:=:;=:'=S'»S7ir;r;|^,:. i;:Sin;;^L-^;T!;,r^^ 1 n rt'i t ohanfics should Ik- reserve I for nn.-roscopic stu.h. 111(1^1 iinpoii.im I luo'r." Ti,; . ni-i\' li(> (lone ui one '"';" On, .UW/..rf. The hen>H,here is passed a^ain thn.ufrji alc.J.ol ,n as'en'li... s.reu.ths until .d.olute a cohol - -"j^ '•^^^., 5^' iMunerse-l in p,.re turpentine f.r several -lays. '"'' '"^ ^^H ;^^^^ ,ll.,n-..a to evaporate shnvly. (ioo.l, l>r""'''\^^\V 7in h > n^ V •husohtaine,!. The nietho.l, however, is rarely used m th.^ uu,Kr> iiux oiaiuiu. p„_,i.:^ „,,riv«e fnniialm in 4 per cent. . r 1 T'l,,. r>T><. i< 11 •irecl in tlie SO U I ion iimiii if Mi fi7() 77//; /;>'/•;. Clip I'.r thf prf^rrvmi'iii ttf inHiT. 'm-opic st-'ctious in a xiliitioti iit turiualiu. till' iiK.ilcl slinwn ill Fi?:. ■'{.'>(■). It is held in position, fivcc dowiuvanl, a^Caiiist till' Hat -iirl'ai'i' of tiic cup by incaiis of a jjlass rod which passes tiiroimh liic rulihcr cork. Thi' ilisadvaiita«t's of liic luctiiud arc till' iinpossiiiiiity of prcvciitiiij? distiirl)iii>; hiihl)lcs of air from Icakinj; in. iiowcvcr inucli care he taken in tlic mounting, the danger of siihsi'i|iieiit dispiaccMieiit of tile contents of tile eyeball, which an; not lirinly lixed in the lliiid, and the dist(.rtion of the specimen by the i)ressure of the jjlass rod, es|M'- cially if the eyeball is empty. The last dilhciilty may Im> avoided by cementing the eye to the Ikisc of the cu]) by means of gelatin, ((ielatin is allowed to swell in water for several hours, the wtiter is |)oiired otT. and an ei|ual voiumeof filycerin is added, and the fielatin melted by heat and liltered. When the eye is to be mounted, the {jelatin is melted, ai)- l)lied in a thin coat to the cut surface of the eye, and the l;itter pressed lirnily against the bottom of the cup, which may |iresently be tilled with the formalin.) The advaiita^res of the method are the ease in mountinsi. the |>ri'servalion of the natural c(vloro ' • specimen, and the iiossibility of utiliziiif: tin- eye later for mi. ro .ic examination, if necessary. .\ modiiication of Kaiserlinji's method may also be used with the .same eye ciijts. The eyes are |)laced in i pel' cent, formalin for twenty-four liours, and are thi'U cut. and the half for the macro- scopic muuiit is wrappi'd in cotton and placed in solution A. com- posed of: sodium aceta;.', ."> f?ni.: |)otassium chloride, ().") jj;m. ; for- malin. 10 fim.: water. KMI <;m. It remains in this fluid for four days, and is then pl.iced in !t.') pe>- cent, alcohol, which restores the original colors. ,ind ;ifli'r twenty-four hours is chanjied to solution Ii, which consists of; ])otassium acetati'. .'{() };'"■! jllyi'erin. tlO };m.: water, KM) <;iu. .Vfter three or four days the eye is |)ermaiiently mounted in a fresh solution of the same formula. M. I'n'.-<('rnitii)ii in (ili/Cfri) .IcUij. If the eyeball has boon hard- eneil in .Miiller's fluid, it should be washed thoroiifchlv in water for sever;il days, and bleached in a .") p<'r cent, solution of chlonil hydrate until as much of the color is removed as ma_\- be possible. It is now ])laceil in a mixture of <;lyceriii and water — at first in the propoiiiiiii of 1 : .S, and then of 1 : 2, for one day each, and is ready for embedding in the jilycerin jolly. The latter is made as follows itlie strenjitli of the gelatin is <rreat(>r than that usually recommended) : ft iirammes of a tine ijuality of gelatin {('oignet & Co.. Paris, oi' (onto I'ils. .Nhigdeburg. (iermaiiy) are covered with ■J.')() c.c of water in an .'igateware vessel, and allowed to swell. Heat is carefully applied, and the mixture constantly stirred to ])revent ^xT^sf — =-^.*-'a..tv.— . *,.' ' J .H- f.}. ig Mnr^kVnmr tfw'^ w i:.\AMiy.iTio.\s OF THE i:yh. (i71 l)iiriiiii>;: dtlicrwisc tlic jelly will liiivc !i hntwuisli color. After the .'iliitiii is tlissolveil, the white of Ml e^K or ;i small amount of pre- pa (1 vfT^r ;ill)uiiiiii (Merck) is ai 1(1. 1, aiiil the solution is boiled vi^orouslv anil hltereil through a unod tilter-pap<'r while hot. The liltrate should have a very pale straw color, and lie perfectly clear. To it is added an equal V(.lume of glycerin (V. I'.), ami 10 c.c. of a 10 |)er cent. ,soluti(m of carholic acid for each HKM) c.c. of the ture, to prevent the growth of bacteria and moulds. The mount- mix iiii; jar is a plam cup, measmniK 1; uiclies m ( li.'imeter and 1 inch lee|), with a flat, well-polished l)a.se and per|X'ndicular sides. It is tilled iiearly to the top wiiii the melted jelly, and the eye is immersed wil h the ciit .surface up. All liubliles of air are coaxed out the meshes of the tissue by means of a needle, and those (.n tlie surface if the jelly are rel oved l)y touching them with a platiimm loop hich has iieeii heated in a Muiisen burner. The eye must iheri bf turned over carefullv, >o t hat no bu!)bles of air are included, the f which mav be detected bv lioldini; the cup over a hand <iil. but if it presence o mirror. If the eyeball is empty, this re(niircs .soi turned with one iieedle, while a second one pu.shes in the sclera and holds the cut edjie below the surface of the jelly, the difficulty will besliMit. The jellv should cover tlie .specim(>n, but should not fill the cup to the t( Tl le eve l^ held itral p )osition l)v means I pin which projects through a piece of w I or card-board | dtil; ice( I 1 the specimen isjilaced under a iM-ll-j.aror over the top of the cup. am other suitable dish until the jelly hardens. After .-several ilays tl led bv cetnentin)! to it a white porcelain open top of the cup is sea disk, and thecuji m;iy l>e mounte(l inaW( filvceriii jelly is (luiie transparent. iodenba.se. ( l"ip. ;!.")". t' (iood an<l fill's the firmh that there is no daiifjer of .subseipient displacement of the cy;- contents. The one difficulty in temperate cli- mates is the meltinK of the jelly in very warm weather. This may partly be avoided l)y turning the specimen cups over in summer, or, better still, by exposinji the mounted UuHe I'ur luounliiig cup. iieiier Sim, ov e.xpo.siiif; uu- iiniuiiM .. specimens t() the fumes of strong formalin placed in a dish under the bell-i.ir while the jelly is hard.ening. Strong formalin added to the gelatin in solution gives it a whitish, semiopaiiue appearance, which hides the details of the eye but does not have this effect when in ;i gaseous state. In forty-«'ight hours the jelly is hardened to a (lei)th of about a quarter of an inch, and this porti(.n will not melt even in a Hunsen burner. If the additional precaution i.s taken to invert the cui)s in very warm weather, no difTiculty should be experienced in jOTserving the specimen in good coiulition. ■ Wall A Ochs. Philadelphia, have the eups, porcelain disks, and wooden bases in stock. I iiii V:' a'ar IV-'. ^91 Hi- Tin: h:YE. The Preparation of the Microscopic Specimen*. Tlic li.ilf tor ini- iToscnpic i'\;iiiiiiialii>ri i^lioiil.l Ix- s.MrcliiMl riuvt'iilly I'nr tlii' |ncsciici> (.f calcurcniis oro.is.'oiis (lriMisii>, wliicli arc iini iincniiminii altera lonH-slaiiiliiin cxiidativc iiitlaiimiatidii of tin- clinroid ami in atn.pliic I'Vflialls. Siicli ilcposits iirciir iiinsi frfiiucritly ill the siirl'acr ul tlic ciu.rui.l, aii.l will niiii \\n- <'.Ik.- nf the inien.t..ihe knife unless re- iiinved. Maiiv SDliitions are ii.se<l for .leeaicilicalinn. Miiller s llui.t has thi- action, Imt requires a very lotid time. Much more service- able is a 1(1 |)er cent, solution of trichloracetic acid, which decalcihes the tissue in a few days, and does not injure its staining .jualities. The solution should "Im- channel daily, and the ti.ssue thoroughly washed in water afterward. Nitric acid, in ;{ to !) per cent, .solution 111 wat<'r, or in 70 imt cent. al.-oh..l, an.l the following solu- tion, conlainiii}! phlorofilucin, also j;ivt' W'od results: phloro>,ducin, 1 pin.; nitric acid, .') pni.; alcohol, 70 pni.; wati'r, .'{0 pin. llaviiiu freed the siM-citnen from chalk deposits.it is ready for eni- iM'ddiii";. For this jiurpose we must have a suhstance which will iii- tiltratiMhe tissue thoroughly and will also be sullicieiitly linn to prevent aiiv motion of the parts'as the knif<' is drawn across. TIk most satisfactory material for thecntin' eyeball iscelloidin. Photoxylon, which has'beeii recommended as of (Mpial value ascelloidin, is still used ill (ierniany, but can no longer be obt.iineil in this country. I'araflin is very'useful in cutting small growths, or when very thin .sections are ne"cess;iry, as of the retina, but it does not infiltrate tho sclera and lens well.' (Vlloidiii is soluble in equal i)arts of alcohol and ether. It is usually furnished in this country ni the form of shavings, in one ounce (piantities (Schering), and is dissolved most readily by covering it for twenty-four hours with absolute alcohol, by which" it is .softened. On the aiMili'ii of an e(|ual (piantity of ether the mass slowly dissolves. It should be of a thick, syrupy coiisistencv for embeiiding. and a thinner .solution, made from the stock solution by the addition of more alcohol and ether, should also be on haiKl. It .should be storeil in well-stoppereil jars, and may 1m> kei)t free from pos.sible moisture by placing it, together with the jars containing the absolute alcohol and alcohoU-thcr, in a large, tightly covered jar, in which there is a (lUaiitity of calcium chlori''" to kcei) the air dry. Before the eve is emlx'ilded, all traces of water in the tissue should thoroughly be "removed. This is done by carrying it again, after thawing, through asceiuliiig strengths of alcohol until absolute alco- hol is reache.;. The ab.solute alcohol is kei)t best in a large jar. the bottom of which is covered with cupric sulphate cli has been thoroughlv dried bv heat. The copper absorbs wati .-cry eagerly, and keei)s the alcohol pure : it should be covered by several layers of filter-paper, or the r.|)eciiii.u .sh.iuM !)<> held above ii by iiioans of wire gauze netting susjiended in the alcohol. From absolute alcohol, after twentv-four to forty-eight hours, the eye is transferred to e()ual parts of alcohol and ether for twenty-four hours, then to thin £A.l.W/.V/ir/'>.No Or- TIIK KYU- «73 ...llni.liii. an.l to thick (M.lloi.lin for iit \vx< oiu; day (■ad.. The ...lluuliM is nosv allnwcl to lianl.M. vory slowly m a glass .li.sli at |(.:i>t oni" inch tlccj), am Uiwccn the eye ai \vhi( ill! ,,, an.l wide ciinuKh to leave coiisidcral)lf s|)ac(' w.Ti. ....• -v' 1 tix- '*''•'■• -^i' =''■■ '•"''''''•' '"•■ '■'•""'V'' •""••:',"">'i I the dish i.s covered witii a timihler or similar vessel, one side ot •h iiiav Iw raised slitjhtlv aft.T twenty-four hours. It is very ■ hat the surface shoul.l harden slowly. otherwis<' large iiortaiit t Mil loillini mill iiK .-nil"-- . . , |,„l,l,l..s collect l.eiu.uth it. The length ..f time re-iuired for the ,f the ether varies, hut usually it will take three or tour I occasionally, hy a needle. ixaporalion o The celloidin should Im' loo.-ient il:iy> from the wall "f the ( lish, and when it is sullicieritly tinn at the hot loll I to prevent the nee( lie from cutting it on slight pressure, the 1)1. H'k mav he remove 1 hy shaking and placed in NO percent ilcc In this it idisorl):^ wa ti I .1.11(1 hecoines fin Tlie Iw-st Mock of I'lloidii should he oiilv slightly opruiue. an. I its surface should not Iv iM-eled olT hv'lh.' linglr-nail. It may he made still firmer Msily I hv adiling glycerin to the alcohol Cutting. After twenty hiur hours in alcohol the hlock is rculy f..r culling, and may he mounted on a firm oliject vliich can hi iiped ill the mien WnO( I mav Im' vised, and if the hlock itome. Mlocks of pure white i :.ie or laple holder of 'h(> microtome a |)ort awav. as .shown in large to enter the ohject the underpart may he cu purposes, may he cut in convenient .sizes, and has the advantage of not staining the alcohol. When the |,i,,rk luvded is too large, a smaller pirc> may he fastened to its umler >iirlace hv means of hrass screws or a T-sh:., 'dhlockmaybocutasdes , lihed ahovo. SuimtHuous cellimliu slioiild he trimmed away, and a << Itlat surface cut parallel to the lilaiie in which the sections are to mat Fig. ;{.>. \ulcanizetl libre, u.<ed for insulating Ic. The l.ase of tlii' ci'l- i.liii 1)1. „k is dried and then im- 1 ill alcohol-ether for a half- llU'fsei III iiiiite until the celloidin is soft- ii.,| Moderately thick celloidin l (Hired on tiie ohj ih'iectdiolder. and the speci linen mounted in it and 1 tirinlv in place for a few miiiut •k intoSO per cent, alcohol to hecoiiu hen the entire hlock is put firm. In cutting, the .siH'ci should he clamiM'd very firmly in the microtome, an. 1 should be li'V.'lle, as p- 1 can sihie •fullv. The knif<> sh..ul.l l)e l.lace.l at as acute an angle Mh.'l.la.lean.l object kept tlmroughlv flushe.l with an. ./.„o/i s'l per cent, alcoiio without ])ressure o tlat .)n the bhi.le hy means of a The knifr .shoalJ 'h- -irawn ,f the lian.l .h.wnwanl. The sectuMis ar 1 1 ivi-nhi. held li.rht brush held in the l.-ft hand, or G74 Tin: icYi:. , allowed to roil up. ami then unrolled when the section is complete. The sections to he stained at once are placed in distilled water: the remainder are put in SO per cent, alcohol. If serial sections are im- l)ortant, numbered circles cut out of thin paper may l)e slipped be- tween each section as it is cut, or numbered dishes may be used, into each of which ten sections are juit. If, then, certain changes are found in any particular location, they may be followed in the sections immediately [)recedin}; or succeedinj;. The eyeball should be cut entirely at one sittini;, if pos,sil)le, as an inexact levelliufi; at a subseciuent occasion may result in the loss of valuable material. The sections are now ready to stain. Small pieces of tissue, such a.s tumors, portions of the optic nerve, etc., may be mounted much more (piickly. From the fixing (luid they are transferred for twenty-four hours each into 75 I'.er cent, alcohol, !)') per cent, alcohol, absolute alcohol, alcohol-ether, thin cel- loidiii, thick celloidin, and then are mounted on a block of wood and covered with a layer of thick celloidin. When this has hardened slijthtly on the surface (after a few minutes) the blocks are placed in SO |M'r cent, alcohol for at lea.st six hours, ami the material is ready to cut witii the microtome. ParaflBn Embedding. The ti.ssue is hardeui-d in the same way as for celloidin, and after twenty-four hours in absolute alcohol it is placed in a inixtun> of ab.solute alcohol and chloroform for twenty-four hour.<5, then into pure chloroform for twenty-four hours, chloroform .saturated with i)arartin (warm) for twenty-four hours, aii'i then melted ])aralHii in a paratfin oven. I'aratfin of two meltinji points may be used— the first meltins at 42°, in which the tissue remains two hours, and the second at .54° to 5S°. in which it remains for tlie same length of time. The oven should be regulated l)y a liiermosfat to remain steadily at a temperatun* slightly above the higher melting point. The chloroform may 1)(> replaced by xylol, and for strips of the retina the process may be nnich .shortened (see page OTSK Small objects remain in xylol four hours, xylol paraffin six hours, and paraffin up to five hours. The tissue may then be mounted on a block of wood and covered with the melted i)araf{in by means of a warm spatula, and then thrown into water to harden ipiickly. or else placed in a shallow glass dish (the walls of which have been coated with glycerin I. and covered with paraHin. Small paper boxes may also he made and used for this ptiri)ose. .\s soon as the surface of the p .raffiii h;is hardened slightly the entire dish or box is submi'rged in cohl water, in order that the paralHn may harden ((uickly and evenly, .\fter the su|M'rfluous paratlin has been cut away, the block is mounted on a piece of wood by warming the surface of the paratfin, ami it is now ready for cutting. Incutthig, the knife is not placed at so sharj) an angle, ami tin- sections are cut dry. They must be kept fnim nilliiif; uj) liv means of a fine camol's-hair brush, .and .should be spread on warm water, in which they flatten out smoothly. If ribbon sections are desired, the block .M-i'i-»..^ I KXAMIXATWSS OF THE EYE. 675 ,f parartiii should he cut accunitcly (ju; Ivduudrilatcnil, and tlio knifo placed :it n« ■\u ;iit aiifilcs to the inicrntoiui The sections should he stainei 1 in a pli i.C :„;,1 th<" paraflin dissolved ..ut b.^fore the stai.i is app I.e. . 1 to fasten them to the slide so tluit the Hrst place, should Manv methods are employei thcv" shall not be floated away. The slides, ui l.r cleaned scruiHilous >(, that the latter may ;lv with alcohol and dipped beneath the sect be floated on. If there is no hm-ry, the smipl( ion. iiiralis ot ( ira ,Mnentin>;U.em fa.st is to place the slides on the top of tl.i ™ Hill IS then dissolved Hill oven for twei itv-four hours. The para li\- xvio il. the xvlol remove. leadv to stahi. If aqueous stam I l)v absolute alcohol, and the sections )iis stanis arc to be used, the slides should ulacei -laiiiinji IS nece I hi SO per cent, alcohol, and then in w ater. If inim ■diate rv, the sections ma% liv means of hlter-i)aper moi • Ik pressed firmly to the slide itened with absolute alcohol, the liar iliiii is lissolveil with xylol, the xylol reniovi I bv absolute alcohol, (1 the sections covere. with a rcrji thin solution )f celloidin. When s thin hiver hardens the slide is i)laced in SO per cei Ihi ihcM ill wa it. alcohol, and tcr. The celloidin does n .t interfere with the subsequent staimn};, am 1 th (■ sec ■tions remain in position Staining Methods. Before microscopic ;tudv the sections should stained. For tliis pur] )ose we make use of two types of stains: 1 Those which stain electively the nu( Ifuselv tlu- c'll protoplasm. Of the former, we may conhne ou lei; and, 2. Those which stain titii Ives prac ticallv to two— ha'inatoxylin and carm ind of the lat- iisiii, fnchsin, and pu 1 i)icric acid are especially valuable. Staining Imlk larelvis usei 1, and each section should be han.lled sei)arately \ltcr suitable staiiiing the sections are (U hvdrated in alcohol, cleared III one o the iMitial oils, or mixture o itlvin Canada balsam iiiounted permanen ;iiid coiinterstaiiiinp with eosinniay 1. The sections are placed in wa ilieii into f carbolic acid and xylol, aiid Stainins; with ha-niatoxylin be described briefly as follows t(>r to remove the alcohol, an. n tilten cell llll'ol Deiafiel-l's luematoxvlin. .\ well-ripened solution is ii( il a laver one half an inch deep can ju d tap-water unti iflh 11 this th(>v remaii 1 three to five mill I led 4 be utes, until sulfi- ■lelll Iv stained (the eel iin should be colored liflbt blue). If, on nnioval to tap-water, the stain is no t sutlicientlv dee]), replace in the -taiiiiiifi .solution It is better to overstain than to understain. <\ a W^ish thoroujihlv in filtered tap-wat.>r, to which a diop or two water mav be added, if it is not suthcieiitly alkaline \o tinns a d.vp-blue color. If the sections are oyerstaine. Miiiioiiia water may tl le se( iliiv mav be placed in a 0,.'i per cent. in 70 per cent, alcohol a moment, unt solution o if hvdrochlorie 1. acid il th(> celloidin loses most of .lor. riien wash thoroughly with alkaline tap-w. ter. ;{. Distilled water. \. Thin alcoholic solution of eosin, one ininute '1." r-r cen t 'dcohol. to remove exces Irate. Carefully straighten out tloat them on the surface of f eosin and to dehy- the sections on the spatula, and ^^WB^"^ '■• I 676 TUE EYE. G. Carbol-xylol (xyldl 3, carbolic acid crystals 1), whore they should spread out smoothly. Here all reiiiaiuin"; traces of water are removed, and tlie sections should show no white patches in the tissue when held over a dark surface. 7. Transfer the section by means of the .spatula to the slide, smooth it out, and press it firmly to the slide with a fine fiiter-pajwr folded in six to eight thicknes.ses. A drop of xylol bal.sam is dropped on and a cover-gla.ss carefully lowered upon it. All air bubbles should be removed by jjentle pressure with the needle, and the sec- tion is permanently mounted. Too much balsam is preferable to too little, as the spiH'imen may be spoiled later by the appearance of air biil>bli's as the i/al.sam dries. Instead of carbol-xylol, oil of bergamot, origanum, or cajeput may he used for clearing, but the .section .should be pa.ssed through abso- lute alcohol, and more skilful handling is riMiuired. as too long action of tlie absolute alcohol softens the celloidin. \ AN (iIKson's .Mkiiioi). 1. The sections are stained with luema- toxylin, as befor(>, and should bo overstained. No ditTerentiation with acid is ro<iuired. 2. Water. .S. \'an (Jieson's solutiim (concentrated aqueous .solutiim of picric acid, to which acid fuchsin is added until a rod color of the desired <lopth is (il)taiiiedi, thirty .seconds. 4. Water, for a moment. "). !•.") por cent, alcohol to dehydrate. ('). .\bsolute alcohol. 7. .\vlol. 5. Balsam. The nuclei are stained brownish red, the other substances deep red to yellow. .Xxis-cylindors are red, an<l the nerve sheaths yellow. .Muscle tissue is yellow, while (•oimective-ti.<sue fibres are red. I'arallin sections are staincMl in the same way, except that they are staine(l on the slides, and the staining usually ri'(iuiros a longer time. Staining dishes with .•irrangements for holding the .slides ajjart ai'e great time-savers, as a number of slides may be handloil at the same time. Carmine Stains. These ar(> especially valuable when the .sections are to be staineil for mii ro-organisms or fibrin, or when the reaction for iron is to be apprie(l. A number of formulas are useil, but the two following nii'tliods will siitlice : 1. Lithium carmine !2.5 gr. of carmine ;ire dissolveil in 1(K) c.c. of a cold s.itiiraled soliiiioti of lithium carboiiatei. Stain for ten min- utes. DilTerentiate in acid alcohol il per cent. sol. of H("l in 7(' perceiit. alcohol I for fifteen minutes, wash in water, dehydrate in alcohol, xylol, balsam. 2. iiorax carmine I carmine 'y gm. and i)orax 2 gm., are dissolved in KtOc.c. of w.ater, the solution is boile(i, !ind .') c.c. of ji ().,'> percent solution of acetic aciil is addeil; filter after twentv-f(>ur hours). k -..-.^.^.VA^JL. ' J., Iff EXAMiyATIO.SS OF THE F.YE. 677 ^fiin for fifteen minutes, wash in water, different iute in arid alcohol l,,t,M-n minutes, wash in water, aicolml, xylol, balsam. Double stains with earmine may b<' obtame.l by a.KuiK to 1 i,.,rt of the lithium carmine solution 2 parts ot a saturate. 1 i.ienc ;„'i,l solution. The nuclei will be stained red and the remauung iii'otoplasm vellow. ^, ^ Special Staining Methods. I. Wkic.ert's St.mn for Neuvk Sheaths. 1. Fix in Muller's solution, and harden sul^se.iuently m alcohol, irilhiiul wnxhimj the tissue. , , , , i •' Kmbed in eelloidin. Eighty per cent, alcohol, sevenil hours. '{' Saturated solution of nevitral acetate of copper, ililutetl one- lialf. in the incubator at ;}5° ('., twenty-four hours. J Wash l'lac(> in 70 per cent, alcohol six to twelve hours. Lut. -,' Stain in Weigerfs alcohol Iwinatoxylin (1 gm. of ha-matoxy- lin' is a.lded to 10 c.c. of absolute alcohol and UK) c.c. of water, an.l ,1,,. solution boiled: add to this solution a saturated solution ot li,l,iuui carbonate h. the proportion of 1: UK) at tlu- tmu- o usmgK Tl,(. stahi should be use.l coM, aiul maybe allowed to act tweUe I,, twenty-fours, the sections stahiing an mtense black. (). Wash thoroughly in water. o * • 7. DitTerentiatc in a solution composed of: borax, 2; potassium t'l rricvanide, 2.5; water, 10(X , ., , i The normal nerve sheaths retain the black color while the degeu- , rated fibres and the remainhig tissue become lifl't l'n>wn- f ^h'';!'*- iVn-ntiation pr..cee.is too rai)idly, the solution should be diluted. Ihe ,„,„rss should be interrupted from time to time and the sections .samined under the micro.scope. as the optic nerve hbres are ex- ,r..,lin.dv fine in calibre and are decolorized much more (juickl} than , no.,, of'the central nervous system. Tlu- ri-^ht time tor interruptmg it ,nay be judg<-<l by watching the ciliary nerves, which often ai - m- ''''s''\vash''tlmnuigillv in water until all traces of the differentiating ,oluti<m are remove.)', .lehy.lrate in alcohol, carbol-xylol balsam -Phis m.-th...l is rea.lilv applie." f tlu- optic nerve has been cut far iiiiiugh back of the eye to "\:iniinati.>n. (i.).>.l results the pieces if the sections in ill (I..") per cent. s.>luti.)n of <• iliiii staine.l aii.l .litTerentiat removal of a piece f.ir special ) be obtained without coppering n are placed for twenty-four hours ' aci.l in the incubator. They are „, ,,„„ „„„.„..„.,.,.d as bef..re, but shoul.l be watche.l .nvlullv The fibres will be staine.l bluish black rather than .lea.l l,la,.k. "This method is applicable f. the sectiotis of th.M-veball, pr..- ^id,■.l that th.. .'ve has been har.lene.l in Miiller s flui.i. SectK.ns lived in formalin al.me will n..t give certain results, even if they are uvat...! with the chr.nnic aci.l s..lution. an.l if tlu- examinati..n of the nerve fibn-s is of importanc.-, Miillcr's Hui.l shoul.l always be used for - ... ' -.t "■■■♦■■i;i of theretmn, \iiit;. Where thi^ w. I IK ■^niall strip ma\ ,uid interfere with an exammnt IV !«• remove i as described in six'aking of the methods tu.lying the ganglion cells. 678 THE EYE. l\ II. Maiuhi's Method. 1. Hx siiuill jHocp.-i of the optic noivo in Miillcr"s fluid, eijjlit days. 2. Freshly prepared luixturo of Miiiler's fluid and 1 jjer cent. Ofiuic acid solution in ecjual parts. Six to twelve days. '.i. Wash in running water. Twenty-four hours. 4. Alcohol, celloidin. Cut. The .sections are dehydrated in alco- hol, cleared in carl)ol-.\ylol, and mounted in (Canada balsam. The (Icjiencrated nerve tibre.< appear as Hue black dots arranged in chains; fat tissue around the nerve is also stained black. .\11 else is li'^lit yellow, often with a greenish tinge. The .sections may also be stained with carniiiie, \'an (iieson's Huiil, etc. If permanent |)reparations are desired, the sections should not i)e covered with a cover-glass, other- wise the black color is apt to fade quickly. On the cut surface of the nerve there is always a deposit of black dots, but they do noi extend far into tlie substance of th(^ nerve. III. (Janci.iox Cki.i.s or the Retina. Tiie study of the ganglior cells of the retina has become of great importance, especially in con- nection with various intoxications. Sections made through tlu^ eye- ball, in celloidin, are usually too thick for this i)urpo e, and small strips of the retina may be cut out with a sharp jk ir of scissors when the eye is cut in half. Il .Miiiler's fluid is to bi' u.sed, a <?ut .should be made with a sliarj i'lstnrnent through sclera, choroid, and retina immediately aftur enucleation, the retina carefully lifted from the underlying choroid, and a strip excised. It may be placed in 20 per cent, formalin, or in 90 per cent, alcohol for twenty-four hours, then into al)solute alcohol one hour, xylol for one hour, xylol par- aflin (concentrated solution of paraflin in warm xylol) one h(mr. and, finally, for fifteen minutes each in soft and hard paraflin. The sec- tions should be from 2 to (> ,« thick. (I. Stoi)>i)i(i irilli Tliioiiin. 1. U) per cent. a(iueous solution of thionin ten minutes. 2. Wash rapidly in water. .'i. Difi'erentiate in ;)() ])er cent, alcohol (watch under the microscope). 4. .\b.soliite alcohol, xylol, balsam. The sections may also be stained with a concentrated a(iueous Folution of thionin, and suliseijuently ditTerentiated \>ith aniline I. 1 gm.; absolute alcoiiul, U gm.: cleare(| with xylol, and momited in balsam. The NissI bodies in the protoplasm surrounding the nucleus of the ganglion cell are stained dee]) blue, thi; nucl<'i a i)aler blue. Coiitnist-stains with eosin or erythrosin may be used, but are apt to blur the finer details. h. Stfiiniufi trilh Tohiidlnr-hhir (Yloycr iiniW. l.ciiliossek). 1. I'ix in concentrated corrosive sublimate .'solution, twenty-four hours. 2. Il.'irden in alcohol. 'A. limbed in paraflin (using chloroform as a solvent). 4. Cut. Mount with distilled water. ICxtnict |);iraflin with xyol and iodine-alcohol (solution of iodine in absolute alcohol). -Ai. . .rii ' aJ.,. Jl ' itl,!, ' ^J-. EXAMiyATIONS OF THE EYE. 679 t()lui< line-blue 5. Stain with concentrated a<iueous solution of several hours. . i i r (). Differentiate in aniline-alcohol. Counterstam with alcoliolic eosin solution (or erythrosin) 7. Rapidly dehydrate in absolute alcohol, xylol, balsam. The .stains are not usually tK>rnianent. IV Sr\iN FOK NKi-uiKii.iA. The det<'nnination of the condition of the neuroRlia may be of value in the *udy of the optic nerve. WeiRert's method is a long an.l rather dittieult one, an.l good results may be obtained by either of Mallory's methods, especially when the neuroglia is patholoRically incn'a.se<l. The first method is as follows: 1. Fix in formalin (10 per cent.) four days. 2. Concentrated atiueous solution of picric acid, four to eight day.s. ■] 5 per cent, solution of ammoniu.n bichromate. Four to six days in the incubator at 37°. Clu nge the solution on the second day. i. Alcohol. ,"). Celloidin. C. Slain bv Weigert's fibrin method v-"'" beh>w). 7. DilTereiitiate with anilin<' oil and xylol (of <'ach. e(iual parts), xylol, balsam. As contrast-stain, fuchsiii may be added to the ' The second method is said to be esjjecially suited for demonstrat- i)Hr the neuroglia in glioma of the retina. The tissue is treated a.s in ilir first method until the celloidin sections are cut. They are then iihiced in 1, (),."} per cent, aciueous solution of potassium permanganate iwciity-five to thirty minutes. •_'. Wash in water. :i 1 per cent, aqueous soluticm of oxalic acid fifteen to thirty min- utes. \ Wash in two or three changes of water. .-) Stain in i)hosi)hotungstic acid ha-matoxylin one to three days. The fortsuila of this is: ha>matoxylin. 0.1 gm.; water, SO gm.: |,h„si)h(.iungsticaci.l (Merck). 20 gm.: jK-roxide of hydrogen, 0.2 gm Dissolve the ha'inatoxylin in a little water, by aid ol heat, and add it, after cooling, to the rest of the solution. '■). Wash (piickly in water. 7. Dehydrate in <).") per cent, alcohol. S. Oleum origani cretici. (I. .\vlol balsam. , , . ,. , Tlu' nuclei, neuroglia fibres, and fibrin stain blue, axis-cylinders .•iiid .'anHion cells i)ale i)ink, connective tissue deep pink. The blue e.,l.,r isslightlv sensitive to light, and is apt to fade to pmk after pn.longcMl .-xposure. If a i)ermanent isolat.-d stain of the neuroglia libn-s is desired, transfer the .sections (after staimng m the phospho- iun"stic acid luematuxvlin and washing in walei i to a oO jicr tit. alc(iiiolic solution of ferric chlori.le for five to twenty minutes, tnen wash in "ater, and dehvdrate as before. The nuclei, neuroglia fibres, ^E«l- X V: swi«wwi««rtl^f^^PP"i^""iii^w OHO TUB EYE. and fibrin stand out sharjily of a clear l)lu(' color. Kvcrythinf; else is docoiorizcd, or apjM'ars (tf a pale ycllowisli or firayisii tint. StainiBg for Bacteria in Sections. For this purpose tiic s(H'tions sliould 1)0 as thin as possible, and the eyeball slioulil not be cut as a whole, but divided after embedding in eelloidiu. With other tis,sues l)aratfin should be used as the enibeddiiiji substance. The use of Miiller s fluiil for fixation makes the search very difficult, as the or- };anisnis ilo not stain well. If. however, the sections are placed for se>-eral hours in a 5 Jht cent, solution of oxalic aciil, satisfactory results may b ' tained. Staimni; -^ :i()i)s. i. Mrlliiilcnc-hlue. 1. Stain in LoetHer's al- kaline metliylene-blue ten minutes (concen; rated alcoholic niethylene- blue solution ;5() j;m.; caustic potash solution (1 : 1(),(XK)), KM) fim.). 2. Wash in water. ."i. DilTerentiate in O.o jier cent, acetic acid one to three seconds. \. Water. ."). !t.") per cent, alcohol, absolute alcohol, bergainot oil, ,ind xylol balsam. The organisms and cell nuck-i are stained blue. If the bacteria retain th'ir color by the (Jram method, this may be employed. It is a valuable stain, as it reveals the presence of fibrin at the same time. II. 0'-niH-\Vi'i<ii'rl Mvlliitd. 1. The sections may be staine<l first with lithium carmine (.see page fiTCt) for contrast, .\fter washing in water the sections should be spread out carefully i^n a well-cleaned sli(k', .so that no wrinkles appear, and presse<l firmly to the glass by hlter-i)a])er in layers. The stain should be freshly prepare<l, and may be made by shaking 0..^ c.c. of transparent aniline oil, with "> c.c. of wat(>r in a test-tul)e, and filtering through a fine hlter-jjaper moistened with water. To this is added a filtered, concentrated al- coholic solution of gentian or methyl-violet, in the proportion of 1 : 10. Stain for three to five minute's, pour off the .solution, and dry the sections carefully with the filter-])aper. 2. Lugol's solution (iodine, 1 gm. ; potassium iodide, 2gm.: water KM) gm.). two minutes. Dry thi>ri>iuihlti. '.\. DilTerentiate with aniline oil xylol (2 : 1) until no further color is given otT. 4. Remove aniline oil thoroughly with xylol. ."). .\ylol balsam. The organisms ami the fibrin will be stained a dee|) violet: certain hyaline substmices. homy cells, karyokinetir figures, and nmcus are also stained by the method. The other miclei should be sfaineil red by the carmine. Parailin sections are stained in the same way, but the <lrying .should be done very c.arefully. III. S'iiiniu;/ of Tiihcrrlr IhuiHur: in Ti.---<n<'. 1. Stain in Ziohl'.s carbol-fuchsin solution for two hours in the incubator, or in cold solution for twenty-four hours. (Fuch-'in, 1 gm.; absolute alcohol, 10 gm.; o [H'r cent, carbolic acid solulion, 100 gm.) ^3^K?^^V hW' JlV^irl EXAMISATIOXS OF THE EYE. G81 2. Wash m wattT. .{. I ) \ivx cci t solution of nitric acid for a fo\v seconds. tinii tU' : '" AMI Tiic section is rose rci I. 4. Wash tliorouphly in water. "). 1)5 ])er cent, alcohol until tlie (•). Water. 7 .\(iueous solution of nietliylene-blue, one-lialf nunutc. 5. Water. !). Dehvilrate in alcohol. 10. ( )il of iKTKaniot. Balsam. (Carbol-xylol should never he used for clearing tissue stained in an aniline dye.) The methods of staining which have heeii given include the most important that are used for the determination of pathological changes. \ description of .special methoils for histological structure, such as Ihedolgi methods for the retina. Khrlich's methyleiu'-hlue stam tor living tis.sue, silver and gold methods for the cornea, etc., would rxceed the limits of the present article, and the .student who desuvs to pursue advanced researches on such lines is referrcil to sju'cial hooks on technique.' Bacteriological Examinations. Descriptions of the Organisms that are Most Frequently Pound in Diseases of the Conjunctiva and Cor- nea. Bacteriological studies are of value only in the acute stages of corneal and conjunctival infianunations. The cover-slip examination may then be conclusive, by reason of tlie large mnnlK>rs of the organ- ism" which are present. liter the siHM-ific organism tnay l)e crowded ,nit by ordinarv saprophytic germs, which are readily introduced mto tile open conjunctival sac. Cultivation of the organism is, in many cases, very important, but this is very difficult with some of the .special Inrms, as they are readily masked by others which are accidentally iirescnt. If possible, where the discharge is abundant, the eye .should he wash '• out an<l the jiatient allowed to wait ten or fifteen nunutes. .\ portion of the reaccunuilated discharge is then picked up by means of a sterile platinum loop, and sm(>ared on the surface of i> carefully cleaned cover-glass or slide. After drying in the air, the smear is p.issed three times through the flame of a Buiisen burner, and then stained with solution of an aniline dye. I.oeffler's alkaline methy- li'iie-blue (page OSO) is one of the most useful. It stains deejily in five to ten minutes. The cover-glass is then washed in water, driejl, • nounted in Canada balsam, an<l examined with a one-twelfth oil- immersion lens. The app«'arance of several of the special conjunctiyai Mn'anisins. notablv the Koch-Weeks bacillus, and the dii)U)bacillus ..rMorax-.Vxenfeld, is sufHcieinly characteristic to allow a iwsitive liagnosis by means of the cover-glass examination. A second smear -liould be stained by the Gram-Weigert method, as follows: ' Two excellent monographs have recently api^are.! In <ierma.i : 'Anleilungzur raikroskopiwhen L-ntersii<-h.M.K. .U-. A.ig.-s," bv ITofes«)r It. <lrwtV, «...! •■ Lie raiknwkoplschen Cnter«nehunp.ineln- -le.i Jes Augcs." by 9, aeligniann, the Imier of which eontaiiis the« anJ other special metbodn In klail 682 THE KYE. w 1. Aniline vvutor, gontian-violi't solution (.page 080), three to five minutes. '1. Lujjol's solution, two minutes. H. 9o |X'r cent, uleoliol until no further stain is amoved. 4. WatiT. 5. Counterstain vith aijueous fuchsin not lonnir thitn ticrntu to thirty seconds. '' lin of the organisms retain the (lee|) violet color, and are termed , ..,vc; others lose the stain and are colored red by the fuchsin, ami are termed luijulivc organisms. If tiie cover-slip examination is not conclusive, cultun»s should 1m' tnade. For tliis purpose coagulated l)lood .serum, glycerin agar, and weak agar are especially adapt*'d. (Jreat care shoulil be taken to prevent contamination by other organisms which are present along the lid margins, and, as in the cover-.slip examination, the eye should first be washed out with ilistilled water and the di.scharge allowed to reaccumulate. .\ .small portion is then picked up by a platinum loop, and the surfaces of sevenil slant-tube cultures or Petri dishes are inoculated. Two days' growth in tiie incubator (37° to ;{!t°) will usually show the presence of characteristic colonies. In obtaining material from the cornea the eyes should 1k> washed out with sKM'ile water, a sterilized cocaine solutio;i instilled, and while the eyelids are carefully held away from the ornea a portion of the material in the bed of the ulcer is removed by means of a pointed, sterilized lance, and transferred to the media. For the de- tails of this work and those of animal inoculation, text-books on bacteriological techniiiue shouhl b(> consulteil. The most important organisms which are pathogenic for the human conjunctiva are as follows: 1. The Koch-Weeks bacillus. '2. The gonococcus of Neisser. ;i. The diplobacillus of .\lorax-.\xenfeld. 4. The dijjlococcus lanceol.-itus of l''raenkel-\Veich.selbaum. 5. The Klebs-Loertier diphtheria bacillus. 0. Staphylococcus jn'ogeMcs. 7. Streptococcus ])yogenes. S. The diplococcus of acut<' follicular catarrh (pseudogonococcus). The first three are unconditionally pathogenic for the conjunctiva: that is, they are not present in the normal conjunctiva, and when in- troduced produce a sj)ecific and contagious inflammation. The others may be found on th(! normal conjunctiva, and produce inflanmiation only under certain conditions of virulence, lowered vitality of the individual, or local lesion of the conjunctiva, such as chroiu'- iiiHam- mation or injury of the surface. Besides these organisms many others, for example, bacterium coli, bacillus of rhinosderonui, Frie(l- lander's pneumobacillus, the o/ieua bacillus and certain of the higher fungi (actinomyces and a<pergillus) have been found in iso- lated ca.ses. The tubercle and le|)r;i bacilli are present in tlie nodu- lar or ulcerative lesions of the external coats of the eve, and mav EXAiflXATIoys or THE KYE. 6«:i 1,.. .Iptocted in a histMloRical oxainiiiation of Mio ti.suo, but do not , .lusc- a conjunctival ca* rrli in the ordinary s«'nso of the term. 1 he <.,-called xerosis bacillus is also a freijuent occupant of tlie conjunc- tival sac lx»th in health and in disease, but cannot be said to be ii.ithogenic. , t- i • i^ * 1 The Koch-Weeks baciUus, described hrst by Koch in hgvpt. more thoroughly studied by Weeks in New York, and later by Morax in I'aris, and MuUcr in \ienna. It is the cause ot acute contagious .•..njunctivitis in a varying i)roportion of ipidwiir cases ...eijendmg upon the locality. It is a very small, rod-shajM-d organism, .esem- l.ling the bacillus of mouse septicaemia, found in large numbers l)oth uithin and between the cells of the discharge. Stains readily with m.'thvlene-blue or gentian-violet; luyntire to dram. I .siially found mixed with the xerosis bacillus, from which it is difficult to separate ill cultures. Culture dillicult; best on 0.5 p«T cent, agar (\\eeks), •i< small punctate, transparent colonies. According to Mnller. it grows '.,n human s.'rum agar; only, however, in i>resence of a certain sapro- nlivte. L'nconditionallv pathogenic for the human conjunctiva. ■2 The Oonococcua (Neisser) occurs usually m tlu" form of a diplo- coccus the edges in contact being slightly concave, so that the indi- viduals are shaped like a coflee-bean. The organisms are arranged u<uallv in small, irregular groups oi\ and in the cells. Stams readily with inethvlene-blue; nviiotivr to Clram. Cultivation is «hthcult; l.,wt „n serum covered with human blood. Produces severe j)urulent uphthalmia, and is the most frequent cause of ophthalmia neor - ti.nim. Unconditionally pathogenic. :{ DiplobacUlus of Morax-Axenfeld. Large bacillus, measuring on •m average 2 n long and 1 /i broad, with rounded extreniiti , occurs '.hieflv in pairs, occasionallv in chains, usually free in th^ cretion in larite numlxTs. Stains readily with aniline dyes; ne{]alm 'f^ram. i:a41v distinguished from Koch- Weeks bacillus by its size. Gro\yth •ibimdant in blood serum in the form of small transparent co Onies, which graduallv sink below the surface because of their hquejochon -./ //„. serum. Vnconditionally i)athog<'nic for man, pro.lucing a sul)- icute catarrh, which yields (piickly to solutions of zmc^ J Diplojoccus Lanceolatus (Pneumococcus) of Praenkel-Weichselbaum. ( XM-urs in pairs, tlu^ in.lividuals l)(<ing slightly oval, with pomted ,, liter extremiti<>s; occasionally is found in short cliams. hach pair nmv l)e .surrounded bv a definite capsule, which, however, is often ,lM-nt on the conjunctiva. Stains readilywitli amlme dyes, and is nu.Hirv to Cram. Grows liest in glycerin-agar (the media shoul. Ih^ <!i.'htlv alkaline), as delicate transparent colonies, resembling dew- droos." Found in the normal conjunctiva, but may be the cause ot a.'ut.' contagious coniunctivitis, u.sually of a mild type, with moderate ,. cretion and much 'fibrin. It i- also the caiL«e of a certain propor- tion of cases of ophthalmia neonatorum, and is the specific organism lor a large percentage of c.^s of ulcus cornea- serpens. Uccasu)n- ally it is the cau.se of panophthalmitis. B^H 084 TUE EYE. ! ! li 5. Klebs-Loeffler Diphtheria Bacillus. Tho diphthoria h.icilliis is « x- cctvliiigly variable in form, soriictimos apix-aring a.s straiKht or slightly curved nnls, with pointed ends; at other times sj)indle and eluli siiaj^'s oeeur, in which «""^inents less deeply stained apjx'ar. On cultures the mori)h<)loKy is even more irregular. It stains ix'st with LoelHer's methylene-hlue: grow.s readily on all ordinary media; Im-sI u|)on Loertler's blood serum and upon glycerin-agar. It is patho- genic for animals, and causes death with characteristic lesions. It is the cause of di|)htheritic conjunctivitis, but is found also in the more su|M'rticial (crouiMuis) form, as well iis in simple catarrh and on the normal conjunctiva. Morphologically and culturally it may be confoun<led with the xrri>si.'< Ixicillu.-i. a very fre(|uent and harmless oc- cupant of the conjunctiva, both alone and associated with other s|H'cilic organisms. In cultures, however, the xerosis bacillus d(H's not grow so luxuriantly, the coloni«>s are u.sually dryer on the sur- face, the individuals do not show such bizarre forms oii blood serum, the so-called lOrnst's granules do not appear so .soon, and the organ- ism is not pathogenic for animals. (). Staphylococcus Pyogenes Aureus. The staphylococcus pyogenes is one of the most common pus organisms. It occurs as a small spherical coccus, usually in groups and extracellular. Stains by ordinary aniline dyes, and is posilive to Gram. (Irows well on all or- (Unary culture-media, and can Ije difTerentiate<l only by this method. It is present on the normal conjunctiva in inflannnations of the lid marjiin, and in many forms of ulcer of the cornea (aside from ulcus serpens); it maybe a.s.sociated with other more pathogenic forms, and is found occasionally in pure culture in simple catarrhs and in pseudomembranous conjunctivitis. It is frequently found in the pus of dacryocystitis and in panophthalmitis, both by metastasis and by direct infection. 7. Streptococcus Pyogenes. The streptococcus is likewise a spherical coccus, usually slightly larger than the staphylococcus, which occurs in chains of varying length as a result of division in only one direction. It stains readily, and is poyitire to Gram. Grows on artificial media, but less luxuriantly than the staphylococcus. It is found in the normal conjunctiva anil frequently in inflammations of the tear ducts. It may be a.s.sociated with other organisms and increase the severity of the process. It may be tin' sole cause of conjunctivitis in one of two forms: 1. Catarrhal inflannnation (Parinaud's conjvuictivitis), which is usually monolateral, and is a.ssociated with lacrymal dis- ease of the same side; it is often comi)licate(i by iritis and swelling of the preauricular glands. 2. \ pseudomembranous form, which is more freiiuent. Here it may be found alone or with the diphtheria organism. The process is usually very severe and the prognosis bad. 8. Diplococcus of Acute Follicular Catarrh (Pseudogonococcus). This organism has been described by many as the cause of acute follicular catarrh in epidemic form. It has a very do.se resemblance to the EXAAHyATIoys OF THE EYE. 685 jri)ii( (COCCUS on tho cover-slip, l)ut is pontive to Gram and is readily ciillimted. Tho diagnosis of gonococcus should not he made without tilt' use of the (irain method unless the direct source of infection is known. Other forms have been descrilK'd whidi were also negative to (iram, but they could l)e cultivate.1 witiiout difficulty. The menin- jrococcus (dij)Iococcus intracelluhiris meningitidis, Weich.«ell)aumJ might be confounded with the gonococcus, but its occurrence on the conjunctiva is excei)tional. In keratitis a variety of organisms has been cultivated from the ulcers, but in many cases the infection nmst Im- l(M)ked upon as wc- undary. Only two forms of keratitis can l)e considered to be caus«'d l)v s|K'cific micro-organisms: 1. The tnie ulcus serix'iis, in which the piieumococcus was found in a large percentage of cases by I hthofT ■ind Axenfeld. 2. Keralomvcosis asiK-rgiilinia, a form of ulcer pro- duced bv the .\siMTgillus fiimigatus. This form is, however, exceed- ingly rare in .Vint-rica: onlv two cases have b(-en reporteil. Other .iigaiiisms found have In'en staphylococci, I'feiffer's capsule bacillus, h'lcillu-i pvogenes fd'tidus, bacterium coli. bacillus i)yocyaneus, diplo- l.a.illus, ozaiia bacillus, and a number of other forms which have not been identifieil (I'hthoff). (I NOSE AND TH !<^vr. ( (■'»■ ) 5 NOSE AND THROAT. CHAPTER XVI. THE HISTOLOGICAL PATHOLOGY OF DISEASES OF THE NOSE AND THROAT. Hv J. L. GOODAI.K, M.I). Preliminary Considerations. A satisfactory )!' the nose ami tliroat is a cl;i.«sification of (lis- l tiic iircsciit' time ditficult to f'>r- IIIU at«". Ill the first place the variety of traumatic lutlucncj to wiiicii tlicsc orpaii ilctcriiiiiiatioii o liistolofiii'a exposed 1 frecmeiitlv renders doubtful the if'tlieir etioloftv, ami, seeoii.C the insufficiency of the lirectioiis .de gajjs which lata at hand leaves in many ( can Ix^hridfied only by reference to analofious proci i'sses in other situations. .Mthough any system ,f grouping that can at the \)ro: A rli\7 "he f<)nuulaterrnuist"nec(>.s.sarily experience revision as our knowledge of patiiological processes a.lvances, yet other things >)eing ciuil that one is preferable which is most readily susceptibh" ot w'lboration an<l .-xiKinsion. In the following pages th(> attempt has |„.,.ii made to l)ring our c.mnaratively meagre information m regard to the patliological histologv of this si-ecial fi.-ld into harmony with the svstem which has been found most useful m mod.-rn g.'iieral patho'logy. We shall recogniz<', therefore, the following main divi- sions: 1. I)isturbanc(>s of Circulation. •_'. Iiiflatnmations. ;{. Progressive Disturbances of Nutrition. 4. Regressive Disturbances of Nutrition. 1. DISTUEBANOES OF CIRCULATION. In the upi>or air pa.ssages the conditions comprised under this h,.a.ling represent a c(.jn|)aratively .small groui), and one also m regard to which we liave but little exact histological data. Ue may dis- tinguish: a. Ansrmi.T. h. Hvpera'inia. . • i i ■ *• The two Drecediiig conditions do not r(>quire particular .iescnpton. GOO yOSE A\D TlinOAT. c. AiiKionourDsis, ropn'sciitcd by urticaria and in- aiifiionourntic (idciiia. I'rticaiia. aitliougii ()l)si'rv<'d upon tlic mucous uioniliraiic of tiic toiijiuc, does not a]>pcar to have i)i't'n found upon the nnicous incinimincs of the uom- or tiiroat. The descriptions hy certain authors of "urticaria" of the piiarynx and larynx denote evidently anjiio- neurotic (cdcnia, since tlic lesions involved not only tiie supcriiciai mucous membrane, hut the suiinuicosa as well. We have no histo- lojrical knowh'dife of thi'se atVections in these situations, hut they arc prohal)ly identical with the corrcspoinlinj^ cutaneous alterations. (/. (Kdema from cardiac or renal disease. This condition is to he sharp'y distinfjuisiied from acute intlanmiatory (cdenia, and from tiie atiftioneurotic alVection. There is no evidence of active irritation in tiie tis,sues. If the st.isis is of lonj: duration the vessel walls of the p.irts become jiradually more penetrable, and a larfje number of white blooil corpuscles find an entrance into the neijrhboring ti.ssues, altiioujth at the bcfiinnin"! of the di.sciuse there was only a serous transudate without any minfilinfi of the corjuLscular elements. This round-celled inliitration finally ix-netrates the deei)er nuiscvilar layers and may become gradually assimilated, with the result of producing more or less marked hyperplastic conditions. c. Hemorrluifies. These conditions in the nose and t' roat an; representiMl by ha-mophilia and scurvy. As we have no histological knowledge derived from lesions of the mucous membranes, the reader is referred to the dermatological accounts. 2. INFLAMMATIONS. Infln'nmations of the upix-r air passap«'s may be divided into the followmg groups: (I.) Neurotic inflammations, (II.) infectious or acute traumatic inflammations. (III.) chronic inflannnatioiis with tendency to hypertrophy, and (I\'.) chronic inllammations with tendency to atrophy. I. Neurotic Inflammations. Under this heading are comprised several forms of inflammation in wliich the characteristic phenomena appear to be brought about through the nervous system. In all instances it is evident that the priniarv exciting cau.-e lies beyond the nervous system, which is merely an intermeiliate agent in the production of secondary mani- festations. Our histological information regarding such lesions upon the nnicous memi)ranes i< extremely meagre. The following groups may 1m' distinguished: heri>es zoster, herpes pharyngis, erythema bullosum. and vasomotor rhinitis Herpes zoster h.'is liii-n ftiund on the nrurou? menibranes of the mouth, jialate. and uvula. It does not appear to affect the tonsils or the pharynx. While the histological appearances do not seem to 'f.i,..-j^j I^F:.AMM^TI(>^s. 691 li:,vo boon (IcscrilxMl in these situations, tlie roiulitions are iimlouht- cliy similar to tliose ol)taiiiinK iiixm tlie sl<in, namely, in the first ~ia>je an exiidatiun of clear iluid between the epithelium and the rite mueosa. whicli in a few days becomes turbiil from the adv(>nt ,,'. leucocytes. At this time a necrosis occurs of the epithelial cells covering "the vesicles, causing them to exfoliate, and leaving a denuded rete mucosa. Herpes Pharyngis. The histological conditions in this arfection are |,i()b:il)iy essentially sunilar to those of herpes zoster. Erythema Bullosiun. This condition, a form of erytliema iinilti- fiirme, has been (h'scribed as occurring upon the soft palate, pillars iif the fauces, and piiaryngeal nmcous membrane. Its pathological .iiiatomy in these situations has not been descrilied. Imt by analogy may besupposed to consi.st in a sharply circumsoibed dilatation (if ,1 ir'roup of vessels in the subnuicoiis tissue, attended by an exudation of iluid through their wails. Vasomotor Ehinitis. Ovir histoloc;ical information in regard to this Mlfection is extremely scanty, nuich that has been written having apparently b(>en inferred from the macroscopic appearances. A CISC of the writer's with jierennial symptoms permitted the excision ,,) ,1 portion of tissue from the septum, which was examined micro- Mupicallv. Tlie tissue, which exhibited clinically i)allor. swelling, ■iiid free watery discharge, showed under the microscope a free des- inamation of tlie epithelial cells, the cytoplasm f f which was swollen. ihe nuclr>i exhibited a diminished athnity for stains. There was no iiicrea.^e in the number of polymidear nein ro|)iiiles in the intercellular -1 Kiccs. Thionin showed little or no iiii rease in the number of secreting . |iiiii<'lial mucous c(lls. The rete mucosa exhibited a moderate ledema, :iiid was traversed bv moderately di! tr-d bloodvessels which showed HO thickening or swelling of their emi. .dial cells. The glands were ii.arkedlv swollen from an increase in the number both of mucous iiid serous cells. Their lumen showed dilatation, with here and there !i!iic()us degeneration of the lining epithelium of the etTerent ducts. lidow the"mucous membrane was a ditTuse inhltration of lymphoid ■ rlls. jilasma cells, and cells showing various degrees of hyaline degen- . I :ition. This infiltration was collected particulariy around the glands, ind did not seem to be more int(>nse than in the ca.se of essentially Mtiniial tissues. I'lie condition differs from tiiat which we .should expect t(, hnd in acute inflammation, chiefly in what may be called a hydropic ilti'ration of the ejathelial cells, in seroi'« transudation, and the rela- •ImIv slight increa.se in cellular inh'.t !■■•; The resemblance, on h. I'.ther hand, to (vdenntous hypertn.,.;, >- -itriking. The material i! liaiid is not suflicieii! to enable us miulate with certainty iiiiversal ])oints of distinction, but atteiu. .ii may be directed to the ■ .v.,ilen ajipearanre of the epitlit-liuiii in the ab-rnce of nbnnrm.il laicous deg(>neration. Whether tli<'se characters are constant mu.st I' determined by further investigations. I! m j r ! I S f 692 yOSE ASD THRfUT. II. Infectious or Trai^raatic Inflammations. By tliis term is dniotcd thosi^ >iif1a!iitaati()!is of the tissue diroctly «l('lM'ii(lciit upon hactcriiil. chcniiiMi. oi pliysicai irritants. It should he recofiiiizctl at tiic outset that from the liistolojiical stand|)oint the tiuestioii of tlie l)acteriai or iion-hactt>rial nature of tiie irritant is a see(>nihir>- one. Tiie elTeets pnxhieed l)y i)acterial toxins may he ahiiost exaotiv (hi|)hcated i)y eliemical. mechanical. .>r physical agents. We may thus have an acute inliannnation of the mucous memUrane due to an incision or to a chemical or thermic cauterization, closely re- scmhlins that produced hy the toxins of the dii)htheria bacillus or the streptococcus pyogenes, .\nother instance n;ay he found in the histo- logical lesions produced hy the bacillus of t\iberculosis and by an asep- tic foreign bo<ly. .\t the jiresent time w(> are passing from a system of classihcation founded upon jiathological anatomy to one based upon etiology, and although the <'ause of many atfectioiis has been deter- mined," yet for a large class a dehnite etiology remains to be estaii- lished. "This is ii,articularly true in the case of disea,-- - of the iiosc and throat, owing to their free and constant exposure to visitations from micro-organisms. While we may, for instance, a.s.sume that an acute inflammation of the throat accompanied by the predom- inance of a certain i>athogenic bacterium i< due to this micro-organism, yet it must not be forgotten that we are dealing with a territory wiiich may in health h;irbor normally a number of pathogenic bac- teria. As' long as the j.atural powers of resistance of the individu.il are preserved, the manifestations of p.ithogenic (|ualities in these organisms is inhibited. When howevei , thi' vitality of the parts is lowered, directlv or indirectly, it is not alone one, but sevi'ral species of pathogenic bacteria which seize the opportimity for nuiltiplicatioii a:id for the development of their toxins. On bacteriological exam- ination we thus get a mixed cultup'. and may be unable to determine the particul.'ir n'lle jilayed by the dilTcrent species in the pathological process. While observers have isolated a variety of bacteria from acute Iocm' inflammations of the ujiimt air i>a.ssages (among which may be ni.iitioned streptococcus pyogenes, stajiliylococcus pyogenes albus, aureus, ;ind citreus; diplococciis lanceolatus, bacillus pneu- monia', micrococcus tetragemis. and streptothrix buccalis), and although these infections pri'sent more or less \vell-ile(ined clinical points of distinction, we have as yet no corresi)onditig histologic.il evidence of individuality. We must, ttierefore. be content with .1 olassilication based n|)on their pathological anatomy. The etiological diTerentialioii of these conditions forms a mo.st promi.sing field for future slud\ . While both a primary trauma (i.e.. an agent which susi>ends the fiorm.;!! function^ and secondary irritation from the introduced sub- stance (i.e.. toxin or other foreign body) are essential to the pro- •hiction of the histological lesions, yet great variation may exist in the relative |ireponderance of tluw two factors. For instance, an IXFLAMMATIOSS. 693 ,,,„„. phnn-npitis n.av ocrur as the rosult of a chiUinp ..f tl.c h.uh. ,1 W.1 l.v l.a.t..rial "...vaMon ..f tlu- tissu.-s. or as tlH- r.-sult of a 1 ,,„i,,l, ,h..r,nic, or pl.ysi.al woun.lin« -f t .. parts, with s..,|on. ary ; „,,„;.,nt of l,a..tl.ria upon tl.o injur...! surac.-s I>' t - .rst in<tan.'.- U,.- d.ara.'t.-r ..f tl,.- l.-si..ns is inHucn.r.l .■hu-f y n tl,.; lur- ,„,.i;,l infecti..... in tl,.- s.-con.! case- by the natun- ..f tl..- pnn.ary 'T)uTh.> l)asis of the pro<rainfr .■onsi,l.Tati..ns. inf.Tti.ms inllannna- ,i„„. ,„av iH- .livi^-a into, first. (A, intiannnatu.ns of un.l.;t..r.n.n.-.l i;,.,.,,.i.,i;,jry; s.Ton.l, a^, intiannnations .lu.- t., a specific nucro- , ',.r.„u^ni Til." fornu-r class will hv first consi.l.-ri'.L ^\ Infectious Traumatic Inflammaticns of Doubtful Bactenology. ll,, s.. co.npriso th.> lars.'r nu.nlKT ..f acut.- afl.'Ctions of th.> nose an. 1 „at Their phenon..-na n.ay l.e nianitest.-.l by a .l.-g.-n.Tat...n an.l . is of C..11 . bv exu,lation fron. tlu- bloo.lvess.-ls. by proUfera ...n ;. ....11 .an.l In- phag.K.yt..sis. nistol.,j:i..ally we n.av .l.vi.le tlu-.n •n , first, acut.. pn.lif..rativc ..r .-atarrlml inflannnat.ons ..f tl... n.ucsa" „rivn., l...i.l tissu..: s<.c..n.l, ..xu.lative .,r fibnnous inHan.n.atu.ns i ,i: suppurative inflan.n.ati..ns. ..itl.er wU h absc.-ss t..nna ..... ..r ,1 ,11,1 s.. phl..K.....n.ms inf!an.n.atiu,.. Tl... .-ccurrence of heso ,,■„,.,„ ,„„;ii,i„t is .l..pen<lent b..tl. up..n th.- severity an, the ,,„„„Hi..a! lo,.ali/,ati.,n ..f the infection ..r trauma The -^^j^!^'^^ pvo,r,.,...s. for instance, n.ay pn.luce a pr..lif<.rativp t.ms.li s or an xn^ativ.. to.isiir.tis. or a., intratonsillar absc-ss. It w, 1 th..refore |„. n.nst conv..nient to stu.lv tl...s.. con,liti..ns fron. the anat..nucal ' .n./ipoint. an.l we shall tl...r..f..n. .Ustin,uish. first, (a) "|Hamn-t,,ms „l tl,'. ...ucous n.en.bra.... ami lyn.pluml tissues: sec.n.l, (b) inflam- „,:.tions of the submucous tissues an.l deeper structures. „ Inflammations of the MncouB Membrane and Lymphoid Tissue. V.ut.. inflan.<..ations of the ...ucsa- may be proliferative or exu- ,|ative. according as the irritatiuR apent is mil. or s..v..re. In the t'rst case the r.^s.ilt is an acute catarrhal rhinitis. ^A^^ynfr^^^J^ huynsiitis. an.l in the latt.T it is a hbrinous uiHammatum of these '"tIu. proliferative or catarrhal inHamn.ati..ns ..f the muc..sa. are ..,!n,..st unknown to us hist..lo«i.-aily, ;.wmg to th..r <''"'1^"[>. 'j nr„v,.rv \ ..as.. .)f acute rhi.iitis stu.lu^d by Suchannck ..xhil>.t...l , .w..lli.'.K ,u.d .i..l..matous infiltration of the mucous n...n.brane, .-:,„.i,.,t..,l with dilatation ..f tl..- blo.,.lvess..ls. {n.-rea.....l_n.u..o,us 8.-- ,.,viion. n.ark...! r,.un.l-c..ll.-d intiltrati.m. partK...la,-ly in the sulv ,.|,i,h.-lial lav.-r, .^scape of r.-.l bh.o.l corp-.-l.-s fn.rn the yoss.-ls an d:..Muan,ati.-.n oi the ..pitl.elial c.-Us. The .nuc.n.s glan. s si m^..l a ,„a,U...l d..}r..ne.ation an.l ..xf..liati..n ..f the .•p.th.-hum. In all pr..b- alMlitv th..se alt.-rati..ns exist in a..ute ph.arynpt.s an.l larv-n^tis, llMir'iM.livi.lual mo.lifications <l<.pen.linp ui...n the anatomical stiuc- tuti' of the part. . , ... ■ „ \Vh..re thi- irritant is of peculiar int.-nsity he pre innnary. phe- nomena of pn,liferati.)n of the tissue cells are followe.1 by hbrinous ■a (ii)4 yOSE AXD THROAT. exudation from tho bloodvessels. It should be emphasized that this foiiditiou is not separated from the iireeediiiR one of proliferation by tlefiiiile etiological boundaries, but represents merely the effect of ,! stronger toxin ujion the affected tissues. In the majority of ciuses this affection is diphtheritic, but in a certain number of cases the diph- theria bacillus wiis not found. Our only histclogi'-al accoiuit of non- diphtheritic Hbriuous rhinitis is derived from .. Ciw of Seifert's. who says : "On the external margins of the section the epithelium is intact, but penetrated by round cells. Investigation of the neighboring places shows an increase of the round-celle<l infiltrati( , in the sub- nuicosa and epitheliinn, with the appearance of a thin layer of fibrin on the e|)ithelium. In other j)laces the layer of fibrin incrca.st's in thickness antl is penetrated by mmierous round cells, but the epi- thelium anil subnmc'isa show no other alterations beside thos<' already mentioned. lOven where thi> fibrin layer is thickest then- is no necrosis of the epithelium. The condition is therefore exclu- sively an exudation on the mucous membrane." Proliferative and exudative inllannnations of the lymphoid tissue are relatively well known t-o us histologically from recent studies of the faucial tonsils. As the structure of the various parts of the ton- sillar ring is practically identical, we shall confine ourselves to a somewhat detailed description of the phenomena as they appear in the faucial tonsils. In diffuse proliferative tonsillitis the follicles exhibit enlargement, due to an increjused number of their lymphoid cells, particularly on the side adjacent to the nearest crj'pt, and of the endothelial cells of the reticulum. The proliferation of these endothelial eel's gives rise to large phagocytic epithelioid cells, characterized by a rela- tively large amount of markedly acidophilic cytoplasm, and an irregu- lar, lightly staining, eccentrically situateil nucleus. They contain in their interior from one to ten or fifteen cells or cell fragments, which are generally lymphoid cells and red blood corpuscles in various stages of digestion. The incorporated cells do not appear to lie directly in contact with the cytoplasm of th(> phagocytic cell, but are generally situated in clear spaces or vacuoles. The lymphoid cells Ix'tween the follicles are increased in mimber and closely packed together. The endothelial cells of the reticuhnn of the interfollicular regions show an increased proliferation, with formation of epithelioid cells. Toward the mucous membrane the lymphoid cells exhibit a transition into plasma cells, and are as.sociated with polynudear nentrophiles. The bloodvessels are dilated, filled with red and white blood corpuscles, and show more or less marked proliferation and exfoliation of their endothelial cells. The ceils of the mucous meni- br;!!if show n contu'ctive-tissu'' |r:i!iferation arid exfoliation. The epithelium of the cry])ts is loosened from a widening of the inter- cellular si)aces, which are crowded with escaping lymphoid and plasma cells. Bacteria, chiefly cocci, occur superficially in the epithelium i'i,.\ri. XX, i ili I 1.1 1 ^i■< c^^^ / / '«i illil '"■ ' l^i''-"-'-t>. i.,..io.mi- ... ll„ „„ M!,. i„,|,,„.,., \.,,i (-.,.>„„ -,.„„ Th.- 1"""~''"'" ' ' • '■■ "1 .il...liv !.•,,!,!, : .lliiu .,,1.1 t. „,„,,,;; ., !,:,,,,,1 ,„;, .■.,!,,.,,, , ,„,. I'l'. i K.,n-I\ mil: ..-1:1,- In ,„ ,t..s\ 1 II ,,.-,,, ,..,,,, \ ], I, ,1,-1, ,,--,,„ l„ ,]„,,, „,,, .,,,,„ ,-,,l,, ,„.,,,„,,,^ (.,,,^„„l ^ 111-^ t...ll^ i", \ I'l .-,,!,, ,-. n- i,.,i„ „.,, ,1 ,„,iv,,, .t.,,,,,.,1 ,>,iii ,,.,i -et-n ., -li.,rl .l,-!,,,,,.,. i,.,,„ ,i,, i. ,,,.,.],, ,„ , i'l.. i.,,,!ii. :.iti..ii .,f ii,. ,,,.;. .111. ;, t.,n-ill,li- Th. PI..!. .11,, :,.,l,-,.ll,-i,,,>v ., -u, lluia ..I III, ,. „ iMth .1 :.,.,-,-i,,i,j i,.,„i 11,, „-,ii.,iiii, ,,..>,.] -1. ... I ,-t \\ ith III illy ti.,ii i.l lb.- -11, 1, ,1111. 1- In.'iin ',1, 1 liv!,-!,( Mil,., iiii.i ,, III, |il\ ., ,,,■ ;.!,;, -I ,11 ;,,^ " "1 .1 1.1 K. - -1 I., .,,,llf !• I .111.1 l,l.,|.,],l;i-,,i 1 .;;,llirr iiti !'I..\'1"I' XXI 1* • % o o I Mi .^ e> 2^* -^ J . -^-^ «SJ* ■^ '-^"^ iti» F'3 ...P><? 1,,, I \lii' -iw '!< 1^- 11' I..I1WTI ..i the fpillu hiiiti Miihi.-m. l!\ ; •< H ! "^Iiu' ihinUi', \\ V, . ., ti.. .,.,:i -I, I ill rli' ;.i..t.-.-.i-ni .-l" tin ..It' ^ ; ■ 'I " iN l;iW. -. .i ■ !i n ult-n-lK' i.iiik -I nil t-i., IIv,i:;TH-'l. jMu-T Ui'ii "1 i.l.i^m.i- t M- ■ .i ■ ' \ -!.t^- ■ -t.titi. ■! \\ U h - ft 1" ■! I"«i.h-tn >irl I'iii'H- ;-rt-rM 1 !i- ■■. IN .ilf ;ii '■■ ; With niiiiMU -i.iiin'i - '•! v.i: Mim -^/c u !iu h slu.w tllf rh.ir I' l-:i-r:. Hlniil\ I'T I'll li-Ml [.J.. !| .-m .;'-L^' 11' 'iti'ii "I e;irl!i' ;rtm. -1 ■-:!!■! ^Mlli iiietlultiK ' lilt- .Mi'l tit lit t ,(I ,,i,. !ii 1- .■ti"i -l .1 vv.ill ..t A ,-TV!-t t'r.Mii .M^f ■>; ■ ^11-1 n,. I k' 1 iIm-i- Ni'i!. r.Mi- l.ixfi-^ '■I h 'MIV f-i-: .'i' llTIl -ll'JW tllf "K^t 111 -Mill ' il \ .11 M,..;. - .H . M..I 11-, : I'll .^■..-vlir tri.itlulioi.Ui-ll tr..:i. tllf it-li- iIhim > .! t, .n^il p, ■' ■. > !ii ■ .'h- iiirttiv- IftltrMu. -lirl' -ill TlH'i'vll wllK-h i- ll\- ; ■,!! .1 -iLl^i- lU-r^tlVC '.1 .!■.:■« '-^1 m-.t!"!). i-i -.«•( i; t.) h.i\'- in> ■-: i.-.TiUr.l l!iif(- \\ \\\\'\v ■ y<AU t''U' th' r wilh -i-\ • ral -ni.i:; it. mm rit*. -'!" tin. '■^■.^r '!' 1t;lii- t'l'. -. An ' villi' "lull i ;ih,t>;'i*'v ' ithIl-i, ;'^ iiiit' i-i-. ^Imw m;- ninnt-i ■ u !U ■ irpoi «ti-'l icIN .III I . .-ll !: ■- -iH .It-. l\hLAMM.\riO.\S. «!»: liiiiii!; tlif cryi'ts, Imt Mitpari'iitly arc al)-i'rii in thf lyiii|ihui.l ti»^iii\ ■|"lii' crvjits arc tilli-il witli cxl'itlialnl i'|)illi(lial cells, Iriicdcylcs. hac- tciia, aiii(ir|ihiiiis (Irliris, ami in fw-vcrc cases lil)riii, wiiicli eiiclnscs cells aiKJ liaetcria in a delicate network. At tunes the lihrin may eMeiiil from I lie crypts into ami I'veii lieyonii the eiiithelinm. pene- trating; nmst deeply in tln' intcrlcilliciilar refiintis. Uacteria are must ahiiridant near the surface of the cryjit, );radually diniinisliinj; in niimlters toward the hasi'. The pliat;ocytic polyiiuclear neiitrophiles contain hacleria in their interior, and may exliiliit :i network frajr- nientation with ili-pirsion of their chromatin. (I'l;ite .\.\.. I'iir. I and I'late .\.\l., l'i;:s. I and r>.) The acute lacunar ulcer.itive tonsillitis of Moini' and othi- i-^ known to us chielly throuirh clinical <le-criptions. .\< f.ir as the w i .!e|- can ascertain from the hi-lolo^ical accounts, it i- possihiy idenlii :il with the condiiion dexrilied lielow imiler >uppmMli\i' ton-illiti-. where .in intr.ilollicular ahscos i- di-cli.irjiinf-' '"'" •' "•'Tl't- //. Submucous Inflammations. I nder llii- lieadinL.' are comprised those diseases in which the >ul)nnicous tissue form- tin' chief seat of the inll.immalory processes. On |ialiiolo};ical ground- we may distinjiui-h. Iir>l, a slajre of tidema; second, a jilastic stace: third, a siippur;iti\-e si.ifie. The disi rilmlion of tlii-se processes i~ larjrely dependent upon the structure of till- tissues involved. Since the inllanunatory processes extend in the ilirection of the least resist.ance. tho-^e ii>sues with a loose or disten.~il)lo sul>muco>a exjx'ric nee jireater alterations than those of a more rt.nipact nature. .\ sul>nnicous (iMJem.atous inllammation of the nose was foimd liy the writer in one instance localized on the septum posteriorly, and was .sei-n hisiolo<:ically to coi:sist in a forcilile stretching: of the envel- opiufi mucous nieml)rane and the underlyinj; connective-tissue sjtaces l)y the escape of the serous fluid into a circumscrilieil ar(>a. Tiie mucous membrane consisted of from three to si\ layers of columnar eiiilhelial cells without evidence of cilia. Here and there the mucous menilirane w.is aliment or represented hy tattered and loosely lianuinj; columns of cells, while in several places vertical cracks and fissures Ihroujrh tiie nuicous memlirane were ap])arent. The individual cpi- theli.al cells !<eei 1 essentially normal. In the intercellular spaces were seen numerous ]iolynuclear ni'utrophilic leucocytes, lymphoid and plasma cells. The body of the ma.-^s below the mucous membrane w:is c(»inix)sc(l of a delicate network of connect ive-ti.ssue libres with wide interspaces. In many places the fibres seemed forcibly ru])- tured from their connections, leaving rafrjied and frayed ends sepa- r;ite(l by a varyiiif; dist.ince. Scattered a!)out in this area were a number of mucous filands of essentially normal size and apix-arance. surrounded by a moderate number of lyinjilioid cells with a tew pla; iii.-i ceils and M.iNt/.illen ill a manner similar to th:it which occurs in the ordinary hypertrophied mucous membrane. There were muner- our thin-walleil channels lineil with endothelium containin<: red blood cor|iuscles and a few polyiiuclear iieutrophiles and lymphocytes. TT^r -JJ, ,J|JV.L'4" (i!)6 SOSE AM> TIUt'iyT. r i \\ % Tlic (i>(|ctiiatiui> iriflaiiiiiialiun of the inula ami lariiyx arc iimnahly •■ssciitially iilciiiical liistolu^i' ally with tl almv sii|>j)iirati(His 1m-Iii\v llic iinicini.-' int'iiiliraiH' iiia*. I> focal or Til ilitTuso. The fofa! suppiiralioii.t arc found in t'lc nose m-: ahsciss of inc septum, aii.i in the ilimat as alt-ccss of th. tonsil, pharynx, or larynx. .\l)scc.-s . f ihi' na.-ai -c|)fn! nccnrs ,is acute idiop.-ithic peri<"hon- <lritls o!' 'he se|it;il cartilape ;uiil a« traumatic .ihsce.ss. In the first in.-taiui' we have tl' li with .1 more or less extensive.- ppurative softeniiijr of the tissues without e\ iilenci' of trauma, or contagion, or constitutional disease. The intlammation ,itTecis the whole mucous memhrane in all it^ layers, the cariil.ij;e, ainl even the hone in the vicinity. While we know that infectious orjiaiiisms .are the cause of the condition, the method of their penetration into the tissues has not Im-cu determined. Th(> tr.nnnatic ahscess dilTeis from the j)reced- iiift condition merely in the tact th;tt a suhmucous or sul)i>eriosteal haniatoma has l)e(>n formed as ;i result of trauma, wit!, second.iry infection and suppur;itioii. The hisfolosiical lietails of the two con- ditions have not heeii described, hut ni.iy he in!' rred from our knowl- edge of analoijoiis |)rocesse>;. Serous Perichondritis of the Septum. In tliis affection the clinical manifestations of bilateral occlusion of the na.sal oiM-nings h\ two pale red tumors yieldinir on incision a serous fluid, and termin.riiiK by a cr-rtain amount of -inking; in of the bridge of the nose, have been siipi>o.sed by some observers to consist histoloj;ie.alh ; a jirimaiy affection of the triangular cartilajje, due to a defteiieratmn of the cartilage, with softeiiinj; and fonnation of cavities tilled with homo- KciH-ous cheesy masses, and iissociated with .serous exudation, pro- liferation, and new formation of bl(HKlves.se|s. My others ii is believed to be similar to perichondritis sero.sa, which freijuently occurs at the dia|)hysis of the lonp bones in younn individuals. In certain ca,ses of tonsillitis abscess formation occurs. The ab.scesses are situated at the bejiinninp in the interior of the fol- licles, enlarge later, and eventually discharge into the crypts. The relative frequency of the.se abscesses varies greatly in different cases, but is ajtparently .as.sociated with a iiu-e "severe clinical type of the di.sease, and has been foui./l p.articularly in asso- ciation with the streptococcus pyof;enes. The presence of the abscess in its early stage i.s indicated by ;i circimi>cribed infiltration of p(»Iv- nudear neutrophiles ainoiifi the endothelial cells of the reticulum occupyitiff the centre of the follicle. The bloodvessels in the imme- diate neighborhood coid.ain l.irge numlxTs of ixilymiclear neutrophiles, of whicii many are .seen in t!i. act of ;)assing thriiugh the ve.s.sel wall. The eiidolhelial cells of the ves,sel show a varying amount of swelling. .Miorocoeei are foin-d in varying jismhImt!^ i;; the regi:.n ucfuii'ed by the polyimclear neutrophiles, lying for the most part free in the intercellular s]):ices, although they not infrecpiently may be ,soeij in the inferior both of the polynuc'eai neutrophiles and of the large /AT/,yJ.UV.I/7".V.V «y7 (l..il»i'li:ii pliMRorytf-s pivviiiuslv Slv .1 I'^rril" ll> I'.K' ivticiiluill. tlx' lollicli' increase:^ \-Ty cou^l .1.1 Witli the (jri^vtli of Iv ill >i;'i'. ::-! til"' I'-iilt Iv of a lici>jhtiiii'<l prolil'ffi tioii (if the ciMlclhi'lial (I'lls of tli. 'I'hosf ill tin- iiniiH'diatc ^itiiiity o f til lisccs- -ll ciiiiin of tlicir cytoplasiii a ii.l an in»'j»ii tv ill oiitliin' o| tli.'ir Ici.IimI, ' I twi-tcl. A markftl „.,rl..iiH, wliirli ai..«aix .•!. iiuat.'.l, iii.lci.l.Ml, - r twi-t.'.l ,n.n-as.> is .i!m.ltaiK'..uslv oLscrvd in tl..- nu.i.l.rr of iiijf [.lia-o- .•vi.w in !lu- vieinitv, wlii.ii rontain also a Kivat.-r min.l«T <.f mcor- ,;.„at.Ml .-.•lis an.l fra«tn.nls. The >iro'.vtli of ll..' al.s.vs> ,s uM.a My |„ ,1... dinrtioM of till- .•.■ar.'st m'l.t. Tlic iM.lv....<-i.ar n.'ulropinl.r, ,• tlic il.sc- iirsl |M'ii.'trnt.' in a nioiv or It -^s coini.ict ' luc ni." !|i.,M- roll.vti.m of IviMi'l'oi'l ••'•"^ ^v'''"''' ''"'i'*'!''^ '!"' '•''"♦''•'' ••'"'■"' luiM -111(1 •i.lvanci'i^ toward ili.' mucous ni. inl-ianc of tlic .-rypt, inllluMc this and raur it to Ik'com.c .-xfoliat..! over a dclinitc area. Tl„. ahsrcss now disd.arji.'s fnn-ly int( tl..' m-pt, \xiiicli l..con.cs „11,..; with iM.lvmiclcar ncisrophilcs. .•.Ilula:- dctntus, and l.actciia. 1 v.in.hoid ai..l"pl:i.-tii:< cclK an- rclaliwly K-ms al.nndant than in raMs uiihout abscess tormation. i'ihrin in the crypts apin-ars, on the „„„., ,,,„„,. „,.„,. almndant. Th- nOative -.,.- ol th- ahscesM^s vanes m-ea.lv in the ditTennt follicles in the -atne tonsil, some Ix-in^r l-arely r-coiinizal.te, while others are already (lischar}:in>: into the crypts. ( ..rasionallv two or even three abscesses are found m a suigle follicle :,i»d these are j-enerally of different sizes. . . , , . In some instances ciicmntonsillar intlainination is ohser\-o<l in a-sso- ,i-,ti„n with or M.hs.Miuent to intratonsillar abscess. In '. e ca.ses „„. ,..,nn.rtive-tissue spaces of the Hculuni a.lj..um.g the tonsillar .,bs, ess are crowded with i-olynu. ir neiitroi.hiles. which •:■ '.xtend in direct nutinnitv toward th. ise of the .irgar. in the dire. ,i„„ of the eircuiMt..nsiliar ab.sc<-^s. It is reasonable to sui-lH-se th; the circuint. miliar inttammatioi, s the r.-sult of the di.scharpe of tl., intratonsillar abscess int.. the eH nnt lymph channels Circumscribed abscc-so- of tlu- pharynx are probably essential!, similar to those of the .irruintonsillar reKion. an.l need not 1m- dis- cussed in further detail. In the lar>-nx they occur I'^mcular y in ,he epiglottis, tlu- aryepiplottic folds, the vocal c.rds. an,l the i er- arvt.-n..id region. The histological picture h.;r.- is exc,-,.liii«l> xari- Mbl... and .l.-iH-nd.-nt b.,th upon the localization ot the l-rocess and the original cause of the inflammation. _ DitTuse suppurativ.- inflammations or phlegmonous inflammations „ecur particularlv »k-Iow th.- mucous ni- :ubraiu-s ot the n.-se an.l throat as t!ie result of an invasi..n of i-yop-mc microoocei 1 he cn- .liti.ms are analogous to those of deep erysi,H-lat.,us inflammations " iV'tofectious Inflammations due to a Specific Micro-organism. Diphtheria. i)ipi.iheria nmnifivt^ it«e!f '.•■'■ the '. u-ous membranes „f the nose an.l throat in the form of an infh.mn..tion, which ma> be catarrhal, exudative, or necrotic. Then- is no reason to suppose that the first condition ditlcrs hist..logically from that occumn- in 698 AOA£' AXD TUROAT. acute iliinitis. Tho formation of tho pscudoinpmbrano bogins usually with necrosis of the epitheliuin aiul with the deposition of an exudate :n and ujvin the surfiu-c of the latter. This pseudonienihrane may Ik' deposited in one or in several layers, which may show certain ditTerences (if age amonji themselves. It consists eith'T of a «lelicate fibrin network or of a chwiy woven network of thick ftlisteninji strands, in the aeshes of which there may Im- either'many leucocytes or almost no cellulai elements. The vijjper layrs of the j)seuilo- inembrane. which as a ruli' contain the laifjest number of bacteria, are frecjuently seen to have imderfione fn ;;menlation into a gramilar detritus. The defjcnerafed epithelium disappears usually through exfoliation. ;ilthou};h at times renmants of tlie epithelium may l)e found. The mucous membrane itself ex|>eriences alterations in the form of hy]>era'niia, round-celled inliltration. and fropiently tibrinous exudate. If the necrosis is limited to the epithelium recovery occurs withiiut sc.'ir form.'ition. If the mucous membrane \< invaded, how- ever, by the necrosis, a loss of sul)slai4.'e occurs and heals by granu- lation and the formation of cicatricial tissue. The bacillus of diph- theria is constantly found in t!ie pseudomembrane, most fre(|uently in the snpi'rficial layers, but also in the superficial layers of the mucous membrane. In the tonsils a dilTuse necrosis of the epithelium may occur, affect- ing the single cells, or there may be a necrosis and ulceration extending into the lymphoid tissue from the cry])ts. There may be a formation of membrane s(>condary to the ulceration, and fibrinous membrane formed directly in the lymphoid tis.sue. In these ca.ses the reticulum is ap|)arently converted into hyaline fibrin. In .soin; cases there may be an extensive hemorrhage accomp.anied by fibrin and necrosis, altlmugh fibrinous exudation without hemorrluige frecjuently occurs. Micro-organisms are rarely found in the tissue on microscopic exam- ination. Influenza. Microsco])ic examination of the nasal mucous mem- brane in cases characterize(| clinically by shnple hyi)era'mia shows but slight alterations, these consisting cjiiefly in a dilatation of the bloodvessels and increased emigration of leucocytes through the e[)i- thelium. In cases of greater severity there appeared an increased amount of infiltration in the .adenoid layer, together with heightened des(|uaination of the superficial epithelium, exudation of blood into the tunica propria and through the epithelium, with imico>is degen- enition of the superficial epithelium. The cedema has been observed te be rather irregularly distributed, being in some places entirely absent, and in otli'Ts concenleil by a proliferation in the lymphoill laye-. ,\ ch.aracteristic feature is the desipiamation of the glandular epithi'lium. which may be exfoli.ated over a contiiuious area, and in this condition filling the lumen of the glands. The [jrocess api)ears to be extremely rapid. The pharynx shows an infiitr.ation of the mucous membrani' with leucocytes, together with dilatation of the cai)illaries and small vein.^. In the larynx and trachea hypera'inia of ISFLAMMATIOXS. 699 tlio iniipous mpmhrano exists to a prcator or loss extent, unevenly .li^trihuted, and at times so intense that the papilhe a|);)ear to consist s.,lelv of dilated bloodvessels. This dilatation affeets the small vems and "the veins of the eapiilaries, %vhil.> the arteries themselves are jieiierally emi)tv and contracted. The mucous membrane is sunul- taneouslv inhltrated with leucocytes, which her(« and there give rise to the formation of small Ivmphoid swellings. In the more marked decrees of hviM'ra'inia there'is stasis of the blood in the vessels which ;nv distended with leucocytes. These latter form small heaps within tiic lumen of the vessels, fre<iuently associated with thrombi and micnwH-ganisms. The vessel walls show proliferation of the lining iiidothi'lium. The limiting membrane of tiie mucous nwmbrane Mopears thickened ami hvaline. The mucous membrane may become tianslucent and siiow mlicoiis degeneration, with at times sup.Tficial areas of necrosis api>earing as small uiceratio.is. the floor of which miv b<- form.'d i)v tiie bare cartilage. In some cases this necrosis i-; ,'liic to thrombosis in the vessels, in others it is |)robably due to sla-is and inliltration of blood. The distribution of the influenza |,:i<ilhis in tlu! mucous membranes of the nose and throat is not known. Typhoid Fever. The inanif(>stations in the upiM>r air pai*sagcs accom- panving tvphoid fever may 1m- divided into three groups: 1.' An active hypera-mia, loosening and desiiiiamation of the epi- thelium, producing erosions which then form the entrance point for micro-organisms which, mingled with the exfoliated epithelium, i)ro- duce a whitish deposit upon the mucous membrane. The micr<>cocci find a favoral)le soil in the affected tissue, penetrate into the vicinity, and till the dilated Ivmph vessels with thrombi. •> I'lcerations occur as a later stage of the precetling manifesta- tions. These mav le:id to perichondritis in the larynx and necrosis of the cartilage, particularly the epiglottis and the arytenoids. .{ Tvphoid ulceration which behaves in the same manner as the cli.iracteristic intestinal afTection. These affect the adenoid sub- <t.ince in the larvnx bv i>reference, and also the anterior commissure and the base of the arvtenoids. The i.rimary swelling in these areas i< diH' to a penetrati.;t, of tvphoid bacilli into the lymph sinuses with a pnuhiction of toxin. The direct action of the toxin upon the tissue causes an inflammatorv exudation of serum ami leucocytes into the ,,Pter portion of the Iv'miihoid areas and the adjoining tissue. Later tlie exmlation disappears .md is followed by an mU'uso des(iuamati(m uf the endothelial cells lining the reticulum of th.- lyni])!! spaces. I'lK'se cells are oceasionallv i)hagocytic. Finally, necrosis and slough- ing of the newly formed tissue occur, and repair by granulation tis.-iiie fdllows from the base of th<> ulcer. Tuberculosis. The histological unit in this affection is the miliary tubercle, a clumi) of eiuthelioid cells produced by proliferation from thf emlotheiial ami connective-tissue cells, with or without the as.>*o- ciatioii of giant cells. It may appear ui)on the upper air passages ■& 700 yosK ASD Til no AT. 1 ill an acute or dmiiiip form, in llic first instaufo as a part of a more or less Rcncrallv distriliutcd acvitc miliary tuiu'rculosis. Tiicsc tn- ixTclfs arc (listril)iitc.l in tiif s\il)c|)itli('liai layers of the mucous mem- hranc. and arc practically identical histologically in every situation. As a rule, a fatal terininatlon of the case prevents their developing into the stage of caseation or ulceration. The chronic forms of tuiwrculosis in the upper resjuratory passages occur as an ulceration or as a tumor, or as a combination of Ixitli. These phenomena vary so;>,c\vhat according to the site of the process. In ihe nosr the lulicrcular ulceration presents itself in the form of an infiltration in the sulu'inthclial region of coiuiective-tissue c(!lls and endothelial cells aggregated more or less closely, and containing here anil there giant cells and a few tubercle bacilli extending ii the direc- tion of the epith(>lial surface. Central caseation and necr isis of these tiiberclcs ensue, with the restilt of causing an exfoliatior. of the o. r- Iving mucous inenibrane. thrombosis in the terminal bloodvessels, and the i)roduction of a graiuilar detritus ujxtn the floor of the ulcer. Till- tubercular tumor, or tuberculoma, of the no.s( is extremely variable histologically, but consi>is essentially of .-in aggregation of connective tissue and endothelial cells wiiich ])roliferale to form epi- thelioiil cr-lls. The new-formed tissue is travi'rsed by young i)loo(l- ves.-els and .ontains scattered through it giant cells an<l tulx'rclft bacilli in varying numbers. The whole is covered fre(iuently by more or less normJil epithelium. (Hands may or may not ocr-ur. Toward the peripheral portion ol thi' tumor obliter.-ttivt- endarteritis at times occurs, le.-iding to thrombosis and peripheral necrosis •)f the tissue. Structures have been found in these growths in the neighborhood of the giant cells and in their interior, comi)osed of coiicentrically arranged, degenerated, elastic fibres, infiltrated with mineral salts, which are sujiposed to arise from the hyaline degeneration of the bloodve-^sels. Tiihirftiliisif: i)f llir fiihsil .appears in three forms: 1. Irregular shallow lesions occur in which the eiiithelium of the eryj)ts is destroyed without the i)re\ious ftirin.atio'i of 'ulMTcles. ricerati'iiis of this sort are superiici;d .an<l affect the who!.- of the crvpt, or at least most of its wall. In the cenH'e of such ulcerations we find no pnidects of ca-<er,us mi tamorphosis, neither epithelium nor gi.int celb The floor of the ulcer consists exclusively of inlil- tr: hi lyii'pli' 'd ti^- le iii which the bacilli ;u-e fo\ind in great num- bers, tlw (■ liiteiils tif th' crypts c()ii<i<l <.|' yellowish-white matter of thick ciin-isteiice. wiilm .' odor, and coni.iining numerous tubercle Itaiilli. b,iter tin lubercul.ir proce« ext.iids into the deeiier lymph- oid tis-iie. giviii'j; rise trei|ueii!ly to cer\ leal adenitis. 2. Theiommoii f'>rm. with tyincal tubercles, gi.aii! cells, and ca.^eous (legenenition in its early stages i^ el,.inieteiizf d by the appenrance of tubercles under the epiiheliuin and around the crypts in the form of small light p-.irit-;. The tii<t of such tubercles generally occur in the Iv.i. )hatic siiuises. When the process is more advanced and some /.vr/-/i.v.v^ Tioxs. 701 tiilKTclc-* have undorgono civsoous inotamorphosis there is :.n mva- si.,u ..f th.> coiuioctiv.. tissu.'. An.un.l Xho. e|)ith(>li()i<l cells there is ., recicri ..f intense n.und-eell.'d inHltration. In tlie follicles it is not „„ss^ble always to separate this layer, since it so.n.-tin.es coalescs with the inhltration of the iieiKhhoiinR tubercf, ami is soinewiiat uLscured by the similar ap!)earance of the follicles themselves lh<- hlo„dv(^sels are numerous and show a marked thickening of their a.lventitia, particularly in the neighborhood of the tubercles, t luse- ous metamorphosis begins generally in the eentre of the tubercle in a giant cell, or at times in epithelioid cells, h urther developmeni „f this leads hnallv to ulcerations which attack the walls of the crypts. Such ulcerations are deeper, their floor is jovered with caseous detii- t us. and consists of epithelioid cells, among which are varying numbers (if giant cells. . , . , ,, ^ -i i „„ .{ \ diffuse tulMTcular infiltmiv-. occurs in which the tonsil loses almost completely its normal s.ructure, and is reduced to a mass o ..ndothelial, ei.ilhelioid, and giant cells in a hbrous n-ticulum covered by mucous membrane. This represents the tubercular tumor above ""rV/Iercm'.^vi.s of the adnmid may occur in a latent form without n,acroscoi)ic alterations, showing histologically tulx'rcles singly ami in .rn.ups on either side of the crypts in the lymphoid tissue, consisting „f farge epithelioid cells containing in their centre one or nu.re large m.,nt cells In vimng individuals the cylindrical epithelium j-rcdonn- ir\u'< but in older p.'rsons the pav(>ment tyix- usually replaces it <in ti„' surface, although 't is often well pres.-rved in the dcM.per; portion uf th<- crvpts The exrcnsion of the tubercular foci varies in diflerent ,••,<(•< bein" at times isolated and at times conflu. ..t. Giant eels .,',•,■ numennis, but bacilli are few. This la'ent tuberculosis may be !l,c tirst and exclusive point of localization, although it i.s more tre- nncntlv associated with an infection elsewh<-re m the body. The'follich's at the bnyf «-/ tkf tomjue are at times aheeted hy ,ul„.,,.ular ulcerations which extend from the floor of the crypt to ,!„■ iM.int of entrance, and develop over a great or less extent of the lingual mucous membrane. . T'lhirrulosis ,>l the lan/nx occurs as a more or less diffuse inhltra- ti„n aiui ulcerati.m, or as a circumscribed tubercular tumor. In the lir-t instance we have to do with an infiltration into the suU .ithehal nvers of the mucous membrane of tubercles, which may undergo ra'-lv caseation an.l pnwlu.-e ulc.Tations of the ov(>rlying mucous mem- brane (,r mav remain for a longer period in a formative state. Ilie tiivt ..uteome" is particularlv j.rone to occur m those situiitiuns most subject to motion an.l friction, such as tb' interarytenoi.l region, liie'mar-'in of the vocal cords, and the epiglnttis. W hen an ulcera- ti,,M has once formed its margins fr.s,uently undergo proliferation. whi.'l, mav .attain a consideralile six.-. Thr infiltrations of longer tinilin" are xeen more particularlv in the neighborhood of the arvtenoTl- and the ventricular bands. In the arytenoid region 702 SOSE ASD THROAT. lesions of [Hrineuritis. ijurtidiliirly pcriiM'uritis of the recurrent nerve, liave bcH-n found in tiic ecntre of the intiltrated tissue. Tlie essential nature of the alterations consists of a compression of the affected nerves hy granulation ti-sue. In addition to the thickening of the neurolenitna, there is an invasion of the tissue by proliferatinji con- nective-tissue cells. The inyeline undertjoes fiaKmentation, and later di.sap|M'ars. Finally, the axi.s-cylinder is completely ilestroyed. This proliferation is accentuated in liie region of the ghuids, where nervous Hlaments are seen to give off nerve t<'rminals ruiming b-tween the acini. In and around tlie tubercular granulations the nerve altera- tions appear in th(> form of genuine nervous tulK-rcles formed by concentric hlaments. without any apparent lesion either of the myeline or of the axi.s-cylinder. These lesions are essenti.dly proliferative and hyperpliustic, and by their anatomical character and develop- ment ai)]iroach neuromata. The (uberculnr tumor consists histologically of a tliffuse tubercular infiltration in the form of granulation tissue covereil with stratified pavement epithelium. The granulation ti.ssue consists partially of round cells with darkly staining miclei. partlv "f epithelioid cells, with a varying number of giant cells, the latter exhibiting \isually caseation. This granulation tissue is dividi>d into different areiis l)y coimective-ti.ssue trabecuUe proceeding from the submucous connec- tive-tissue capsule. The final stage of the tubercular lesion is a sclerosis, more or less generalized, consisting histologically in a thickening of the interstitial fibrous tissue, principally around the ves.sels and below the e])ithelium. If ulcerations have occurred previously the epithelium is w.-mting, and the surface is formed by scar tissue. In the lymphoid ti.s.sues the follicles are fre(juently atrophied and degenerated. Lupus. The histological conditions (occurring upon the mucous membranes in this affection are essentially like those in true tuber- culosis. The unit is the Iujjus nodule, which invades tlie mucous membrane irregularly and at different depths, and is sharply distin- guished from the surrounding tissue. The nodule is coinpo.sed of gramilation tissue consisting of fibrous trabecula' of varying size l)enetrated by numerous bloodvessels, large, strongly refractile, deeply staining, nucleated cells, together with smaller cells ami (>pithelioid and plasma cells. In the later stage the blood and lymph vessels exhibit a proliferation of their adventitia in lus.sociation with pro- liferation of the connective-tissue cells. This stage is followed by n>trograde metamorphosis, which is mani- festeil first by a diminution in the vascul;irity of the centre of the nodule. The cells become inflated, gramilar. and fragmented. In ni.iny pl.ices there appear giant cells resembling those of tulKTculusis anil syphilis. A portion oi' the lupus ti.ssue exhibits an organization into younj; connective tissue which later cicatrizes. While this process is going on in some nodules, others arise in the vicinity and extend iis far as the submucosa, with the result of producing an irregu- i !i Pl.ATi: XXI ^v,- i-*- . Pi < .lil.TiiiiM' P.-r !• Ii. 111111111^. Sfcii'iii llu<iiii|li ii Spur- • >l ilif Sfpliil CiirUli\c|i', -.Ipiwinc) rii. II 11 1 1 ' il ,l:i--i ^ himI NfW I \ -|i iitiifi I C'iii 1 1 lii()i'. H.i'i I lalc ix \ 1 1 n-i'' .-1 1 1. IXfLAMMA TWX^. 703 lar .litTuso infiltration ..f all the layrs ..f th.' imu-ous nion. .run.-. This niuv un.l.T«u .•icalrizati.m ..r Icul t.. a rnn...-ctiv.'-t issue l.yi..T- ,,n|.hv, \vitl. til.- rrsi.lt of i.ro.l,.,-i..fl .M.lai-.Ml papilla' with .•orn- .pu'uiinsrlv laPK- iiifrpapillary pro!., ..Rations, llu- .-pitli.-huni ...a rshil.it p'rolif.Tati...i. vacuolization, aii.l ...ay Ih' thrown ofi 1 > . |,n„.,.ss of suppuration a.ul.|."s.,ua.,.at.on. This may ovntuallv h. a l,v fibrous contrai-tion an.l cicatii/.ation. leaving a thin supeiiicial ^''sypWlis. The histolonical unit of syphilis ai.pcars in the mucous ,„eml.ranes as a sharplv eirc-umseril.e.l aiul (■..iiipact mhit.ation in ,1„. papilla- a..,l mucosa" of .oun.l cells, which .lo not pass into i.er- „.:.„;-nt ..rpans of conne.-tive tissue, l.ut always un.l.-rpo n-tropnnlc .n.tamorphosis. .-ither l,y ab-sorption or snppu.ati..... This ii.hl la- li„r has a diaract.-ristic .lir.-ctioii an.l metho.l ol projiress. a.-c.nl nR ,„ which the infiltrati.,., on one side c.nstantly .-nlarp-s. an.l ..n the „.|,.T si.le exhibits retrofira.le .netam..ri.l.o.sis. The onlarjiement and ,hr r.-troijressi..n tak<- place always in a centnfupa manner. riie initial l.'si..n mav occur in three forms ui-oii the tonsil, namely, th,. erosive, the ulcerat'ive. an.l the anpnous. Our histological infor- iiK.tion regarding these vari.-ti.-s is meagre. S.-con<larv lesi.ms in the tonsils an.l neighboring mucous mem- l.ruies are "seen histologicallv t.. consist of an infiltration of endo- ,l,:,h,.d an.l plasma c.-lls which are situate.l i>>larH';proui.s together i„t.Msp.>rsed iK^t ween the loo.s<-ne.l epithelial cells. Many of h> latter exhibit a nuclear fragment at i.m. The pajnlla- are enlarged, the blood- vessels are .lilated. the f..rn.er being infiltrate.l, and the latter en- velou(-d with a thick mantle of roun.l cells. Tlu- palatal muscles mav .show an inv..lv.-mont, consisting of an i„fil.rafi..n ..f th.- bloo.lve'ssels ..f the perimysium corresponding to ,l„.ir arrangement ar.nm.l the primary muscle bundW, ui. to luir l„nnching an.l final t.-rmination in the capillaries. I here is a so a nrnliferation of the p..iimysium its<-lf. In assoc.ation with these Ui„ns giant cells may ..<-cur in th(> sarcolemma, and the- transverse Miiations of the muscles may di-ajjpear. , , , w Tertiarv l(>sions .-.re supi)..se.l t.. arise from unabsorbed exudates |,.|t b.hii.d from the s.-cun.lary stage. Wo may distinguish the ,.,n„na an.l the granuloma, th.- latter having been report.-. 1 only rom !he tissues „f the nose. The gumma c.nsists in all situati.ms ol the -iiiw histological .■lements. nain.-ly, a n.'.re or less comi.act aggre- ■atiim of proliferating en.loth.-lial and connective-tissue cells, epi- •hrli..id cells, an.l giant cells. The blo...lv.-ssels in the v.cmity shew , !hick.-ning ,.f tlu-ir a-lventitia. H.-tn.gra.le metam..rphosis takes ,!:,.■,• bv ca.s.-ation, b.-ginning in the giant c.-Us an.l epithelioid cells, xt.-ii.ling periptierallv, and leading to .-xfoliation of the overlying mi.'ous membrane. , , The granuloma, which apiiears clinically in the nose as a broad or .,.,!unculate<l tumor .f varvinj; size, situated upon the mucous mcm- ■lane of a friable consistence, but without tendency to central .-.JW.^yj] 7(^i XOSE ASD Til HO AT. softoniiip, is sopii histoldRically to consist of an ondotliolial and con- nect ivc-t issue |)rolif<'rati(»n, witii piant ceils atu! tliicl^eiiinn of tiic vessel walls, in the younjter stap> closely resenihling guniinata. Later, tliroujtii a swelling of the deeply-situated tumor, the mucous mem- brane is forced out above the original level, often IxToiniuR [M-dun- culated. Ketrograde metamorphosis occurs in the older portions of the jirowth, namely, at its ])eriphery, in the form of oblitcrative endarteritis with thrombosis and necrosis. A form of sy|)hilitic lesion occurs at the biise of the tongue as an atrophy of the linjiual follicles. This is due either to an intorstitiiil iiitlammatioti. leading to a diminution in the number and diameter of the linsiual follicles, or to scar formation following tertiary lesions of the mucous meml)rane. Leprosy. In leprosy of the upper air j)assages four stiiges may Ih' distinguished: the prodromal, infiltrating, ulcerating, ai'd the cica- trizing. The prodromal stage may be extremely prolonged. After marked infection and swelling of the mucous membrane the di.sea.-e attacks particularly the septal cartilage, being freiiuently superim- (loseil upon a rhinitis sicca anterior. For this reason nasal hemorrhage lias been fnM|ucntly given as a prodromal sym])tom of lejirosy. The stage of inhltration consists of a firm swelling and reddening of the mucous membrane of the sej)tuni lus well as of the turbinates, associated witli a liyixTsecretion. at (irst serou-;, later purulent. The infiltrations m;iy ri'inain diffuse or pass to the formation of individu^tl no<lules ranging from the size of a pinhead to that of a pea. This infiltration shows a tendiney to nipid necrosis, most fre(|uently in the anterior portion of the cartilaginous septum, and attacking at times the bone secondarily, either by caries, or at time-- by osteo- porosis. There is an enormous crust formation, extremely hard, and a.-:si>i-iated with fetor. The stage of cicatrization follows the completion of the ulcenitivc process, and leads to the extensive cutization of the mucous meni brane. the surf.-ice of which now resembles dry leather, is ana'inic and whitish yellow or brownish red. The turbinates are greatly re- duced and sometimes absent. Synechia or atresia fre(|uently exist associated with local .'ina'sthesia. ,\t times exten.<ive suprrficial iilcenitioMs occur as the result of trophoneurotic disturbances in the regi(,n of the trigeminal nerve, which begin with the outbreak n) follicles re.<eMibling those (if herpes and jjcmphigus. Mycosis Fungoides. Hi.'<tologic;illy this process consists of .in infiltn- tion of ly|iical round cells |irocccdiiig froiTi the vessels in the chorion and subcut;uieous tissue. This infiltnition is deposited in a fine net work of lejic'ite fibrill.iry comiei'tive tissue. The e|)it!ieliuni appe.'i.' at \\v>\ proliferating, growing into papilke, later flattened over tl>" nodules. The round-celled infiltration appears aggregated In-twe. n the coimective-ti.-isiic si)aces in the form of foci of varying size, lik ■ a nodule, whicli, however, toward its |)eriphery a,ssunies again ti'' character of ;in infiltnition. ISFLAMMATIOXS. 706 Thcso prowthfl, rosoinbling somewhat lymphoid strncturcs in upiM'ur- aiicc, iilthoujjh no foliiclrs arc rccoKniziihic, occur upon the mucous nicnihrancs of th'' throat, ami may i)ccoinc suixThciaily ulcerated. Leptothrix Myc«ri«. The h'ptothrix liuccalis, whicli occurs nor- mally in tiio moi;th :is ii saproiihyte. jissmiies at times pathogenic properties. The nmcous membranes of the lymphoid tissue of tho fauces and of the larynx and (esophagus when jtreatly depreciated in vitality as the result of |>reviuus prostraiint; disease, may become susci-ptilAe to tiie development cf the le|)t.)lhrix buccalis, the threads of wiiich mav penetrate between the upixT epithelial layers and into the orihce of "the jjlands. Tiie invasion of tlie tissues by the mycelium may l)e followed by a secondary involvement of (,ther pathojiemc .M<;anisms, such ti!< the pyogenic cocci and the diphtheria bacillus. Structures occur at times in the ton.sils having a certain resem- l.hince to actinomvces. The structure is of botryoid shape, v th a diameter of 0.5 min., aiijM'aring when stained with alum carmine an(l tlun by (Irani a.s a dark b'ue more or l(s< compact network of threads lying in a tine granular substratum, wnich partakes of the carmine .stain with irregular intensity. Toward the periphery of the structure the threads radiate omward and exhibit nodular thicken- ings, due to irregular clumps of threads and c()cci. Toward the centre tiie threads cross each oilier, are much shorter, and resemble sharply- iieiit rods. Tre(>-like liraiichings of the threads are common, pyr- ticularlv toward the periphery. Huge regards tlie.se structures as lielonging to the group of actino- myces, which are. however, not identical with human actinomyces. Tl'iev belong probalilv to the groui) of leptothrix buccalis and are probably closely relate(l to a form of streptothri.v ilescnbed by Sbarazes. ., , , It is possible that the mycosis ot the tonsil and t>harynx may oe proiliiced bv the growth just descrilied. Rhinoscleroma. In tbe nose and l.iryx th" .-ifierte.! tissues are swn histologicidh 10 consist .i' c-rtain typical .■!emen!ary lesions. Tiie -ubstai.ce of the swelling is com|)osed of large |.l;!sina cells, irregu- larly distrib ii.'d in all layers of the mucous membnine and m the suliimicous li,ssue. Tliev accompany the bloodvessels in the new iu.rtioiis of the growtii. "The plasma cells do i- i contribute directly id the hviiertrophv. but it is iK)ssible thai they iK-c.me cliang«>d partlv into spindle" cells, and then give rise to the formation ol new lihriliary tissue. Two forms of retrograde n.etamorphosis occur m the plaMiia rrlls. These may Ik- transformed into swollen, liydropic, >.>-c.dled Mikiilic7. cells, or "into hyaline degenerated cells probably i.lentical with tlie so-called Hus.sel"'s fuchsinopliiles, described under colloid degeneration. The hydropic cells lie <'lose together, have a distinct contour and springy cytopliusm dilated iiit<. largo masses m which there is a but slighily refractile, faintly staining, h.ilf-fluuj iiKLss within a small facetol n"uclens. In the vicinity of these typical degenerated cells transition cells occur which are ^^een to l)e derivetl I»^ '»)( '• 'Hi n 'it! III. "nij XDst: AM) Tjino.ir llMiil .l.'Kflionilr.l |.la.s|lia crlU. li, ll,i> >|;,|;r , ;h ufl, ,, «•<- from MX I" .'ifjlit liacilli ill the cells near tin- iiuclnis, «|,i,li ij,. always .-it iv>;iilar.lislaiiccs. This stajre a|.|.cais. Iiowrvn . lu !).■ inpi.ljy tinislir.l. ami whi'ii llic cfll iiii'iul.raiir hivaks the ||iii,| , rii.ni- inp'tii.T willi S..II1C of the liacilli, liii.i an rxit ami till ilic maivsi lyiii|.li -pacs. 'I'licsc cilis. arc however, iniiinalely relal.-.| to the .lii'eei action ,,1' the liacilli. Ill all iii>taiices the peculiar ca|isiile liacillii< is present The cells which show hyaline .lejjciieralioii occur iisiiallv inilaled. rarely in small collections. riie\- corres| | tu (he hyaliii.' ilet'en- erate,! cells found ill other chnuiic intlammatioiis of' the iinic,.iis i; ' mliraiic. Glanders. This :ilTecti,,n appears in the iio.se and larviix. usually in tlie form of nodules .md nodes, n.ore rarely as ditTiiM iiifiitrali.iiis coll-istinj: of elii.sely .applessed roliml cells without jriilllt rp||s. IJie nodules suppurate nipidly. and the component p<ilviiuclear leucocytes cxhiliit frastmentatioii of their nuclei. In tln' ii('iKhliorlio<id of'thc nodules the ti.ssiie shows fieciueiitly lieniorrhajiic inliltnition. If the nodule lies in the neichliorhood of il„' surface of the mucous niem- hrane there occurs e.irly an inliltnition of pus corpuscles into the (■|iitlieliiim. ;is the result of wliii-h small pus foci arise. Later these foci coalesce and frivc rise to the formation of ulcerations. During the early stajre of the nodule iii.iiiy liacilli lyinp more or less in grouiis arc found in it. When the m.duie supimrates. however, the miml)cr of liacilli diminishes, aixl in chronic glanders they ,ire not to be demon- strated microscopically. Chronic Inflammations with T«sndency to Hypertrophy, rh ionic mllamiuatioiis of the upjier air jia.-.sa^'es may lie diviileil histologically for piirpos s ,,i- cmveniemv into, first, super*;,; d inflammations df the mucous memlinine: second, inflami;iaii..ns affectin<; the paren- ch>m:K third. infl;iimiiatioi,s inv-'ving also the periosteum or pi ri- cn.i' i:iti uaml iioiie. Sii' 'i dni-i iiisare toa ciTtain extent .irl.itrarv shic. ilitTereiit .lejrrees of tiie afTectioii may he found in il.e.sanu- tissue in adjoining p! ices. In spite of the apiiarcntly distinct picture presented hy these jirocesses in the iio.se. pharvnx. and larviix, a detinite iiiorpholoffic.al unity i.- nvcaled hv a" histoln<iical ".study. .\!tliou>;h an .iccoiin! hased upon the regional distriliiitioii of the".e aheratiniis necessarilv involve- the repetition of histological terms to a consideniMe exfnt. it appears hetter adapted t,, present clearly our existin-r inlnrm.' (im We sh;ill therefore consider the cliaiiRi^ as thiy oecm m their dilTerent points of localization in the iio.se. M;isopls;irynx. pharynx, and Larynx. Nose. In supei(ici;il inflammation ;iii infiltration of mononuclear neiitiop.i ies ;iiid plasma c<'Ils occ'iis in the adenoid l.iver and in the vicimfy of the liasenieii! meniliiime, localized particularly around the smalier hi,,, dve-sel.-. and iho efferent dm ts of the plaiids. .Mast- zelleii are usually present, and there is an incre.n.se in the mmiherof cells siiMwiiiK folloid (h"<rciieration. The papilhe of the miicmis mem braiie may he h-nfrthi-ned int<i wart -like |.roiiiineiices, ;ls the result ISFLAMMATIOSS. 707 I tliri'c factor^: first, |)r(ilifir!iti«iii of the fibrous tissiio: sctoihI, prulitrraliun ..I' tin- coluinnar rdls of the siirfacf ami of thv tells of tlif iliK'ts of tlif >:lnnil- 1)\ s.«piu«'iitation parallel to llit-ir lotiji axos: iliini. ., iliiataii f ih.- cliirf .I'lcls of thr ^lan.ls ami their eoiimiuiii- (■:iiiii).'aciii rhisroinliiiiatioii of |iliemimeiia [.nKliices tlie inullxTrv hyliertropliii - of liie inferior ttirhinated iiolie. Associated with lhe>e < iiatijres i- tlie pre>. nee of a eertaiii amount of (eilema in the tissni's, ino-t riiarke.1 in the anterior end of the mid. lie turhinale and in the -inuses. irivinit rise to the eireuniserilM-d hypertrophies known as ixihijii. The stroma of these Rrowth< consists of a more or less loose coiinirtive liss\ie. the meshes of whieli contain round <'ells and alhii- minous fluid. Tliey are coven'd hy a cylindrieal epithelium whieh, in Fi.i :t.'j9. Ilyinrlrophli' iiilUmiiiatioii of ml.lill.' mrblimU-. IVIow the coliimiwr epithelium 1« « luone cwle- i.iuloii!. (•..imiTtlv.. lisMie with « KlUriliK bUifKlvtwl» iilkI iHcrm.1 sUuiamur ,lucls. Below this if a .Un»r imiiiectivc tis>\ie Willi iimcm« k1hihI>. l.liNKlveaKl*. iiii.l iiitiltratliig ivlln. The bone preaenU irri'Kular lliiikeiiliids mid pnicusBcs iliarailiTislic of hyjierpliuilk' iwrioetltis. p!ac(>s exposed to external irritation, tends to bocomo altered into pavement epitliermm. The glands of the frrowth may be increased ii number, having; in the majority of ca.ses the character of mucous L'linds. At times there occur with thorn so-called serous glands. Tlie ■icini of the elands often show cystic dilatation, which may at times lie so niaiked as to form a cyst "occupying the greater jjortion of tlie polvp. (Fig. :i.'}f».) Two forms of degeneration are found in the chronic inflanunatory • iiresses under consideration, first, mucous degeneration of ,he epi- , helium of tiic surface and of the ducts of the glands; second, a colloid MICROCOPY KESOIUTION TEST CHART lANSI and ISO TEST CHART No 2i 1.0 I.I ^ lis 11-25 IIIIII.4 m 2.2 2.0 1.8 1.6 M APP LI ED IIVHGE In 5 r^ "^ochesttfr. New vofi, 1*609 vSA "«ag (716) 482 - 0300 - Phone ^= [7\6) 298 ■ '5989 - f o- 708 NOSE ASD TIIHOAT. or hyaline degeneration of the migratory cells of the connective tissue. Where the inHainnuition is more deeply situated the infiltration extends to the glandular layer and to the periosteum, frecjuently infiltrating the germinal layer of the latter. All the medullary spa<-<"s are more or less completely Hlled with a compact cellular inhitration, particularly in the vicinity of the vessels. Clinically this deep inflam- mation comprises ca.ses of marked degeneration <)f the middle tur- binate and chronic ethmoidal sinusitis. In such ca^es the inflam- mation has probably extended from the periphery into the ileeper portions of the tissue and the medullary spaces. Ethmoiditis. The inflannnations of the bony ti.ssue in the nose are observed in the ethmoidal labyrinth in two forms, first, a distinct new formation of bone; second, an absorption of bone. New formation of bone is the result of proliferation of the germinal layer of the turbinate. Large imcleated cells are .separated from the infiltrated germ layer and deposited as an osteobhistic layer upon the oUl bone. From this osteoi)lastic layer a compact intermediate substance or osteoid tissue is formed over a large portion of the protoplasm of its cells, which encloses the rest of th(> osteoblasts in irregular cavities divided by prolongations. This osteoid tissue lies partly diffuse, partly in cir- cumscribed prominences on the old bone, giving rise to a diffuse thickening of the latter or to prickle-like bony excrescences. The new formation of bone coiLstantly progresses by the (le])osit of new layers of osteoblasts on the osteoid tissue. In the same v.av there may be ob-served a new formation of bony substance proceeding from the medullary cavities by adhesion of the cells of the medulla to the old bone as an osteoblastic zone, which after the formation of an intermediate substanc(> becomes osteoid tissue. Here and there the medullary spaces apju-ared narrowed by the new-formed bone. Clinically these cases are characterizi'd by diminished resistance ami a crackling sound when the tissues are touched w-th the probe. The other alteration in which absorption or rarefyii.g osteitis occurs, is characterized by the occurrence of numerous giant cells or osteo- clasts in excavation.-? of the bony lacuna". These vary in luimber according to the degree of absorption which is takitig" jjlace. The trabecuhe become generally thinner by the erosion of the osteoclasts, so th.'it the medullary spaces continually increase in size. a:i(l the bony trabecuhe become thinner. In advanced stages the erosion of numerous trabecuhe may result in the coalescence of adjoining med- ullary spaces, producing a cavity which by continued progression in the [irocess may become a bony" cyst. Such a cyst is usually lined with columnar riliatfd epithelium, contains no glands in its interior, but a certain number of arterioles, veins, and microscopic erectile tissue. It is difficult to state why in one case hypertrophy of the bone predominates and in another j.bsorption. It is pos.sible that the i.illannnatory infiltration which penetrates the substance of the tur- INFLAMMATIONS. 709 binates may load in some places to a stasis from coinpression of the veins. On the other hand, a congostion c.f the periosteum excited by the infiltration may produce hypernutrition by which the hyper- plastic growth arises. • • . t.. In a few instances polypi have been founil containing bone. In ino^t of them it was found that a single bony tube extended through the whole polyp, although in some cases there was a branchmg, b.-ginning at the point of attachment of the pedicle These tubules .jimved a well-developed medulla. The condition, therefore, was an actual hyperplastic structure due to a proliferation of the penosteum of the turbinate in association with rarefying osteitis. Neither rarefying osteitis nor hyperplastic bony alteration is essen- tial to the formation of polyps. The ix)lyp is an crdematous hyper- tiophv of the mucous membrane in which, just as in the case ot hrm hypertrophy, the process may l)e limited to the superficial layers or eitend to the depths. It is wholly immaterial whether this inflam- matory hypertrophy is excited by a diffuse catarrhal involvement of the whole nasal mucous membrane or of only a portion of it, or by ''"in'nasa'r polypi the existence of nerves has been demonstrated, although in general these structures are poor in ner\-e fibres. Ihey •ire characterized by several peculiarities, extending over long dis- tances without giving off lateral branches, the nuclei showing a narrow and elongated, somewhat irregular shape, lying extremely close to the ner%-es, so as to give the impression of for mg a swelling ot the nerves themselves. From the course of the nerve fibres ind the iH-culiar arrangement of the nuclei, it is apparent that we have to do with newly formed ner\-e fibres. Granular cells and individual ter- n.inal corpuscles were not observed. The fibres terminate in the ti.<suc of the polyp itself, and do not extend into the epithelium. Hyperplastic Perichondritis and Periostitis of the Septum. The anat- omy of sinirs and deviations of the septum does not come within the iire^ent consideration. Certain histological lesions are, however com- Inon to all the varieties, chief among which may be mentioned hyper- ui'i^tic perichondritis and periostitis. Examination of a septal spur or of a healed fracture of the septum shows in many cases at the ,,oint of convexity a heightened proliferation of the cells of the peri- (•liondrium or periosteum. In the case of cartilage, the linear nuclei of tiie germinal layers increa.se in thickness, becoming triangular or -tcllate Simultaneoasly the protopliism of the cell is observed to retract from the cell wall and become gathered around the nucleus, with the result of creating an elongated or oval deficiency in the cell. The acidophilic fibrous tissue in the vicinity becomes at the same time more homogeneous and translucent, and assumes a distinct tinge with t)asic dyes. These phenomena occur irregularly at the margin of the cartilage, with the result of producing prolongations and excres- <'(>nc('s of the intermediate chondroid tissue. As the latter becomes older the cells resemble more and more those of true hyaline cartilage. » If h'l);: n '.- i i no NOSK AXD THRO AT. In tho case of bone analogous alterations are found to occur, the details of which have been previously described in t' • account of hyperplastic periostitis of the ethmoid. At the line i racture the fragments are separated by fibrous tissue traversed ..y bloodvessels of varying size. In this situation the proliferation of" the perichon- dreal and periosteal layers ))ro(iuces a diffuse deposit of the inter- mediate substance. The writer has obsened the formation of a sesamoid fragment of cartilage at the apex of convexitv of a trau- matic deviation of the se])tum situated in the fibrous tissue between the mucous membrane and the line of apposition of the fragments. The mucous membranes covering the convexity of the devia-tion con- sists of stratified pavement epithelium, behnv which is a nmco.sa showing more or less tendency to pa])illary hypertrophv, except at the apex of the convexity. In this region a thinning of the mucous membrane frecjuently occurs, and there is no evidence of glands Hypertrophy Id the Nasopharynx and Pharynx. Chronic inflanuna- tions of these two regions may be advantageously considered to- gether. We I! make a secondary division into chronic inflannna- tions of the lyii.,,hoid tissue and of the mucous membranes. Although these two structures are usually affected simultaneously or in ii.s.so- ciation. an indeix-ndent involvement of each may occur. The lymphoid .structures comprise the jjharyngeal tonsil, the col- lections of lymphoid tissue in the vicinity of the Eustadiian tubes, the faucial tonsils, and the lymphoid tissue on the posterior pharyn- geal wall. Chronic inflanunation of these lymj)hoitl structures j^re- sents histologically essentially identical pictures. In all we have to do with a unit of structure, the lymphoid follicle, covered with nmcous membrane of varying character, which in places where the follicles are aggregated in large numbers .sends down invaginations between them. The i)henomena represent a heightening merely of the normal processes, in that the endothelial cells of the reticulum are seen to proliferate more actively, giving rise to epithelioid cell< with phago- cytic jjroperties. The follicles exhibit an enlargement, as the result both of a.n increased number of their lymjjhoid cells and the endo- thelial cells of the reticulum. The nmcous membrane of the crypts ai)pears looser and with larger interspaces than normal. Lvmphoid and plasma cells are found here in unusual abundance making their way into the crypts. The rypts are filled with amorphous detritas, exfoliated epithelial cells, leucocytes, and bacteria. In comparing the i)ictures presented by chronic lymphoid hyper- trophy with tho.se seen in acute inflammation, it is to be noted that in the former condition the alterations consist pre-eminently of endo- thelial proliferation with but relatively slight increa.se in tlie number of lymphoid cells, while in the latter instance the reverse is the case, and although we see here increased endothelial proliferation, the enormously increased number of lymphoid cells in the follicles and adj'iining lymj)h sinuses and crypts gives the cfiaractcristic feature of the picture. lyFLA MMA TIOXS. 711 Tho histological chans.-s which have just ....... doscnbo.l as <.ccur- ring ■u^ tho faucia! f.nsils arc repeated without essential points of .liffereiice in the i)harvngeal and in the lingual tonsil. Th<> chn.nic inHan.n.ations of the pharyng.'al mucous meinl.rano hav not been studied histologically with the same degree of care iis analogous changes affecting the larynx, and our histological infor- mation is so meagre that it seems better to refer the rea.ler o ho account of chronic .liffuso hypertrophic laryngitis, he histological .lescription of which may be assumed to apply to the processes in the jiharynx. FIO. 360. »ei«ratlng the muscles of the part from the overlyi.ig tissue. Chronic Inflammation of the Pharyngeal Recess or Bursa. It is nrobable that independent inflammatory disease of tho bursa phar- V K" extremely rare. Tho so-called T.^rnwaUlfs disease, a name wl'Sdl wJs^Ipphetl to chronic catarrhal inflamniatioii of the structure in .luestion. hiu. been shown not to occur, at lea.'.t the "so of this tern', has been greatly restricted Catarrhal processes f /he narn^ pharvnx involve either tho whole mucous membrane of the vault l,r omain clefts in the mucous membrane, by preference the central cleft of the adenoid, which is also the deepest as a rule. The fos^o; 712 yoSE AXD THJiOAT. of Itosenniuollor may rptain socrotion to a marked degroo, particu- larly when they are divided by folds. Cases occur of atrophic catarrh localized exclusively in the vault of the pharynx. Chronic Laryngitis. Under the influence of recurrent attacks of acute catarrh, the mucous membrane of the iarvux is j)rone to take on hypertrophi • changes, which vary markedly according to the pomts of localuation. The small-celled infiltration dejwsited by the acute mflammatiuTi. as the result either of unhygienic su. .undings or abnormal con.litions of the i-atient, does not attain complete absorj)ti()n. but becomes a,ssociated with the jmjliferation of con- nective tissue. Each attack increases the formation of new tissue Ihe histological manifestations are essentially similar in all the forms the si)ecial features of each of these being ^ven by its localization! Although the process of chionic inflammatory hypertrophy may affect the larynx diffusely, it is apt to attain its gre.-.ifst development m one or more circumscribed regions. From the u.iatomical stand- point we may therefore distinguish: Chronic diffuse hypertrophic laryngitis. Hypertroijhy of the tissue lining the ventricles (so-called prolapse ot Mie ventricles). Pachydermia of the vocal cords. Polyp of the cords. Vocal nodules. Subcordal hyperfrnphy. Chronic DilRxse Hypertrophic Laryngitis. The inflammatory altera- tions are situated chiefly in the connective tissue beneath the epi- thehiim. reaching their highest development in the vicinity of the l)loodyessels and the efferent ducts of the glands. They niay also give rise to a thickening of the i)erichondrium and cartilage The epithelium may un.lergo metaplasia into a stratified pavement epi- thelium, which in advanced Citses may consist of from fourteen to twenty epithelial layers. The epithelium is everywhere infiltrate.l with leucocyte^, most abundantly in those places "where the under- lying vissue exhibits (\s])ecial infiltration. The membrana proi)ria may become thickened and distinctly fibrillary. Heiow the stratified cylindrical epithelium the papilhe of th.. nuicosa exhibit pr<.liferaii„n. branching, and multiform circum- scribed prominences. The connective tissue „f the papilhe is soft poor in fibres a-d exhibits a marked diffuse infihration with leucocytes. The submucosa shows alterations which vary in different places „, intensity. It appears hard, compact, markedly fibrillary, containing only a few .spindle cel.'s. The round-celled infil- tration appears at times diffuse, at others circum.scribed in the form ot nodules most conspicuously around the efferent ducts of the elands Some of the cil. exhibit hyaline degeneration. The blo„,lvcs,sels are in general larg.- and thin walled, well filled with bloo.l, exnopt where Tl..- mucous menibran . has un.le.-gone fibrous changes. The mucous glands may exhibit hyperplasia. The epithelial cells may exhibit a jyFLAMMA TIOSS. 713 liiilh degree of mucous degeneration. The perichondrium m the rcLrions corresponding to the most markeil alterations of tlie mucous nu'uihrane may be infiltrated with leucocytes ami show a hypertrophy of the cartilage. . . Hypertrophy of the Ventriculw Begion. This comhtion consists histologically of marked hyperplasia of the connectiye tissue of the yeiitriclo of" the larynx, which extends also to the upper aspect of the vocal cord, and "is frequently associated with pachydernna of the vocal cords. The histological details may be inferred from the pre- ceding description of chronic diffuse hyiM'rtrophy. Pachydermia of the Vocal Cord» Pachydermia of the vocal cords consists histologically of an inflammatory hypertrophy of the con- nective tissue of the mucost), affecting subsequently the epithelium. This is particularly evident in those places where the process is able to develop undisturbed by external influence . Histologically the .■pithelium is seen to be thickened and horny in its upper layers, which are formed by flat cells with indistinct nucleus or without a nucleus. \inorig them" there occur layers of cells in which keratohyaline may 1).- encountered. The lowe'st layers of the epithelium, w^uch are situate<l upon the connective tissue, are composed of cylindrical cells. Between these and those which bear keratohyaline are layers of jM.lvgonal cells with prickle processes and deeply-staimng nuclei which correspond to the rete Malpighii of the external skin. These horny alterations occur not only in the vocal cords anil those portions of tlie larynx which normally bear pavement epithelium, but also in other regions covered with columnar epithelium, as for instance, ill the ventricular bands or ventricles. These latter situations may exhil)it a transition from the columnar to the pavement epithelium. ( )ii the free surface of the vocal cords there occur in pachydermia, in addition to the normal folds, actual papilla>, which may penetrate hijllier into the thickened epithelium than the level of the normal folds. These are particularly ell developed in the region of the vocal processes. While the con..,'ctive tissue thus sends j)apilla» into ilie epithelium, the epitheliu n in turn penetrates the connective tissue with interiiapillary j^roiongations which may be divided into several summits. Tlie subei)ithelial layers of the connective tissue exhibit an increase in till- number of round cells, particularly in the neighborhood of the irlaiids. The cells may penetrate the cylindrical epithelium of the Fatter and fill the lumen of the efferent ducts. Keratohyaline is apt lo occur together w^'h the formation of papilla, thus giving the tissue ail epidernioid character. The origin of the depressions at the summit of the pachydermal swellings on the vocal process is not wholly clear. In ca.ses which have been investigated histologically the dejiression in the centre of the swelling is .seen to correspond exactly to the point of the hyaline .artilaginous process. This 'after is surrounded by h\-pertrophied connective tissue, which arc aid the point of the cartilage i;' prolonged 714 XOSE AA'D THROAT. upward into papilla' i-ovorcd with a thick iayor of pavoinpnt opi- tiu'liuin forming tin- margin of the growth in (lucstion. Virchow iM'licvcs that the ilcprcssion occurs from the ch)scr approximation of the mucous membrane to the point of the cartilage in the centre of the growth, rather than at the ])eriphery. Fraenkel exi)laiiis it by the mutual pressure exerted by the vocal processes during phonation. Ulcerative processes are apt to occur in pachydermia, most cases being of long duration. They begin in all cases from the surface, and perhaps occur by the nibbing of the ai)posed portions of tiie mucous membranes on each other. Perichondritis may Ik jserved in association, but its relation to the ulcerative process ' clear. Fio. 361. Vocal cord, normal. It is possible that some of the cases reported owe the origin of these proci'sses to tubercular or sy])hilitic or typhoid infections. Polyp of the Oords. Hy this term is denoteil a circumscribed hypei- tropiiy of the mucoas membrane of the vocal cord a.ssociated with a'denia. The hypertrophy afiects all the superHcial lavers of tiic cord, and is therefore distinguished from fibroma, wliichis a totalh' different structure and consi.sts of connective tissue covered with mucous membrane. In the l)olyp, on the other hand, tli(> individuiil constituents (nan)ely, connective tissue, elastic tissue, glands, vessels. and epithelium) bear the same relation.ship to each otli«T as iv tli'' mucous membrane of the vocal cord, and no one constituent i)r(- dominates over the others. The polyp exhibits a loose large-meshed connective tissue. Sonir of the meshes are so large as to give the appearance of cysts, bu: ISFLA MMA TIOXS. 715 itr not tnic rvsts, (^incp their walls consist of connective-tismc fibres ui'out endothelial lining. Th.'se eyst-like dilatations may (.eeur at ti , t)ase of the growth, and also immediately under the epithelium. N.xt to the connective tissue the elastic tissue takes up a large i«>r- tion of the laryngeal iM.lyj), in some instances b'ing even more abun- ,liiit tlian the white fibrous tissue. (Mands are usually piesent. 1 He ,.|,itlielium varies in thickness from two to many layers, even at tunes hriiig so thick as to deserve the name of pachydermia. It consists nl stratified pavement .'pithelium which may at times be horny ami ,„av contain epithelial iH-arls. K|)ithelial pockets are sometimes tnund in the form of round or oval cavities under the epithelium. In most cases the basement membrane marks the liii' iH'tween the rpitheiium and the connective-tissue portion of the tumor. The degenerative processes in the tissue of the laryngeal polyps arc somewhat complicated. V.- the result probably of stasis of the l.lood and Ivmph there arises a homogeneous infiltration with pig- ment and thrombosis, leading finally to the f..rmation of peculiar liomogeneous, oi)a(iue, hyaline, yellowish, or brown masses penetrated l.v small irregular cavities. , ,, . Vocal Nodules. Some confusion exists with regard to the nature nl the so-called vocal nodules. Three hypotheses have been brought forward: . . , . , ., 1 ,\ |)hysical, namelv, mechanical friction of the margins ot the ci.nls at points determined by the conditions which cause swelling in the vocal cords. , i • 2 A physiological, the vibrating nodes of the vocal cords, bring points of the most vio!.-nt action, are predisposed to the formation iif the nodules. , . , . i i 3 \n anatomical ' "^ v< ?al nodules stand m relation to a gland situaU'd at the p(. •• of the free portion immediately under ilic margin of th' • . The present coiisit. ' >o is limited to those cases dependent upon a hvpertrophv of the ei-itheliuni. The swellings exhibit stratifiec. |.;ivement I'pit helium ranging in thickness from 100 to 400 /^ due If, a considerable increa.se in the lavers of polyhedral and cylindrical rclls. At the level of the polvhedral layer the protoplasmic sub- stance is well marked, the nuclei are large, and stain well with carmine. Til" cells are intimatelv connected with each other by a protoplasnnc -iihstance and prickle' cells, without the interi)osition of leucocytes. Tiie mucosa is composed of fusiform cells with bipolar prolongations, .vhich one mav follow over an extent of 60 //. The deeper layiTs .f the section show a few strands of elastic fibre. There is no actua i.apillary layer present. The fibro-ela.stic mucosa is thickened and listinctiy less vascular than normal. In some cases a process of ' Icfjcneration and cyst formation occurs. Hypertrophic Subglottic Inflammation. Chronic inflammatory hyper- tn.])hv occurs at times in the subglottic regions of the larynx and 111 the' trachea in the absence of tuberculosis and rhinoscleroma, prob- 716 SOSE ASD THROAT. iilily Jw tho rosult of recurrent unite infliuniiiations which do not attain complete al)sori)tion. The inutoinical basis of the affeciiim is similar to that described in chronic diffuse liyiK-rtrophic laryn- gitis, consistinj; of an increase in the mucous and submucous con- nective tissui', with a tendency to nieta|)lasia of the epitlieiium into stratified epithelium, and loading in severe c.-ises to stenosis of tiie larynx. Ghronic Inflammations with Tendency to Atrophy. V^'^e may rec(ij;iiize two essentially distinct forms of the atrophic process in the nose and throat, first, a genuine fetid atrophic rhinitis, njusopharyu- gitis, and laryngitis; second, a localized dry anterior rhinitis. Fl'j. 362. Atrophic inflammation of the middle tnrblnato. Below t lie stratified pavement epithelium Is a (■"Uiparalivcly denae network of connecltTi-iissiie fibres, showing toundcelled iiiHIIralion with watteri.ll hlooitvessels. Below this are Irregular sinuses in a compact mass of conncelire tiwue. By diffu.«e atrophic inflammation is denoted a chronic inHammatoi y atTection characterizfMl clinically by a more or less general progri>ssivi> atrophy of the mucous membrane and underlying structures, tin' formation of a tenacious, at time etid secretion, and exhibiting mi tendency to spuiitanetius recover}-. Our histological information is derived from a study of the lesions occurring in the nose. In difTu.«e fetid atro])hic rhinitis we find histologically a nictapla.<i:i of the ej.'itheliiim associated with c. ^rnificati.in, dogenerative chanir-- in the glands and in the wandering cells, together with bony absorp- tion. ISFLAMMATtONS. 717 IxiunininK those iiltoratici.s inoro ia detail, we t nil in the hrst i,..tance the lu.r.nal c.hi.nnar ciliated epitheUunj t.; he more ..r less universaliv replaced hv stratihwl pav-nu-nt epithelium, with a Wu- •v ;.,-hurnv chaiip. in the up,H'r layers H.low he mucous ,H,,nl,rane there is an iutiltrati.m of n.un.l ce Is. particularly in the ! 'i zone. exten-liiiK more or less .leeply int., the region <^ , ,rla,uls. particularlv in the intertubular tissue In the vunuty „r this infiltration are found numerous fibrillary nuc fate connective- t ' strands, running us.-dly paralU>l to the surface a.ul vary K i„ „„,„1„T acconling to tlu" durati..ii an.l stage of tlu- attectu.n. lon- ui exists betWHM. the stat.-ments of diff.-rent observers as to certain .„irestati..«s in the mucous membrane and infiltrating ce V degenerati.m of the.se n lis has been observe.l and is by son e ,:.'anled as tlu' essential feature of the process. .It np,H-ars nmv vusonablv certain that while M dro|.« "lay occur in the glandular „„.liu,n an.l sometimes in .he free epitheha evils a« far as ».<■ , ,iti,.,. of the etTen>nt duct on th- surface, nevertheless ^•""'f'- f ^ra- „s may ..ccur in all nasal affections without .ussociated fe <.r .^ ;„,,phv ' It is possible that another process of .legenerat ion whuh ......u'rshere. nanlely, hyaline metainorphosis of tl>;P»-^'"«;",J;.S have le.l to erroneous conclusions by earlier observm. Thm h> aline lj:en.-rated cells, the so-called Russell's fuchsmophiles. are found not '.nh- in the subepithelial layer, but also in the dee,K-r layers of the mucosa, in the erectile tissue, and in the medul a. The Erectile tissue shows a gradual weakening of its muse la .„..,. ratus and in advanced stages distinct shnnkmg. h. I raenkel h'.s .l..scril)ed an endarteritis obliterans, but his findings have not '" Th.-',^li;Xum in the affected portions shows marked prolif^^ratbn^ with hire arul there an increase in thickness Large P-'y""';';;^ ^'^^ Mr found in varying numbers, the f-<'«ll^<»;^f •'''.^''f;; '-^'"^^1" ,:,llv dinctlv on the margin of the bone an.l the lacuna>. In their vi,.i,litv there is evi.lonce .,f bony absorptmn. with the resi.lt that ,hr bonv partitions supporting the a.ljacent medullary s, aces gradu- ,llv.lisappc.ir. Sniall pieces .,f bone are split off and absorbc.1 !hVr.. tllus tak.^s place' gra.lually a loss of the bony fra"«'^vo^ <^ ,!,.. turbinate.1 bones. Howship's lacuna- are f';""'|;"; V?, "f -Imridanc. At times no ost.-obhustic layr is found. These altera- :Z ie possibly instrumental in altering the nutnl^ion and cim.h^ ,nn in the bone." Bv some observers they are regarde. as c.nstituting .,in,l.!"ndent primary pr.,c..ss. which lea.ls through aterations in h. arfries to . ^condary changes in the «y^'-hing_ structures Th.. attempt w.vs ma.le .some years ago t' ..p ain the ^ "sat^on o t,„phic -hinitis by the presence of a specif.c ''a'-tfrmm Scm ral ...anism.-^ were isolated an.l claimed by the .hscoven-rs as the specific ...„ts. It is sufficient at the present tinie to statr that no confir- "ation of these claims h..s been establiNhed. Its ongm from chronic imisitis with empyema seems probable in some instances. ■M 718 XOUE AM) TUROAT. EhlniUs Sicca Anteilor. My this ffriii we iindiTstiirKl mi nfToctiun iif tlif imicoiis iiicmlxanc of tin- cartiliijtirious .xi'iitiim iirfsciitiiij; .1 pii'turi- of dry nifiirrh Ic-uliiiK to cpitlitlial iiictaplasiji, and frc(|uciii!y to Imctcrial infcrtioii. Tlif mucous mnnhranc in tlic atVcctcd rcjtion • •xliil)its or r more laytTs of a pcniliar siihstaiicc situated ahovc and upon fhr supcrticia! cell layer, wliieli sliows in it.> linetoriai reae- tion a reseniManee to keratoliyaline. In and Im-Iow the inueous ti.ein- l.rane are numerous^ iiyahne dep-nerated |)iii.snia ceils, iiiiustzciicM, and a few eosinophilic cells, A l.arKe amount of |)iginent, prohaiily luemato)tenous (staininR reddish hrown with carlH)l fuchsin), is dis- trihuted in the mucous membrane, partly in and partly external to the cells. This condition is the luost important etiolojiical factor in habitual i.se-bh'ed and in perforating ulcer, probably also for perichondritis of the sei)tuin. 2. PROGRESSIVE DISTURBANCES Or NUTRITIOM. Under this heading are comprised alterations characterized by jtrogressive non-intlammatory increase in tissue volume. We distiii- «uish new-prowths with mafignant tendency and new-jirowths of a iM-nigii character, the first growing into the tissues of the vicinity, torcing them to one side and actually replacing tln'tn, while the latter remain relatively well ditterentiated in their growth from the vicinity. Malignant Tumors, of these we may distinguish two chief fpes. according as they rise from the ectoderm (or entcxlerin), (,r "froni the mesoderm, the former being represented by carcinoma, the second by sarcoma. Carcinoma. These growths a.I-e through proliferation of the super- hcial epithehum, or the glandular epithelium which grows into the neighboring connective tissue an<l produces here w simultaneoas pro- liferation. For these rea.son.s carcinoma Inis two const'tuents, namely, cancer cells and a va.scular stroma. The cancer cells appear 'mor[)lio- logically as large cells po.ssessing Ijirge round or oval vascular nuclei with large refractile micleoli. They preserve to a certain extent die arrangement and form of the mother cells. The stroma varies in cotisistence and thus infl-ences the den.sity of the tumor. Carcinomata are divided intoepitheliomat.' an<l adenoearcinomata, the first arising from sfpiamous cylindric;.|, or tubular epithelium, and the second arising from the hning epithelium of the various glands. In the case of the epitheliomata. but little confusion can arise as to the (|uestion of their malignancy. In adenocarcinoma, on the other hi-id. there is frequently a striking resemblance to a genuine adenoma. We find all degrees of transition from localiz«M hypertrophies, in which all the constituents of the mucous niembraiir are involved, to papilloniata and .adenomata, and finally to rarcinn- mata. The only sharp line of demarcation between the benign ami PROURESSIVE DUiTUBBANCE. >#' NLTBITWS. 71i) m:iliKii!iiil >jr<)\vth.-i ill this list is in th<" tcmlcm-y of tli«' latter iiionc 1,1 invade tiif tissues of a ilitTrrciit Idastodcnnic orij{in. llotli ci.itlu'lionia and adt-nosarconia occur in all parts of the upper :iir passap's. In the nose carcinoma is comparatively rare and iiMialiy of the Rlandular ty|K>. In tSe pharynx and larynx epitheli- iiiiia is more fre<|ui'nt. Sarcoma. Tlies<' tumors consist to a greater or less extent of iinma- iiiie fonns of connective tissue produced through proliferation of crlls of mesodermal nature. The cells are usually numeroun, and . \l:il)il ftreat variation in iiuinl«'r, size, and shaix-. The jjround sul^ >i:Mice may ranp' from one hut slightly develo|>ed and apjiarently iiMiorphous, to one that is moiv abundant and compact and more or |,» lii)rillary, approaching in its apiK-arance th<' mature connective tissues. Many sarcomata exhibit an alteration of a ])ortion of their lioues into a mature coime<'tive tissue, such as Inine or cartilage, riie development of hloodve.s.sels is at times extremely marked, :is in angiosarcoma. Retrograde metamorj;Vi -s occur in sarco- mata under the form of fatty degeneration, ''iseation. li(|uefaction, and ulceration. Histologically, the followiuM .arieties are distin- uuislii'd: First, round-celled sarcoma, where the growth is made up of round cells with a small amount of internuHliate >uhstance. The -ize of the cells varies, giving small round-celled sarcoma and large r.iund-celled sarcoma. S<>cond, spindle-celled sarcoma, consisting of .joiigated cells, large or small, with a ver\' slight development of iiiteimediate substance. Third, endothelial sarcoma, arising through |iroliferation of the endothelial cells, i)articularly of the \yiu]>h vessels. I'ourth, angiosarcoma, which includt's the forms whieh are jKirtii'u- larly well supi)lied with l)loodves.sels. Sarcomatous tissue surrounds the vessel walls, which may exhibit irregular dilatations, giving a hya- line degeneration which may result in complete closure of the lumen. Iiv;i'iiie cylinders and knob-like protuberances are thus jjroduced, t' liming the so-called cylindroma. Melanotic sarcoma is a fonn in uhicli a portion of thecells contains a brownish or black i)igment. Tlie form of the cells is immaterial. These growths exhib'^ marked malignancy. Sarcoma may exhibit a combination with the mature ti. . of the iiesiHleriii. giving osKnisarcoma and chondrosarcoma. Sarcoma may o'-cur in all regions of the upper air jjassages. They le found with i)articular frequency in the nose, while in the larynx liey are of extremely rare occurrence. Benign Tumors. Of these we distinguish genuine tumors and 'Minnrs arising from sta.si.s. Tiue tumors may aris«- from the ectoderm, i)ro<lucing i)apilloma ml adenoma, or from the mesoderm, giving fibroma, lipoma, myxoma, ■ lioiidroma. osteoma, and angioma. Papilloma. This variety of tumor is characterized by the presence -i riumerons fii)rous branches covered by epithelium. In the nose 'his epitli lium becomes atypical and approximates the squamou . 720 yOSE ASD TIIBOM'. type in those situations whoro it is cxposcMl to extornal irritation or rul)binj; of its surfaces. Kvcrywhoro the marked feature of the growth Is the proliferation of tlie epitheUutn. The stroma is scanty ami abuiiiiantly suppHed witli i)loo(lves.sels. In si)ite of its simihirity to cancer, on account nf its tendency to active atypical i)roliferation, the non-malii^nant character is shown by Hie fact that the epithelial covering of the tumor is sharply Ihnited Ik'Iow and does not at any place penetrate the underlying tissue. The growth is always to be distinguished from papillary hypertrophy, in which all the elements of the mucous membrane jjarticipate. Adenoma By this term is denoted a tumor which imitates the physiological glandular tissue in a certain degree, but does not exhibit its function Although the adenoma resembles the normal structure of the gland it differs always to a greater or less extent, partly in the size and jjartly in the arrangement of the epithelium. Their line of demarcation from sim])le glandular hy|)erplasia is by no means sharp, nor, on the other han ', are they definitely sejjarable from adenocarcinoma. The chief points of distinction in the latter case consist in the regular arrangement of the epithelium and the sharj) .separation of the adenoma from its surroundings. Pure adenoma in the no.'se is rare. It Is more freiiuent in the palate, where it is often associated with a dilatation of the lymphatics. It is rare in the larynx. Fibroma. This growth consists of fibrillary vascular connective tissue of a more or less compact structure. In the septum it occurs at the junction of the cohnnnar and triangular cartilage, and shows an epithelial covering with the characteristics of the external skin, overlying firm, fibrous, closely-ajjpressed bundles which contain numerous spindle-celled elements, but few round cells and blood- vessels. In the nasopharv'nx we see all gradations, from the pure fibromata, consisting alniost entirely of dense white fibrous tissue, to those of a looser structure with more numerous cells and bloodvessels, which a|)pr()ach in typi' the fibrosarcoma. In the larynx the true fibroma is rare, and is found chiefiy on the vocal cords. Lipoma. Thes(> have Ix'cn observed upon the mucous membranes nf the nose, the tonsils, and the larynx. They consist in their centre of fat tissue surrounded by a more or less abundant connectivi' tissue in the ])eripheral portions, and .iie "ov-red by the mucous membrane of the ])art. They are apt to be a.'*.sociated with other growths, particularly fibromata and myxomata. The fat tissue in these growths is distinguished from normal fat tissue in the greater size of ts cells and lobules. It may be as.sociate(l with greater devel- opment of fibrous tissue, ])roducing a (ibrolipoma. Myxoma. True myxoma has not been reported from the nose. It rarely occurs in the larynx, consisting of a homogeneous ground sub- stance wiiti delicate fibrilhe containing mucin hi the meshes, together with stellate antustomosing cells. PI. AT!; XXI II. FiU-Mli'l'Ill mn. ill mill lirnm lii.i'i ccll-^ nii' >lii'\\ 5r ]. .11. ii ,.'■ \Vi mill ~ ,|.-.. 1I1WI1 »' i. rKooJiKusiyj-: DiarrniiAycEs of yvTRirios. -fix Chondroma. These jjrowtlis consist of eartiii.-'e, n.ost eoiniuoiily hyaline cartiiii^ie, altli»iu>;li yellow elastic, and h.,, icartilajie may occur. In the nose they are extremely rare, and arc either supposed in .some cases to i)ej;ii; as |HMlunculated outgrowths which, by disa])- pearance of tlieir pedicle, become free, or in other cases to arise from islands of cartilajic which persist from fcetal life. In the larynx tfiey may occur as eccliondromata of the same form as tiie parent tissue, or as chondidinata, in which the type of cartilafje is diiTcrent. These ^r')Wths are prone to retrograde metamorphosis in the form jf mucous dcfteneration. They may also exhibit ••:ilcification or actual ossifi- cation. Osteoma. These growths in the nose are sui)])os('d to arise in one of the accessory sinuses, and are composed in their outer layers of compact osseous ti.ssue, .-ilthough the interior may be made up of spoufiy tissue. Tliey are apt to be broken ott' from their point of attachment either by traumatism or by atrojjhy from jm'ssure, jM'rliaps resultinp from the occlusion of the nutrieni, bloodvessels. Angioma. The.se p;rowths are found chiefly in the nose and larynx. We disti^'duish simple and cavernous angiomata. The simple angioma consists of numerous capillaries and veins which exhibit circumscribed dilatations in th;- form of globular, fusiform, or cylindrical enlarge- ments. These are closely related to tiie so-called bleeding polyp, a form of tumor whicii is characterized by an excessive, simultaneous, sudden growth, and is es.>;entially benign, although apt to recur. The hy|)othesis of Siebenmanii, that it is due to rhinitis sicca anterior, is at present plausible, but not demonstrated \\\\\\ certainty. The «'pithelial covering consists partially of stratified cylindrical i |)itholiuin, the lower layers of which are composed of large polygonal nucleated cells, from whicli the upi)er layers are sharjjly s('|)arated, being Hat- tened and distinctly horny. The pavement epithelium is not sym- metrically distributed over the surface of tin- new-growth, but sends downward slender jjajiill.ary prolongations. The main [lortions of the growth consist of a loose connective tissue formed at its bii.se of delicate fibrilhc. Toward the |)eriphery the round cells are more abundant. In the middle infiltrated portion are numerous dilated blood and Uiuph vessels, giving rise almost to a cavernous ajjpear- ance. Angioma cavernosmn resembles the above growth, but shows par- ticularly a new formaiion of the vessels, which undergo secondarj' <lilatation. They are situated exclusively oti the lower turbinate or septum, and consist histologically of a covering of stratified ciliated epithelium overlying the cavernous blood spaces, separated from each other by trabecuhe. These sinuses are round or oval, and lined with smooth endothelial cells. In the deeper portions they become larger and more irregular, and the septa exhibit a greater thinning, and (irially nipluriiig of their walls, leading to a rontiuenee of the adjacent sinuses. Both venous and arterial bloodves.sp|s show a thickening of their walls. 46 nV^XESSES^TS^BSS u r22 yoSE A.W THROAT. A lliird fortn in* tlioso vascul;ir fjrowtlis is the fihroaiiftioiiia which exhibits a smooth surface l)eariiij; stratified ciliated epitiieliuiii over- lying a body of Hrin fibrillary connective-tissue strands, and con- iaining numerous irreftuiar sinus(v resultiiif; from dilatations of the veins or arteries, which, fro :i erosion of the tralx'cuhe, may become conHuent. There is everywhere a round-celled infiltration, particu- larly in the vessels. Retention Tumors. Betention Tumors of the Epithelium ; Cysts. In the nose, cysts of varyinji size occur, most fre(|uently in polypi and in the antrum, resulting from the occlusion of the etVerent glandular duct, with resulting dilatation of the gland. ;Mich cysts are lined with e[)itheliuin and contain mucus. In the septum a cystic enlarge- ment is occasionally found as the hnal result of a ha-matonia, which in place of suppurating becomes encapsulati'd, and is found to contain a fluid which is either clear and transparent, or fine, graimlar, and viscid, or ai times shows the reaction for colloid. In the na.so|)harynx a form of cyst occurs which is supjjosed to arise as the result of inflanmiatory |)roces.ses atTecting the pharyngeal tonsil, leading to adhesion of tiie surface of the median folds and converting the median furrow into a canal open at both ends. When the mouth of this canal becomes closed a retention cyst may be formed of varyiiig dimeiLsions. ii is possible for this to occur in other parts of the pharynx where the folds of the pharyngeal tonsil lie in close api)osition. Lami)hear repc .s a case in which the mass on microscopic ex.amination was found to ])ossess a wall, the outer and inner surface of which wa.s covered with stratified pavement epiiiieliuni. The inner surface w;>.s smooth, e.\ce])t at its attachment to the pharynx, where th'>re were a few crypts. The mucous mem- brane was rich in lymph corpuscles, but there were vorv few lvnu)h follicles. In the tonsils cj'stic growths may arise from the occlusion vi a lacuna following inflanun.ition or tor.sillototiiy. The walls of such cysts are formed of fliittened e|)ithelium, and the contents con.<ist of fat droi)s, plates of choie.sterin, exfoliated epithelium, and leucocytes. In the larynx cysts have been observed in the various ligaments ;is the result of glandular occlusion. In |)olyps of the vocal cords th.'M' m;iy occur genuine cysts, or p.seudocysts due to (edematous infiltnition in a circumscribed area. In the latter instance there is no 'ining epithelium, the walls of the cyst being formed by the hyper- trophied connective tissue. Cysts of t-mbryonal origin als) occur in the larynx, due either to the ocdu.sion and dilat.Mtio.i of the thyro- lingu.'d duct or to a jiersiste-it branchial cleft, which may give rise to superfici.'d fistuhe, which are later transformed into cysts by closure of the oixnings at the extremi.ies. Retention Tumors of the Mucosa. Of these we distinguish dilata- tion? of the bloodvessels and of the lymphatics. Hetention tumors of the bloodvessels from stasis occur most fre- quently at the base of the (ongue as lingual varix. We have no exact HEURLSSIVE DISTURDASCKS OF SiTIilTlOX 723 liistoloRical kiu.wlodKe of tl'is (-oiHlition, but it is probably analogous to similar lesions upon the skin. , , • . i Tumors of the Ivmi.hatics from stasis, or lymplianRiomata. have l,een rei)()rte(l fr.)m" tli<' pharynx and larynx. In a ea.s(> ot lym|)han- .ri„mu of the epiglottie lipiment the tumor was seen to consist of a wi.le-meshed, loose, vascular, connective tissue contanung many cavi- ties vurviuR in size up t<. 1 mm., j.ossessing a thir lininp ot eiido- tlieliunraml Hlle.l with a homoseneous mass contain n>l a few round ,rlls. In manv places in the connective ti.s.su.- th.'se sanu^ masses ,„Tur. The tumor-like formation is in geueral sharply (litTerentiatwl Iroin the surrouiu'iiiK tissue. 4. REGRESSIVE DISTURBANCES OF NXJTRITION. These alterations in the uj.per air pa.ssapes consist I oepenorat.ye Mu.l of atrophic changes. The most important u. this .^j.ecia held ,,,. the mucous and horny .le-cnerations of the epithelium, lloen s ,„u.scular degeneration, and hyaline degeneration of plasma celN. Of the atrophic changes the most nmspicuous are those occurring in th.' Ivmphoid tissue of the nasopharynx and the i)harynx. Mucous Degeneration. Mucous degeneration of the epithe lum nceurs in the nose both in the superficial epithelium and in the ducts ,,f the glands It is most commonly found in association witii hyi)er- tn.phic inflammations. Th.> suiierhcial epithelium may iKCon.e to- tailv or partiallv degenerated. In the first instance al d..- cylindrical ,.pit"helium is transforme<l cell for cell hito an .'pithelium n.nsi-tmg „|- .roblet cells filled with mucus. Partial mucous .legeneration may oecTir either bv simple increase of the normal goblet cells, occurring hetween th<. cvlindrical c.'lls. or by the <'e">7-"'''\';f/''y'\!'™f, ,.,.!ls in the recesses of the epithelium. .,r u, the imd.st of "tier is, normal cvlindrical epithelium. The epithelium (^ the efTe rent ducts „f the glaiKls mav undergo a similar change. This condition ma> NO occur in oza-na, and also in apparently normal cases Si:.ce it ..difficult to demonstrate the efferent ducts in thes<- structures they niay easily produce tlie iinpn>ssion of purely epithelial formations. ' ' Homy'iegeneition or KeratosiB. By this term is denoted a chronic degenerative process of cornification affecting the walls ot the a.una^ „fthelvmphoi.l tissue in the pharynx, nasopharynx, and baseot tlic tonl'ue. in association with a mycelial organism. (I late AAl., ' 'tI.c structures which appear clinically as white excrescences pro- tr.iding from the orifices of the cryi-ts are seen histologically to ronsi<1 of sacs or cvlinders. the walls of which are relative!) ver> ihick at:d consist p:irtiallv of stratified layers of lu.n-nucieated horny ,.,.ithelium, an.l i.artlv of a homogeneous horny substance, such as . ' peculiar to the human hair. The central lumen of the excrescence 724 mjhj:: asv Tint oat. ..r prickl.' IS iiariow .-uid filled with .Ictritus and hartcria In Z.-iikcr siMrinirns stained with lueniaiuin and •■.,sin the hornv .•iMthcliuin stains hiij,r|,t rcl. Th.> peculiar h<)ni..jr(.ne(.us lu.rnv substance ..n he other nan.l, appears a clear light blue, iiere and therewith a fine hKht y<-ll()w piKnH>ntati(.n. whil.- in the most peripheral layers red Cngat.., structures in.licate that there still remain portions of flat .'lonjiated cells or cell m,cl.-i in that part of the prickle which pr..trudes Irom tin- crypt. Th.. ..xternal surface appears somewhat shredde,!, and is h(.r.> and there invaded with bundles of leitofhrix tiireads. ' The epithelium of the surface appear- normal both in reRard to IS tola thickiKss and the appearance . its cellular elements. On the other hand, all the crypts thn.uKhout the wliol.. length of their lumen ("xhibif an enormous thickening of th.'ir epithelial cells h, th.> epithelium of the crypts the cells of all the layei^, particularly the middle, appear elongate.l, and th.- superficial'lavers somewhat t attened. The cells which are in contact with the hornv plug appear thicker, are stained mon- deeply, and show a peculiar granulation of their protoplasm. Small, strongly refractile granules, apparently Identical with the pigment granules <.f the homogonoous blue-staining layer, are .seen arranged chiefly in regular rows. Keratohyaline and eleidin are apparently absent Keratosis appears fre,,ueiitly in a mild form, in otherwi.se normal Oiisils here and there in the crypts. In the first fd-tal months horny epithelial cylinders and epithelial pearls are found in the ton- sillar crypts and also m the pharyngeal solitary follicles and the ymphoid tissue of the nasopharyn.x. The so-called tonsillar concre- tmns are to be reg;irded chiefly a.s decom,K,.se,l pro.lucts „f the cor- mhcation m which lime salts have been .leposited The leptothr.x threads which occur in this con.lition are morpho- h.gically Identical with th.- leptothrix buccalis, and are probably here merely saprophytic. This organism occurs with particular abun- dance ^yherever epith.-lial structures px,,erience the lo.ss of vitality being abundant at times in cancerous ulcerations, leucomatous fi's^ sures, and hyperkeratosis of the lingual i)apilhe A Form of Degeneration of Striated Muscle Occurring in the Uvula (Hoens Degeneration). Histological examination of relaxe.l uvuhr sh.nv.s peculiar degenerative changes in the striate.1 muscles asso- ciate,! with marked nuclear proliferation, and leading to a nearly «r quite total disappearance of the contractile substance of the affected nmscular hbr... In the beginning of the process a peculiar bleb-like or yesicle-hke homogeneous deposit takes place at the r.oripheries of he muscle fibres, appearing as a narrow bright margin or line of homogeneous nature, at tunes raising the .sarcolemma here and there into smal Webs or b istei^' rransverse striation becomes less mark«! and lonptudma! .str.d.on beromo.. replace,! by wavy undulating lines •o respoiuling to the ,n,!,vi,lual fibrilhr, which have now Lorn.: twLste,! upon this, prosenting an appearance not unlike tho strand^ REORESSlVi: Pl.STVRHAycES OF MTllirwy. 725 ,,f i rope Tliis upiM'iiraticc is most noticciihlc at tlic free ends of ,1,,' fibres and becomes eviden* only after tlie marpnal elia.iKc begins ,„ i.uMiifest its.-lf. The final staf;e of the peeuliar .legen.Tativ.- process i< n died when a veritable cylindrical i)hig or mass composed o lun, blebs containing small and large misshaped nuclei mtermmged with pigmentary detritus is f..rm..d. Through the mi.ldle of this there runs longitudinally a mere shadow, deiu.ting the former site .if a muscular fibre. • . . i , Proliferation and polvnu.rphism of the nuclei are proimnent ph.- „„„„.na in this p.-culiar metamorphosis Alterations are also apj.ar- .„t in the m. lei, consisting of a Hattening at th(> ends, with a hollow ,1 the central porti»)n on either side, giving them an appearance '.(..embling empty cotton spools. Other nuclei appear eh.nguted with marginal crenalions or serrations. Tlie majority of the nuclei show n.nmletelv suric.unding them a halo of a clear homog<-neoiis material which does not stain. With the gradual disai)l)earance of th.- mus- cular fibre this material augments in amount and becomes arranged invsruhirlv in the centre of the bleb in small clumps. i;videnVes of the regeneration of the muscle fibres have not iM-eii ' '' Hy^e or CoUoid Degeneration. In both normal and i.athologically Mtered mucous membranes, ,.articularly in hypertrophic rhinitis, there .„...ur at times homogeneous gh.bules, most numermis m th-'se situa- tions which exhibit the round-celled nfiltrat.ons. These sl-''"';- '«; M.pposed to arise from pla.sma c<;lls by a ^\^^^^^}';:^^^^}''^ n.'.'mblesthvroid colloid in Its staining reaction. U '"<?-^->^V . *" t'l; . I„ specimens stained with luvmatoxylin and acid fuchsn. tlu Mucleus api^ears dark blue and atrophied. The degenerati.m begins with a slight swelling of the cytoolasm. which becomes dark and l.roken. Thes,- fragments increa.se in size become mounded nM..-e n.fractile, and stain more deeply with acid fuchsm. The cell, now ,„u,.h enlarged, has the form of a sphere, aiu many of the fra|j"«;>'Jj coalesce t<. form larger ones. The atrophied nucleus is usuallv still visible Finally there arise completely homogeneous oval structurcN .taining .lark c'herry red with acid fuchsin The advance, stages o d.-,.n..rati..n are more commonly h.un.l than the early stages. In ,!; b,.ginning their structure is pn.bably plastic, so that through ,.l„s,. apposition of th.' small granules an.l th.nr coalescence larger ,MMnul.'s are forme.l. It has b.-en a.ssume.l that the pn-sence of hvaline an.l cUoi.l , '.."generation in th- iiy,,ertrop u.;.l •";!^-""'^. "";'?;- I, nine is not acci.lental, but stan.ls in intimate rc>lati..iiship with tlie nature .,f these hypertrophies. It shows no ten.lency to sp.Mitaneous ri'tro!iressi.)n. , i i 1 1 ♦„ My s.,me auth..rs these corpuscles have been regar.le.l as blasto- mvetes, but this vi.'W .loes not seem at the P'-'''^'^"^ June tenable Atrophy of Lymphoid Tissue, \\-ith a-hnncng age the pharyngeal an.l faucial tonsils exhibit n..rmally r..trogra.ie changes. J'Jf^'mu.^. as the phenomena characterizing these processes are essentially iden- 726 NOSJ-: .lyv TtlROAT. lical in the tw.. situations, tiu- (•..nsi,i..rati()ii will be limited hero t<. sX/rT,"'" !" ''"/'^"""' •""•^"■^' ^^■*'"''> »'»^-^' boon num' ul • s u.I.ed. ll„. retr..gr:ui.; nu.ta,n„rplu.8i.s lx!Rin« in tho regions wIhtJ. th.. conneetiv,. tissue or.gnuilly ,,re,l„n.inated, namely, iS the t ub- ecula. .m.l U.e subnme.us e.„u,e..tive tissue. It may , rogres^ Tng he trahe.-ui;e u. the f„nn ..f an irregularly sclerotic Voc.ls. or n a ..re ho nog..„eous an. symmetrical n.anner, extending f on. the . a.. .,f the organ toward ^Ih- n.ucous .ne.nbrane of its free periphery e s eviX:.'!;;"" '"T; ^^"■/''"'"''"''•='' -"'< -f the reticulum exhib t \>> .■Mdence ,, prolif<.ration an.l become fewer in n.anlx^r. Later hoM. form ng th." germ-cntre of the follicle entir.-lv disappear „d there ,s left to repres<.nt the follicle n.erely a heap of lynu hoi?f 'cil « u-luch progress,v,.ly decrease in .m.nber until finally tl- C er site of the folhcl,. ,s occupied wholly by connective tissue in which fat ...ay be deposited. The follicles most remote from the rm expl r ence th,. greatest amount of atrophy, while those nearest t^he cryp'S^ and those particularly nearest the orifice of the latter preserve cor^ resi)ondu,gly best their functional activity. preserve cor- ^^B^R CHAPTER XVII. METHODS OF EXAMINATION; INSTRUMENTS AND APPARATUS AND THEIR USE. By J. i;. NHWCOMB. M.D. TiiK miuMtos for a • .)IM'r examination of the upper air passages ■irc a'snital)le source of light, adetiuate reflectors, correct atti- tude of patient and examiner, anil approved instruments. Students should he encouraged to follow a uniform method of exanunation in every case, so that no (mint shall be overlooked, and every etTort shoul.l'lx. made l.y those giving instruction in these l'[a>'clies to inculcate careful habits of observation and to develop the faculty „f definitelv recording the fimUng« "' <''ifl> ^■. , , . ,. , . Anterior" Rhinoscopy. Source of Light. The ideal source of ght i. the sun, for then'by are the anatomical structures seen in their ,ru. color, a matt.T verv difficult to attain by artihcial hght, which has its own color, dependent on th." source. As sunlight cannot 1„. relied upon, houvver. artificial illunnnation ..s rn.ployed. I he .in.plest m.'thod is that of the ordinary candle flame but it is too U-A- and Hick.-ring, except for emergencies At the l«'' ^l^' "" rxcell.'i.t view mav b.' obtain.'d if the candle flame is backed b> the l,„wl ,.f a polished" tablespoon which serves as an improvised reHecf.r. Here the light is thrown directly upon tlie j.art to be observed. In citi... the Welsbach-Argand gas-burner has come into almost uniyersa u.e It gives a clear but whije light. i:iectncity n>ay be used, and is ...ining into more general employment If used, the glass bim. ..ontaining the inca.ulescen; filament must be frosted <"• ground, othr- wi.e there will ai)pear in the reflecting mirror an image of the hlanent „bscuring th.> clearness ..f vision. No matter what source of hgh is emi.lov.'d, all ai.paratus shoul.l be so arranged that it can be raised and llnvered and swung from side to side. The general ^n-''inS<""0" „r ,he light van be appreciated by reference to Fig. 363. In order t ,.,.Mcentrat<- the light some form of condenser is employed. When ..jcrtricitv is unavailable perhaps the most satisfactory arrangement is the \\Vlsl)ach-Argtind gas-burner place.l either on a swinging bracket or attached to the frame of a student lamp. Reflectors are eith.'r worn on the forehead or are attached directh t„ the illuminating appar "us, as illustrated in Fig. 363. The major- itv of phvsicians wear tin minor on the forehead. . • , • "Then- an- several varieties of head-bands, but the one advisexl is tint known as the Pomeroy (Fig. 364), which has an arm to which ( 727 ) 2M A 'AS/; .i.v/< rniui.ir. th- ni.rn.r is attaclHMl l.y a m.iv, rs.l j.,int. [..Tinitfinp .,f n.pi.l an.l .a.sy ina.i.|,ulatio„. I he inim.r slu.ul.l have a .lia.nct.T.,f fn.m thnv to tour uu'lirs and a f.,cal ,lista.u-.. ..f al«.ut fourf,.,, indi. s Tl... h.vd-l.aii.lmaylH.ina.l.M.itlH.r..fliKl,tw..|,l,i,,K,,rh."avy(-.,r,|,Mlril.l),.M, inatcials whicl. aiv prclVrahlf t.M-lastic. Th.' mirror is plum! over the Kiu. 36S. Light ^nd condenser. ovc corresponding to tlio side from whicii tlio light comes, and i)inocu- iar vision is easily secured hy looiving tiirough the cential jx'rforation Head-I)ands witii a fran.e-piece resting on tlie bridge of the nose are to bo avoided. So also are sjiectacle-frames to which tiie mirrnr IS attached, hi warm weather the use of the spring head-band is more comfortable. This may be used to carrv the ordinary mirror, or may have attached cords terminating in an electric lamij. Such METIlObS Of hXAMISATIOS. 72U ;m apparatus i Fmr. Mm is kmiwii as a ■■plu)tn|ilii)ri'," l\w iihmIcI ,livisctl liy I'liillips Ix'inn in iimsi l'rc<|Ui'tit use. Fill Mt \i> The Pomen>jr hiiidband and mirror. Tlic relative attitiitles of physician and i)atipnt are seen by reforent-e I"i<r. Mu. A satisfactory arrangement so far as seats are concernctl FlO. 365. Spring bead-band. i< to liavo the pation. sit on a stool which can bo raised or lowered. while the physician sits on a revolving stool of fixed height. Behind liie natient should bo a rest for the head and shoulders which can 7;m) XitUt: AM* THROAT lx« raif^'d iiml lowered at will. Tin- object w ruit mily to fix the u|i|M'r part of tlic ImmIv, hut also to prevent the patient (in cane he should iiitike ail incautious inovtMuent) from doiu); hiins<-lf harm. ria. :iM. Phillips' photo|ihore. The in.«truinents ie(|uire(l for anterior rhiiriscopy aro some form of na.xal speculum, a cotton-tipped applicator, and a flexible probe. Fia. 367. AllllU'lir "f phy^tielnii nml [wlteii, one of aluniinuni beinji preferred. The fir.«1 dilate.s the parts to Ik' examined the second can be used for the removal of any secretion, ^^^ METltom or iCXAMJXA Tloy 781 whilf tlic third fimblox us to oxploro the (Ici'iht rpcpxtwtt of the imrcM, ami l>v f.inlart to .li-t«'riiiiii«' thi- density of the tissut's. In th« hands of the |irii<'tis«'(l ohwrviT it f)«'c«)in«-s priwtioully u prolungution of Bnnwortta'i iwwl iiwculuoi. Fill :lfi». Uartmui'i nu*l •peenliim. Fio. ro. Fio. 371. Dnplay'n luual ipeculiim. (•.likel'i spec-Hum. Fio. S7S. \lyle«' nasal speculum Oleuon'8 nual ipeculum. his fiiigor. Of niusal s|)f cula there are many varieties, sou t; of whicli MP' liere shown. (Figs. 368-373.) m^ 7:J2 ^UtiE A.\l> TlIliOAT. Tlic so-called sclf-rctaiiiiu}; specula are not of such >;reat si'ivice as their iiaiiie would seem to indicate, for the I'orci' of the s|)riiij; ajjainst the nasal ahe incessary to hold the latter open is often painful to the patient ; nioreoxcr they often sli|) out durinji an operation, much to the surjji'on's discomfiture, (ileason claims to h.ive overcome these objections by the instrument which hears his name. (Fiji. -Vi^.) He states that it is impossible to shake the instrument out of the no.se, no matter how violent the patient's strufTfiles. It may be attached to a head-band, .so tliat tiie tip of the nose is elevated, exjiosinfi the cavities tor operation, thus !ea\in{; both the surgeon's hands free. With any instrument the examiner should be careful to exclude his hand from the line of vision. The |)ati<'nt having been seated as indicated, the light should be so placeil as to come from a jioint a little behind the jilane of th(> patient's faci' and at the vertical level of the top of his ear. The liead-mirror is then adjusted so as to focus tiie ligiit upon the nose. The organ should be carefully examined as to its contour and sym- metry and the existence of lesions in eitiier the skin or subcutaneous tissue. Certain skin ervthemata may be due to intranasal conditions causing pressure. The condition of the ahe should be noted, whetiier they are freely open or collapseil, and whether, as sometimes happens, they are contracted during inspiration. Thi' instruments are to be kept ill a bowl of weak carbolic .solution on a table at the side of the examiner, ;uid after each usage sjiould be di|)])ed for a niom(Mit in boiling water. Too great stress caimot be laid on this matter of th(> care of instruments. The first and middle fingers of the left hand shoulil rest on the bridge of the nose, while its tip is elevated liy the thumb. The blades of the speculum, warmed and dried, are now inserted in the nostril as far as the nasal bones, but not beyond. ( >bv'. usly only the cirtiliiginous |iortion is dilatable. The ahe having been gently opened, we first determine the position and state of the .septum, noting any deviations as a whole, any local thickening, spurs, or ridges, etc., and then the condition of the imicosa, whether covered with the natural moisture, thick tenacious nmcus, crusts, oi' erosions, '["lie nature of doubtful areas will l)e determine(l by the use of the cotton-carrier, which will r'move .secret ions unless unusually adherent. Till' probe will determine tlie consistence of any redundancy of tissue. The condition of the turbinated bones should next be ascertained, whether of normal size and shajie, whether hyjjertrophied or atrophie(l, whether in contact with the septum, causing intranasal pressure, and whether the Heshy masses sometimes seen are polyps or merely polyjioid degenerations of the mucosa. The proi)e should be pas.sed between th<' bone and the septum if possi})le, to iletermine the |)atency between these structures. It will also determine the presence and often the nature of foreign bodies. \'ari;itions in the jiosition of the !).itient's head will enable .ill i)oitions of the nares to be lirouirht into view. Thus it should be depresse(l in order to bring under inspection the nasal floor which, it will be remembered, gradually rises from METHODS OF EXAMINATION. 733 ,1„. n'lsil .M.tranop, passes ovor a nmn.lo.l on.in<-i.cc ai.-l ll.cn s .. . s „• . t uluallv hackwanl. Corn-spunclingly. n, ..nler t.. n|s,..'ct t ». <• 1 no tl.;- lu.a.1 shuul.i h. ti,.p.",l somewhat backNvanl I n.l . ; Ti . • irr...i.stan(M.s tl.o sui.criur turl.inat<.(l h..nc is no seen u ; , .• . V ew^ is sonu'tunes visible in conditions of n.arked ■' iValo t e posterior pharyngeal wall. If the patu-nt >s Mtrti ,. »i.,. i..tti.f "k'"' in ranid succession we can some- ;';:;:: :i;.;::;;;;;; r .! li'v ;:/ ti' t.:;:..;/ of the ten., paiati m„sde , lavs around the -hanmlar process of the internal pterygoid ; ., e -he sphenoid l.one. Another n.etho.l sometimes ot value is •^ ; '. ,h nares. ilhiminat.- one with tlu- light, and th.-n look .nto 'tie If the tissiK^s are inflamed we may hrst spray with a .,k < line s. l.tion or with one of adrenalin, and then wait a few iiu„e. ef ore proc-.-ding with the examination. The shrinkage of :; ! whi,.h will take place from th,-se ap-nts w, 1 .>tten clear up ,,l,.,.ure Doints and bring into view lesions previously hull™. Poiterior Rhinoscopy. This requires the use of the ongue de~ in tlTinaniu'r mentione.l below, an.l of the small post- i n rr r. Som.-tinu's th.> ,.atient will have suH.cien control ver tl ongue to place it in the proper position, but this is elv he cL;. Mir oi^ havc> been d<-vis.><l whereby the angle o !; 'elm nt of glass t<. handle can be varie.l at will, but tins is m.t ; :.'. V The gla.ss should first be cleansed, then warme.l ..r a V .. nds ov.-r the gas Hame or some s.mn-.- of hea until the 'ijht which immediately forms over its surface has < -PF-- , lf^,o source of heat is at hand, the gla.ss may be rubb.Ml ^M ^ a lu , ■ soap and then rubbed off with the tmger. .mough of s. p> h n i< l,.ft to prevent the condensation of the breath on the gla^s Still ,.. i i I • s been suggested bv liaurowicz to substitute Or the soap ': .- 'l per cent.^.lution of coM lysol. The mirror is d.ppo.l in 1. obi and then shaken ,lry. l^nough of the lysol fi m will ..;,,";;; the glass to pn-vct condensation of f-^^;^^ vi..w is still ..erfect. Lvsol being a valuable dismf.rtant '""> 'n>lj«-< ,".,.„olic' solution in- the bowl on the examiners table so.lo h„w..v..r is somewhat disagreeable. I'mally. the tnn p.-ratirre of < Inmor should always be tested. a« by contact with the skin of the ''''-n,;!.;';'^' lnananivr.-s having been executed, the mirror is care^ ,„lv passed between the uvula and right faucial pillar, and t en ,;;ne,'l so as to bring its face upward. It is a goo. I }>'=';>• '-J^; .,t least to iH.ise the thinl finger of the right hand at the left corn, i ■ pa ie.Vs mouth; the ,H.siti..n ..f the mirror can then be varun . il Iv rotation of the han.ll.' b.-tw.KM. the thumb an.l hnger ot „ 1 n.l so as t.. bring successiv.-ly int., view the vari.ms por urns , ' th.. nas.,pl,arynx. While as large a mirr.,r ^.1">"''' ^.^^ . ^^ ,S,i. ,,„n>ose as space will permit, n.. one vi.-w inclu.les the entire ,Vt.! be exainin...!. so by the n.tation of the in.rr.ir a composite vi,.w of the entire region can be built up in the examiner s mind. 734 A'OA£' AyV TUUOAT. Atti'iition sliould first Im- fixed u])oii tlic posterior etlpe of the septum in the median line. .No matter liow miieh deviation from tlie normal there may he anteriorly, if is very rare to find the posterior septum »)ther than straiftht in its median line, although there may he localized thiekcnings on either side. These thickenings are generally (ed<'ma- tous in nature, and (luickly disappear under cocaine. Next to he determined is the condition of the posterior extremities of the tur- binates. As compared in color with the anterior they are ajit to ho of a more grayish hue. more va.<cular, and often are lohulated in appearance. The patency of the choanu' should he looked into, and as well the condition of the jiharyngeal tonsil, whether enlarged or not, and whetluT there is any persistence of tlie origin; ,1 median cleft. The edges of the latter are .sometimes adherent, forming a ma.ss known as the "pharyngeal hui-sa." ("oinplete adherence gives the coiuhtion known as cyst of the bursa or Tornwaldt's disease. Lateral rotation of the mirror Aiil bring into view on ,ach .<ide the fos.sa' of Hosenmiiller and the JMistachian cu.shions. The foregoing mameuvre is |)erhaps the mo.^t difficult of all in the examination of the upper air jja.ssages. The least gagging of the p.itient raises the soft palate, and so .shuts off the view. To prevent this we may order a bromide gargle and may give the remedy inter- nally, an ice-wat(T gargle, or may apply a weak cocaine .solution. In some obstinate cases, and generally in young children, a digital oxaminati<m is necessary. For this purpose the head of the patient .should be encircle<l with the left arm. and as he o])ens his mouth the finger thrusts his cheek in lu'tween his molar teeth, thus preventing him from biting. The index finger of the right hand is then passed Fin 174. Br40WDCH While's palate retractor. rapidly behind the soft palate and the various structures j)a'pate({ in the order mentioned above. In ca.se this is not satisfactory, or if a wide .space is n<'eded for in.strumentation for any rea.son, cords m.iy be pa-ssed through the anterior nares. drawn out through the- mouth, and tied over the upper lij). thus drawing the .soft palate forw.ard. X'arious palate retractors have been devised, the one in common u.se being known cts White's. (Fig. ."^74.) While such instruments are occasionally of service, they are not well borne by the majority of patients. When well borne their iLse is gener.Tny innu'ce^sarv. Tr:iiisillumination as >is(>d for the detection of sinus disea.se is doseril)ed in another chapter. mm. METHODS OF EXAMISATIOS. 735 Pbaryngoscopy. Tlic jjositions of oxaniinrr ami patient are as already dcscrilKHl. Tlie lips should Ix- cvcrti'd and search made for (•rui)tioiis, excoriations, and for the general condition of the teeth. Of tongue depressors there is an infinite variety. The model known as Tiirck's is perhaps the most useful. Several sizes, all metal, should Fio. 375. Fig. 876. IJrck's tongue depreMor. ho at hand. For children the model devised by H. I). Chapin has proven of much use to the writer. It can he used in the youngest ii\f;mt. Tiie utmost care should be exerci.sed in keeping ail tongue ,1.1 (lessors surgically cl(>an, and they should be sterilized in boiling water each time they are used. Corrugated surfaces should be avoided in their coastruction, tus they •tre harder to keep clean and offer no advantage. The patient having opened tiic mouth, the depres.sor is placed on the tongue and gentle pressure made directly downward. Force employed cither to draw the tongue forward or to push it backward will surely excite pigging. The |)arts having been thus (•\posed, we note the condition of the mucosa lining the oral cavity, the ton- sils, whether enlarged or not, the con- dition of the lacuna', whether or not tlic faucial pillars are adherent, the ciiiidition of the uvula, soft jjalate, and |ili;irvngeal wall, whether normal or iiiHained and presenting ulcerations, etc. As in the nose, the use of the cotton-carrier and the probe will elicit valuable information. The l:itter also enables us to determine the condition of innervation of the soft palate. Particular attention should be paid to the color of the ))harvngeal mucosa. An ana'inic a})i)earance is suggestive of iiii)erculosis: patchy symmetrical redness may suggest syphilis, esi)e- •pially if aec.)!!-.|)anied by pain without apparent cause: the throats nf users of alcohol in excess are apt to be raw, congested, and intensely irritable, while tobacco habituds present throats with a dry, glazed Cbapln's tongue depressor. 736 yOSE AXl) THROAT. surtacc. Tlic irritability may Iv rcfcrnvl jtartly to tlic gastric rondi- tidii wliicli always aceoinpaaii's to a greater or less extent these two eonditiotis. The examination of the tongue is not eomplete without the use of the large mirror used in laryngoscopy (see helow), hut here it neeii not he passed so far hack. A most careful exi)loration must )>e made of that jHirtioti of the tongue occupied hy the fourth or lingual tonsil, namely, the area hetween the circunivallate papilla' and the epiglottis. Two conditions should he looked for, first, a possihle enlargcTuent of the tonsil itself, which may present either as a cential mass or as l)ilateral masses sejiarated hy a dee]) furrow, or still again as smalli'r ma.s.ses scattered irregularly over the area; second, enlarged veins forming the so-called lingual varix or liemorrhoids of the tongue. These two conditions are often respon- sihl<' for nnich ])harvngeal dysa-sthesia and ohstinate cough. So, also, the glosso-epiglottic fossa' are often the receptacles of foreign hodies. In examining the jjharynx for the latter, palpation should never he omitted, for the finger will often detect the sharp points of fishhones, I'tc. not visihle to the eye. N'arious models of small electric lam])S have heen devised and can he passed directly into the moath, thus giving a hrillitvnt illumination of the entire cavity. Flu. S77. Lari'DKnacopic iind rhinoscopic mlrron. Larjmgoscopy. This re(|uires the use of the larger sizes of mirrors. (Fig. 'M7. 1 The |)osition of examiner and jjatient remaining as hefore, the latter ])rotrud(-s the tongue, which is grasped hy the examiner with a towel, .lajianese pa|)er napkin, or a small S(|uare of gauze. The rjauze is greatly to he preferred to tow(>ls, which may he the carriers of infection, whereas th( gauze can he thrown away after us<>. The left forefinger of the examiner, gtiarded hy the gauze, is laid along the level of the patient's lower teeth just ahov(> the incisors, and the tip of the tongue is held hy the thumb without traction, for the object is not to draw it forw-ird. but to simply jjrevent it from sli|)ping backward. The foregoing ]>reliniinaries accomplished, the large mirror, held as shown in Fig. .'^78. invariably clean.sed, warin(>d, and tested on the skin of the examiner's hand, is intro- dufcd either by a free-hand movement or with the third finger of the right hand resting on the left corner of the patient's mouth, METHODS or HXAMiyAi'ioy. 737 and earned h:iek\v:ird without toiiehinR the parts until the point of junction between the glass and handle rests at the base of the uvula. The latter is then lifted gently upward and backward until it is almost horizontal ami the parts come into view, as seen in FlO. 378. Method of holdiag the laryngeal mirror. Fig. 379, which, however, is partly schematic and represents the positii.n of the cortls in deej) inspiration. The various parts named should be carefully iivspected for the possible presence of foreign bodies, ulcerations, and infiltrations, and the patient directed to tak»' series of short deep inspirations, so as to make the rhyth- iiiieal e.Kcursions of the cords as pronounced as possible. In this way tlieir mobility is the more easily determined. The respiratorj' The larynx In deep ImplraUon. 1. Ungual surfaoe of epIglotUs. i. ''« laryngeal surface. 3. Its I iishion. 4. Pharyngnepigloltlc fold. .) .\ryeplglottic fold. fi. eushlon of epiglottis. 7. Gloseo- <|.iglottic llgmnent. «. Glos-so^plglottic fos.ia. 9. SlnuB pyrlforrais. 10. Posterior line of larynx adjoining iiwiphagus. 11. Interarytenold space. Vl. Arytenoid cartilages surmounted by cartilage* ■f .Santorini. 13. luterarytcnrrfd fold 14. Cartilages of Wrisbtrg, 16. Ventricular bands or false ..nls. li;. True cords. 17, Laryngeal ventricle. IS. Vocal process. 19. Thyroid cartilage 2U. 'riTO-thyrold membrane. ■>!. Cricoid cartilage. L>-.'. Tracheal rings. 23. Spaces between tracheal rings. (Cohen.) <late of the larynx having been thus inspected, the patient is directed lo plioiiate soiiie vowel, as "a" or "e" in high pitch. This act depresses the base of the tongue and raises the soft palate. .\t the >aiiie time as the pitch is raised the whole laryngeal bo.\ rises. In this way the position of the cords in phonation is easily made out. .Fig. .380.) 47 H5^ 738 yosK A so tul it. Flo 4SU. Fbonalion poaltlon of the vocal cords. In the civso of nervous patifiits it is best to introduco and witli- (Iraw tilt' mirror several times l)efore any attempt is made at actual inspection; so, also, some patients do better if they liiemselves are allowed to hold the tonjjue in the gauze napkin. By these devices their confidence is jtained and they understand just what is desired. A point apt to confuse l)ef;imiers is the fact tiiat in the mirror the antero-posterior position of the )iarts is re- vii-<ed, so that the arytenoiil cartilages, for in- stance, seem to he toward the examiner. This fact must especially he home in mind in all instrumentation within the laryn.v. In ([uiet respiration the movements of tiie cords are often not ajjpreciahle, especially to a hegiimrr in larynp)sco|)y. Two other methods of illuminating the interior of the larynx are sometimes used. In one, ;i small electric hull) is attached to the mirror handle in such a way as to project slightly in front of the gliuss. Tii<> latter is used as before, and the examination can lie matle with the physician and patient in any position comfortable for both: in the other the larynx is transiiluiniiiated by a powerful electric light placed externally over the cricoid cartilage, the laryngeal mirror being introduced as l)efore. This method, however, shows little more than lights and shadows, and while it may detect the jjresence of infiltrations anil new-growths, it has never come into general use. All the information it gives can be more accurately determined by other means. Still more recently the X-ray luus been used in a similar manner to locate foreign bodies. For clinical purposes other than this it is no* (^s])ecially serviceable. Some years ago Kirstein, of Berlin, revived what is probably the oldest method of inspecting the larynx, namely, that of direct vision. This he calls autoscopy: jus has been suggested, orthoscopy is, from a mechanical point of view, the more correct term. In this method an endeavor is made to have the axis of the mouth cctntinuons with that of the lower ])harynx and tracliea. This is effected by having the patient bend the u])per part of the body forward, and at the same time throw the head slightly backward. Xo mirror is u.sed, but rather a specially-sha|ie(l tongue de|)res.sor, to which may be attached an electric light. The examiner looks down upon the cords them.selves and not ui)on an image of them. Kirst(>in claims that this method is applicable in about one-half of all jiatients, a statement which is not borni' out by common experience. The method is without ana'sthesia often painful and nM|uires an umisually good control of the parts by the patients themselves. Foreign IxkUcs have been removed with the aiitoscope in positio!\ and. we belie\". sonie tumors, but the instruments require a special shape, and the method has never come into general use. Still another method of practical value is that of Killian. Here IILUUL METHODS OF EXAMlXATJoy. 739 tin- patient stands up or sits witli tiic iiead IxMit forward, wliilc tin- cxarniiicr Ivnccis before liini and lioids tlie haek of the mirror up apiinst tl-e uvula. Tiiis enai)les us to Ret a view not so much of tlie anterior part of tiie larynx, as by the usual method, but to see tlie posterior wall, the |>osterior ends of the cord, and occasionally -lijihtly underneath their surface. The forepoing manipulations have been spoken of as ea.sy of |)er- tormanee. They >;enerally are after a little practice, but occasionally a patient is seen in whom the configuration or irritability of the ])aris renders it impo.ssible to see anything whatever until he has been -ubjected to a course of training. No force should evt>r be used, instruments should be warmed, every movement on the part of the cx.-iminer should be deliberate, and rverything be done to secure the pa- tient's confidence. On the least appear- ance of retching the mirror should be Fio. 3*1 thdra (I il the Nasal spray tubes. and not runserted patient has had full time to rect)ver him- self. Persistent gentleness will finally overcome all ob.stacles and enable one to secure an intelligent view of the laryn- j;ral structures. Douches and Sprayt. In nearly all cases of na.sal disease some method of cleansing is neci-ssary, and a.s this con- stitutes the major part of home treat- ment it deserves detailed consideration. Medicinal agents are a]>()lied to the nasal tnssu'by means of spraj's, douches, etc., or topically by means of the cotton carrier, powder blowers, or in- lialers. For jjurposes of spraying we have at our command the familiar -jiray tubes for office u.se. which may be supplied with air from a reservoir filled either by hand |)ower, hydraulic motor, or electricity, for home use the Bosworth atomizer answers every need. Many I if the various atomizers on the market are objectionable in that they throw too fine a spray. The ordinary toilet atomizer is entirely useless for the treatment of catarrhal states. If the menstruum for ilie medicinal agent is an oil or vaseline, a special form of atomizer i< reciuired, and we have found the one herewith shown (Fig. 384) lo answer every purpose. In ca.se vaseline is used the whole bottle ran b(> immersed in hot water for a minute or two until the contents are li(|iiefied. Of preparations made with water as a ba.«e there is an infinite variety. M the outset it may he said that the faithful and systematic use of any one of a very large number that might be mentioned will ;itVord better results than the desultory employment of some fanciful and new formula. In many cases a .sterilized normal salt solution mim 740 yilHJ-: A.\D THROAT. answers rvcry rciiuirciiKMit. Tlic ailditioii of an alkali is often ad- visable, and we may order the familiar coinbination of eijual i>arts of connnon salt, IncarlHUiate and borate of soda, one teii.s|)o<)nfiil to Air pump and reservoir. Fio. 383. Naaal atomizer. a pint of lukowarni water. The object i.s to prepare a solution which shall have the saline strength and temperature of the nornial blood plasma. There is thus no osmosis through the nasal mucosa from METHODS OF KX.lMIS.lTluy. 741 saliiK' solutions of dilTcrciit densities, and no harm to delicate struc- tures from a sudden elian^e in temperature. Ten grains of the salic- ylate of soda may l)e added to each teaspoonful of the ahove mixture. When distinct antise|)tics are needed there is a wide variety to choose from. Li.sterine and the familiar Seller tablet are perhaps the most widely known. Boroly|>lol htu* given the writer much satisfaction. It may l)e us<'d in the strength of 1 to 5(K). Of all the.se i)reparations one or two teaspoonfuls can lu' used in a ghtss of lukewarm water. .Many more might be mentioned, hut while the writer has no objection against recommending prejiaratioiis made by manufacturing clu-mists who confine their sales to i)hy.sicians and druggists, it is important to iK-ar in mind the limitution.s of this class of remedies. To say that they cure catarrh, as is alleged by some of their promoters, is not true. Thi-y cleanse the na.sal i)assages; if alkaline, they will have a detergent effect and so slightly reduce redundant ti.ssue, bu' they Fio. 3M. Vaseline atomizer. are not strictly curative for other jjrocedures are often nccessarj'. They h.'ive an antiseptic action, r»,Ithougli from the fact that the nares :in> constantlv flushed with bacteria-laden air, it is not possible to maintain ui ii.s;>ptic condition. With the foregoing prejiarations all the jiroblems of intranasal medication, so far as concerns acjucous solutions, can easily be met. Many persons who suffer with hypertrophic rhinitis are fairly coni- fortable so long as they make the nasal toilet once or twice (laily. They become accustomed to this procedure and do not mind it. In iiiaiiy such cases no surgical intervention is at all necessary. The foregoing statements .seem to be a fair exposition of what aciueous <iihitioiis do in the nose. The indefinite claims of many chemists that such solutions will cure catarrh by stimulating the mucous membranes i.s absurd. Most noses, at least in northern climates, are I 'verstimulated already. hi recent yc'ti-s various oily menstrua have become very popular. riiey may often be used with great advantage after the nares are 1 leansed by watery .solutions. They mechanically coat over and protect the delicate tissues, and may also be the carriers of various 742 AOA/i AM) Til IK I AT. Klu. :i)Wi, Mictliriiial .•lR(•Ilt^'. Of tlicsi' oils allxiliiic, l)onz()iii(>l, aii<l cucalyptol may Im- nainril as types. Tlicy may 1m' used citiitT pure, or contain in solution or mixtuir such rctiH'dics as menthol, pine-needle oil, resorcin, eamplior. etc. I'lvery physician has his favorite comhina- tioii; hut here apiin it is to l>e noted that the faithful and sy.stematic use of any one properly indicated will );ive more satisfactory results t'''in the desultory employment of th<' latest pharmaceutical fad. Of course, the f;eneral truth is applicahle here as elsewhere, that a remedy tiiay after a time h)se its ertcct and may pro|)erly he replaced by another, even of the same cla.ss, hut tiie general caution >;iven is justified. It should he added that there is a limit to the .idvantaKes of oily prepa- rations, for if continued too lonji; they are apt to caus<' a dryness of the na.sal mucosa. I'iach case must he consid- ered hy itself and watched to prevent the occurrence of this result. tM'veral other methods of cleansing till- nasal fo.s.sa' are yet to he men- tioned. .\ \cry useful device is that shown in Fig. ."is.^, in which a soft ruh- ber catheter with a nuniherof perfora- tions along its sides is attached to the common rubher hand-hulh. It is filled by suction, and the mode of use is at once apjjreciated by reference to the figure. Again, the nares may be cleansed by the nasal douche (.jxTjited on the jirinciple of the ordinary fountain .syringe. This method has Iiitniiia>Hl iutheter-syrin8:e. Klo 38fi. NiisKi douche fuii. i i the disadv -'tage of being liable to injure the lui.stachian tube and of causing possible middle-ear trouble, M.any pati<iils. however, can use it with safety. During its employment the mouth sliould be held ippeii, the >oll [palale iai>cd, and all ai!em|)is at swallowing, speaking, etc., carefully avoiiled. Xo patient should 1k> allowed to inaugurate the process himself without a previous dem(mstration by till' physician either on himself or on the patient. Many ])hysi- METIIOltS Of KXAMIXATIOS. 743 ciaiis coikU'Iiih thp ni.tli<i.l i-titircly fi«r the rnisoii alx.vc stated An .Hicifut sul)stitut.' is tlic iinsal .lmi<' ]>. Muny "f til"'**' ^^«>l«l m th.' inark.'t arc •■ntiri'ly l<>" s.nall. 'In;- fui. should hav.- a capacity (il at least .V) c.c. The saiii" precautions should i)e ohserved as with the louche. The l.ulk of tluid us.-d in llushii-n the nose in thit* manner ..,.. IMS to he more ethcient than thi- hue sprays. Klu. 3«7. nHnl ruliber («»tn»«l »yrt!ife. For cleansing the nare-< from Ixhind we may use either an atonuzer with a louK curv<>d tip, which the patient learns to l-ii-ss In-hmd t he M.lt palate, or the hard-rul.her postnasal syrin^'c. (I' IR :iSi ) Ihe l-ittcr i~ a most useful instrument for otiice use. It should Im' eare- fullv introduced I.etwe.M. the uvula and the faucial pillar, care beuiR iMken not to injure the soft pahite if the jKitient makes an incautious KiQ. ;iiw. Phllllpn' TOtton holder. ,M.,v.Mnent Tt so divides the stream of fluid hy means of the per- forations in its tip that the .lelieate Eustachian cushions are not in.ured and vet the v<.lum.> of fluid is amply sufhcient to thorouRlih ,.|;.aM<.> the eiitire postnasal space. .\fter using any nasal cleansmp Ihild tlie i.atient should blow the nose gently, always having one "' Tru'li'ppiicati.m of ].igments is generally made with a cotton-carrier. .\ piece of copper win' roughene.l at the end and inserted in a imrror- f 744 yost' .IA7> Til no AT. Imiullc answers t-vcry puriM.sc. ("otlon should Im- krpt in a riTcptai'lf such a.s is shown hrrcwith. (liji. '.iss.) The nose is (irst clfanscil and then dried. The niedieinai ajtent can lie apphed to any special [H-rtion of tissue as desired. The preparations most commonly used are stimulating agents for atrophic comlitions— c. </.. ichthyol for atrophic rhinitis, varied in strennth according to the decree of atrophy, 1h*- Hinninjj with 10 per cent ichthyol in jjlyccrin or alteratives in hyper- trophic conditions. A valuable comhination for the latter purpt»<e consists of iodine j{r. v, pota.-^.-. imlid. ^r. \, in half an ounce of j;lycerin. This is u.si-d in increasinn strengths as the ca.se proj;res.s«>s toward recovery. Another coinhination is made of cocaine pr. xl, lialsam of Peru .Vs, oil of peppermint and ali-ohol aa ."ivj. If the means used for cleansing the nares prove ini-tlicient for the removal of thick crusts, we may employ various kinds of forceps. Knight's dressing force|)s are sutficient for this jjurpose. (Fig. ;{,S<J.) Kill. ist. Knight'i iiual ilrewing rorc«|«. Flo. ;)au. Ntial insntnatnr. For the api)lication of powders the insufflator shown (Fig. 390) will suffice. It is simple in construction, eiusy to keep clean, and answers just as well as the more elaborate powder blowers. MKTUOltS OF EX.IMIXATIOX (4a liiuilly. wp iiiiiy affect the imsal iiiucdta l>y hiiviiiK tlx- |.atn-nt mlialf various n-iuc<lifH, hut fur tliin purpose no s|M'cial a|»paratus is n',|uireil. The »u><lieiiuii apeiit may In- <lrop|M'(l on ••.ttoii phiced ill an onhnary sinelHiiK salts lM)ttle. This hitter is as rooiI sis the more ehiborate inhalers. Oocaine and Suprarenal Extract. The n-medy generally ein- plove.1 for local anusthesia in the now is oocuiTie muriate. It is iv.ciiiunended ih.it the remedy U" kept in the physicians oHice in powi' 'i-s of definite strength, so that one dissolved in a drachm of sterile water will make a 10 per cent . solution which can he diluted as desired, lor the ordinary intranasal operations 10 or even 20 per cent, may lie used. There is doubt as to the necessity of such strengths. Some time may In* gained by their use, as naturally thf stronger the solu- tion the more of the drug absorbed in a given time; but for such procedures as the u.se of the cautery, saw, cutting f-)rceps, snare, etc., a .'» per cent, solution is .strong enough, especially if there Ix? added then to 2 per cent, of sodium sulphate. The latter remedy lavors absoiplion. It is a good plan to spray the nostril first with a _' per cent, solution, and then apj.ly the 5 per cent, on cotton, which >liould remain in contact with the field of operation for at least ten minutes. If the spray Ik- used care should 1m' taken that the amount of drug used does not exceed a safe internal dose, and for that reason the atomizer or sprav tube should 1m> graduated. The cotton i)ledget ^llollld l)es(iupezedsufhciently to prevent dripping, and after its ai)pli- <ation the patient should incline the head slightly forward, so that tiiere can b(> no possible trickling of the overflow into the iiiuscjpharynx. !: this occurs i)haryngeal reHexes are set up and it is difficult to control the i>aiient. IdiosyiuTMsy to cocaitie is one of the things that cannot 1h" foreseen, and the iihysician .should always handle this [lowerful remedy with circumspection. Where constitutional symptoms occur we most commonly note a Iceliiig of constriction about the throat and jKissibly the chest, with |.;i!e face, dilated pupi'.s, and rapid pulse. If these syini)toms sujier- \rii,., all further attempts at operation must for the time be discon- tinued. The patient's clothing should b' loosened alM)Ut the neck :ind chest, he should lie with head low, and a simple stimulant given -e. (/., an matic spirits of ammonia. In seven" cases stn)ng coffee, latTeine, or spirits may 1h' needed. The utmost caution should be .xeipised in placing solutions of the remedy in the patient's own hands. It it is ever necessary it is advisable to keep him in ignorance of 'he nature of what is onlered. The freedom with which cocaine is ^niil by druggists, the familiarity of the laity with it, and the numerous • ases of the cocaine habit which in n-cent years have been n-ported jiv i'ollowing its use in the nose, all render these cautions more than !'^rf'.!!K-(()ry. We know of no fatal c.i.ses fmm the «'ffect of a single iiitranasalapijlication, but there have l)«>en s«'veral narn)w escaiK'S. In view of attendant risks, an effort hius been made to find a sub- -titute for cocaine possessing equal aniEsthetic power, but devoiil of I 11 n ^ II J; fi u 746 yoSlC AM) TlinoAT. iliiimn . \ ai'imis iiiodifictitidiis of (■(icttiiic itscll' liavc Ix'cii sii<rf;('st('(|, ncilal)ly plii'iiatc of cDcainc. wliicli is liifihly (•oiiiiucikIimI hy various (•liniciaiis. It needs to l)e f;iveii in sli^Hitly stnmjier slreiifitii than does tiie cocaine itself. TnijMicocaine. an alkaloid oi)tained tnun .lava cocaine, is another sui)stitnte, Imt has iiover come into jjeneral use. liucaine cX" and 'W') has heen (|uite extensively eni|i!oyed in a t) per cent, solution in the same f;(>iieral way as cocaine. IIolo- caiiie is another remedy of this class. The three latter are undoiiht- edly less fjenerallv ellicient than cocaine, hut accordiiif; to universal experience are freer from toxic efTects. Ignite another class of remedies for the i)uri)o.se of aiuesthesia is represented hy guaiacol. Its etTects, however, are more or less uncer- tain. It may he dissolved in .-ileohol or preferably in olive oil, as the latter metistnunn is less irritatinj;. (iuaiacol does not mix re.adilv with olive oil even the purest. Th(> latter imist first he cleared df its allmminoids, resinoids, and coloring: matters hy zinc sul])liate, and of its fatty acids by ahsoluto alcohol. The followini; mode of preparation has been foimd by exjierience to be a suitable one: To a friven wei>;ht of oil 10 per cent, of dried zinc sulphate (by w(>ight i is added ;uid the mixture heate(l ovei a water-bath for one hour. It is thi'ii filtered, and then 12..') jier cent, 'by weifjht) of absolute alcoiiol is added. Tin n.ixture is frrMiuently shaken for a few davs anil then decanted. The result is a cle.ar limpid fluid with which Jiuaiacol, say .') per cent., mixes re:i<lily. The aiuesthetic action of jiuaiacoj is much slower th.an that of cocaine, as we nmst wait some fifteen iriinutes for absorption to occur. It h;is no adv.antafie over cocaine, but is often a reliable substitute if for any reason the cocaine i> inailmissible. It may be tioted here that the effect of cocaine is greatly prolonf;ed by the subse(|uent apjilication of a 4 \m- cent, watery solution of antiiiyrine. The latter is also an excellent ha'inostatic, but has no direct ana'sthetic etTect. A. \. dray has recently siisigested the followinfr modification in the use (pf cocaine. He employs two solutions. Solution \ consists of cocaine hydrochlorate, 20 per cent, in rectified spirit: solution H ol from l."> to 20 per cent, of eucaine "H" in aniline oil. Some of the euc'iine does not entirely dissolve in this strenjith, and the bottle should be well shaken whenever used. Ten minims from each solu- tion ,ire mixed, the (hiiil speeilily becominj; clear, (iray .admits that this combination is somewhat burninji in the nose and throat, hut claims that this dis.advantasre is more than comi)ensated for by the deeper .ana'sthesia obtained. ;ind es|)ecially by the absence df syiMiitoms of cocaine intoxication. He a<lvises its" application on a strip of jrauze nitlier th.an on cotton. The .|uantity mentioned is i|uite suHicieiit for the |)aiiiless ri'inoval of .septal spurs, cauterization, etc.. .and even f,.r the painle<s excision of toiwijs !n tipjilyin-r tlie remedy theelTe'.l appears to be j:re;itly (Mlhanced if it is jrentiv niijbed for.a few seconds over the field of oper.ation. ( )ne di.sadvanta<'i' noted METHODS OF EXAM ISA TloX. i4; marked fibre of in one or Uvo iiislanccs lias he,>ii tlie effect of tlie aniline oil, wlucli i. a powerful n.nii.uiM.l aiul has eause.l a peetihar l.lueiU'ss ot the lips, siipi.osedly due to the conversion of oxylueniojilohin of the hlood into nietlueniojilohin. . . Si I'UAHKNAi. KxTKACT. Quite a.s valuable n. ii. •« n field as cocaine l',,r aiuesthesia is the su]>rarenal extract, .inli iiu- su. iK.niostatic properties. It acts on the uti tiip^ d jnnsc ul tlic vessel walls, whereas cocaine prodiic it- constii.ig: ijl ettects ihroURli the inedimu of the vasomotor n. "" At first the dried saccharated fjlaiid wa.s employed in powder. A rei>;- (luantity. <-,v twenty firains, mav be a.hh-d to a drachm of sterile water and the n-ultinf: inixture eni|')loved on cotton i)ledpcts. A more satisfactory method is to allow the !nixtun> to stand for twenty-four hours, with fr,..,uent shakliift, and then to filter. The result is a fluid of a port- wine color with an odor like that of pepsin. All th.' foregoing troiibl." lias iK.w b.rn obviated bv the isolation of the active principle known •,.. adrenalin, which in waterv solution makes a colorless lu|Uid, an( i- <old in the streiifith of I to KKM). This may be dilute.l for clinical ,,<,. to even 1 to oOOO. It possesses all the ha-mostatic i)ropenies .,t the crude extract, and is much more agreeable to handle. More- over it can be sterilized at each use without impairment of its lueino- Matic pro|ierties. If then we prejiare our operative field by cleansiiifi. (Irvin'r cocaine application for ten minutes, anil adrenalin ai)i>lica- ti,;,, fur hve minutes more, we have an ana'sthetic, bloodless area or id.'al conditions und.'r which to operate (luickly, safely, and agreeably. Cocaine and adrenahn can al.so be combined m the same solution In the use of this class of remedial agents it must never be for- .'olten that reaction alwavs follows the immediate effect an<l that [here is alwavs subse(|iient rela.xatioii of the vessels, with jiossib e l„anon-ha"'e ' ('onse(|Uentlv the post-oi)erative tamponment should never be neglected. Following the general law that action and reac- tion are e.|ual. though opposite, it might be supiiosed that vascular nl.axation after adrenalin would be dangerously severe. On this point clinical opinions are at variance. Personally, we have never had reason to temper our first enthusiasm over the immense value nf liiis agent in rhinological i)ractice. \.lrenalin taken internallv raises the blood pressure to a m)talile ae.M-ee It Would .seem the remedv par excellence for con.htions o i lit umescent rhinitis, such as occurs in hay fever and other allie( clinical Mates. That it has a >st admirable effect here cannot be d.mbted. li ,iets promi.tlv, do, lot seem to lose its j.ower by frequent repe- iiti,,n .and causes no svstemic disturbance. The claim is made that it. inlern.al a.lministrat'ion is beneficial in hay fever. On thecmitrary it is asserted bv some eminent jilivsiologists that it is decomposed 111 stomach abs.iri.tion, :md that it cannot possibly exert through this ...,i,!,!ab«ut channel anv local effect on the nasal mucosa. On such ,1 point as this we need 'furthiT testhnony. ( )ccasionar.y its n action I- so severe as to cau.se an actual (cdeiua of the mucosa. r48 SUHE ASO TlIliUAT. Epistaxls. llxcluiliuK llu' call's due to accidciytai or surgical trauma, tlic most lfc(jii("iit source of misal lieiiiorrliaf;e is tlic septum. Its anterior mucosa is relatively thin. and i)earin<j,as it does, the im])act of the vjirious irritants from the iiisjjired air, it easily becomes eroded. TIk- liability of this accident is increa.sed if a spur exists at this point. A crust is formed by the ini.vtiire of dust and mucus, and this is carelessly removed by the jjatient, who takes otf some of theei)itlielial covering of the nuicosa, generally by the coimnon habit of '•pickiiij; the no.sc." The moist surface tints left attracts other dust, new crust.s form and are removed, and finally we have a true erosion. Ilemorrha.fje at this site is favored also "by the distribution of the se])tal artery, which is a branch of tlie upper coronary from the facial. Tl-.e erosion prows deeper and (h'e])er, and may finally perforate the septum. After this happens the edfr^.s; ,,f the oi)eninfi generally heal and the liability to bleedin<; disappears. Hlood effused in one nostril may run backward around the posterior edge of the septum and escajM' anteriorly from the other side. Most nose-bleeds cea.se of their own accord. The familiar cold etTusion to the back of the neck acts through the medium of the vasomotor nerves, and checks some of the milder ca.ses. In those coming uiuler the attention of the physician the tii-st thing to do is obviously to locate the bleeding point. The nose should therefore be cleansed with cotton pledgets or by syringing with a warm alkaline (<T common .salt .solution. Hot water alone is .sometimes efficacious. If the bleeding area is small, pressure with a It of gauze may be sufficient. It is well to coat the gauze with a bit ol .soft-rubber tis'sue, so that its removal will not start up the bleeding afresh. The appli- cation of the solid silver .stick often stojjs the hemorrhage instantly, although it is well to protect the area subsequently with a bit of cotton. Instead of the silver we may use chromic acid or the galvanocautery heated to a dull cherry red. If the bleeding comes from a i)oint which we cannot definitely locate, such local measures are inapjili- cal)le, and we may use a syringeful of ])ure hydrogen jieroxide. This generally causes immediate cessation of the "flow, and gives us time in which to arrange more permanent measures. Cocaine and adrenalin solutions are not of much .service in checking bleeding which has been going cm for some titne. for the fkiw prevents proper absori>tion of these remedies. ( )ccasionally, however, adren:din will under these conditions act surprisingly well". W hen it becomes necessary to i)ack t:i- naris a long strip of gnuze not over li.alf an inch in width may be used either drv or dipped in some iistringent .solution. We have found a l.') per 'cent, solution of the aceto-tartrate of alum very valuable for this purpose. It is antiseptic ;is well as .astringent. By means of nasal dressing forceps the end of the strip is laid .aN.ng th'e floor of the no.se, which is then packed in sui-cessivi- loops from ixlow upwani, I'are lieing taken that the 'oops are carried back bey id the bleeding point." In re- moving the gauze it is well to moisten it by allowing it to soak up METUODH OF EXAMIXATIoy. 749 Fio. 391. .mu> wann alkalin.' s,.luti.m; if it , vnnoyvd when hll< Ij • In." n.l.lMT tissue nuMitionoa al...vc is .>si...cially scrv.cca hlo lu-n-. A bli ul ,H.4>in.' ..f the gauze int.. the nostril is t.. he (•(.n.U'nuie.l, us is a so e ;rof iron solutions, which leave a thick n.ag.na, ''-"""S " ^J i ,<,„.ction The antero-posterior jiackinfj is i.-eh the pre erahle plan. u:0 harpen that xL bleeding point is v h-M-k that plugging „f lie posterior nares is calle.l for. The instrument generally sug- .es el L this purpo.se is known as liellocq-s canula. A sinal so nihlxT catheter is just as serviceable and far more likely to be at , O -ith a little vaseline, it is pa.ssed through the nans t fit ap K>ars in tlu- pharynx, whence by means of torc-ps it m . , ou 'through the mouth. To its end is attache.l a cord which i' passed in the mann.T above describe.l. T.. the end ..f the cord hanging out of tlie mouth is fastened a tampon of gauze and then l,y traction on the cord from the nares the tampon is drawn into the mouth, being guided by the finger ui. behind the soft palate into the naso- pharvnx and posterior naris. The manipulation is seen by reference to I'ig. im. The tanijK)n should be so att'liched to the conl that one end of the latt<'r still hangs froin the mouth after the former is in position. This end is fastened to the nasal end, and the l,„,p niav be led over the ear. Such I ampons" should m)t be left in positir.n more than twenty-four hours, owmg to tlic iiossible danger of decomposition of the blood and consecpient septic inva- -^ioii of the I'Aistachian tulx-s. Hofon> their removal is attempted it is well t(' iiislil a little warm oil into the nostril (the patient being recumbent), as it Softens the gauze. The loop is tlien cut piuggiim the iweterior n»res, :ii„l the tampmi removed by traction on . * ♦!,„ i.,tt,.r «n „,„ nu.uth el.d of the cord, the finger being hel. against tho a ter. so as to make the directi.m of traction baekward and downward. \ari..us rubb,>r receptach's, such as con.ioms. etc., have bun ,.e..;;m,nen.led for anteior insertion, to In- filled with -ater wlm-h will ex.Tt elastic pressure, or with cotton. In place of anterur am- pons we mav use the Rernay comi^ressed sponge, as advocate dbj Simpson. Th.-se sponges are made of cotton material, stenl.ze.l, ami an- h.ghlv absorbable, exerting by their expansion hrm compress om ('ha,.i«-H suggests the advisability of attaching by means of co h..li( n .. JX of "iVtta perr-ha on the si.le of the sponge corn>sponding to tlu' blee,rin; point, so as to off.-r a smooth rather than a roughened surface. This facilitates removal without bleeding. 7oO yOSE AM' Tim OAT. Ill cases (if r|)i.> (axis wliicli arc as cirrhosis of tiic liver, etc. II expression o f sol lie visceral lesion we iiiav in connection witli local nieas ures (inler a larffe blister placed over tlie hepatic reirioii. This is of service in alcoholic patients. So al.<o we shouM always examine the condition of tlu> heart, and order whatever may he approjiriate for the individual case. In seven- ca.ses Iwnefit lias heen derived hy temporary ligation of ;i linih, so as to shut off for the time being a portion of the lilood from the gciieral circulation, and so reduce blood pr(>ssure. Removal of Foreign Bodies. These are found more frecpuMitly in chiidicn than in a.dults. and should always be sus|M'cte(| whenever a child has a unilateral nasal discharge. The bodies an- <renerally smooth fjieas. shoe buttons, beads, etc.) and cause no pain. They may become incrusted with lime salts, and .so form true rhinoliths. In attempting removal the naris should first be well illuminated and the location of the body (|et(>rniined. Gentle syrinjiinp; will remove accumulated s(>cretion, and the na.sal probe may V of use if the body is not visible to the eye. Unles-s it is firmly impacted an ordinary dressinii forceps will easily remove it. If it prese'its a smooth surface on which the forceps will not hold, a bent flat wire ma\ be passed over it.;md it can then bescoojied out. If it is impacted the u.se of cocaine and adrenalni .solutions is to lw> commended, as by their action on the surroundiiift tissues the latter contract and" thus loo.sen the foreign body. If the latter is very far back the finger may Ih' passed into the nasopharynx, and there field until the forceps is intro- duced anteriorly. Such a maiKeuvn- jirevents the i)ushing of the body into the na.sopharynx, and will steady it until it is gras|K'd by the forceps. Ordinarily the foregoing man(ruvros can lx> [x^rfnrined without general aiup.sthesia, but 'f the patient is unrul;- and the exact location of the body cannot lie de;erniined, it is advisable to give a few whifTs of chloroform. The extraction of rhinoliths re(|uires the eniploy- iiient of .some kind of crashing forceps, and the mass is then removed piecemeal. In all instances no after-treatment is necessary lieyond simjile cleansing for a day or two. With loo.se l)odies in "the nares of very young children a blast of air through the patent nostril from a Politzer bag may exjiel the offending mass. Acid Caustics. While all the caustic acids have at times been ii-sed in the nose, we now generally confine ourselves to chromic, monochloracetic and trichloracetic acids. All should Ix' preceded by local aiueslhesia. and an> [ireferably employed fused on one side of the end of a flattene.l prolw. Care should Tm- taken that tlieir action i.s acpunitely confined to the spot desired, and the n>st of the no.se may be protected by pledgets of cotton or by the us<> of sfiecial .specula. Mosworth has clearly set forth the fact tliat the object of this class of remedie.-. is "not to destroy ti.ssue. but to constrict the blocMJ- ves,sels. diinini.>;h nutrition, .'ukI thus counteract hypertropt>y." In the latter st.ate it is the deeper layers of the mucosa that an> affected. METHODS OF EXAMISATIOy. 751 ('(.nso(iuontly any inc T(>ly siiporficial caustic destroys only the cpi- ih( •Ihl lavcr, while not at all reacliiiiK the true s(>at of the troui.l. 1 in the nose for one of two jjurpos In jieneral, caustic.! are uset i'it hereto (lest r.iv the vitality ..f the stump or pedicle of a new-g; -wth to reduce hypertropiiu'd tissues. as much !is possible the ith adrenalin, and iir intlannnatory excrescence, or I'licrefore the i)referal)le plan is to U sen inhination ll'i,",'\o'hii'Hr'd<.wii"tiio Tissue thus constrinjied. I'or this purpose ..Inomic acid is an ideal aR.-nt. It acts l.y oxi.lation on the tissues, .,„d is self-limited in its effects in that it becomes m tlie very process of oxidation of organic tissue onverted int.. ox.de ot chronnum, which is insoluble an.l inert. It ctui be easily hand e.l, but must be kept from the air, for it readily deli(,uesces. It may be drawn m lines MloiiL' the turbinal borders, or maybe used in the mgenious manner .u.r.r,.sted bv M. A. Cloldstein, who inserts a fine trocar and canula intT the turbinate.1 tis.sue parallel to the surface then withdraws ,!„. trocar ami u.serts a probe on which is the chromic ;icid, and which projects slightlv l)eyond the end ol the canula The whole apparatus is then withdrawn, making a continuous submucous cau- terization. . . , 1 f .1 ,.,„ The monochloracetic and trichloracetic acids are used for t ><> sa u „ur|...ses as the chromic, the monochloracetic acid being slightly the 'tionger. Thev niav be used on probes or cot ton -earners. A special advantage of these two agents is that after application they absorb uinisture from the air. They therefore act as a nu.i.st protective ,|ressing on the area, leaving, after their slough is detache. , a smooth surface Nitric acid is now rarely used in the nose, and the sanu may be said of glacial acetic acid, though the latter makes an excel- lent application to the stump of warty growths. Intranasal Adhesions. Thes(> may aris«- from processes of disease, hut more commonlv follow ill-adviseil or carelessly performed oi.era- lions within the nasiU chambers, whereby the opposing ^"rfaces be- ,.,„..,- bare.! and are not kept .separated until healing ..ccurs on bot .ides The adh.'sion mav be small or large, soft or dense. It can b.. easily severed, but will quickly reform. An endeavor shoul. I be made to not merelv cut through the a.lhesion band, but to actuall> remove a definite Width of it. For this purpose some iorm o sc >- .ors with double cutting edges may lie used. After .sectu n a ui eheeking of bleeding a thin spatula of gutta iktcIw may be sli.. between the raw surfaces, or gr(>ased tampons may 1k^ applied or drv tampons surrounde.l bv soft rubber ti.ssue. The dressing should heehan.i-d dailv and every can> b<' taken to keep the surfaces apart until thev have"l)ecome coate.l with epithelium. It h.as been recom- mended "to i^rartise systematic friction of the adhesions by means of a cHon-carrier, the claim 1 >ing niade that it is thereby possible to thin out til., a.lhesion-ban.i uid gradually cause s' t" '^^f]Wf without caus--.g any l^reach of surface. (Hhers have «"SS<'sted the a.lvisabilitv of passing a wire loop around the band and r 'tally 752 yu!ii: Aso riiuoAT. tiglitcning it from day to day, so as to slf)\vly rut throiijih the adho- sioii. Still others have iMiiploycd silk threads in the same luaime;- as for separatiiif; adhesions of tiiifjers whieli hav(> become wehhed from a hum. The obvious lesson is to prevent as far as possibl(> the orcurronre of the condition. This can be done by the use of some sort of shield speculum, so that when the acid, cautery tip, or cutting instrument is applied to the tissues the opposiii}; areas shall Ije pro- tected from injury. Electrolysis. Electrolysis in tlie nose is practically confined to the removal of .septal spurs and deviations, rareh- of certain tumors. In the former class of ca.ses it is of value only where the sejttal excre.s- <'ence is cartilaginous. We do not feel disposed to admit the truth of tiie claim that true bone is destroyed by electrolysis, although this result follows under certain conditions — electro-cauterization. The principli ' of ai)])lication of electrolysis are the same with organic as with inorganic substances, namely, the evolution of oxygen from the positive and of hydrogen from the negative pole. The mere fact of organization of tissue does not interfere with electro-chemical decom- position. True --artilage is destitute of nerves, and therefore of sensibility. It is e(iually devoid of bloodvessels, (>xcept for certain loops which here and there run in from the jjerichondrium. It is nourished by imbibition from the mitritive supply of the neighboring part.s. In the nose it is covered by a mucosa which is both higlily va.scular and highly sensitive. .Most of the outgrowths removable by elec- trolysis have nere a covering of thickened mucosa and an increase of cartilaginous elements, a true hyiK-rplasia. In cases of long standing there is generally, in adilitioi;, an infiltration of lime salts and sometimes at the base of the iniiss, tnie bone. For electrolysis we may employ by means of modern apparatus either the street current .>i the usual galvanic battery. If the latter is usecl it should have at least thirty elements and a steady deliverv of current. \ rheostat and ampere metre are rc(|uire,l, and also double needles, for the bipolar met hod has been found i)referable to the monopolar: that is, both positive and negative needles are to be in.serted into the tissue to he removed. The needles may be of either steel, iridoplatinum, or gold. Steel needles are cheap, firm, and p(>netrate easily. The needle ordinarily used by sailmakers is recoimnended on account of convenient size, finish, and esjM'cially fineness of point. Its diameter varies from 0..") nun. to I..") mm., and length from 7 to 10 cm. The instrunuMit makers furnish a mon' delicate apparatus, but these nee(lles in .small gutta percha handles comiected with the battery wires answer every purpose. The aver- age seance should not exceed fifteen minutes. Cocaine an;esthesia should lie employed, though f!;irel asserts that there is only insic- nificant pain when the needles pierce the nuicosa, and none at all when they finally rest in the area of .selection. This, however, has not been the writer's exfx'rience. Not more than 30 millianipdres ilETUODS OF EXAMJyA'J'Ioy. ToJ :iri' necossiirv, and 1") jiciu-rallv siiHicc. The rheostat slioulil l)c |ilacc>l ill tlx" niaxiiimm of rcsistaiicr, and the latter slowly diiniiiislu'd until the proper reading is observed on the ampere meter. The aim is I,, detaeh the onViKUnK mass in a plane parallel to the normal plane of the sei)tum. , , • ■ i \ horie-acid wash will sutHce to wash away the detritus ahout the needle holes, and its use should !)e followed by the insufflation of H.me aiitisc])tic powder (aristol, nosophen, europhen. ete.). An rschar is formed whieh eomcs away in the course of eipht or ten Several weeks (>lapse before the parts finally mould down into what will be their eventual shape. Small exerescences about the line of seetion ean l)e triminetl with the Raivaiiocautery. The advantages of this method are the following: it is blootllesf', the held of o!)eration can l)e kept in view throughout the entire (.IM-ration: there is no inflammatory reaction; no possibility of after- intrana.sal adhesion.s or deformity: it is an alternative in certain cases of marked thickening associated with deviation of the septum where an operation for straightening is deemed likely to prove unsatis- fictorv and it will often l)e ix-rmitted when a cuttuig operation would l',e irfused bv the patient. Its disadvantages are the somewhat elaborate ajMiaratus reijuired, the time necessary, ami the fact tl.-t it is not api)lical)le to bonv growths. In general it may l)e sau that th(> results eHVcted bv electrolysis can be more easily secured bv other methods. The use of sujirarenal extract has robbed mtra- iKisal operations of their greatest disadvantage. These can now be made perfectlv bloodless. Furthermore, perforations of the .septum l,v electrolvsi.s (no matter how carefully used) are not beyond the i,ounds of possibility. However, it is a resource at our comnand when for anv reason a cutting operation is not jM-rmitted. MetaUic Eectrolysis. I'nder certain conditions it is possil^le to introduce din'ctlv into the tissues the salts of certain metals, espe- cially the salts of copi)er, although zinc and iron have also been used. Ihe'inode of eniplovmeiit consists simjjly in makuig the positive pole .,! the metal to be used. This is applied directly to the mucous sur- t:.ce to be treated, while the negative may b' place.l on the back ot (lie neck The salt formed in the tissue by the passage of the current H an oxvchloride. The advantages claimed for this method are, first that the salts can be carried by diffusicm to the most obscure •md inaccessible parts; .seeoml, that these na.scent salts are much more active than in their usual chemical combination; and. third, that as the pathological conchtions usually lie deeply under the mucous membrane thev can lie reached by the imiiregnation of the tissues with the metallic salt far better than when it is simply ajiphed to the mucous surface. The particular line of cases which seem to l)e lieiiehted are hypertrophic rhinitis, excessive secrelion of th( nasal mucosa, irritable cough due to catarrh of the pharynx or larynx, and epistaxis with excoriations, etc. 4S 04 yOSt AXn TUllOAT. f f Massage. (Vrtain intranasal (•(tn( lit ions arc jircatly honctitcil hy the a|i|)l;cati(in of the (icncral principles of niassajrc inoditicvj to nicct local anatomical cundilioiis. Its general result here as elsewhere is t> restore the circulation to its normal state and to remo\-e the effects if disturlK'd circulatory activity. In atropine rhinitis massage leads to an increased biooil supply, and thus to a restoration of the normal in'riMiasal moisture. In hypertrophic conditions it .seems to have an alterative etTect, leading to the removal of the products of nutritive hyperactivity. Certain etTects may follow also from a n-fle.v inllueiice on more distant structures. I'ndouhtedly the credit of introducing this therapy into rhinnlogy heloiigs to Hraun, of Trieste, who, at the Merlin ("onj;res.s of 1S!M), gave an ex])osition of his method ami its results after an extensive clinical e.xperience. Tliis author unfortunately surrounds the subject witii a certain amount of difficulty l)y stating that tlie projK'r application of ma.ssago in this locality i.s very hard to ac(|uire. Then' is a gen- oral insistence that the movements of the ma.s.seur shall lie n-gular anil of e(|ual intensity, otherwise infiannnatory conditions ^^' made worse ratiier than In'tter. The two main methods of intrana.sa' massage are stroiiing and vil)ration. In the former simple prolM's wound at the end with cotton are used. They sliould Im" stiff enough not to liend under pressure, and the cotton should l)e firmly wound and carried a short distance down the stem. Cocaine m weak .solution is first ap[)lie(l to the parts, and th(\v are then ruhhed witii the prol>es dipjied in whatever medicated solution is indicated. Seme advise the api)lication of a lubricant previous to massage. Hraun suggests mentholated vaseline, I'enivian i)alsam, camphor, menthol, etc. .\ series of ])robes should !h' |)repared, so that each portion of the nasal mucosa shall receive its (lue sliare of tlie topical agent. Tiie duration of friction of eacli area sliould vary from a few seconds to a inimite. It is ot)vious that the old leathery nuico.sa of a marked ca.se of atrophic rliinitis, esiwcially one .attended witii crust formation and oza-na, will nvpiire a more forcitile and per- sistent friction tlian a case of hyperpla.stic deposit where a restoration of circulation is . !1 that is desireii. If the niatKcuvre is properly executed the patient will cxim rienco no pain nor will there l)e any liemorrhage. In addition to tlie common hyi)ertro])liic conditions and atrophic conditions, it may be added that some cases of the liay-fever tyjx^ wliich jiresent distinct local sjiots of hyiiera-stliesia iiave lieen l)eiie- fited by friction over these areas. Such a treatment, if carried out in the intervals between attacks, has seemed to less<>n the preilis- position of the patient to the disea.se. Tt seem?-- p.'iradoxicnl to prescribe the s.tuio fre;itinent for condi- tions so opposite as hypertrophy and atrophy. Tlio answer is that vari.atioti of duration ami intensity of massage makes of it really two dilTerent agents so f.ar as its effects are concerned, and that METHODS OF EXAMIXATIOS <0U clinical pxporionrp juslifics the statonionts nuulu as to its curativr clTccts in Ixitii tlx'sc conditions. Ccrtai" advantages of tlio method ut once suggest themselves. .No cumi crsome apparatus v.- re<|uired. It is all on the examiner's talile. The treatment can Im- definit<'ly localized, and by a suitable bending of the probe every part of the na.sal cavity can Ik- reached The i)atient bears the treatment well, and then- is an entire absence of anvthing calculated to terrify the nervous. In "ad.lition to the stroking or friction method we have the vibration method, which is, |;erhaps the one mor<' (ommonly us(mI. The fatigue attendant upon its employment has le.i t>> the application of electricity as the moving force of the proln-, and several in.struments have In-en devised for this purpose'. That of Freudenthal is the most practi- cable. The immber of vibrations can be regulated up to nearly S()0() per mimite. This is, of course, a far greater number than can Ix- reached by the manual method. Some of the statements of the PIQ. S92. Freudentbal'B electric vibrator. laitidity of the vibrations of the arm muscles seem to the writer little siiort of absurd. By the electric vibrator the strength of the vibrations can lx> delicately adjusted. Seances should not be held iift<'ner than two or three times weekly. Still another and ingenious method may be mentioned, thi>t of Dioiiisio, who inserts into the nasal passages a flexible rubber bug, which is then inflated with air. The bag is connected with a chamber ill which, by means of a piston-action and cylinder, there is a rajnd increase and decrease of air pK«ssure. This is obviously transmitted tluinigh the tube to the bag. The method is an easy one loT the pliysiciiin, ami several sets of tubes may be connected with the pressure ciiamber, and thus several patients treated at the same time. The strength !ind fre(iuency of the pressure variations can be regulated to a nicety. The sen.s'ation experienced by the patient is likened to a tremor of the parts treated. Dionisio claims that in this method the vibrations are homogeneous in character and are not shocks. « 750 yoSE A.\l> TlinoAT. Septal Spars and Deviations. Tlic iiMsai septum i:^ nin'ly iHrfcctly stiaiuht, :illliiii|i;li in tlif iiiiijnrity of cases the ilcpal'l lire in tliis icspcct friim the nnrinal dues rmt call fur (i|M'rativ(' iiitcrvi'iitinn. If fur any cause the fartilaninous portion of the scpliiin IxTonics markedly deviated, the turbinates on the side liecomin}; uiuisually patent eiilarjic so as to functionally compensate, as it wen', for tiie lessened function of those on the occluded siile. It is a common e\|HTieiice, iiowever, that as soon as the se|>tum is strai>;htened, (s|M'cially in younj; patients, the turliinates resume their normal size. Our first duty then is to put the septinn in a normal position, and the turbinates will thereafter <;enerally take care of themselves. For the removal of mere excrescences, such as the ordin.ary crests, ridpes, spurs, etc., wo have at our disposal various knives, the saw, and the trephine. Some of thes(> excrescences are made up principally of mucosa, and can hi- n-nioved by the cautery, (ireat care must Im' exercised in the ap|)lication of this powerful agent to the cartilage itself. Reaction is apt to be severe, and if much cartilage has been attacked there may Im' a necrosis around the operative field. These outgrowths reiniiring removal may contain lime salts, ami even true bone and the choice of instruments is conditioned on the finding of the composition of the part in each individual case. The |)robe may assist us li(>re. Tlie nostril should be cl^ ui and then cocainized, .\drenalin may be applied subsequently to or along with cocaine. It is advis- able to aiuesthetize a ticM consider- ably larger than the sjKit to lie ope- rated upon, so that the cont.act of instruments with surrounding parts does not aiuioy the I'atient. Simple cartilaginous growths call !«• removed with a stout scalpel having ;i thick short l)lade, or with in instrument constructed on the principle of the s]iokeshave. The objection to many instruments of the latter c!as.s is tliat they are difHcult to engage in the substance of the growth, and do little more than scrape off the mucosa. Where the growth is larger and the use of the knife is iisappiicable we may use a gouge, chisel, or saw. The latter is in most common use, and the model of Hosworth meets every mechanical need. (Fig. 394.) It.s bla<ic is a.- thin a.> pn.ssihlc con- sistent with strength, ()ne-«'ighth of an inch wide, five inches long, with a cutting-edge of three inches, with thirty teeth to the inch, each tooth being an exact e(iuiiateral triangle, with no 'To.ss-cut or Nichols* spokeshave knife. MJCTIKJJJS or AAM.V/.V.1I70A'. 767 set to tlic tci'tli. iIk' IimikIIc Ix'iiijt thrrc inches Iomr aiul <.l suMici.'nt .iz.. til lM'C'a.<ilv nn. -x-il 1)V til.' liiiiul. Tlic cutting l)lii.lc iimy iM-.-itlicr upward i.r (l.'.wiiwa'rd. Tin- ..l.j.-cl is t.i rciiiov.' ti.c prnj.Tliuii in -.well a niainuT as to leave the side of the s-ptun- smooth. \\ liere the projeetioii slo|M's downward toward th.' nasa. tioor it may !«• necessary to start with the saw l.lade nearly horizontal, uradually 1 1, rninc It toward the vertical as the plane of the septum IS approached. In cases in which it is iiniMwsibk- to p-t the l.lade ot the saw past Flu. 394. Boavrorth'i ntMl utw. the projection we mav mi'ke a channel at tlie bottom by the romovnl ,,| a core of tissue with the tn'phine in thi' manner to be mentione(.. •I'lirouj;!! the channel thus maile the saw is thrust, and by .uttmp ,ither outward or upward, as th.' cas<- re.|uin>. th<- lU'cessary amount of tis-^ue is removed. The saw ..[M'r.ation is al.so api)licaNe to Ix.iiy .uitjrrowths from the ).osterior portion of the seinuin. The use of adrenalin makes all those i)roce(liires i)ractically bloodless. Nual burn and trephines. .Vuother method of removal of septal outgrowths is by means of Inirrs and trephines. (Fig. 395.) These are inserted m a flexible hand-shaft, and power is supplied either from the dental engme, i' 758 AO.SA' AM> Til IK) AT (Irivfii hy the foot, or by ;iti I'lcrlric motor, Tlic itn'p:initioii of the ticlil is tlic same a.-* hcforc. The |iortioii-; of tis>iic rcmo\i'i| an' in llif form of cNliiKlrical cores, ami tlic iionli'rs of tlic cut must Ik- triiiimcil hy scissors or some similar instrument. The fact that the surfiwe is not left ;ts smooth us with the saw ieails many to prefer the latter instrument. After any of ilie forecoinj; operations the riaris shouhl Im' Husheil out with some antiseptic solution ami thoroujihiy dricil. ,S>me anti- septic p(>wi|er shoulil then Im' Mown in iiristoi, europhi'ii. nosophcn, etc.). Opinions ilitTer as to the ailvisaliility of packing with jiauze or inserting plujts of any kimi, with a view to the prevention of hemorrhage. In any event the patient must keep i|uiet for the iirst few hours. Then- is houiul to Im' a vascular reaction as the effects of till" cocaine and ailre!i;ilin pass off, ami if this he too active hieeiliii); may occur. Some physicians pve their patients ji solution of ;iilre- iialin. with ilin-ctions to use it ;is a matter of routine every tew hours: others prefer to insert tam|M)iis, its mentioned in the para^rraphs on nose-hleed. These rem.ain in position twenty-four hours, are care- fully removeil, and not replaced. It is advisahle for the patient to Hush the strils two or three times ( lailv, an( 1 wl lenevi r he IS m the o|)en air to wear a loose plu)i of antiseptic cotton just within the vestihule. This sifts out the dust frotii the inspired air, and thus furthers sjM'edy liealin;i. The nmco.sa is .'is a rule ((uickly restored. In all the forepoinjr fri'-at can- should he taken not to hreak throupli into the patent nostril. While no special harm n'sults from this accident (certainly none from a pliysio|oj;ical point of view), a septal perforation is an amioyance to the |)atient. I'ortunately most per- forations made hy surgical trauma lical kindly, pro\ ided they are kept clean. During the actual time of operation a clo.se watch sliould Im' kept on the nnuo.sa of the sound side, .so that the .'iccideiit alluded to may lie avoideil. It has Iweii I'ecommended to inject sterile w:iter under the mucosa on the sound side, correspondinj; to the o|K'rative field in the occluded nostril, so as to lift it up from the c;irti!a);c for the time l)eiii<r, and thus lessen its danger of perf'iratioii. It has Im-cii found that as the water is ahsorhed the tissues return to their normal condition. Patients shoulil 1m' cautiotied not to attemjit to remove the crusts which form over a healing area, as they will event- ually separate of their own accord. Premature removal delays healiiifr. There are some ca.ses of septal deformity in whic! thi' estahlish- ment of ;i jiennanent jx-rforation has relieved the .sy!h|)toms of which the ])atient has complained, hut the; v very few ca.ses, if any, in which the ohstruction to the hreathwa. caimot lie otherwi.se removed. I'^ven if the perforation is ]iurpo.se|y made, healinp of the edpes is conditioned iii>.)n tlip ahsr-iice .:[ any dyscra.sia. f-an-fu! afii-r-treat- nient, iind a sufficient intelli<;ence on the part of the p.atieiit to (;uar- antee that the wound will Ih> protected from nuchamcal irrita- tion. MtynioDS of KXAMISMin.W 759 Straightening of the Masai Septum Aftrr tilt' rrllinval of luc;il ,.X,T.sn.ncrs tlir SfptUni in;iV still hr LoWt-.l ..V.T t.. ..Iir :^hI.- Mll.l „.,,uin" slraiKlil.'iiinn m, ;. wl.nlc. Whil.- many .li»T.T.'nt ..,HTaliuhs Invc Iktii .l.'vis.-.! with til.' latt.r .'11.1 in view, that kn-.wn as tli.' \<(\i .,|M'.'ati..ti is lUHloul.t.'.lly a|.|.liraMc t.. iiior.- ca.s.'s ihan is any uth.T Sudp'stcMl l.v Dr. M. .1. As,-h s.,.m.- ten y.ars aj:-. -r ni-.r... Kiii. ;i3«. Kl'i. w. rui. 3*. Fiu. ;iiw. Plo 40O. Aich'i! «et of septam liwtniment*. it has hmi givon a nmst faithful trial an.l has fulfilio.l all tho noressary n-<niir."nionts for restorii.K pat.'ucy to both nostrils llu; mstru- „„!..t. -irp h<"-..vvith shown an.l as well th.- tubular splints t..r inser- tion in tho n..s.>. Thon> an^ vari..us nio.l.'ls of the latter, soin.- p.'i- f..ratc.l an.l some solid. The pcrf..rations have never seeni.'.l to the writ.T t.. offer anv advantage except that they make the splmt r" 760 SOUE AXO TIIHOAT. «iiii('\vli;it liplit(>r in wcifiht. Cork splints have Ih'cii iisod in- Mcrriis and (itlicrs. Hut no matter wliat particular splint is iiscil it is to l)c r<'ini'inl)cr('(l that in each case the splint is to Iw fitted to the nostril, and not the nostril to the sjjjint. Hence, we may be ohlifjed to shorten, rouml off corners, etc., so as to ensure a proper tittiiifr. The Asch operation reijuires fieneral ana-sthesia. but nitrous oxide will ;niswer. Adrenalin solution should be thoroufihly applied to both sides of the sejitum previous to the administration of the ana's- thetic. although .s(>vere bleeding is unconnnon. and is checked by the gentle pressure of the .splint. If any adhe- Fio. 401. sions exist between the .septum and the tur- binates they are broken up by the use of the curved gouge. The ste|)s of the operation are thus described: Tiie blunt blade of the ::> i.ssor> is inserted into the obstructed nostril, and the cutting l)lade into the other. A crucial in- cision is then made, the scissors being with- drawn for change of position in the si-cond cut a- near as possible at right angles at the point Asrhv uttsai sriiute. of greatest convexity. The .same instrument may be used for both incisions, although two instruments are here shown. (Figs. '.MS and .{97.) The forefinger is then inserted into the obstructed nostril, the segments made by the incision are pushed into the ojjposite nostril, and the pressure con- timied until they are thoroughly broken up at their base and t.. resiliency of the se|)tum destroyed. On this ixnnt dciifiuh thi success of the openitiiin. jitr unless the jraeture of these seiimenis is nssured, the resilieiiei/ «/ the eartiliKje irill not he orercome. and the i>}>er(iiiim will fail. The septum is then to be str;iightene<l with the f1at-t)Iaded forcei)s. The nostril is then wiped out and the tubular .sjjlint inserted on each side. These support the septal fragments and. as stated, tend to prevent secomlary hemorrhage. The jiatient should Ih' kept in bed for two or three days, iced cloths being l.-iid over the nose for the relief of pain and swelling. Jioth sides may be sprayed out every two or three hours with an antiseptic .solution, .\fter twenty- four hours the sjilint on the originally patent side is removed and not replaced. The nostril is cleansed and an antiseptic powder insulHated. Ii is well for the |)atient to wear a loose phii; of cot- ton in this side for a d;iy or two. The tube on the originally ocluiled side may be allowe<l to remain in position for another day, when it is removeil, the nostril cleansed and dusted, and the tnlie ri'iitnrrd. it acts, as s.aid. as a splint for the se])tum, and should now be removed and cleansed daily for a week, then on alternate lays, and at lengthi'ning intervals until healing is complete. If it is properly htte(| it is worn without pain, and is not visible. The patient if not too young can bo taught to attend to the latter niaiiijiiilatiwiis liim.srlf. The tube nuist be of such size that it can be inserted without any pre.s,sure, el.se it will gradually Ijo crowded METHODS Of EXAMINATIOX. rei out l)y the l)Ut i)arti;illy success tissues l)oliinil, ami the operation will i)e at the most (•OMSK .;ful. It should he worn for five or six weeks. J 1k> seen daily by the sur«;eon, this time may be lerably shortened. Small" bits of graiiulati(m tissue in the nos- lUioii or removal with forceps, in order to If the patient can I care should 1h' taken to so iril mayreciuire cautenz leave a perfectlv smooth surface, an( make the crucial incisions that the tube will rest on the Hoor of the nose. .\nother oiM-ration, devised by A. W. Watson, is especially appli- cable to those cases in which the deviation is marked but low down, so that it is nnpo.ssible to brinp the lower fragment into place. In- stead of cutting out an ellii)tical piece, iis is recommended by some authors. Watson makes a bevelled incision, the edge of the knife licing directed ujjward and to.ward the opjxisite side and carried liirough the cartilage, but not the mucosa, of the opposite side. The incision is made on the cn'st of the deviation. If a vertical deviation exists at the same time a triaiigular-shai)ed portion with the ajK'x upiH-rmost must 1«^ removed. The ui)iM'r portion in the horizimtal iiiiision is ])ressed over toward the other side, where it hooks on to tiie lower, and is thus held in i)lace. The projecting base can after- ward be removed. . (ilea.son has devised a procedure, thus describctl by him: The licid of operation is cocainized and exposed by a self-retaining sjiecuium. A thin .saw is introduced along the floor of the septum heiieath the deviation, the sawing is begun in a horizontal direction until the blade has jH'netrated somewhat deeply into the tis.siies, when the direction of sawing is rajmlly changed from horizontal to iH'arly vertical. It is of the utmost importance that the saw .should be licld "exactlv parallel to the .septum in order that the cut shall be ;iroiiiid and" not through any part of the deviation. The length of the vertical crura is then (juickly increased by means of a small bistoury curveil on its Hal. and the Hap is thru.-t through the hole in the sejjtum vith the forefinger. While the Hnger is still in th(> nares it is carried up along the anterior :ni(l i)<)sterior crura, in order to Ih" certian that the edg<' of the flap has coiiiplct.'lv cleared them, and the neck of the Hap is then sharply bent, h is not iiecessarv to ilenude the edges that are in contact, as the pressure results in necrosis at least of the superficial epithelial layer nl the mucosa, .'liter which the i)arts unite. The sjiecial claim ma<le tnr this operation is that it destroys the resiliency of the Hap (a condi- fi.iM of success in any oi)erati(m) at its neck, for it is at this point, and practically here alone, that resiliency i ■ active, that is, at th.e neck if a comparatively long, narrow tongue, and hence has a powerful leverage to overcome before it can thrust the inferior edge of the fli.p l>ack through the septum. The neck should be bent to nearly a right iiligle. The Pin Operation. One of the earliiT oj-.f-nttions is known as the pill o|ieration, because after the septum is crushed or fractured by the f 702 SOtiE ASD TUUO.IT. A(l:iiiis or Stoclc str'.tatc l'nrcc])s, causiiifi iiiulti|ilf incisions, a pin is used to ri'taiii tlic I'rafiincnts in |)laci' until licalinj;. 'I'lic pin is inscrtcil from the concave siilc of the septum just l)ack of its anterior horder, passed diafionally throufrli to t lie convex side, peiietratitif; the latter, tluMi across the vertical incision failher on into the tissues back into the sejitum. much as two pieces of cloth are pinned to>;ether edfje to edjre. It shoulil he puslied home far enough to bring the head to lie on the septum at the \><nM of entrance It may he covered by a bit of rubber tubing, and care must be taken that it d(M's not become lost in tiie tissues during the iiifianmiatory swelling of the latter. It should be n'lnoved in tin- course of thr(>e or four weeks. In the nu'autiine iiotii nostrils are free for breathing, and should be kept scrupulously clean by mild antiseptic washes. Sterilized normal salt solution will answer every purpose. If the bony se|)tum has been fractured, the pin, of course, will not jM-netrate it, and so the former must be kept in position by pads of antiseptic gauze renewed freciuently for a week or ten days. In addition to the foiegoing varieties of septal deflections and out- growths there are others which cannot well be brought under any well-de(ined category. In some the mucosa may be di.s.sected off from the cartilage, enough of the latt<'r removed to restore |)atency to the nostril, and the nuicosa replaced, being held in position by fine sutures. The dis.section of the nuicosa is, liwwever, rather a ditficult matter. Still again, various punch-fore jis have Ihm'ii devised, such as the one here figured. With such instruments the sei)tum is frae- SU'liMte iniiich-fc)n'eii(* tured, the resiliency of the fragments destroyi-d, and the parts held in |)ositi<in by various splints or tampons. In such ojM'rations general aiKcsthesia is necessary, with preceiling apjilications of adrenalin. Forward Prolongation of the Septum. Occasion.illy the septum seems to have such an .antero-posti'rior measurement that it cannot be accommodated within the bony framework designeil for it. As a conse(|uenci' one end .appears to bend forward at one anterior naris and shows |)rominently, pushing the lleshy colunma to the other side. Till- obvious syrii|itoms due tn this condition are those arising from moderate nasal obstruction, aggravated by a tendency of the ahe to collapse, excoriations from lodgement of dust, etc., on the projecting end of the septum, and dislodgement by the linger of theiiatient, lead- ing to cracks and fissures. The nose seems distorted. es|)ecialiy on its tij). I'or the relief of the condition, Farlow, who has |)aid sp.ecial 3IETU0Df> OF EXAMISATIoy. Ids Httcntitm to these cjis) s, iidvises tlie removal of enough of tlie anterior (■ml <if the eartihi<:e to relieve the tension under the skin, and in ease ilie eartihige is ocrhKled to cut otT enough to allow free respiration, lie thus deserihes the jiroeedure: An ineision should lie nia^le through I he mucous memhrane parallel with the free edge of the septum and near enough to it so that the perichondrium can be stri])ped back troni the cartilage on both sides through one incision. Wheti the car- tilage has been bared it is trinnned ur.til sufficient tissue has been reuMived to relieve jiressure. If the se|)tum deviates higher up in the other nostril, or if the deviation and prolongation are in the same nostril, it is well to make several cutsinto the cartilage at right angle to ihc original incision, or even to remove a triangular piece from the cartilage to reduce its size and elasticity and allow it to Ik- jnished to liie other side, .\fter tiie above, procedures, bleeding is checked, the edges brought together, dusted, and, if neces.sary, a tine stitch or two taken. Healing promptly results, and the symptoms disapiK'ar. Nasal Polyps and Hypertrophies. The liistory of the treatment of nasal polyjjs presents tlire(> distinct periods. In the first ixTiod thes-^ iirowths were removed by ai)i)lications of various caustics either li])- plic.l to the surface or injected into the nia.«s of the polyps. This caused a sloughing with its attendant danger of sejjsis, though this accident does not seem to have been very freciuent. Tannin was insufflated and occasionally some iron solution was injected into the mass. It is needless to say that all such plans were .slow, disagn-eable to the patient, and unrelia'ble in result. Polyps were then considered tumors, and some of the older text-books .still sj)eak of them as myx- omatous in nature. We now know that this is far from the truth. Myxomatous tissue is homologous with fat tissue, and both urc almost iiiikiiown in the nose. Present-day teaching is t't the effect that polvps are nothing liut cedematous iiiHanmiatory outgrowths, merely the histological elements of tlie na.sai mucosa under jK-culiar n- x-hani- lal conditions. The second period «as marked by nMuoval with forceps uiserted lares. The mti.ss was grasjx'd and pulled away ' .mage was thereby done to the delicate intra- ,ch use of forceps is in the light of our jiresent lo, lowed the clarification of our ideas of pathology lather blindly iiit I ly brute force. nasal strurtures knowledge iiiadi i Tlie third peril. - ... nd the introduction of cocaine, which by the contraction of sur- : undiiig ti.-;sues more clearlv isolated the ])olyps. It was seen that lirirl)!isescouhlbeeneircle<i by a .stiff wire ami that they couhl bo -moved on the principle of ecrasement. The credit for perfectmg ills method is given by common consent to the late W . 0. Jarvis. hose snare is herewith figured. (Fig. 40:?.) Later models substitute for the pins at the handle a screw-clamp. riiis snare is somewhat slow in action, but it is jireferrecl by many, iiid IS of special service in cases in which the polyp is silualeil far liack in the nares, n-ijuiring the paying-out of the wire to encircle the 764 yoSE AXD Til It OAT. l)asp hoforo tlic looj) is tiplitcncd. Sajous iiKxlificd tlic snare in such a way tiiat a iimcli shorter piece of wire is re(|uire(i. Tiie jiriiiciple of hotii instruments, iiowever is tlie tianie. Hoswortli lias devised a Klo. 403. Jarvis' nasal tfiiaix-. Fli.. 4U4. I Bosworth'8 snare. O Flii. 406. WrIght'H snare. pnare in which, after the haw of tlio |K>ly|> is tnieirded, hnt a ■^ing!:- inovemont is recpiired for detarhnient. Wripht has ennil)ined tlie ideas of the thn'e snares named in the instniinent bearing hi- METHODS OF EXAMINATIoy. liio naiiip. It is :i jjowcrful and rather rapidly acting snare. It euii In- manipulated with one hand, however, and meets every rwiuirement in the removal of polvps. In the actual operation the nostril is first cocauuzetl. As the ixjlyps often completelv hlock it up, it is .litticult and often nn|)ossil)le to eompletelv ana'sthetiz.- the operative Held, hut the use ,>\ a strongly- driven spi-av and of cotto.' p''Mlgets will Renerally eflect the desired result Suprarenal extract m.. . he used with a view to the prevention of hleediiiji, l)iit this is rareiv severe. The favorite site of polyp ■Towth is from the edges of the hiatus semilunaris under the middle Uirhinate. The snare selected aiul threaded with No. o .<teel piano wire is pas.^ed with the K.op at Hrst vertical and then horizontal so as to slip aromid the polvp. Much is said about the pedicle of these j;rowths. hut we rarclv we the exact .seat of attachment. After the boi. is passed it is graduallv tightened, and just as we feel that sever- ance is al)out to take place it is well to give a .«udden traction, so ijs to remove a bit of thi' niiicos, to which the polyp is attached. Ihis maiueuvre can be rei)eated until the naris is clear, the oju-rative held being cleansed bv svringing from time to time. It often liapjX'ns that the patient leaves" the surgeon with a nose jjerfectly tree, but in twentv-four hours tinds it as much stoi)ped as ever. The explanation is that other polvps from practically the same or neighboring bases have b-en crowdJ'd bv mutual pressure up into the accessory sinuses .,r the sinuosities of the nasal chambers, and that by the n moval of ilie masses in front and lowest down they are by gravity and nose- l.lowing dislodged from their position, and thus fall down to tak,- the place of tho.se Krst removed. A continuation of treatment will hnally live the nose. In regar.l to cauterizing the ba.se to i)revent recurrence, authorities ,liff.>r. Hosworth .says that he has ••never been able to ivco.niize the base from which a i)oivpus has bwn severeil, and conse- • lucntlv he thinks it uiiwi.-^e to subject healthy tissue to nijury m the blind attempt to cauterize a region that cannot be seen. If as occasionallv happens, the polyi> slips away from the wire loop, M luav be held by a slender hook or forcei>s while the loop is adjusted. Ket w^en .sittings"the patient .should keej) the ikw; clean with some aiiti- sciiiic solution: no other after-treatment isreijuired. ^mw have recommended the galvanocautery loop for the removal -if polyi>s. It is not easv, however, to manipulate the .<ott platinum loop of this instrument." This difficulty is somewhat overcome by using iridoplathium wire instead of simple plaiinum. Moreover, the .■urient acts as a cauterizing agent and produces a slough \vhich may !,(. followed bv intlanimatorv action hi a region in which it is most Icsiiable to av(Md it. Sad accidents have followed the use ;-,f the autery in anv form in the n-gion of the middle turl)inate, owing to •he importance of structures higher up. I':iectroly. ■ has been sug- ,-t<d but thi.« belongs to the category of curious rati., r than of prac- "ic.il tiierapeutics. It is tedious, and" at the present time practically never used for the removal of polyps. i r 7«« XoaJi AM) THROAT. lor th(> roniDViil i.f nasal liypcrtropliirs. that is, rodun.Iaiit turhinat.^ tissue, the ('(ild-win- snare is a most useful instruineut. While tiieiv is a eoUMiiendahle reaction against the excessive zeal of a few year- apo for the .lestruction of turbinate tissue, there are cases in which the tissue has U'conie useless for functional purposi-s, and its removal is rightfully demanth'd. For this purjxise the snare can he u-d ;h for polyps. If the amount of tissue to he removed is small or of such a sha|)e that the wire will not easily enpige arouiul it. it mav he trans- fixed with a needle over which the loop can Im- slipped. For the removal of an entire turbinate bone we may use the tur- hmotoiue, so-called, which, constructed on the jmnciple of the spoke- shave, IS pa.ssed behind the ma.s.s, which is removed with a (juick motion. More often the n>moval of onlv a portion is necessarv and the snare suffices. (Fig. 407.) Portions of the middle turbinate Flo. 407. Snare engiglng posterior turblntte can al.so he removed by cutting sci.ssors, the cadges of ;vhich mav Iw .serrated, or by instruments constructed on the rongeur principle. " Fl(i. 40H. Serrated nciswrB. Oalvanocauterization. The use of acid caustics has alrea.lv h'or nientioned. There remains to s|H.ak of the galvanocauterv," whicl) lias come into such general emplovment. It is. perhat)s better- adapte.1 lor work .m the hiferior than .m the middle turbinate: ii used m the latter regi„„ it .houid he with the greatest caul ion ..„ account of the vital structures high.T up. The source of electricitv may he either tli.> street current properly reduced and controlleii METHODS OF LWAMlSATWy. 767 or any one of thn various batteries. Tiie cords should he attached •() an interrupting handle, and of the many varieties on the market iliat known as the Schecii liandle answers every re(iuirement. It can l»e used also for tlie electric snare. The various forms of cautery points are herewith figured. Fia. 400. Scbecta cautery handle. The part to Ijp cauterized is anspsthetized with cocaine, and the point is then druwn along its ci-nvexity, .laking one or two deep furrows, the object IxMiig to pin down the n-dundant tissue. The electrode -should be heated a little beyond cherry red. After its withdrawal the nostril should be sprayed with an antisejitic solution and a dusting Flo. 410 Cautery points. powder insufflated. The patient may Ik- given a powdei of a little lociiiiic. bismuth, and acacia, to us«' on subse(|uent days to allay severe •'■action, and tie should wear cotton in the vestibule to keep out the lust. Seances may be re|)eated after a week or so, when the .slough 'ollowing the cauterization will have come away. CHAPTER XVIII. ..^KLAMMATOUY DISEASKS OF THK UPPER AlH PASSAGES: HAV KEY Kit ; RmNOUHIKEA; ASTHMA; INFLUENZA. By CHARLKS W. lUrHARDSON, M.D. Acute Rhinitis. Acute rliinitis is an acuU' iiiHamination of the nmcoas iiicinl)raii<' lining; the nasiil pavitics. This inflaiimiation is attended with tiie usual iiiieiioinena tliat attend acute inHauunatory cliauftes when at^'ectinR iiuious surfaces in general, i)ut is altered soniewiiat in the nasal chanihers on account of the underlyiiij; vas- cular turhinal tissues. The inHanmiatinn is rarely limited to the nasal chanihers, more often extending into the communicating acces- sory cavities, as the frontal, ethmoidal, and antral cavities, and frc- <|uently extendinji downward into the pharynx, larynx, or outwanl through the Kustachian tulws into the inuhlle ear. The term catarrh i>as U'cn u.sed from earliest days to designate an alteration in the |)hysiolo<;ical function of the nose characterized hy an increased How of .-iecretion. (iaien, ("elsus, and others of the earlier medical authorities suiijMised the flux which attends this dis- ease in the acute stage to have been an outixiuring from tl;e brain: therefore tlii' comlition was supposed to Im> of be; :it to the affecteil individual, and on this account the (lennan custi. i of congratulation on sneezing is supposed to have its origin. Etiology. There is no disease in the whole rangi of meilicine in which so many, so diversified, and often su( h -ontradictory factors ap|)ar- ently enter as causative elements in its prodtiction as in acute rhinitis. Tl;.' jiredisposing factors are first to be considered. There is no doul)t that as long as the bodily condition is maintained at a perfi'ctl,\ normal tune liy proper attention to the .skin, the digestive organs, and the ordinary hygi<'nic rules with regard to clothing, exercise, ventilation, ami rest, that a reasonable amount of exposure to heat and cold may be made without interfering with the physiologic,! I function of tlio nasal mucous membrane. The most potent preilis- posing cause of acute rhinitis is therefore tlie lowering of the bodily tone, rendering it incapable of resisting the exciting causes. Sucli cond.itiims may be brought about by improper clothing, uiulue ex- posure of certain portions of the body, improper attention to thi' skin, acute indigestion, constipation, acute or chnmic; mental excite ment, and excess in mental or physical activity. The various dia- thetic contlitions, by lowering the g(>neral tone of the individual. ( "<w ) iMLAMMATOIiY DIHEASEH OF THE It'l'Eli AlJi rAS.'^AUEH. 7G9 rcinlcrs liiin siispcpvil)!^ to attacks upon the sliRhtost ox|)osurp. Thin 1- iiotKMl ill tlic uric-acid (liathesi:^, in tlioso suttVrinn from nourats- tiicnia and other nervous iilicnonicna. It is also very conmioiily noted that certain indivithials have a marked predisposition to cold- catchinji, and that tiiey will have seizure after seizure throughout the chaiiKeahle season. This condition is said to !«• hereilitary, and Dl'tcn I'lanifests itself in other ineinlM-rs of the same family. Altera- lioii in habitat is oft<'n attended with freijU-'it attacivs of acute coryza. i'lii^ is |)articularly noticed when the change \>-- very marked, as when persons accustomi'il to live in high altitudes move to th ■ lowlands, or when- the rev<'rse takes place. This is no doubt due to the process of acclimation and want of jiroper appreciation of the altered atmos- pheric surroundings. Thos<' occui>ations wliidi expose individuals enii)loy:>d in them to sudden and marked variations in the character and temiM'ratun' of tiie atmosphere render them especially prone to rold-catdiing. Chronic changes witiiiii the nasal cavities or naso- pharvnx are a decided predisj)osing cause of acute rhinitis. The chronic dianges which are most potent as provocative agents are spurs and deflections of the sei)tum, chronic hypertrophic rhinitis, Mdenoids, and postnasal catarrli. The above enumerated chronic cniiditions have, by their alteration of the mucosa, placed it in a receptive state, whereby only a moderate degree of exiM)sun> under unfavorable concUtions is followed by an acute attack. All ages are susceptil)le to attacks of acute rhinitis, although i' is more fmiuciit during child life and adolescence. The aged seem to find a certain dcjir if exemi>tion from acute rhinitis. The male sex. on account nf being (Muploved in all occupations which ibject them to exposure ti. a gn-ater extent than the female sex, a the most frecjuent suf- I'l'rcrs. Exciting Causes Tlie gn-atest and most fn-quent exciting cause of nil acute rhinitis is the exposure of a portion of the body to the in- lliience of a moist atmosiihere at a moderately low temperature and niiiving at a medium average of velocity. In other words the expo- smv of the bodv to a draught of moist air. It is a common obser- v.ition that colils are much more fre(|Uent during the changeable d.iiiii) weather of the fall and spring than during the extremely dry cold weather of winter or the hot weather of summer. A teiiiperatuiv Ix'tweeii .3')° and 40° V. whicli is moist is the Micist active exciting cause. At certain periods of the early fall and <piing. in which the above atmos]iheric comlitions are fre(|uent, colds MMiirto l)e epidemic. Is the epidemic the result of a given .specific i:mse. or the n>sult of a number of jM'ople iM'ing exposed to the same atmospheric change? A number of workers in this field have at- irmiited to isolate a micro-organism as the active agent in acute rhinitis, among whom might be mentioned Reinsch, Hajek, Klebs, Wright, and othere. W hile it is possible that acute rhinitis is an infectious disease, no one has yet discovered the acceptable micro- organisH), nor has it been possible by inoculation with the serous 49 770 SOUE A XI) Til HO A r. ox.Klat.on fn.m the afTcrful ,„i.s.il raviti.-s to pro.luco the .lisoa.so 11.0 woar.i.^' of wot apparrl, ..s,MTially of ^^ot ,„ .la.ii.. s\uk>h an.! .to,.k„.Ks tl„|.s allow...K u IhorouKl, ..hilli,.^, of a., .-x,;.,^..! ,K,rti..n of tl... l.o,ly. .s u v.-ry art.y,. ..x.-itiuK oau.s... Tl.r al.i.lii.K ii, ov.r- h..at..,l a.ul .ll-vo..t.lat..,l phu-.-s of a...us,.,.»...t.. th.-atn's n.n.-ert- hall.s, oil,,.,. r,)o„.s, fa,-tori,-s. a.i.l privat,' ,lu,-lli.,gs an- .H.t,...t .-aii^.s Many of the acut,' ...f,-,-tiou.M .lis,.a.s,-.s aro .■x,'itinK fa,'tors in th.t th,.y are an,-n<l,.,l w.tlx an acut,- rhinitis as one of the ac-innDanv- inK symptoms. S..,.;, a.v nu-ash-s, whoopin^r-c,,uKh, s,-arl,.t f,-v,-r rotl.,>!n typi.us mt,-rm.tt,.nt f,.v,T. an,l smallpox. ( ortain ,lruKH' c .,'m.(..ls. ,-,T,.als. an.l .Insts from manufm-turinR pl.H..ls, tl.ronKh" thoir pl.ys.,al proiKM-t.t's or by m,.chani,-al irritation uiv,. ris,- to ooryza. .-VIso n..Kl.t Im- m.-i.tioncl tl.,. rhi.iitis ('x.^itcl hv tho action of til,' stroptocw,.us, ,-rysi|M.latous coc<...s, ai.,1 the gonococeus. Symptoms. The syn.pt..n.s of an act,, rhinitis are u-suallv of •. m.l.l const. tnt.,.nal an.l active local charact.T. Th,- invasion n.av .0 pn.c^,l,.,l l,y a MmfT of lassitn.le, l.,.a,la,.he. or slight chilly .sensa- tion. Ihe ear.,.st an.l otl,..i pathoK..on.onir local sv.ni.to.;, of an .np,.n,l.,.K ool.l, o(t,>n n.an.fest,.,! tw,.nty-four ho..rs* In-fore consti- t.,t.onal ,,r o Iwr L.ca syn.pto..,s. is a f,.,.|in« ,.f h-ritatio... .Irvness, ...., h,.at ... the r,.of ot the nasal cha...b,.rs an.l vault of the pharynx W tl. the ons,.t of tl.,. attack «e have a f,..|ing of .lepr,.ssi,;n, hea.l- ac ... .nab.hty to ,.,)n,.,.ntrat,. the ,..in,l. in.pair...,.nt ,;f the apix-tit,. (.....st.pation, an.l a febrile .l.sturbance varving from •»!> to 100(leert.,.s' Tl.,.re .s ....,mn-n.ent ,.r ron.pI,.te lo.s.s of the special .s,.ns,.s of sm,.|| an.l aste. The local syn.pt,..,.s .luring the first twentv-fo.ir hours ar,. thos,. of f.iln,.ss an.l h.-at an.l ,lryn,.ss in the nasal cavity, with ore or ess .l.th....lty ,n Im-athhig through one or iK.th nasaUham- rs. U .,. ..asal chamnT may be fr,M. while its f,.llow is open, an.l th.s c«n.l.t.on n.ay .,u,,kly alt.rnate as to the ..hamln.rs afTecte.1 S H.ez.ng ,lur.ng tins stage .s oft,.,, a very ,)ron,.unc,..| an.l ,list.vssi„g sx n.pt..,.,, an.l .nay ,.ont.n.ie so thro.ighout the h.vasion until rv^u- lut.on ,s brought about. Th,. s,.,.,.zi„p paroxv,.ms an- m ,v ^r - nounc,..l ,lur.ng the n.orning hours. .At 'this -period we have't ..■ vo.ce ,..or.. or l.-ss m..lil...|, charact,.riz,.,| as the nasal v.m-e Tl,. su..,.,.,..l..,g .st...g,. ,s on,. att,.n,l,.,l with a profuse salin,. s,.rous trans, - .1 t.on wl.,ch .s of an ,.xm.,ling|y irritating charact..r. oft,-,. ,.a..si,K xc..r.at.on al.o.it the ah.. a.,.| upjK.r lip. WV also , ft,.n n.,tice .7 tl.,s t.me a crop of labial or nasal l„.rp,'s which a,l.l gn-atl - to tl ,' , , \ f r. 'V'"','"''""^, '" '^••'•""=;-'--'>'-^. ••""! •"...•o.,s to ..,u..opun.- ^^.th br. k,.n-,lown an.l .l,.s,|ua„.at,..| ,.ellular ,-l,-„„.n..s an.l le.u-o- e.vt,.s, .t beco,nes less Hui.l an.l t,...,|s t.. c.llect in incmstati.'ns Th. Y-nos 2,^atly n, ,|,ff,.n.nt m.hvi.h.als an.l in il,e san.e i,..iivi.iuaH a pat.ent n.ay be fa.rly fn-,. of sfnosis .luring the day, yet up,m ISFLAMMATOHY DISEASEH OF THE I'J'PEJl A IK PAHS AUKS. rctiriiiR at night it is iioticod that almost iiiiiiicfliatciy a (•"niplctc ;iii(l |HTsistf'iit l)I(wl<a)i(' i>f iMith chariilMTs occurs, th«> ol)stna'tion iM'iiig mori' |)roiioiinwil in the dcix-ndcnt chanihcr. t'ouphing at rnght is an cxtrcin^'iy distressing syniptoin to many patients, and is |iarticularl} noticed in children. This night-coughing is due to the irritation excited by mouth breathing and the acricl secretion irri- t;iting an already ()ver-s<'nsitive pharynx. Cough may In- more (»r le.s.s |>res<'nt throughout the waking hours. Besides the characteristic alteration of the voice, due to the i)lockage of the nose, we may have liojirseness to aphonia, due U> the amount of synchn)nous involve- ment of the larynx. The severity of the headache is dependent upon ilie amount of fever and the extent of the imf)lication of the ethmoidal ;ind frontal sinuses, llarly in the attack then- may Ik> noticed a tceling of stuffiness or fuhiess in the ears, often ringing or undue resonance of the voice, acute .son'ne.ss or actual j)ain, and dizziness. ' >ften in children and in .severe rhinitis in adults we have acute simple ■r suppurative otitis. Freciuently there is congestion and reilness lit the conjunctiva. Diagnosic Tlie diagnosis is readily made from the local and con- -titutional symptoms present. In all cases a thorough ahd careful I \l)loration of the nasal chamlH-rs should Ih? made by anterior and |i<ist<'rior rhinoscopy. During the initial stage the mucous mem- lirane will be noted as intensely livid and fn>e from moisture, and the turbinates .so swollen as to come quite or almost in contact with r:i(li other ami the septum — practically obstructing the view beyond tlic vcs'St.ie of the nose. During the second stage the membrane will lie noted to Ik* of a deep-red coIct, .succulent, and with descjuamated (•(■lis here and then' disseminattnl on its surface; the amount of ob- -tniction due to turbinal engorgement is not as great as in the primary -tajie. During the third stage the membrane is not so vividly red, tlic turbinal engorgement is not so great, and the inferior and middle iiicatus will be noted as showing more or less mucopunilent di.scharge. The complications of acute rhinitis are those conditions due to a lirccf extension of the inflammation through continuity. We may li.ive extension to the accessory cavities, temjxjrary occlusion of the lacrymal duct with epiphora, conjunctivitis, pharyngitis, tem|)orary 'l)stmction of the Kustachian tul)e, acute catarrh of the tul)e and liie middle ear, acute simple and suppura*' ■■ nfiammation of the middle (>ar. riie prognosis is very favorable as to recovery. Caution should ''(• (liiserved as to pn)gnosis in the very youn;^ and the aged, as exten- sion may give rise to serious involvement of pulmonary tissue. Due I lort should be made to bring about complete resolution in order t(i prevent the catarrh from passing into the chronic state, or the ' -tablisliM'.eiit of the tendency in rer'iTence TreatmeLt. It is greatly to be deprecated that an acute rhinitis w con.sid, red such a trivial affair by the avonige layman, and that it is permitted in the large j)roportion of cases to follow its own course 772 .VOAi .'.V/. nil!>M I I i: I h m r i- . ii 1' ^ without i'fT( rt to lirifip al>niit [HMit n'-.lutioii. It woulil he well it \vi' could ccliicatc tlic l;iity .. to tl ri .iistii-ss oi iicglcitcil ;icutc rhinitis, ami ihr iiii|Hirtaiii( i.f Uriiiniiij; I to a (|uifk ri'soiiitioii There seems In he no ilouLi that iliiririK tli- •■arly slap' the attack can Ih' siM'eilily hroupht to resolution hy n'sirtin^f to ahortivc ireal- niciit. The patient should Ix- |>ut to iVmI, .'• at lea-l confined for twenty-four or forty-eifjht hours n \ dom . This ronhnrnieiit is not always possihle. hut it is de.-i 'n!,!. vhei practic.iiile. j'he im- portant part in the early tneatmeM .~ 'l.e . .(oration of the equi- lii)riuni iiriucen the disturlM-d ai-'iiiii ..i tic. vin and the engorged iiiusal niucoiLs memi)rani', which i» i' -t accoiMj Ushed lhrou>;h active diaphoresis and local de|>letiou. '.:i> ii.jphore-is can Ik- as well excited i)y the administration of .» wifyious ,\ , i,jfi,t of ta.siefui hot drink as throujjh the agency of druic? . Tl. lei i-'iou i Im' Hmiteil. better liniite<l to a strict liipiid r' iracter A Dover's powder of 10 grains may Ih; given, or ()..«) of hmmide o, j.il.JU' iiiuy I..- given at hedtime. A.S a gcxMl derivation, as well ;u4 for il- active" depletory effect, ralimiel in diviiled doses, followed f)y a saline purge in the moniing. materially aids the resolution. For pur|M)se- < active Kn-al de|)letion I know of no remedy that acts :i.s thomii iv jis a tablet of O.ill of cliloride of sodium introduced in each na -iT chumlxT, .- suggesteij |)y Kyle. When the patient cannot he i'ontinp<i ab,so- luteiy to the hou.se, hut is able to remain within doors the greater jxirtion of the day, I have found codeia and ammonia carlMmat", ii> cherry laurel water, by its mild di.iphoretic action, to uccomplibi great good. It is administered as follows: e.Kleia, Oi»! Ammonli carboiiat.. i.ao Syr tiiltitan.. ai.oo Ulyr, rirni-. H.UIl can ho atTord Aqui»- liiun>-c«nu«l art ito.uo 91g.— Te«8p<«.iiful every hour uiili; C.urth done, itien evtry two hours. For relief of lieail p;iin I imd that applications a.- not borne applied to ' .c forehead as continuously .x* pos.v.hl.' the great, -^t relief. If the .abortive treatment fail-, as it will in niany cases, the further treatment must \h^ .sympton-itic. The bowels .should be k. pt freely evacuated with morning a'ld evening doses of .sixteen grains of so.lium phosphat<-. Aeiite rhinm occurring in the litha'- i.c can b. q be eombated by a strict dietam and the adirinis- tration of jiiliia and ()hi!sphate "of sc linin. In the rheumatic tin constitutional treatsiient should 1m' the .salicylate's or salicm. Jr; ilu malarial brisk purging with calomel, foil. wed bv the ailministr. 'ion of quinine. Should the <li,stention of the turbiisites Ik' so gr.it a.« to give rise to distressing symptoms temiMirary rehcf may 1m> art nied through the application of cocaine ■ r siiorarena! OYtru.t. ( . ;..,. and suprannai (wtract deplete tiir.Kigh c.ntraction of the ti mal vascular tissue. It is pxcreme y uKwi.se to jl.ice cocaine in th«' luuuU oi the patiei't for self local adriiinistrii- !i, on account of tlie ;asipr ISHAMMAruHY Ul^EAsty of THE 1'Pl'i.H MK l\i«> i',£f,. 77y liirh t'S'vT cxistK of *'\i unless it cair 1m >>ri'scnlM-i iiii;r,v in- nf iIk> iiatiin' ul u-cil i i |x'r (•<■ t. !ii|i tnry It shmiM In- r(|H'iil( IIJ5 in liic imlivi'unl tho c ,tiiw> liuhit, -uch fi rtn 'imi tliv [cili' lit will Im' t'tully (Iriis; litiHK I'tnjiloytMl. ( 'icuiiic is ln-sl OILS sc)hlti=>ii As !!- I'tJon i- very tnnisi- :)>. fr<i|U<-iir! iu* (• I i'liii lurs. It may licttrr, h siuuru! if 1 f(ljp-t.s '>f al»M>rh'-!it itoti with tlu' .soiutldii ami iiitri'MHiijn ;iti's«> iiii'i the nusnl rhrun- loi-scnts. after wi ^ch »T, winTt' tlicy an- ;ilKm'"'il !i» ren :un :i few hi- (•<■!! 'M is niiiuvctl. isi,;>ran'iia^ ■•vra'-i i Inn; 'p! ilc|(lotiuii I ■ '■<wih-aoti<in, a- i' ii-is IS w ;l ,(- a mort' pn i.tiijifd tioii ti i-o«'a. it uith any <■! tin iliitif "^ whii" .n-coii' thv rile su[intr('ii il i-\tnifi m i iispd .mi not sf«-iii 1(1 li: ■ any u(i)ili;i«ant (tin^' •I'll locally. . - iH'Ht iKiil :i (irdiiii: ^ ijIC^ >rcil liy Iii|i;il aiiil nay I' IntnKluc use of focuine, or I I Vf'li ■'t ailvatit.if IS nior*' till n .ugh rati, iti'iii ti.r if 'lie i, fr iy. .,- IT'' w' 1' 'llH'S 'llllS ila, as il tin M Maeente fur four spraj iMg: A.!'-l., * Ar-= l«: A.iu. . ,|- then fill' - .ttci ted), hot), r I 111 ,!■ <*'('('! 1 staj. iliic 1 illii hat till- >pr:iyi iii n Kaliiie K'piil , I'ioii thr ■■ or fi riiis solution iii;i eonsi>»t . f bicarlmn oi •■,■!. '■: to ',\0 (i! 'I'pi.i :tt\: -Ul'! as the >,-iin(' pur|i(i>' ' ii^ ■ adi' II". 1^ talilct- ]>■<■ till \t< the uiirc nt tcj.iil milk (•(■lit. ution ' •' horir acid. -' iiK-. Iff this cleans!"!; with "th !i (M) i-'aii -los rp [MirjMi.'^c en Ik* made 'i(i|-cai;ip!; >r imHiip fMi!iit!"ii,' in ■•tin/'ij 111. uiii is th< -nstn iiiiiii 'lic •:>! (nit i! also iiti-ii -hv 1.1- ;i ci tion s«'iiis to 1m^ followiiijt a protracted (iiirsc . pit«- nt i 'M» :mt>uts pinplo ved, it is wise to u.se so?., •nild rofuse niueopurulciit dis- of the nose with a mild '.> .lily gives marked relief, and liilxirate of soda. 0.(50 I, if not blotter, .solutio' for 1^ w.ff one of the nasal |>lasiiiii \ very eomfortitifr solution iiijr iO (if sodium chloride (■xp( I solution is a 'i per ions 11 ie twice daily it this i the abt.vc sfilutions, of a inen- liich iK'iiEoinol or other form of 11, adds not only greatly to the laterially in liringiiig alxmt reso- jmprnin. i ;iil>' -m. oual (It i j- McFiirl«ne) : iuiii chlori ' '■' >t. VMM gr>mme« -ttum unlplit. (1.0!»7L> •• Sodium fhosphite. 0.0I«2 " I'ott^ iih fhloriite. ".(WM " PotH^^ium ttiilplmli* " O.OlBi M Potassium phosphatu. 1,, " O.OTK! " Menthol. u '• 0MVi2 " Form '-.la for hol-€amphor-iodlne solution ; Menthol, L.-iO Camphor. 0,60 Iodine. UtB Bcnzoinol 32.00 774 AOA£' AX J) THROAT. i f astringont in :iquo(ni>< solution to aid in Ijrinping al)out rosolution. Tiip two iM'st agents of this class arc cither a ] jut cent, solution of silver nitrate or chloride of zinc. The acute rhinitis occurring in early infancy is an extremely distressing atfection, as through its obstruction of normal rcspinition it interferes seriously with the slrep, prevents the infant from nursing, and may, hy in'ii)airing the nutrition, give rise to more serious complications. Great relief can be given these little sufferers by irrigating the nasal chamber with a tejiid alkaline solution introduced l)y means of an eye drop|)er. The head is well held a-id the tip of the eye dropper is introduced just within the V(>stil)ule of the no.se, and the solution forced through drop by drop until each na.sal chamber is cleaned. The use of the alkaline .solution can Ix> followed by a few drops of a 1 jht cent, solution of camphor in benzoinol or albolene. Prophylaxis. It woul.l seem irrational to close this subject of acute rhinitis without referring to the importance of proi)hvlaxis. Proper clothing and proiH>rly protective clothing are most in\])ortant in the prevention (.f colds. Too heavy do*' ,ng is as i);iil as insufficient dothmg. W( il-sel(>cted underclothing of medium weight is ami)ly sufficient for use in t<'niperate climates. Proper regard should be had to the foot covering. The shoes for out-of-iloor wear should have thick soles, and when allowed to bee le damp should 1k' changed nmnediately. Rubber overshoes siiould alwavs be worn on damp or ramy <hiy.s. Mufflers about the neck, scarfs, and furs should be discarded. ( )f all means to prevent cold-catching I know of no means so potent as a moderately cool bath, between ()0° and 70° F., taken every morning or evening. Chronic conditions of the na.sal chamber should be corrected. Chronic Rhinitis. Simple Chronic Rhinitis and Hypertrophic Rhinitis. Chronic rhinitis is a chronic inHainmation of the mucous membrane lining the mtsal cavities. It is characterized bv an altera- tion of the mucous membrane and a change in the ([uantitv and (luality of the secr(>tion. In the milder typ(> the swelling of the mucous mem- brane is moderate ami the change in the secretion more i)ron(nmced th<- so-called simi)!e chronic rhinitis. In the more severe tyjK- the swelling m the mucous in(>nibrane is greater and attended' with a permanent dilatation of the bloo.jve.ssels and incn-a.'ied growth of the mtrava.scular connective tissue, with an alteration <,f the (lualitv of the secretion, th.; hy|MTtropliic rhinitis. As a i. Milt of the .swefling of the mucous membrane and increase in submucus intravascular tissue, we have more or less encroachment upon the iiurmal lumen of the nasal chambers, whereby there is interference with free nasal respiration. This engorgement of the tnrbinal tissue may involve only the inferior turbinate or afTect both the inferior and middle turbmate. It may .show tumor-like m;is,ses affecting the anterior extremitii's of the inferi.ir turbinates, or similar con.jitions nfTectin" their posterior extremities. In either circumstance \\\v<.v enlarge'^ njents are known as hyiK-rtrophiea and are designated as anterior ISFLAMMATOliy DISEASES OE THE Vl'l'EH AJJi I'ASSAUES. 77.5 or posterior, apponling to their location. Ofttiincs wo find on tiie surface of the sei)tuni, esiwcially about its cartilaginous portion, masses of erectile tissue under varyinj; states of iiypertrophy. A similar condition is often observed at the posterior border of septum, where it stands out as elliptical masses rounding out on either side of the free |Misterior edfie of the se])tum as observed in the rhinoscopic mirror. The pradalion between the two types of chronic rhinitis is Ml difficult that it is sometimrs almost impv ibie to determine where the simple form ends and the hy|)ertropluc oeghis. The application of <'ocaine will often enable us to make this ilistinct. After the appli- ••ation of the cocaine solution, if the swelling all disappears, the nmcous membrane apparently being tightly adiierent to the turbinal body, the condition is one of hyjM'ra'mia, and should be classed as a simple chronic rhinitis. If after the api)lication of the cocaine, however, the nmc(tus membrane does not contract down up(jn the turbinal bodies, but presenting here and there- redundance of tis.sues, we recog- nize that we liave a true hyperplasia, and the comlition should be designated as a hy])ertroi)hic rhinitis. Etiology. W h('n one considers the physiological functions of the nasal chambers and the varying chiuig's to which this action must acconnnodate itself during the twent} /our hours, we can readily understand how it can become the sut)ject of varying degr(>es of (hsease. The various organs and structures of the Ixi y are subject, more or less, to periods of increa.sed activity, but no organ is called upon to meet such varied changes in physiological functions a> ihe nasal chamlxTs. The atmosphere in its varying vagaries as to its density, humidity, and temperature, the changes produced in Ihe :itmos"pher(> by artificial agencies, as heating and overcnwding, dust and emanatiims contained tlnTcin from animal contamination, all call upon the nasal chambers for varying active changes in its vascular ii'iision. The most frtMiuent cause of the chronic tyjx>s of rhinitis IS the acute rhinitis. The occurrence of fn-qucnt acute attacks which are n(>glected and not brought to complete resolution leave after each >ucceeding attack a certain amount of residual inflammation which often terminates in hypertrophy. Climatic influences no doubt exert ,1 most potent influence in the production of hypertrophic catarrh. A moist, temperate climate, with freipient and sudden changes both ill the degr(>e of humidity and tein|)«>rature, are most potent iigents lor the i)roduction of chronic rhinitis. The bi'fore-mentioned con- ditions i)revail along the Atlantic .seaboard and in the lake O'gion of our country, and, as is well known, this type of catarrh is very preva- lent in these regions. In the high plains of our Western country, strong winds laden with alkali dust also produce these changes. It is remarkable how a change in atmospheric surroundings will often produce a most marked temjjorary benefit to chronic rhinitis, the -risri'ial state n'curring when the patient returns to his former habitat. I l)elieve this improvement is often as nmch due to the alteration ' 7(G SOUE AyV TUllOAT. in the indiviiluiil's Iml)its of life tliroujili ahscncc Iroiii his formal (lailv lif (', as Tl to the alteration in the atniiisplicric surnuindinjis. If actiun of various aiiniixturcs wliicii arc convcvcil hv the atinos- phore. as the (hist of the streets siireharKcd witii ti certain chemical fact( he excreta of ani- ls, millers, •rk in iries and reducing estahlisliments, and under mals. the dusi I'n.m factories, the dusts to wliicli stonemaxn. and l)r()nze-\\drl«'rs are exposed, the chemicals set free hv this ftroupin}; could he included the inijalatii.n of heated atniospju., observed in such occupations as tiiat of plaie-|jrinting and hook hiuditifi. have their deleterious effect th riie hahits of life and (>ccui)ation are instrumental in prod ucini: ondition. Thorn can he no douht that the excessive use of tobacco, either hy chewinji or sinokiiifi, tinDugh its constant irritation <if the nasal mucous memhrane and its toxic action on the vascular system, causes enjiorgement and chronic ( hanges in the nasal mucous memhrane. The same may he said of the action of alcohol. A .sedentary occu|)ation which permits of only a moderate degree of general muscular activity and out-of-<loor life, with abiding in over- heated and l)a<liy ventilate.! rooms, exerts its deleterious inHuiiic Various disturb;mces on the part of other •••gans or systems of the body, such as the cardiac, hepatic, gastro-int<'stinal. and thet Tl m tile svm pa- mucosa. u- ic nonoiis system are attended with changes in the nasal lose constitutional conditions which are known as litluemia. rlu\. atism, and neurasthenia, scrofula, syphilis, and tuberculosis, are ail predisposing f.ictors in chronic rhinitis. I am verv much inclined to doul)t whether there is a condition which might Im- called the catarrhal diathesis. I am more inclined to believe hat the coMstitii- tional conditions ju.st enumerated ar changes o f a <-li more iiistr imeiit:il in producing ronic typ(> in the na.sil mucous membrane than main le nasal chambers are willing to admit. I.oc.d changes within tl acces.sory cavities, and pharynx are often the primarv disturbing factors. Hy far the most fre.iuent of these an influence is an alter, 'ion in th local ( •hange ertmg iiiisiil septum, either in the form ol a dellectioii or of a s,'ptal spur. Through the instrumentalitv of 'jmrs and deflection of the septum the i ias;il cavities are im iirrent in the nose is disturbed, the f obstructeil. the ;iir ( stances which gain .'iccess to the nasal chamiiers ■ '<r less th oreign sub- are not removed in K' usual way, the secretions accmnulate. and the local nutrit sutlers. When the nas;tl chamlM-r is obstructed bv a deflect spur of the septum, the incoming column of ion ion or :iir is carried over th.it portion of the tnrbin.ite body behind the ileflection. upon which it diminishes the atmospheric pressure. This diminish<'d .atmospheric pressure when persiste.l in continuously, gmduallv results in tur- gescence . -111(1 hypera'ini;!. which in turn are followed bv tissue growth in that jxirtion of the turbinate affecteil. Di ceessory sinus by the irrit.ant actior, of tli^ increased .fthe sease the iia.s.'il mucosa give ri.se to n purulent discli.'irge upori In ethmoid disease the d lore or less swelling of the turbinal ti.s.--uo lange produced in the middle turbinate mf IXFLAMMATORY DISEASES OF TUB UPPER AIJi PASSAGES. 777 alw.iys very i)roiiouncP(l. Ailcnoid growths, as well as ciilargfiiiciit dl' the faiK'ial tonsils, an- very active factors as primary agents in the |iro(liiction of chronic rhinitis. They not only act l)y interfering with the return of venous hlood, thus |)ro<lucinj; a passive congestion, hut also by interferign with the proper ventilation of the nasal chambers. The consideration of the etiology would be inconiplet" without taking into consideration the |)ossil)le activity of the various micro- cirganisnis which are found in the secretions of chronic nasal catarrh. The pus-producing micro-organisms are fre(|uently fo;::;;! in the secre- tions of chronic rliinitis, but the same organisms are never found in the substance of the mucous membrane. The mi<To-organisms so found are tin; same as those found in normal nasal chambers, and therefore have no influence in producing chronic rhinitis, which is i-lciuiy a non-infectious inflammation of the nuicous membrane, ('inonic rhinitis ah'ects most fre(iuentiy young adults, the male to a greater extent than the female sex. Symptoms. The most pronounced symptoms which are noticed by the sufferer is the alteration in the nasal secretion and tiie obstruc- tion to normal nasal respiration. Tile nasal secretion is altered in (juantity and (|uality. The amount "f secretion normally s»'creted by the vascular tissue of the nasal cliamber during health is about a pint during the twenty-four hours, which is taken up during the nr^ural jirocess of respiration by the incoming air, so as not to be appreciated as moisture within the nasal iliambei"s. .\dded to th's -crous secretion, which may be increased "I- diminished as hypeuemia or liy|)ertrophy is present, we have an iiKicased admixture of mucus, leucocjies, and epithelial cells as a iv>ult of the eiigorg( ' r-ondition of the chronic inflamed mucous inembrane. During tin arly stages of chronic rhinitis, when liyjK'r- :i'inia of the mucosa is more jiroiiounced, we have an increase in the :imount of secretion jiroduced, the amount varying greatly in indi- ^ idual cases. Often jiatieiits note the amount of s<'cretion produced liy the tumiber of handkerchiefs used during the twenty-four hours. Till' secretion not only is removecl through the anterior nares, but niicn gravitates back, and is drawn out of the pharynx iiy the un- plfisant nasal screatus which we so often notice. When the liyjjer- 'niphy becomes great there is stagnation in the turbinal bodies and III interference with the exosmosis of serum, wliii-h naturally diniin- i-iiis the amount of discharge. In this latter condition the patients iiiMiplain of a feeling of f'l'-u'ss, as though secretion existed, which, I'li'W as they may, they .:"i. ' remove. They speak of a feeling of !i<'Mt and dryness. Tlu j i.i y of the .secn-tion is also variable. \\ hen the discharge is ab. ■ i it it is more sero'i.ucous or mucous in 'lianicter. When less abun lant it is more mucopurulent, showing I iiiiHlerate admixture of leucocytes and epithelial cells. It often, ■lull dcliciciit in water elrmeiits. dries on the sejuum and cm the turbinal bodies in the form of flaky crusts. The secretion rarely has anv odor. 778 At*.Vi,' AM) TlJJi'JAT. i As a n-sult of the vasruliir growth, tho thickciiiiip; of the mucosa and tlu' uncertain vascular tension of tlic vessels coniposin<i tlie tur- hinal tissui', we liave a varying amount of steno.-is of the nasal chain- t)ers, an.l, as a H's ih, tiie interference with normal nasal res|)iration. It is interesting; to observe how the character and (le>;ree of stenosis manifests itself in the tlitferent individuals and in the same individuals at (litTcn'iit limes. The stenosis may l)e most marked in o; i- nasal chamher constantly or affect one nasal chamber solely. It fre(|uently .shows a very vacillating ti'iidency, obstructing; the rif;ht cavity at one nient, the left beinj; practically free, and, without apparent rea.son, .suildeiily reversing; the situation. Many individuals note perfect freedom of bi-eathinp; while moving about dunii;; the day, noticinj; the obstruction only when lyinj; down to rest at ni<;ht. Tliis ob.struc- tion, wiiich is present at night, may obstruct both nasal chambers, or may Ix- noticed in the na.sal ciiamlwr which is undermost. The change of atmospheric surroimdings will often diminish or intensify the stenosis, that is, while abiding in ove,-|ieated and overcn)wde(l rooms the stenosis is usually most profound, whereas moving about in the open usually gives the greatest freedom jxTinissible. As a n'sult of this stenosis, and mouth-bn'athing, which it entails, we have resulting changes jjroduced in the naso- and oropharynx. The changes set up in the u])per jiharynx are usually in the way of chronic inflam- mation in the mucous membrane, with increased" glandular activity. A.S a result of these changes we have that train of sym|)t<)ms often pn-sent which are due to tiie accumulation of thick, ropv, vi.scid secre- tion in the nasopharynx, ♦he effort to remove this s(>cretion being often attended with retching, nausea, and vomiting. Another result of the nas;d obstruction is enlargement of the unila and intiltratioii of the pillars of the fauces. The mouth is usually dry and the tongue coated, especially on awakening in the morning. Cough is not only fre(|uently present, but ofttinus is an exceed- ingly distn-ssing symptom. Some individuals mav be practically free from coughing during the day, but upon lying down at night i"t (|uickly makes itself manifest. This night ccmghing is due partly to the mouth-!)reathing and often to the irritation of the secretion which |)asses into tlie pharynx while the patient is in a n>cunibent position Cough which is present more or less luring the waking hours is due U) the changes excited in the pharynx and larynx. Headache is a very fre(|uenf and often very distn>ssing .symptom of chronic rhinitis. Its freipiency would makeit one of the iiiost pro- nounced of the secondary symptoms of chronic rhinitis. Most fn'- quent'y it is a brow-pain, being located over the forehead, more marked in the morning on arising, almost or(|uite disapfM-aring during the day. \ feeling of jiressure or general fulness about the head or occi|)ital uneasine.s.s is often noticed. A general feeling of hussitude is froijuentiy |)re.sent in the morning. Snoring is coimnon. Impairment of the .senses of taste and smell are occasionally present in chronic rhinitis. The obstruction of the nasal chamber?! aa well ^ ISFLAMMATOUr Vl!iEAiii:s OF TUK UPPER Alii PAHSACiES. 77!) iis actual structural changes in the mucosa of the olfactory orfcan arc rcsijonsiblc fur these conditions. With the impairment of tlie olfaction we have its correlated sjM'cial sense also suffering. These changes are in no sense an essential anosmia, as there is usually a comj)lete restoration with tiie return to the normal. Sneezing is a common symptom. Fre(|uently patients have ))ar- oxysms of sneezing when rising in the morning, which suhside during the picparation of the toilet. Paroxysms often manifest tiiemselves when the ])atient isexijo.sed to the direct rays of the sun. The gn'ater the hyjK'rtrophy in the middle turbinate region the more marked is this disturbance. The timbre and character of the voice is altered in proportion to the |H'rsistency and amount of the na.sal .stenosis. The voice is that characterized as na.sal, and differs markedly from the voice produced by enlargeti tonsils or adenoids. no. 411. Anterior rhlnoacopy, showtDK anterior hypertrophy of Inferior turbinate. (Cohcm.) The diagnosis is made complete through physical examination of the nasal chambers by anterior and posterior rhinoscopy. \W anterior rhinoscopy it will l)e ol)ser\'ed that the nmcous meni- lirune is of a deep re<ldish api)earance and (juite succulent, with strands of mucus nitming between the turbinate bodies and the .sep- tum. In the mild types the turbinal tis.sue will be projecte<l outward toward the septum in an even, round manner, nearly a]>proaching <i intact with the septftl walls. Often wel)-likp crusts of dry mucus will be found in the vestibule of the no.se and over the surface of the turbinate. More or less mucus is observed in the inferior meatus in this condition. In the hyix>rtn)pliic fonn, on account of the pro- liferation of the cellular elements, we find the nmcous membrane paler than in the h\i)era'inic form. The swelling of the mucosa in I ills type is more irregular than in the iiypera'iiiic tyjM>, and shows :i marked tendency to the development of re<linidances at the ante- rior and posterior extrctnitios of the inferior turbinates, whicii often 780 yasE AMt rnii'iAr show a nijiDsc appearance. At linies the liyiMTtrnpliied tissue over the aiilerii)!- extremity shows ahimst a tiiiiKir-hke swelhii}; haii^iiijr linwii ainl lilliiii: lip till' inferior meatus. The ni"<'ater liie rechiniiancv of lissui' the p.iier its color. \\'e often timl liypertropiiied mas.ses of erectile-like tissue on the septum wail ant<'riorly. Ky posterior rhin- o.sc()|»y we find varyinji decrees ; '.-n of swelling of the p<'sterior ex- tremities of the turbinates. Tin- posterior cii'l of the inferior tur- binates is most frei|iieiitly alTected. ,ind they vary from a sinjjle roundin<r of the posterior extremity to larp' tumor-like masses that till out liie posterior nasal orifices and pn'trude into the pharynx. They are either ru'j;ous in .ipiwaraiu'e. or s! iw that singular indented- like surface which his caused them to be likeiieil to a mulberry. Tiie color of posterior hy|n'rtrophies is j;rayisli white. Tiie imic<-ia of tiie |K)sterior extremity of the .se|)tuiu often shows an I'lliptical jirayisii- white swelliu'.;. Tliroiiffh the use of cocaine ami the ])robe we are able to (lifTerentiate with a dettree of iiic(>ty the liypera'inic ca.ses from the hypertrophic and the amount of hy|K'rtropiiy |)res(>nt. .\ ."> per cent, solution of cocaine sutlices for this purpose. It is Ix-st brought Fill. 41i. Flii. 413. * . f \ / Ki(i. Ill' -HyinTtrojihy nf posterior cxtremiiies of inferior lurbinate an obwrved IhroiiKh iwsterior rhiti(i»icopy. Kui. 413. -KIlipiicHl swi-llliiu'son i>'nlcriur fiiinlus of «L-pluio, with hypertrophy of right, midilli-. antl iiiferior lurbiitateH. into contact with the mucous membrane by introducinji a small pleiijret of cotton saturateil with the cocaine .solution into the na.sal chambers. The cotton is allowed to remain in contact with the turbiiial tis.sues for a Tiionieiit. when it is withdrawn, .\fter waitini; a few moments for the action of the dmjr, on inspection we will find the mucous membrane very much contracted umler the influence ol the coc.'iine. In the simple hyjM'ra'inic condition tlie cavitv will be ([uite roomy and the turbinal tissue firmly drawn down over th'' turbiiial bodies, eNcejitinK where here and there will be iiot<?(i slighi swelliiifis which will indent upon the use of the probe. IM'LAMMATOUY J)ISEASi:s OF THE Vl'PKH AIR I'AHiiAaES. 781 In the liyiMTtropliic form tlicro will alsti Im- consiilcral)!!' retraction: l)Ul, ncvcrtlu'lcss, tliorc will he iiotcil a ciLshioii-likc iiia.s-i on thf anterior extreniity of the inferior turbinate, slightly mobile on the use of the probe, likewise masses on the body, which aiv velvety to the feel of the prolK' and which indent upon |)ressure. It is remark- able how the action of cocaine causes the almost complete disajjjx'ar- th. Ixv Flu. 414. Mulberry-like enlargements of poaterior extremitiea of inferior turbinate. (Cohen.) .nice ot |)osterior hypertrophies, liowever ponderous tney may \\v fre(|uently note also pciiduious-like inass<'s which hanjr from I he lower border of the middle of the inferior turbinate, and which can Im- lifted u|) from the floor of the nose. The middle turbinate [ircsents vary- inj; defirees of swolliiif;. showing enlargement along its inferior bor- der, about tiie middle, or increase tiiroughout its whole contour. Oft- times we find the middle turbinut« showing almost a myxomatou's de- geiierativft change-, approachin;;, if not ((uite passing nto the change known ;us ethmoiditis. It is remark- aiile to observe how often one nasal chamber will be continuously more seriously affected thiiii the other. It is ([uite inii>ortant in making these, a.** well as all examinations of the nasal chambers, to UM' the na.sal probe lilM'rally, not only before, but after the instilla- tion of cocaine. Complications. The most fre<]uent as well a.- the most distressing com|)lications of chronic rhinitis are those due to changes in the .luditory apparatus. There is no doubt that the greater proportion (if all cases of middle-ear catarrh are excited through the action of chronic rhinitis. The change within the Eustachian tul)e and middle ear is not only due to the direct extension of the catarrhal inflani- niation through continuity of surface, but is also jiroduced through tlu> imjierfect ventilation of the tube and middle ear. This rarefi- ciition of the air in the tul)e and middle-ear chamber, after more or less prolonged maintenance, results in hyjiera-mia of the mucous niinilii'.'ine and other changes which are designated as hyiiertrojihic c;itarrh of the middle ear. This condition produces varj'ing degrees of impairment of hearing, tinnitus, s<>nsation of fulness in the ears. .■iut(ii)honia, vertigo, etc. The eye often shows changes as a n'sult of chronic rhinitis. We find as the result of the inflammation along the course of the lacri'nial duct various changes excited within the canal. \\'e have also simple <'oiijunctivitis, jihlyctenular conjunctivitis, and keratitis. .\ numlx'r of apparently serious nervous complications result frussi tlio ititerfcrpnce witli nasal n-^piration. The most interesting of the.se is the dread of suffocation, often observed in nervous females. I have often had patients affecteil with hypertrophic rhinitis tell me diat it was impossible to assume the recumbent position at night, 782 yoSK AM) Til It OAT. 'm on account of tlic sensation of ini)M'nilinp sufTocaiion. Thoy have tlistressinj; dreams, pressure about the head, impairment of memory, and the inalnhty to concentrate thi- mind, supra^lrl)ital neuralgia, sjiasms of tlie mu.sch's of tlie face, epil('j)ti" convulsions, astiuna, and spasm of the larynx. There is no doubt that changes of a hyjH^rtroithic character, espe- cially about the middle turbinate, are to a marked ext«'nt a factor in giving rise to purulent conditions in the accessory sums. Diagnosis. The diagnosis is usually made complete by the grouping together of the subji ctive symi)toms and the result of the rhinoscopic examination. H.sjH'cially is to be empha.siznl the imi)ortance of making use of cocaine and the prolie in the physical examhiation. There should Ik- no difliculty in difTerentiating this con<lition from other affections which may involve the nasal chamlxTs. From .syph- ilitic infiltrati(m and gummatous growth they can Ik- differentiated by the absence of other lesions of syphilis, the history of infection, and the fact that infiltration and gummatous dejM>sits do not con- tract under the action of cocaine, and have a dense feeling when touched with the probe; from na.sal j)olypi by the jjolyp having a grayish-blue transparent appearance, iM'ing mobile, and by their pediculated well-discerned attachment about the middle turbhiate. Spurs and d( flections are readily differentiated from the fact that they are firm .swellings affecting only the inner walls of tl-.e na.«ial cavity. Prognosis. The prognosis is usually favorable, although at times it re(iuires a protracted course of treatment. The severity of the case and the amount of hypertrophy In'ar no relation to the time nM|uin'd in the healing process. Often cases with enormous liypertrophy will yield rapidly, with relief of all symptoms, while ca-ses with simple hyi>cnemia will try both the patience of the physician and the indi- vidual affected. Too nnich a.ssurance should not' be given to the relief of symptoms and reflex disturbances apparently due to the chronic rhinitis, as such conditions may be influenced by other i)atliological coiulitions not observable at once. The rapidity of result is often influenced to a marked extent by the patie'it's willingness to aid and follow all directions as to rules of liygiene. Treatment. There is no local pathological condition within the na.sal chambers that retpiires such a thorough consideration, both con.stitutional, hygienic, and local, as does the therai)eutic considera- tion of chronic rhinitis. Without a thorough correlation of the two plans of treatment it is absolutely im{)ossible to bring about a la.sting effect as the result of treatment. T'.e hygienic surrf)undings shoulil be carefully iiupiireil into, and wherein they are defective as regards care of the skin, clothing of the body, aiiil protection of the feet, thev .should iie rectified when possible The <|iet i-.f the p;!'l''!ft should be c;ii, -fully gone over, and that which is suitable to the indi- vidual should be din'cted anil insi.sted ui)on. Fre(|uently an office worker will h^ following a dietary suitable onlv for an athlete or n IXJLAMMATonr DIHEASKS OF THE I'PI'ER AIR PASSAdES. 78^ lalM)ror. Fresh air in sIccpiiiK apartments, dwellings, and ofiices should he re(|uired, and the avoidanee of overcrowded hadly-ventilated iialls and hmhus of jjeneral asseinhlage. Kxereise, f;oo<l hours, mid corn-etion of hahits of excess should Im" made ohiigatory when eondi- lioiis demand them. l'ro|H'r medieation to meet constitutional dis- iiirhanees that are din'ctly or indin-ctiy niHuencing the nasal changes should Ik- c(»nsidered. Removal from unfavorable occupation or climatic surnjujidings is not always possible, but when feasible, it -Imuld be done. And, lastly, if not least imjjortant, is the correction of any disturln'd condition of tlu" alimentary canal. The local tn-atinent, which plays an imjKirtant role in the restora- tion to the normal of a chronic rhinitis, has for its o'.ject the reduction of hyiH'nemia, the removal of .structural hyixTtorpiiy, the less«'ning uf cellular and glandular activity, and the restoration of th* normal iihysiological functions of the nasal cavity. In the milder tyjx's of liyi).Tamia and moderate degret- of hyiwrtrophy the local apjilication of non-irritating alkaline .solulions, to which is added some antiseptic :i>:ent in conjunction with the constitutional care, will often bring iltout a complete resolution. The .solutions which are most applicable for such pur{)ose are iis follows: Salil blcarbonatti, Sodil buntlii. .Sodii cblorlill, tA 82.00 M. Slg— Small teupoonAil to ■ pint of water. Acldi rarbol., 30.00 Sodil 1,1 nrb., 2.00 Sodll L/iborat., 3.00 Glycerlnic. 4.0O A(|ii!e destUlat., 180.00 M. Sig.— ror local um. To these .solutions may Ix.- a<lded, acconling as the condition seems to demand, any one of the a-stringents, as nitrate of silver in 1 jkt cent. -nhition, suli)hate of zinc in 1 |)er cent, solution, chloride of zinc in 1 nil-half of 1 |)ercent. solution, and sulphocarlMilate of zinc. These solutions are introduced into the nasal chaml)ers either by the us<' of the atomizer or by one <>{ thi- various modihcations of the nasal douche, as the Dessau or Bermingiiam douche. Due care should be ilisc ned to note that !)oth nasjil chambers are free enough to permit ilic return of fluid. Thorough care and caution should be given to 'lie us<' of sf>lutions for this purpo.se, and I cannot too strongly con- 'liiiii the indiscriminate placing into patients' hands of various a)lu- ' II HIS with imi)erfect instructions as to their use or abuse. It is always ctter for the physician when possible to have the local treatment lioniughly within his care, allowing the patient t<i use only a mild ilkaline solution, solely for cleansing pur}X).ses. When' a.stringents ■'TV u.sed ill jujueous solution it is !idvisah!e there.ifter to spray nut the iosc with one of the forms of refined petroleum, such as albolene or li'iizoinol. In.stead of an astringent solution, one might accomplish ln'tter results after cleansing out the nasal chambers by the use of an rH4 SOSE ASD Tim OAT. f=r f I! altfiaiivc, with a vawoiiuitor stimulant, such aa the nu'Uthol-cainphor- iodiiic siilutiiiii. This siiUitiiiri is not 'is U-Mcticcnt in its action in tnilil hyiK-rtropliics, i>ut is cxcccclinjriy aniccaiilc and pleasant in its ininnMliutc cH'ccts. Mori" fici|ucntly these simple measures will not U' attendeil with tlie desired results, ami ot'ttiines at the bejrinning the amount of structural clianj;*' will demonstrate that time so emijloyed will he w.isted, and that the only method l>y which results can Ix'nained is thmunh active local tn-atment. \'ario\is methods have In-en sug- ;;e>ted for the purpose of reducing the hyiKTtrophies, most of which are through the use of agencies (iroducinK destruction of tissue. The method t<i 1' employed, the amount of reaction n-fpiired, the aRent to Ih- employed and the success attained are largely the result of individual experience and skill. It is well to l)e skilled and exjjerienced in iill the various agents that are employed for this puri)ose, and then to u.s<' that agent which is Ix'st a|)|)lical)le to the case in hand and that will most thoroughly and (luickly accomplish the sought-for result. The methods in vogui' an- pres.Hure through .soft-rubl)er splitits, cau- terization, actual or chemical, the .snare, hot and cold, and the more or less complete" removal of the turhinal hodies, partial or complete tur- binotomy. For the ti-chnique of oiM>rative intervention reference imist Ix- directed to the chapter upon that subject. Wagner calls attention to the fact that the use of flexible metallic tul)Os worn for a short period for many days woultl bring about a resolution in hyper- trophied tissue. In my observation in the wearing of splints for the correction of deformities of the .septum I have been impressed with the thoroughness of the nMluction of the liyp'rtDphy in the turbinate, when any existed, and the i)ennanency of this action. It .seems as though this woulil then'fore be a very etHcient if rather un|)leasant method of accomplishing a rapid anil radical resolution. I'llectrolysis is also suggested as a mi-thod to lie employed in the reduction of hyper- tro[ihies of the turbinal tissue. It is an advant'igeous method, as it is altenile(l with little or no local reaction. Its chief disJidvantagc is the slowness with which results are obtained. The chemical cauterizing agents are chromic and trichloracetic acid. These are es|M'cially applicable when the hy]>ertrophy is uni- form and not very tiiarkecl, showing no tendency to form tho.se masses known as anterior or jujsterior hyjK'rtrophies. In the application of these agents it is well to ha\'e the nasal chainl)ers as free from moisture as possible ;'nd to make the points of application over a limitei I area, sn as to pin down, as it were, the mucons membrane to the ])eri- osteuni. If through this means a mnnlx-r of minute points of cau- terization ap' made on the an-a of liyjx'rtrophy there will be a gra<lual obliteration < tin overdist ended venous channels and a reduction of i!ie mtnsv :-i'i!!;!! foi'iieetive ti^-ise .•■.-; the result of the adliC'^io': and contnicti 111 of these points. Latterly, Dr. N. II. Pierce, of Chi oatro, has .suggi sted the sui)mucous ii c of chn 'iiiic acid, and the result- of this iiietho<; of application are highly axtisfaetory. I have founi IXFLAMM.iroHY DIHISA.SES OF THE UPl'KIi AIH PASSAuKS. 7ho the iiicthod fxtronioly easy in tpchni(|ur, and ;itton(|('(l with unifurni ;: I icMilt.s. Dr. (joidstcin, <>f St. Louis, has su^K'''*''''! " six-cial trocar iiiil canuia and cautery cariicr for this |iur})<>s«'. Tlio naivanocautcry I- useful in the same class of cases as the ctieniical ajjents, and should !)<• used in the same manner. The (i^ivanocautery is a most vulualile anient, which unfortunately has bi-en much abused. The disfavor into which the Ralvanocautery has fallen is, no doubt, larpely duf to the fact that through the faulty methods of its application marked reaction-* were freciuently excite(l with profound constitutional disturbance. This was due to the method which was in vopue some lew years ago of Roing throuftli the nasal < !iatnl)ers with long linear rMiiterizationsi'xtendingdown to the turbinai Ixmes. If a very finely |"iinted electnxh- is used, and fnun four t<) six minute but dfH'|) cau- iciizatious are made, the advantage is largely in favor of the galvano- ("lutery over the chemical agents. The galvanocautery ia less painful in ai)plication, with net after-pain, its action can l)e mon* accurat^'ly LMUfred, and there is no violent pan)xysm of 8ne«'zing and headache. In favor of the chemical cautery is the simplicity of its application and ilir abisence of any bleeding, and the mild course of the healing pro- iiss. When we have large redun(hint ma.sses of ti.ssue forming at the interior or po.sterior extremity of the turbinates or hanging from the middle turbinate or the fr(H' border of the inferi-.r turi)inate, tiie most • tllcacious and most resultful method of [trocedure is their removal with the hot or colil .snare. The hot .sn;ire is used by some in prefer- inif to the cold snare, because thnmgh its caut«'rization it is suppo.sed ii> occlude the venous channels and prevent hemorrhage. The objec- li' 11 to its use is the fact that we have with its applic;ition a bunit and \v(.und<'d surface. Through the introduction of the suprarenal extract ;iiid its active j)rinciple, adrenalin, we need have little fearof annoying licMiorrhage with the cold snare, and as its use leave.-^ a perfectly clean- lut wound which heals kindly.it is much to Im> preferred tothe hot snare. < >ccasionally we find large pendulous gn)Wths of iiy;» rtr(i|)hieil lis-iiie along the fn-e border of the inferior turbinate and large infil- tr.itcil middle turbinates, the former filling up the ii>li'rior meatus and tjif latter coming in contact with the septum or m; king firm pressure liiireon. The only operative intervention that will .ffectually reduce this form of hyjiertrophy is by partial or complete excision of the tur- i'inate. Any of the various oj)erative procedures of partial excision, ;i> suggested by Kyle, Hohnes and others, isusually attended with most s.itisfactory results. I find that the cutting away of the lower bonh-r '!' the inferior turbinate bone just through the centre of the ilownwani ■ iirvc and extending through its whole length in an antero-posterior iircction, taking away as it <1(K's all the redimdant tissue with a small n:irgin of bone, results in the formation of a linear cicatrix along the .';i.,lf free border of the turbinate, with a free ivspiraw>ry space ami -ullicient turbinai ti.s.sue left to ade(|uately carry out the physiological : unctions of the na.«al chamber operated upon. The above-mentioned Iteration can be performed with scissors, saw, or conchotome. 50 7m« .\osf: .i.\/j TiinoM |*r| ii i i I : i I 'i: f ii IH Iroin wh.'it roiilts I Ii.i.f .S4(ii from (■(unplcic liirMnotoniy, I atii ratlicr ..|)|mim.,| In its appiicaiiii!: as a suriri il proci-duiv in ai'iv fnriri i>f cliMiiic rhinitis. lit tin- few ca; CS III |)lct«> >f th niv I <• iti- M'cn fcrior Mirbiiiati wliicii I have s<H'ii (Ik patictit n-lifvcl i.f the liy|H-rtn i hy aixl jjiv.-n ,ihs<iliitr I'rccil.ini (i., f|„. n-spiratciry I'lr ■nt, Imt tiic siifTcrinn caiisr.! I,v the pharviinitis si<-ca r.-siiltiii>r lia.«i I..-.-I1 tiiaiiilul.lly j;ivatcr than thr" inconvcni'i'iicf .■ausi-| l>y til. !.r.'vi(iiisly cxisiinji hyi-irtrnphy. 'ccasionally we liii'f hirffc (Ifii-, liy|..T(n.|.hifs winch have liccn vainly attackcl aK.-iii and anaiii liy various cautery aj^i'iits, ami yet they "recur. The niethod ol panial exi-ision Kiven alnive almost always'^ives complete ivliel' in thrs* cases. In summing up the treatineiit of chronic rhinitis 1 sliMiil.l .sf!it4- that a due regard nm.-t 1m' >;iven to the prohahie c;,iisative l.-iclors. and tJiesc should he n'liioved when |Mi.ssili!c. Du- attention shoulil he paid to the -onstitutional condition, hahits and hyuienic •surroundin^rs of the patient, anil that local treatment in.s'tituteil which will hriiijt a!M)iit th'- most .satisfactorv and ifuickest result. (»vero|M'rafive treatment shoiil ! Ih- cautioned" af;:unst, and ine local tntiiment m.-*titnti-il >houlil Ih ,|on(. under as fhoroush aseiisi> as l)o.s>il)lc. Fibrinous Rhinitis. Fibrinous ir iweudomemnranous rhiniti.s may Im> descrilM'd as an acute infl.tmmation of the uasiil mucous inoii!- brane allmded with the formation of t ch.ir.icteristie e.tudation ujion the surface of th(. mucous iiKinbrah, In con.sidcriiifj this sul)- ject one must r>-co>;nize tl;e fact that tin n kv various ty|><v of false deposits in the nasal chamlM'rs which aiv due t.> ditfereiit e.vcitant.-. but which :in' often cla-ssified tojr-ther. Kyle ii;,s well divided thes*- mto thni' ty|ies, namely, cn^upous or i)s<"'udomeml)ranous rhinitis, tibrinopiastic rhinitis, and diphtheritic rhinitis. AlthiMij;li fibrimms rhinitis is apparently a well-defined di.s<>ase wliicli imi.st have always attraited the attention of the rhiiiolopist, it has only U-vu within ti-.c last hfteen years that it has be«"n thoroughly descrilMvl and its clinical ))osilion to a certain decree definite!} e.staliiished.' This eondition i> markedly a disejise of child life, as it is ob.scrved in the pn"|W)nderatin}r projiortion of c.a.ses in children und<'r twelve years of afrc. It mani- fests itself in two types of m ■mbniiioiis exiid.ition. In the one tliere is an outpouring i.f an albuminous exudation which forms a mem brane upon the surface of tlie mueos.i and does not in\olve its .struc- ture. Tliis meml)r;me can Ik- .s<'i)arateil without causing bleedinjr. and leaves a [HTfectly inta.t mucous membrane. In the .second tyin- of cases the e\uda»!on is of a highly libriiions coafrnlable material, which not only i.s thrown f)ut upon the surface, but also involves the substaii'-e of the mucous membrane. This exuil;,le a^ it unilerp>es coajrulation c iitaiifrles within its .subst.mce leucocytes, epithelial dt'bris. and imi.ierfectly I'orjMed ce!!^■ T hi'-.u- ;!<-|>o-!t^ nu'v eximd ih^.m-'li out one or l>oth na.s.al chamlx-rs, forms on the surface of turbina'ti'- and septiiin, is detariinl witii ^rn-al diftieuliy, and when attempts an m.ide at its forcible reminal there usually follows free bleeding. ^^mfm I.MLAM.^fATnny IHSE.lSf:S Of- TIIK I'Pl'fCR Alii J.USHAi.HS. 7S7 Etiology. Tho piinly cnuii nis ty|«- "f I'xuduU- is iiion' fn-qiictitly tin' iinxluct of Incal irritatiuii where eell re.^islaiiee is lowered. Tlie irritatiiiii may lie <lue to injury or to llie action of cuusticd or cautery. Ill :ill [irolciliility iiiiiiiy cases 'if this ty|x' of CAiiihiti tn .ihserved in child life lire due to iiiechanic;i irril tioii Various ciiemical aircnls \vh( II inhaled, os|<<'cially if there is ainady a solution of the contin- iiity of the mucous membrane, will Iw attended \,ith the formation of a crouiHius exi»datioii. This form of memhrane is .-«'n iti its purest ty|M> as occasionally followisij; the aj)|i'icaiioM of the jjaivniio- .aiitery." The meiiihrane thus (K'currinn si it.self as a grivish- white. thick, aihuniiiious, semitranspaivnt lirposit, more or ie.-s adiuiciit at the |<oiiit of injury. Iiut only feehly adiien-nt over the reiiiaiiuiijj portion of th(> niu<'o.si. upon which it n-sts. Tiiis tyjK- of iiieir.hraiious riiinitis is as fre(iuently ol)ser.ed in the adult as in ciiiidhi'od. The etiology of the true tilirinous dejMisit as occurrinc; in tiie nasal ,'!ia.nlier is still •». suliject of considenitioii. It is no <|oulit a distinctly pr'anary "niiditioii ilue to tlie activity of various fi:riiis of c(«'ci, or an atteiiu. it! lonu of the Klehs-LoeHior Itacilnis. \arious forms of cocci hivc Ix-tii found on bacteriological ob.s«'r\atioii li\ different authors. The staphyli>cocci j)yogenes, the stn-ptococci, \(Mi llotTmair's l.icillus, the pni-innococci. and the niicroco<'cus lan- (•(■nj.iius an- the type of cocci usually obs«'n(Hl, while as fn'(|uently ihere lia- Ix-eii observed a Klebs-Loeftier bacillus of low vitality. Tlie relaiionshi]) of this bacillus of a wraiv .lej^'ree of virulence to i!;r true Klel):--I,oetil' " bacillus of diphtheria has n lieeii clearly ilitineii. Wel.nowclii ally that tht fe is anotliei < librinou.s ( Aud.-ition if the na.sal ch.imber, na.sal diphllseria, nti ;■ i ^\ '» the pn.-cnce of the K!eb.s-Lo,>tHer b.icillus, which in it- .< 'u!. ' M.i^-al liistorv is entirely lilTerent from the condition that ■ .'av lave ■iinleriKiisideratioii We also know th;it the clini'-aMii-;: ■■ '. .i.^nous rhinitis .•^eein- to 1k' the same, whatever form of baciiUls . ,;fe.sent. We know < iiuically that the true Klebs-Loettler bacillus produces only one type of di.sease when present in th.' f.iuces, and the streptococci another tyjK , which are in their clinical a.spects unlike. It remains tnr the bacteriologists to explain t4( us why the dilTerent tyiKs of inicro-orp.'inisnis produce in the na.sal chambers a clinically id "tical picture. .Vccording to .Vbbott, ( ultures made from tlie na.s;il •liain- l)eis of a patient affected with this form of disca.se caused iKaiti in iruinea-pigs within forty-eigl ' hours. The dejMisit is usually lini'tid to the ;interior portion of tin nasal chanilxT.s, over the .surface of the M|ituiii. and inferior tur' nate. It may be bilateral or unilateral. I'hf membrane rarely extends iH'j'ond the liiniis of the nasal cham- bers. It is also very intert'sting to observe that this afTection is not Ncry infectious. It seems that in mo t of the cases in which infection ha- followed after expoxire llie TeMiitiiig disea.'^e i,a5 iM-pn in the t'orin of membnuious rhinitis rather than true nsisal or fnucial diph- liii'ria. There an* s«'veral cas<»s of f.i icial inferr;(>n aiid to have •'(■(•urred after exposure to fibrinous ihinitis. ^r the numlx-r of cases 7«8 yOi>£ AXD rilHOA T. I that I havo had uiidor my (>l)s('rvati(tn infection of otliors has I'ovcr ofcurrctl. From our i)r('scnt knowledge of tiiis pon(htion, and . <|h'- cially on account of the fn'iiucncy of tlic fin(hii); of the Klelw-Loctficr l)acilhis, it is prudent and advisajjlc to make cultures of all oai<c.s and to insist upon the tliorouph isolation of jjaticnts. Symptoms. This condition is frciiucntly ushcrod in by more or less ijronouncod general syinj)tonis. Thcif is usually a chill or a chilly sensation. There is generally a feeling of malaise, depression, loss of ap])etite, thirst, and ni children extreme irritahility. The temiM'rature at the onset n..)j;es from iM»° to 101° F. : after the sec Olid day the tem|)eratun> runs ahout 100°. \t (tther times the gen- eral symptoms an- insigniticant. Then> is nasal obstruction in the side affected, and in case both cavities are involved it is complete. At night the breathing is very distressing. There is a seropurulent discharge from the nose. There is impairment or los.s of the sen.se of smell. Frontal headache is very marked, a.s well as neuralgia along the course of the tiiih nerve. In littli! ones the ntusal obstruc- tion, the mouth-breathing, the febrile disturbance, the nasiil dis- charge*, and the disturbed rest at night form the most amioying symptoms. On examination of the na.sal cavity the characteristic appearance of the condition will be observed, the vestibule of the nose will be noted to Ik' inordinately congested, while on the se])tuni and over the turbinates will be ob.served a distinct, well-detined. grayish-white membraiii', which is very tough, fibrinous in character, and which can only be separated in small shn-ils, such separation being followed by copious bleeding. The swelling of the mucosa with the su}jerim].osed membranous dei)osit cai.sos a complete and abso- lute occlusion of the nasal chambers. Diagnosis. The diagnosis is usually n>adily made from the history, .symptoms, aiid the local condition observ-ed. (tne condition witii which this disease might be confounded is that of a foreign body in the nasal chamber. In the ca.se of a foreign body the mass of floccu- lent exudation which simulates croiijMius exudation can readily he removed, and the foreign body may be recognize<l on insiK-ction or by the use of a prolw. The diffen-ntiation from true nasal diph- theria is usually nmde without difficulty. In na.sal diphtheria we have marked general symptoms attended with considerable pms- tration. In fibrinous rhinitis the symptoms are much milder. .\as;il diphtheria is always attended with postna.sal and faucial de|M>sit. with a profus(> sanguinolent seropurulent discharge. Fibrinorhinitis is almost never attende.l with extension to the pharynx and fauces, the discharge is more seropurulent and not very profuse, and then' is absolute blockage of the nasal chambers. In nasal diphtheria we may h.ave nephritis and j)aresis: in Hbrinous neither of these condi- tions. Pi'ognosis. The prognosis is extn>mely favorable as to life. Chauveau reports a case of death, but it was apparently due to a secondary development of tulxTcular meningitis nither than to the membranous tSFLAMMATORY JUSKAHES Of TUE ViVEU AIH VAUSAUES. 789 rhinitis. Tlio disoaso follows no roRular course, and has an indpfinitc duration. In favorahlo cases it lasts al)out ten days or two weeks, at tiie end of which time there is a complete exfoliation of the mem- brane with a gradual n-solution of the inflamed nuicous surface. In more unfavorable cases it may j>ersist for a period of si'vend weeks. Treatment. The constitutional treatment, which stH'ins to be the most inii)ortant and resultful in this disease, ha.-s lu'cn generally along the line which has been followed in fibrino])la.stic exudation when occurring elsewhere ui)on laucous surfaces, the hrst indication being tlie thorough opening of the bowels through the medium of fractional doses of calomel combined with bicarbonate of sodium, followed by a .saline. This is foUoweil by the administration of the tincture of the chloriile of iron in 1 gramme do.ses every four hours. The calomel should lie repeated fre<iuently ei ough to keep the bowels in good condition. As there .sei-ms to be strong evidence through bacterio- logical investigation that many of these cases owe their existence to the presence of a bacillus identical with the bacillus of faucial diph- theria, it would Im^ advisable, where such bacillus is found after culture experiments, to administer from 2(K)0 to 4(KK) units of antitoxin, according to the age of the patient, and to repeat the dos? according to the methods adopted in the treatment of faucial dip'htheria. Anti- toxin should, in all ca.ses where the Klebs-Loeffler bacillus is found, give a-i radical and decided results as it does in faucial diphtheria. .Vs the treatment previou.sly emjjloyed lias had no influence what- ever upon the bettering or shortening of the attack, we shall look with considerable interest for the action of antitoxin in this disease. Patients should lie isolatcnl. and this should be thorough until the roult of culture proves the non-existence of the Klebs-Loeftier bacillus. Local treatment ha.s ajiparently accomplished little in the improve- ment or shortening of the attack. Attempts at separation of the membrane seem unwise. Clearing of the na.sal chambers with an alkaline antisejjtic spray keeps the cavity clean and lessens absorp- tion. Kyle reconnneniis a 1.") per cent, solution of chromic acid. I li;>ve foui'd the best results to follow the use of a 5 per cent, solution ot' lactic acid. This should be carefully applied to raw surfaces with a cotton-carrier after cleansing of the na.sal chambers. Atrophic Rhinitis, .\trophic rhinitis is a chronic catarrhal in- ilammation of the nasal chamber liaving an uncertain onset and an imletinite duration, being attended during its cour-e with increasing and |)rogressive destruction of the glandular and epithelial structure, a'l.l the formation of crusts and scales within the nasal chambers, wliicii occasion a distinctive odor, terminating in a true- sclerosis of tiic na.sil mucosa and atrophy of the turbinal os.seous tissues. Before entering u])on a consideration of this subject we shall dev()te a few words to the discussion of the existence of two distinct diseases, namely, oza'iia and atrophic rhinitis. Oza-na is simply a term, as its derivation implies, to designate the existence of an odor issuing 790 yOSE ASn THROAT. \i from tlip nasal chaiiibors, and can Ix' a])pli(Ml witli equal force to any (li.si':i.se(l condition of tlio nasal diainhcrs which is attended with an unpleiusant exhalation, as for exaiupie, to nasal sy|»hilitie necrosis, toreign bodies, rhinolitiis. and sinus diseases. ( )z:i'na in itself ex|)lains nothing: it simply indicates the feature which is most unpleasant and intolerable in certain dise:used conditions of the niisal chainlx-i-s. It is, in fact, a term which by some authors has lurn apolied to tlistinguish a more severe type of atrophic rhinitis, or this disease in the most active stage of its development, wherein the crust for- mation is most abundant and in which the stench is the mort |)ro- nounced symptom; the j)athe' -^V'-il changes and the train of sub- jective and objective symptoms are the :;ame as in the condititin which is more generally described as simj) e atrophic rhinitis. The odor may be the most pronounced and distrcising sym|)tom in atrophic rhinitis; it may come and go, it may b<' m.irkedly ii..inifested at one |)eriod of its life-history, and almo.st disa,)pear at another, it may be i)ilateral or unilateral, and it may be influenced markedly by ( fforts at cle.'inliness and through the use of reiaedial agent.s. Liuler these circumstances it seems rath(>r illogical to designate as a distinct disease a .syt!iptom which is but the |)roduct of ii well-known and characteristic disease which has a well-dotined clinical history and produces uniform pathological changes. Etiology, 'lucre is no dise.i.se ill rhinologj- in which speculation has lM>en s" ramp.mt in the eonsidi ration of its etiological factors as in atro|)hic rhinitis. These theories have all been made along sci;>n- tihe lines, advanced by numerous authors after painstaking care and investigatioii : i)ut, unfortunately, their conclusions are very diver- gent. .\o doubt this marked liiveigenci' if theories is largi'ly due to the fact that no one lias been able to trace a given case from the absolutely normal conijiiidn into the developinent of and through the successive stages of this disease. We :u'e at the present time apparently as far from the universal aceeiitance of a tenable theory as to the etiology of atrophic rhinitis as in the beginning of the investigation. TIk' various tlu'iuio wi.icli li.ive been advanced to explain the origin of itrophie rhinitis are of interest, and are here given 1. The theory has been ad\ anced that atrophic ridnitis is a secjueia t.' and an advanced form of hy|)ertrophie rhinitis, .\ecording to ■(';is vi w tli'Ti" is fii-t thi' intrava.scular connective-tissue hyper- li-ojihy ■ind ceHular intiltration. fcilowed by coimective-tissuc c.in- tniclioii. resu !in<r in more or less de.-iruction of Uie nutrient arteriiil supply to the !iiu<'osa ami .s-<eous structure, producing an atrophic chanire within the boiii' and mucosa. 2. TIeit the condition is the result i>f !in anatomical alteration in the osseous framework of the nasal chambers — .a) tli.at tlu eoiidition is due to abnormal widening; (b) that it is the result of abnorm;i! shortKc^s, lihi (■• that it is due to congenital shortness of the nasal fossa' (Zaufal, Ih iimami, Fraenkel. Sauvage). I^i ISTLAMMATORr DISEASES OF THE UPPER MB PASSAGES. 791 •< Th.t itrcnliie rhinitis is the result of a mrulent rhinitis in '"■'f Xs'a result of suppurative changes in tlxe accessory cavitk^ mmmmmm. sMmmmm "'''"••''^rf;:f.;;iiatt;r;ni^^^^^^^ r";;::;ji;J':\;h iiiltloi/oft and subsequent sclerose of „.VH.osa ana atro,^.y ..n.one ^,;,,k. who a.lvocates this theory, ll.w.l- Ik K'IS \1>'I .li»r.>v.Tnl a l.ac'illlis lUrli In nam 'i "i ,av,. rise to the evil snu-ll. Stra..a f.-un-l an '"'*'^"^ '.^"J J^^^ mt^si l'J-2 yoat: AXD throat. jl.uioii discovered tlie same bacillus, and states that it is the producer of a chronic purulent rhinitis which is acconii)anied by fetor and leails to turbinal atrophy. Abel, in reports made after further investi- gation, states that whatever the slape in which the |)rocess is observed, if the essential features of the disease are present the bacillus is found. By absolute healinjt, that i>. the disap[M-ar:uice of crust, fetor, and all mucopurulent disciiarKc, the bacilli also disappe;ir. The exact period of life in which the atrophic changes commence is very dilKcult to determine. It evidently begins early in chihi-life. This proce-ss, li'-" other chronic inHammations commencing gradually without marked .symptoms, does not attract the attention of the patient until the process being well advanced distres.ses the parents on account of the offensive odor. It has been ofwerved ius early as the fourth year of life, and I have observed well-advanced ca.ses :n children ;is early ;is the ninth, tenth, and eleventh year. In fact, the most dis- agreeable ca.s<'s, on account of odor and well advanced in atroi)hy. that I have ever witnessed were manifesteil in two sisters of nine and eleven yi'ars. It is peculiar that the disease! .seems to affect the female s<'x more than the male. Whether the tact that women seek treat- ment more fretiuently than men for Mich disturbatice explains the preponderance of ciises observed in wo;nen over men, it is impossil)le to state, but I am inclined to believe that it is numt>rically more fre- quent in the gentliT sex. In my ex[)erience it luus lieen overwhelm- ingly more frecpiently olxserved in women tiian in men. This condi- tion, while obtaining among all classes of people, is no doubt observed more fre(iuemiy .imoiig the poorer classes. With us I think it apjKvirs more frwiuently among the first and second generations of the foreign born. Symptoms. ILsually with those affected with atrophic rhinitis we obtain a history of a long-existing catarrh. Freipiently we learn that since early childhood the afflicted individual has had more or less discharge from the nose, which was i)urulent in ciiaracter arnl attended with Tuore or less excoriation of the ahe nasi or upper lip. During the early history of the individual the general health wa> excellent, but as the disease became more manifest there was a In- of flesh, impiiirment of appetite and develoimient of an;emia. On iaspection of the external no.se, changes of a cliaracteristic type will l)e observed in some individuals, while others manifest no change This .tlteration consists in .slight spreading and sinking of the nasii! bones, which give an undue witlth to the root of the nose. The thro local symptoms which characterize the disease are the secretion, tin odor, and the .atrophic changes. The .secretion of the na.sal chamber^ is markedly .altered in this disease. The .source of thi> secretion, whether it is the product of the ctit.irrhal changes in ttie nuico.sa or the outpfinring of discharge from within the accessory .sinuses, whicl. .'iccmimlate within the nasal chambers, is still a disi)uted ipiestion While (irlmwald ;ind others may be correct in their contention tii.ii fre(iuently atrojiliic rhinitis and .sinusitis go hand-in-haiid, the view JXFLAMMATOUY VJHEASKS OF THE ll'l'ER AJll PAHSAaKit. 7«J3 \v(»ul<l not <'Xi)laiii the origin of the idnitipiil spcrotion in atro|)hic liiiiiitis in cases wiiiTc sinusitis is i^nown not to exist. Tl'is seeretion vaiie:. greatly iiccording to the stage in wiiicii the ilisease is oi)serve(l. Ill llie very early liistory of tiie cases it is inclined to he more Huid, aiitl is frecV/'ntry ohserved in a seniili(|uid state, filling the inferior iiicatMs, wliii.' over the inferior and niiildle turbinates it forms soft puitaceous whitish masses which sei)arate themselves easily from the underlying mucous mt inhrane. As the jjrocess becomes more ailviuiced the Huid secretion is diininishe<l and the crust forms more (ir less completely over the whole mucous lining of the njisal chambers, ("rusts formed iii this stage are of a reddish-brown or greenish color, aiitl scale-like, firm, and tenacious in their adiiercnce to the mucosa. ( )ft times in this stiige of the lesion complete mucous casts of the nasal chambers can Ix" obtained by removing the crust by means of forceps. Alter removing crust in this .-«tate, and gently insiimating the j)robe above and b'lieath the middle turbinate' and in the mucous folds in tlie vertex of the nose, we can often observe more or less liijuid secre- tion. In the nio.st advanced form, when atrophy seems (|uite com- pletc, diere is not nmch crust formation, what little forms adhering ill .-iiiall ina.--ses of a greenish-brown color over the (lej)res.«ions or on she upper surface aiul borders of wliat remains of the atrojjhied tur- l)iiials. Fetor is usually present in most cases during .some period iif the existence of the disease. The fetor varies not only in different periods of the same ca.se, but also in different ca.sps as to the degree of its intensity. It is a peculiar odor, which is quite characteristic, iiid i.nce noted is never forgotten. The odor is characterized as a iiiiwiy rat-like smell. It is usually most intense during the greatest iiciiviiy of the crust-forming period, and is markedly offensive in tlin-r cases attended with large jniltaceous greeni.sh-vvhite ma.s.«es. The disagreeable stench is the mo.st di.stn .-ising .symptom to the poor siitf. nrs, ;ind often causes .'ilmost .social ostracism 1" young girls when .•<o aftected. The odor is not appreciated by the patient on account of tiic destruction of their own olfactory .sense. Tlie atrophic changes cxtiiiiling to the jiharynx and larynx give rise to excessive dryness 111 the pharynx and the formation of crusts in the nasopharynx which are r;iised and exix'ctorated. The voice is hoarse, and may be aphonic Mil Hii-'iii^ in the morning, cletiring up -is the crusts are removed and the sivri'tion <\<-ited. An irritative cough is frequc'^tly present. Ileiiiorrhage from the nose is an occasional .symjitom. due to the Liceration of the nasal mucosa by the separation of the crusts. Nasal ■ .li-trucion. on account of the cavities being filled up with crusts, ■iiid conse(|uent mouth-bn>athing, especially at night, is frecjuently a -viiiptom. FIead:iche. frontal in tyjie, is usually present, and mental iiiactinn with lielietiide. and more or less imjiairment of the memory, iiKiv !"■ present. Xervoiisiiess. hysterical manifestations, and melan- ■liiilia ari- concomitant symiitoms. usually brought about either through ostracism or the voluntary shrinking frnni .social intercourse liv the patient on account of the consciousness of the disagreeable (94 yOSE AXD TllHOAT. odor ciiuinatiiiR from tlio lu. :il diaiiihors. The sense of snicll is almost always impairctl or lost, ("oiitrary to what some ol)s<'rver.< state, 1 believe that j>erforatioii of th<' septum is uinisually rare in atrophic rhinitis. I have al.so been impressed with the infrcMiueney of vatarrhal and suppurative ehaiifjes within the middle ear in individuals affected with this di.sea.-<e. and. conversely. J have noted the extreme rarity of atrophic rhinitis in those ai)plying for treatment for affections of tln^ tube anil the middle ear. Certain ocular <lisorders are manifest dis- turbances during the projjress of atr.jjihic rhinitis. Amonp these we may note tlie various forms of conjunctivitis, blepharitis, dacro<"Vstitis, and anomalies of muscular tension. ( )ii inspection of the na.sal cham- bers various chanjres will be observed aKfctiiif; the soft mucous tissue according to tlie state in which the di.sea.se ha.s advuucod. .Vs is well Fig. 413. An advauted stage of alroiihy v{ luuoHsa and bony turbinBls, a> seen in atrophic rhinitis. known this di.-;ease usuallv affects both nasal cavities and produces tiii^ chaiifr.'s simuitane'iu.sly in both chambeis: occasionally one chamber will be affected, and at a later period the other, and very rarely the di.sea.-<e .-icems to involve only one of the two chambers. < hi Hr>t inspecting the na.sal chambers they will be observed filled with tli( crusts so characteristic of the disease, and these tuust be thoroufrhly removed Ix'fore the exact condition of th(> underlying structure ran be determined. One is immediately impressed with the extreme roominess of the nasal cavities. In tJi" early stages of 'he disease tli'' mucous iiK'niiirane jiresents a )ale-reddeneil appearance. The inferior turbinates .<eem somewhat shrunken, ami the middle may appe.i- somewhat pendulous, or the reverse condition may Iw present. Hot' turbinates may appear somewhat shrunken in one nasal chambc ISFLAMMATORY DISEASE.S OF THE UPPER AIR PASSAGES. 795 tlic mucous incinhrauc apparently drawn tiplitly over tlu' surface of the turbinates, wliile in the other cavity one of the turbinals may seem to i)e hypertro|)liie(l, while tiie other is contracted. In a more advanced form the turbinals are considerably reduced in size, tiie mucous membrane contracted down firmly on the osseovis framework, and of a pinkish-white, sclerosed appearance. In this state there is considerable space between the turbinals and the septum. In the more advanced stapes the cicatrization ot the Tuucosa is complete, and tiie inferior turbinate ha.s underRoue such complete atrophy as to iippear only as a more or less prominent ridge on the outer wall of the nasal chamber, while the middle turbinate appears as a very thin plate, much shortened in its vertical dimensions. In the advanced state the atroi)hv of .soft and osseous tissues has been .so complete that a view of the pharvnx can re.adily be obtained by anterior rhinoscopy, XI that the upper surface of t lie soft jialate, with its movements in (lcf;lutiti(m and phcmation, the mouth of the Kustachian tub<', and the post pharv-nx can be clearly observed. The diagnosis of atrophic rhinitis should be accomplished without much ilitiiculty. There is hardly any other affection of the nasal (•ii.imbers which presents such a clear and characteristic chain tif symptoms. Krom a syphilitic caries or necrosis it may be readily differentiated by the presence of exposed or necro.sed bone in syph- ilis, which is never present in atrophic rhinitis, by the difference in liic odor, and by the evidences of constitutional impairment noted ill the sy])hilitic and not observable in atrophic rhinitis; from a toreigii bodv— in this condition we have the sudden on.set, the obstruc- tion, usually unilateral, and the ])resence of the objc-l, detected by inspection through the sjM-culum or by the use of the probe. Prognosis. When one considers the vast amount of therai)eutical material that has been brought to bear U])oii this disease, and with what avidity each new agent is hailed, we cannot but be impressed with the great stubbornness of the di.sease and how futile all efforts so far have Iweii in bringing about a cure of the di.sea.se. I have never seen a cured case of atroi)hic rhinitis. I have seen ca.ses of atrophic rhinitis that have apparently nm their course, with large patulous cavities, atid freedom from odor or crusts. These are spent (Vises, not cured cases. I would therefore state that atrojjhic rhinitis ill I lie present knowledge of our therajieutic resources is not a curable lisease: but under carefully carried out C(mstitutional and local ni'atment it is su.sceptible of improvement, with a lessening of the iitivity of its destructive jjrogress, with amelioration, or even a "iiijiiete abeyance of its most unpleasant ami annoying syniptom.s. Treatment. Whatever line of local treatment is in.stituted it is ilisiiiutely necessary that cleanliness form the primary and essential ature (if this treatment. Thorough cleansing of the nasal cham- 'Ts once or twice daily with an alkaline antiseptic wash introduced ly anterior and jwsterior injection until the solution C(mies through irar and free from crusts or secretion is very important. The solii- 7!'<? yoSE AMf TIIHOAT. tiniis arc iiitidilucfd (interiorly l)y any of the various f(»riiis of iia«;il iloiu'iii's, pr('fcral)ly by those exerting only a moderate (le>;ree of pressure, ami posteriorly Wy the postnasal syriiipe. i'atients shoulil l)e tlioroujilily iusiructed in the use of these nu-chanicai deviees and in the danjrer ineurred hy forcihly l)lowin>j of the nose durinn the use of the douche. As the (juantity of solution which is to 1h' used is larjje it is wise to select some solution which will accomplish good results without iH'inj; very expensive. I know of nothing that t'(|uals a normal saline .solution. This can Im- prepared each time hy adilijig a teas|)oonful of salt to a litre of hoiled water, or by using the tablet of nasal phusma before referred to. Another solution which is also verv erticacious is one composed of one teas|)0()nful of a 10 per cent, solution of permanganate of potash to the pint of warm water. Ht^ric acid may \yc used in the strength of Id to .'{() grammes to a litre of water. In the early stages of the cleansing it will In? nece.ssarv to aiil the action of the solution, on account df the densitj- and tirnmess of the crust, by the u.se of cotton-covered probes. Daily or every alternaf'-day the patient should be carefully cleansed by the attendant jihysician, and he should go over the whole nuicous surface as care- fully as possible with a cotton-protected prolx", removing all crust and pus from within the folds and duplicatures of the mucous ineiii- brane. Due caution should be observed in using instruments for douching and sprays, to see that they are as sim|)ly contrived an jMissible, that they are aseptically constructed, and that tliey admit of sterilization. Various forms of local treatment have been suggested, mechanical and medicinal, to meet the various theories that have been suggested as to its etiological factors. Cleanliness and active irritation through till' medium of irritative drugs is suggested by those Ix'lieving it the seciind stage of a purulent catarrh. Those accei)ting the histological changes believe in curetting, galvanocautery, and vibrato-massage, (irimwald and his adl'.erents resort to the opening uj) of disea.sed sinuses. Bayer ami those acceptinp the trophoneurotic idea resort to interstitial electrolysis. Indeed, excellent results are c'aiined hy those resorting to the u.se of eli'ctrolysis in the treatment of this disease, and as its application is so readily made I should strongly ailvise its use. While the bacteriologist has suggested the various active germicidal agents, formaldehyde and bichloride solutions, among the various local mechanical agents that have been suggested are t.-nnpons ((!ottstein\ use of curettes, and the action of electricity. There is no doubt that the (lotlstein tam|)on is a valuable agent in the treatment of tiiis condition, especially in that class of cases i:i which from various cin'umstances frequent irrigation cannot be eiii- plo\e,l. The tampon is readily made by the ]>ati<'nt out of absorbed' coMiiM. and is easily introduced and removed from the na.sal cham- ber, riie mass should be large enough to tit well into the na^:ii chamber, and should be nearly ;is long as tiie little finger. It should ! '■ well greased with a neutral non-irritating oil, or, better still, witli i (■': m IXHAMMAroKY l>I.St:.lSES UF Tilt: ll'fEIt AIR VASS.UlES. 7:,7 ■>5 or 50 n.T cent, solution «f ichthyol. Whcr.' inoriiinR or . vciiiiiR rlrausiug is tl.oruunl.ly rcs,.rt.Ml f. it is ..i.ly lu'C-ssiry t.. w. ar th.- lan.iH.n fr.-in tl.r.'.- t.. f..ur hours .hiily m ••acli imsal chamlM'r. Il.e ,M> ',f il.is ajtn.t will ih.1 Lriiijl about rt'solutum: but witl. thonrngli HcaiisiiiK an.l tlu- us.- of tl..- taiupoi. iiMMlicat.-d witl. ichtliyol th.-rt> will bo a u.arkca diniiiiutioii in cnisi formation an.l Icsscnui},' ol ti.e olTcnsivc odor. I can sc<- no reason for tin- us*- ot il.c (urrtt.^ or .nlvanocautm- lus pa.t of tiu' routine treatment m this aiunent, nor do the advocati's of vibratory or interstitial massajre seem to assert ■,nv result from their treatment. This method ot vil)ratory ma.s.s.,iie, oriL'inally instituted by Braim. is still stron^rly a.lvccated by many of his adherents. It may be used l)y han.'. or motor. In this eom.try SImrley, Price-Brown, and Bishop claim excUent r-sii ts fn.m its „>.■ -Vn'oiiR the local reiiu'dies that an- mow Immiik ised. :uid which seeminL'lv exert more or less intiuence for g(.o.l in this type ot catarrh. nnv be m.-nlioned .ormaUlehyde. xO.ich may be .'.ed m the stren^Mh of i to r)0(K), praduallv increasiiiK the strenpth as it becomes beaiable t,i the patient. Stearate of zinc, to which is adtl.'d 1 pramme o pnwdere.l nitrate of si'ver to the ;{-> K'"- insuttiated into the cleansed insd chambers, shonl.l not Ik> used more fre.|uently than every il,ird dav. Both of these age;its are stimulatinp ami cau.se more or l,s-; oain' Mentliol is extensively used alone or in combination with ,Mu>phor'or io,line in oily s..lution. Uliile I believe this a pood protective and an exceedinply [.lea.sant apeiit after thorough cleans- iM.r of the nasal chambers, nev.'rtheless I cannot vi(>w its use but as^'iidini; and abetting th.- progress of thedi.sea.se, and therehm- won d a,lvis,. stronglv against it. In ichthyol we have an agent which, ^vhen iudi'.iouilv u.sed in connection with thorough cleansing, or in roun.vtion with cleansing and tamp-.i-'ng. gives results whicii are ,:,r superior to those attainable by any o^her form ot treatment with . liieli we an- -4 present co.r .Tsant. Th • ichthy..l should at hrst be u-e,l in l.^ p-r cent, solution, rapidly increased ie strength until it r.|, l.e l)orne in 7.5 per cent, solution, or to the full strength of the ■ \ni" The drug should be thon-ugiily in.stilled into every portion ,,t the n:«al clwunber that can be n-ach-d by the dttendant. at least .very sen i.d dav, Somers. of I'hila,leii)hia, claims great succos in ihe i(-sseiiing of crust formation and diminution of odor by the use .1 iusuiflatioii of a -.'.i per cent, powder of citric acid and sugar of :nilk Careful examination should be made iii all case:, tor di.seases ; eommuuicating sinuses. The antitoxin of diphtheria ha.s been ,i-e.l ii, treating this di.sea.se without any permanent results. In the Miimagement of all ca.ses of atrophic rhinitis there is one feature that -hould stronglv impress itself upon the therapeutist, and that is the •iiaiiifest nc'd of radical constitutional treatment. I have never seen case of :;;roi hie rhinitis in which the individual possessing it did •lot impress n,e as one wh(. w:i.s constituti(mally below par. The aI.oI,. hvgienic >urroundings nee<l careful overlooking and correcting vheiiever at f.'^ilt. They should be housed, fed, bathed, and clothed ;iH .vo.s/- .i.\7* r/ntoA T. I itvi t m Ml ,jf :i.«i well as is coiisistoiit witli thfir al)ilit> to provitlu. TIhv ^lioiitil. Uiilfss iiccfssity ftH'l)i(l, live as i iicli mil-ttf-doors as |M>ssil>lc. ( )rc-a- sioiial cliaiijro of cliiiiatc ami surnmmiiiijts cxi rt a ilccidcil hcricficial iiithu'iic)'. Tlif cnrn'ctioM m ilisurtliTfil conilitiiins <<i tlic aliiacntarv canal is vrry in'tciit fur jjimmI, csiii'cially of tlir li.ihil of rniis! mitioii, wiiicii is so prt'vali'iit aiiioiij; this class of patients. It will also Im- foiiml that thcsi' patients improve more rapiilly under a treatment that includes some of the following coii.'-titutiohal a/."'nts: iron, iodine, arsenic, cod-liver oil. or the hypopliosphites. Hay Fever or Vasomotor Oatarrh. Hay fever is characterized as a |K'culiar form of catarrhal in- flammation of the mucous membrane of the nasal passa^>s, occurrinp with a dejtree of ]M'riodicity. The most fn^piently occiirrinp tyiM- of ixTiidic viusomotor catarrh is that which I'xists durinn the tloweriiiji of certain plants, such as tiie rajiwivd, the grasses, and the j;olden rod, which in our climate usually takes place in the month of .XuRust, this form Iwinjr c<immonly designated as hay fever, .\nother ty|M' makes it.self manifest during the latter part of May and .lune in this climate, this form Ix-ing commonly di'signateil as rose-cold, .\nother type makes it>elf manifest during any [period of the year, in winter as well as summer, app.-irently due to various .sources of external irritation, and i- designated as [mt- emiial vasomotor c.itarrh. Hay fever first attracted the attention of medical world through the fthle description of this condition liy John Hostock. in ISIK. Tlir Kinilition had lK>en recognized for .-ievend centniie.-; iii>\ious to Hostock'^ descrit)tion. Thosr to whom nc are ind<!>ie 1 f.n our present knowledge of this diseas" an> Phoehu-^, Helmlioit/. iiiiu, Hlackley. Weyman, Meani. Marsh. Daly, Hack, Roe John .Mackenzie, and I'/ishop. Etiology. It is generally accepted that there is essential to the development of visomotiT catarrh the pn-seiuc of three factors, which are cl.issiiied as. lu'-^t. a neurotic temperatiieiu : secondly, a hyiK'nesthetic condition of the terminal tilaments of the sensmv iicr\c>. usually hiougiit ahout hy some local change; and thirdK'. the pn •-;<;(■(' of M.iiii' sutiice of local irritation. It is a well-known l";Ht tliai ili(i> • who sulTer from the various tyfx's of va.somotor disturhanci's .show by their very presence, their .nctions. their (|uick, nervtms wav-, the existence of the nervous teii:iM'rament. iIk neurotic iiabit. Tho-e atTeetetl witii the .•ulmetit belong to tliat class of individuals who arc intense in lli'ir natures and given to mental ralhcr than [)hysicil :icti'iity. The jicriodicity of the attack points al.so strongly to ; - 'it'r\ous character. It is more common among the In-tter class, amoi ;.' those who live more or less luxuriously. It is distinctly hereditar- . .•uid oiten afflicts many members of the same family. It is also pnn - '■ I!' among 'hose who evidence a lowered nerve activity, as i ■ n, ill .stliemc, although not as common as among those who shiw i ISHAMMATilRY lilSKASKS OF TJIK I'l'rEH AIH PASSAUES. iliHii'i' 111 iiiaikcil 1KTVOU.X activitv. TIk 7{»9 srivat iirrvoiH strain aii<! mental im-ssiirc ( >.•«• who an- siihjcpt to the ii'iifs II >minoii to the <'iiviroii fa jm-at fity arc iiiiicli iiuin- fn'(|u..tit sufrcr.>>, fmn, tl i.ila.lv than thiis<' who Icuil the cv ili'nt vilhiRc and coiintrv life. .\ •Ml and unexciting existciK •«' inci- ,f , ,., , ,, , iW wH'nw to Ik- cxenii.t. It atfiM't- ihildr..., of tni.l.r ag.- as well as the age,!. altho.J, n.oir i.nval.nt dunng nnddle adult life. The hy,H.m.nsitiven..s« of the |«ii|iljer.d nerve Imngs u;. the eonsiderafioi, of the various lorn! p..th..log,,a| d.sturl.anees whirl, nmy l,y their existence give origin tn the hy|M-rsi.,.s.t.v.. condition. The (|uestion of the existenc.. of ccrtani an-as of hy|H.rsensifive tissue which can Ik- located with .•xactness ,n tho.se who an- susceptible to or suffer from v,i.so,notor catarrh cannot In- doubted: l.ut that the«. an-as an- constant and are '■Nit.d to certan, regions of the nasal cavities is not dci.K.iistral.le. I has also Ik.,.,, del non.st rated that there are many local patf gical •liMMges ,,, themtsal chamlK-rs which. I,y the irritation of the fija- .1.. .It. o( the .s,.„.sory nenes distril.ute.l throughout the na.sal cavi- i-v ungmate reflex .hsturl.ances which aid in the ,,ro,luction and ...nntenance of vasomotor catarrh. Drs. Daly. M.k-, llosworth. and link «^.r.. tl... stro„g..st and most ardent ndvocates of this local •M -'111 ol vason.otor catarrh. Among th... intrana.sal conditions which may he mentioned as pro.jucing local irritation are acute and chn.nic c.-. arrh, liy,K.rtrophic catarrh. hy,K.rtrophy of tlie mid.ile turl t.ate p..lv,... growths of various kin.ls. spurs and deflections of the seZ,,; .uiil di.s<.ases of the communicating sinuses. The pn-s^-nce of one of M lM,^r, v...r...ty . f irritatmg agents ,nay he tl„. <.xternal exciting cause '"■ ••^m Ik. n„ douht that there n.u.st Ik> son,e .source of external "itaiiun to tur,...h. as ,t were, the stimulus to the alreadv irritated i.n.cosa and th. susceptihle a.i.l over-charge.l nervous svs te, , s -M csseiitial that the so..r"e of local irritation should "he the .sa„,e in .III (.ises. The source of irritation may Ik- the odors of animals ynmis drugs, a.s ammonia, ipecac, salicylic acid, the , last of the " .Is. exposure to the direct rays of the sun. the cKlor of roses an.l the 1-1 -n ol various plant.s. I, is ,,uite noticeable that a p,.rennia frm ■ 'Mia. k e> s experiments in the causation of hav fever the ,,ollen ..;. .IS IS exciting cause l.us fn-en almost uni^.-rsallv accepted ' . at t ...se ,l,sea,ses are more pn-valent during the pLriod '"" I. the pollen of eertam flowers and plants are being ,li>- n lated strengthens greatly the theory that' the.se variou, t.ll e s '■ the direct exciting cau.se of most of the c;,.ses of vasomotor ca arr Mer, ni""-;"'';'"^ *'"' '"'"' '-'''"'"^i'''" ^-'-"S- and /ie «,ur o f ,,,!'•' '•'•';P"':^'V'-l.v»re inpnnlucingparoxvsms of vaso t catarrh . i.s ,,,„te impossible to state. There is no doubt hat '" ui t,e t,,„pora,nent. \ery rarely do we find anv natholoeicl ■ '^...ge m tliese cases in the nasal chamber, other than the disteSd, MICROCOPY RiSOlUTION TEST CHART (ANSI and ISO TEST CHART No 2) u; |2.8 m Ui, Hi 1^ IIIIIM Hi %am b ■ 40 12.0 .8 1.6 A /IPPLIEDJNA^GE _lnc ^a— ■■ '16) *82 ■ 030G - Phone ii'j- 800 yO.SE AM) Til no AT. relaxed, and palo turhinal tissiio, witli tlio outpnurinfr of clear, watery secretion, the relief of which is in no way hronjiht ahont by local treatment. Only occasionally can these patients mention any source of irritation or any condition that seems to excite an exacerbation. When such local source of irritation is given it is generally some unusual excitement which imiires.ses u|)on one the jjecnliar nervou.s character of the whole disturbance. The type (»f nervous condition which is usually present in p<M-emiial vasomotor catarrh is that of exhausted nerve energy, neurasthenia. In the disea.se of hay fever and the various disturbances of this class we note one pathological feature which is ever present, and from whose pres(>nce most if not all of the sym])toms originate: that condition is a vasomotor paresis. According to Hishoj) and others the central disturbance is excited by an increase of uric acid in the blood, brought about by either an excessive ])roduct of the acid or a dimini.shed excretion of the same. This ])erversion of nerve function, which leads to disturbances along the course of the na.sal and bronchial sympathetic, may not i)e as nuich due to increa.se of uric acid in the blood as to other excretory elements which accumulate at times in excessive ([uantities in the blood. The condition of uricacidirmia lias al.so been mentioned by numerous other authorities, and treatment directed along this hne seems to be attended with marked improvement in many ca.ses. Symptoms. The j« culiar characteristic of hay fever and rose-cold is the periodicity of the symptoms, the persistence during a certain interval, and the usual abrupt and comi)iete subsidence. The attacks occur with marked jx'riodicity, the ])ati('nt being usually able to tell to the exact day when the invasion is to be expected. The attacks usually become mon' .severe with each recurrence, and after a few- years it is not only the upper respiratory track that is involved. i)ut to this may be added an invasion of the bronchia! mucous membrane. It is also to be note(l that after several years of successive inv;ision the attacks do not terminate .Ml)ruptly with the onset of frost, but grad- ually subside, while slight local irritation might provoke a full recur- rence. The attack is ushered in by a sensation of dryne.ss, fulness, and itching in the nose at the vault of the pharynx and at the imier canthus of the eye. The above-described symptoms last but for a few hours, when they are followed by violent |)aroxysnis of sneezing, which rei)eat ihemselves again and jigain throughout the day. Ia- posure to direct sunlight or dust product's a paroxysm of sneezintr almost instantaneously. There is intense itching of the con.jm.ctiv:e, increased lacrymation, and considerable photophobia. The na>al nuico>,i is swollen, the na.sal cavities being partly or comjjletelv ob- structed wi' " ■■ ■ P rge, more or loss acrid in cl lar- ■ter. There is fre(|uently a dist'e.ssing c<(ugh, especially at nigh riiere is congestion of the eyes, with more or less putfine.ssof the eyt ' neural; lid and dgic I )ains in the e\ei)alls. There is fre(|uently marke. distress over the whole head, or the ))aiii may be localized only ov the frontal region, producing a seasation of great distention tliereit JM-LAMMATOIir VIJSEAHES OF THE UPPER AIR PASSAGES. 801 lividt'iiccs of tubal catarrh arc not wanting, as is frwiuently shown l)V itcliins or soreness alonji; tlie course of tlie Eustachian tube, a feeUng oi fulness'or pressure in the ears, and more or less iini)airnient of tlie licarinj;. Tlie amount of constitutional symptoms (lei)encls to a certain degree upon the severity of tlie attack. Tliere is usually >ii,,iv or less irritability of the temper and other manifesiations of extreme disturbanees of the general nervous system. The i>atient becomes pale, anil there is a general lowering of the physical tone, as shown bv lack of vigor, incapacity for mental activity, inii)airment of the memory, lassitude, loss of appetite, and marked disturbances of the digestive functions. The attacks of sneezing and discomfort generally subside during the night. There is occasionally a slight elevation of temi)erature in the evening, with the excretion of a scanty highly-colored urine. The patients freciuently complain of more or less chilline.ss. There may be, to add to the patient's discomfort, a general hypersensitive condition of the scalp or areas here and there over the general cutaneous surface. The local appearance of the nasal mucosa shows more or less turgescence of the tissue over tlie turbinates, which may be so great as to make a complete obstruc- tion of tl'.e nasal chanibeVs, or it may be only partial, giving rise to alternate relaxation and obstruction. This swollen mucosa in receiit cases presents the bright-red appearance of the ordinary hypertrophic rhmitis, but in cases of long staiuling the membrane has a sodden, i)ale appearance. The membrane is usually extremely sensitive throughout to the use of the probe. The congest' I mucosa is usually somewhat more resilient than simple hypertropiiic tissue, and does not indent so easilv at the touch of the probe. After several years of successive invasion of the hay fever, wherein only the nasal and ocular manifestations are i^resent, "we have added to these symptoms from the bronchial mucosa in the form of asthmatic paroxysms. The severity of the asthmatic seizures varies in proportion to the other sympt(")ms. At each following invasion the asthmatic feature iiecomes more pronounced. The asthma of hay fever exists by da> MS well as bv night, and may persist after the subsidence of tlie n:isai symptoms, so that the patient becomes a confirmed .osth- in;itic. . It Diagnosis. The peculiar periodicity, the invasion at the period ot the vear when hav fever is persistent, and the peculiar train of symp- toms makes tli(< lUagnosis a very simple matter. When to this we liave added the nervous symptoms and the nsthmatic attacks, the diasjjnosis is extremelv clear. Prognosis. The prognosis, so far as life is concerned, is favorable. W hen Msthma hi's supervened the lot of the sufferer is a very unhappy one indeed. The conditions spontaneously disappear, and there Mcms to be a tendencv for its sul)sidence with age. Relief can usually he obtained if the means of the sufferer will i)ermit. Treatment is more successful in relieving the attacks and producing j)ermanent riiip- thaii was formerly the case. .51 802 XOUK ASU THROAT. Treatment. In discussing tho treatment of ha> fever we shall first taive up the consideration of the treatment i)et\veen the attactcs, ((() the preventive, i';) tiie constitutional, (r) the local; s<'eoiid, the treatment of the attack, {<i) constitutional, ih) local. During the interval of the attack the various etioloj cal factors should be thoroughly considered, <'liminated if possible, or their jxitency diminished. The general hygienic surroundings of the patient, ills sanitation, as well as his physical regimen, shouhl be carefully considered and regulated. We often find that those who are affected with iiay fever are individuals who spend many hours of the day in batlly ventilated and imperfect i* lighted office buildings, subjectetl to intense nervous tension or work that retiuires a high degree of mental activity. These same individuals usually take no ujKMi-air exerci.se, and frecjuently spend the evenings in diversihed but con- tinuous mental strain. These people must be taught to live ration- ally. They nmst work under better hygienic surroundings, they must diminish the hours of strain, they nmst take active exercise in the open air, and h:n <■ a more rational and suitable diet prescribeil, to which they mu^ ulhere. As long as there is evidence of a defi- cient elimination of the products of imperfect digestion, or tiie accu- mulatiitn of those ch(>mical elements in the i)loo(l, only present when the relations between assimilation and elimination are iint normal, the patient should be kept on a liciuid diet or a very rigid diet, of wliich liijuiils form the i)redoniinant part. I usually find it expedient to give a dessertspoonful of the effervescing phosphate of .soda night and morning, to be increased or diminished according to its action on the bowels. It is usually well, also, to admini.ster three or four tim(>s daily a five-gniin tablet of the effervescing citrate of lithia in a glass of wjiter. ('old bathing, cold sponging, and the cold bag t() the spine, especially in tho.se showing vasomotor disturbances, are especially api)licable. The marked neurasthenia should have the l)enefit of the rest cure, .\mong constitutional remedies certain tonics, alteratives, and nervines are found of special value. These drugs may be used singly or s(>verai in combination. Among the tonics are iron (Hlaud's pill) and strychnine: among the alteratives arsenic, and among the nervines are be'latlonna and phosphorus. The coni- |)lete cessation from occupation, removal of the apparent source of the local irritation, and chanp ■ of environment, habits of life, and location are the most potent agents to bring about relief from the paroxysms. Some people .seem to feel the greatest benefit from a sea voyage or the abiding on an i.sland in the .'<ea so distant that the influence of breezes from th{> mainland are lost. Others get the greatest practical Ix'iiefit from going to the northern mountains and the lake regions of Canada. The White Mountains have one or more imnume places. During the interval in the attacks the nas.al cham- bers should be placed in order should there be the slightest local pathological change. Hypertrophies, polypi, deflections, and other local disturbances should i>e removed or corrected. jyFL.iMMATORY DISEASES OF THE UI'PEli AIR PASSAGES. 803 'riiKATMKNT OF THK AiiAcK. Th«' l)cst trpatinpiit for tho attack is t(( send tli(> patient at once to (tii(> of the itimiuiic places, tliere to re- main until the occurrence of frost at his [jlace of habitation. The ini- nume place from which I havef;ain<'(l the Rreatest a(lvant".jie is Beth- lehem, in the White .Mountains. If the patient is obliged to remain at his lionie, then fjreat relief can he assured him hy ap|)ropriate pen- erai and local treatment. Bishop jjives duriii}? the attack teasixxinful doses of Ilorsford's acid phosphate two or three times daily. He claims tliat it lessens the uric-acid coiulition of the blood by lesseninjj its solvency and aidhig its elimination. He and others claim luost posiiive results from thi.'-' line of treatment. Dilute hydrochloric acid or the nitrotnuriatic acid mif^ht be substituted for the Horsfcrd's acid l)liosphaie. Tlie diet should be regulated, the digestion corrected, and the amount of work iliminished. Among constitutional renie- tlies those that t.)ne up the nervous system should be administered, such its iron, strychnine, and phosphorus. Among all the remedies that have In-en heretofore suggested for the constitutional treatment of hay fever during the attacks, I know ot no drug whose action is so constant, so consistent and uniformly successful as suprarenal extract. The suprarenal extract should be given in doses of three to five-grain tablets, or the powder in capsules every two to three hours. The drug can be pushed until there is noted a feeling of vertigo, nausea, chest constriction, some slight nervous excitement, and increased activity of the heart. I have noted this mild toxic action of the drug in those with high nervous organization much earlier than in those of more robust natures. It is in the local appli- cation more than in the constitutional administration that the drug slinws its distinctive usefulness. Locally the drug should be used in aciueous solution of the dry powder, prepared according to the foi inula suggested by Ingals. Previous to the use of the drug the nasal cavities should be well sprayed out or douched gently with a solution of biborate and bicarbonate of soda, with a few drops of carbolic acid, and then a pledget of cotton introduced into each nasal chamber saturated with the a((Ueous solution of the extract, anil there allowed to remain for several minutes. The drug can be used also by atoniization of the same sf)lution. This may be repeated several ti s daily. This internal and local administration of the suprarenal extract will not always give absolute certain results, but it will give relief and more relief tlian almost any ag(>nt I know of, and, so far as we are aware of, with no unpleasant after-effects. Many have used this agent with the same results that I here speak of, and are as warm in its praises. I may mention Drs. Bates, Bean, Douglas, Louis S. Soniers. Henry L. Swain, K. \V. Wright. S. Solis Cohen, anrl Mullen. 1 here is .some peculiar property in the adrenalin solution that causes 1 t(i occasionally give rise to a paroxysm similar to hay fever, and I would therefore strongly advise against its use to meet the indi- c.itions here outlined. Cocaine has [>revious!y been extensively used to give relief from the na.sal stenosis. The effect from this drug is 804 yOUE ASD THROAT. I only transitory, possesses no doprpc of permanency of action, antl is very prone to give rise to the liai)ituai use of the drug. Dr. E. W. Wriglit, wiio lays great stress upon the hypersensitive condition of the na.sal mucosa as the important factor in many cases, suggests a frictional massage of the mucous memijrane of the nose, in order to increase its resisting powers, so that it can withstand the irritation and excitation from the impact of the pollen of plants. His method is to resort to gentle massage of the nmcous membrane with a cotton- covered probe. At the meeting of the Section of Laryngolop, tnd Otology of the American Medical A.ssociation in .June, 1900. Dr. H. H. Curtis read a pajM-r upon the subject "The Immunizing Cure of Hay Fever." In this paper Dr. Curtis stated that he had, through previous suggestions in the treatment of cases, thought of the i)ossibility of im- numizing in hay fever by the admi.iistration of a tincture or fluid ex- tract made from the flowers and pollen of the ragweed. The Huid f 'ract and tincture of ambrosia artemisia'folia should' l>e given in two to ten-drop doses in water three times daily. A solution ui tea- spoonful doses is also prejjared. There have been reported a number of successes as well as almost an eijual numlx'r of failures after its use. Further use will either prove its fallaciousness or its value. Bhinorrhoea. This is an obscure and curious affection which is exceedingly rare, and is characterized by the escape of u profuse, thin, watery discharge from the nose. lij the consideration of rhinorrh(ea we arc impressed with the fact that then> are two distinct types of this condition, one being attended with the ilischarge of a Huid from the nasal cavities, which has its ■origin in the arachnoid space, atul the other with the e,sca]X> of a similar fluid, but which is secreted from tjie nasal mucosa. St. Clair Thomson hi his able thesis entitled "The Cerebro-si)inal Fluid, Its Spontaneous Escai)e fro II the Nose," has added greatly to our knowledge of the former condition. Cases have also been reported suice. Dr. Thom- son has collated in his work eight undoubted cases similar to his own. and twelve cases probably of the . ame character. Most of the.se cases ha-l been classed by various authors as ordinary cases of rhinorrluea. Etiology. The facto'- which play a rule in the production of th;it class of cases which are clearly attended with the escape of cerebro- spinal fluid is somewhat obscure, nevertheless it is extremely sugges- tive how fre([uently there were evidences of "crebral symptoms and retinal changes. Out of 21 cases, 17 cases exhibited cerebral symp- ton>s, and N ca-^cs showed retinal changes (ThomsonV reports!. Fracture of the skull involving the anterior cerebnil fossa is occ- sionally attended with the escape of a clear, limpid fluid from the nasal fossa. The nasal for r. of this disease is somewhat obscure as tn its etiologv. In most cases there seems to he a well-marked neuroti' temperament which usually manifests itself by .some disturbance of the ISFLAMMATOny inSEAHE^ OF THE UPPER AIR PASSAGES. 805 syinpathotic. It is supposed to bo due to the impairment of the inhib- itory influence of the trifacial or to stimulation of the sympathetic. Symptoms. The affection is characterized by its chief .symptom, which is the discharge of a clear watery fluid from the nose. The ilischarjie may be bilateral or unilateral. When bilateral it indicates more frecjuently the nasal type, when unilateral the cerebro-spinal type. The fluid may be bland and non-irritative in character, or it may be acrid, exciting excoriation of the ahe and the upper lip. The amount of secretion may vary from a few ounces to a pint in twenty- four hours. The di.^charge may be continuous in its How during the twenty-four hours, during the working hours escaping from the nose, and (luring sleep p:«ssuig into the pharynx; or it may be intermittent, ceasing entirely while the patient is asleep. When the discharge escapes j)osteriorly into the pharynx during sleep we may have cough- ing and spasm of the glottis. The discharge u \y occur at periodic intervals, or, while for the most part continunis, there may be inter- vals (if a few days wherein it ceases. The attack, when occurring at periodic intervals during the day, is usually preceded by more or less formication, itching, or paroxysms of sneezing, which subside as the flow is established In the periodic or nji.sal type the attack lasts (iiily a few hours, recurs at regular or irregular intervals, and the amount of discharge is variable. In the continuous tyjx> the dis- charge is persistent through many months or years, and is very constant as to the amoimt. In na.sal hydror-ha>a the discharge has no distinct point of exit: it seems to be an oozing from the general mucous surface. In cerebro-spinal rhinorrha'a the discharge is noted as issuing between the middle turbinate and i.he .septum, high up. 1 Aaminations of the na.sal chambers show very little alteration in tlie mucosa. The mucous membrane may be a little paler than normal, and in the advanced cases the middle turbinate may appear waterlogged. Occasiomdly mucofs jxilypi are found. Diagnosis. The diagnosis of tl i affection is easily n^ade through its characteristic symptoms, the How of a clear, limpid, watery fluid from the nasal chainb(>rs. The important feature of the diagnosis is the (litToreiitiati(m of the purely nasal from the cerebn .spinal rhinor- rhiea, and is as follows: yai^t Hhinorrhira. I'Ih' IIdw is usiiitlly periodic, preceded by riic (lisdiarKP Is not contlnuoii" It iistiHlIy ceases at night. Arnouiu of (Iis<'harKe iliirinff twenty-fojir h'.ur>i and at dillerent i>erl(xls of the day is vari- ill.r Tlio dtscharKe usually issues from both nasal Crrftyro-tpinal Rhinorrhcea. The flow is continuous. It is attended with no symptoms. l>ocs not cease during sleep. Amount of disc'liarge during the day and at different periods of the day is constant. n is always unilateral. The iiandkcrchiefs moistened with the secre- tii'ii, after dryiug are stiff. ciu'inicn! rxamiiiation ri'vpaU thp prpjernff .f iiinriu and albumin, and it does not redu(>e I VhliUK's solution. The handkerchiefs moistened with the dis- charge dr>' sofl. rhnmiral tix»n*.:nati.^n rpvpftlis tl p abispnrp of mucin ; prntelds arc practically at tent, and it reduces Fohling's solution. ■J^-f; 806 yOSE AM) THROAT. ! [ PrognosiB is ralhor unfavorable as to improvenicnt or euro. Treatment. It is very iiiiportaiit in all cases of nasal rhinorrhiva to make a careful differentiation as to the possible origin of the Huid, as it has an important bearing uj)on the therapeutic measures to Ik* adopted. In the eerebro-.'spinal type, as indicated by St. Clair Thom- son, all forms of local treatment are absolutely useless. In rhinor- rluea of a purely nasal type, jtartial relief may be obtained through the use of cocaine, atropine in a(iueous .^^olution, as reconunended by F. Kerper, and sujjrarenal extract. A thorough study of the case from an etiological point of view, so as to enable one to apply that general therapeutic resource which may be of value in the individu;'' case, is absolutely essential. Influenza. Influenza is an inflanunation affecting the mucous membrane of the whole upper respiratory tract and the bronchial nmcosa, with more or less well-marki'd systemic symptoms, evidently due to the action of a sjjecitic bacillus. This disease is mildly c<mtagious, as it is frecpiently noticed that it spreads throughout all the members of a household when one member becomes affected. Influenza respects neither age, sex, nor social condition. It is conuiion to all latitudes, although more prevalent and more active in the temjjerate and collier zones. Etiology. From the fact that influenza is more prevalent during the fall and spring of the year, it has been stated that its prevalence at these times was due to the changes which were taking place in th(> atmo.-<pliere at these .>*easons. Its |)revaleiice at thes(> j)eriods is probably more rationally explained b the lowered bodily tone inci- dent to exposure, which renders the muco.sie susceptible to the inva- sion of the specific bacillus of influenza. Numerous bacilli have been described as the active agent in the production of the pathological condition known as influenza. The bacillus de.'^cribed by Pfeiffer is the one generally accepted as the exciting etiological factor. Symptoms. The invasion of influenza is usually marked by very decided constitutional symj)toms. There is usually a very decided chill or chilly sen.sition, which is followed by a rapid elevation of the temperature. There is marked prostration aiul bodily weakness. Loss of ap{)etite. often intense frontal headache, intense muscular soreness, and ])ain in the extremities. The muscular soreness may attack any group of muscles, but most frecjuently affects those of the back and neck. The 1emperat\ire ranges from 100° to 10;{° F., and is fre<iuently irregular in its tyi)e. Tli(>re is usually manifest<'d an intense catarrhal infl.iiTimalion of the whole up])er respiratory and bronchial tract, with the array of symptoms incident thereto. Thus we have the usual syniptotiis attending a coryza, more or lesj soreness in the pharynx, with ))ainful deglutition and hoarse- ness of the voice. The outpouring nf secretion, estal)lishe<l shortly aftei the invasion, is usually very copious and of a mucopurulent lyPLAMMATORY DISEASES OF THE UPPER AIR PASSAGES. 807 i'liaractpr. Cough is a very persistent and distressing symptom. More or less i)iiiii about the chest vvalls is common. Puin aiui discom- t'ort in tiie pharynx and larynx are fre<iuently out of uU pnjportion tc Lie amount of intiammation evident upon inspection. There is not (mly a marked degree of actual physical depri'ssion in many cases: but this is often added to and intensified by the mental depres- sion and the disturbance of the central nervous syst«'m. Physical examination will reveal the usual changes which we have learned to note as being present in acute inflammatory disturbances of the upiH>r air tract. In the chest we will f.nd the usual evidences of an acute bronchial catarrh. Prognosis. This dise:i.-*e usually runs its course in 'ibout ten days or two weeks, and if due care is exercised in its management it most fre(|uently terminates in complete n'covery. It is a most serious condition when affecting the very young or the aged, as ttie intense .'tdynatiiia is prone to be followed by exhaustion ni the physical power; or the exteii ion of the inflannnation into the capillary bronchi is apt In lie followed by catarrhal pneumonia, either of which conditions may prove fatal. Complications are very common in this affection, and when occurrhig they add to its complexity and its gravity. Complications. ()net)f the most fre(|ueiit complications in hitluenza is the invasion of the auditory tract. We may have tubal catarrh, sinii)le or exudative catarrh of the middle ear, sui)purative otitis, and mastoiditis. The simi)le and exudate catarrh are the most frequent complications in connection with the ears, and their characteristic symptoms, usually intensified in this disea.se, add greatly to the mental depression. The acces.sory sinuses are freciuently affected. Tiiere is no doubt that sinusitis is frequently dependent on a l)re- vioiisly existing attac' of influenza. The antrum of Highmore, the etlimoidal and th'- :■ i '■uises are the cavities most freijuently atTected. Periton^^ ;• ss is a complication that occasionally l)re.scnts it.self, altno- (*>ink it is present as a complication only in those who are su'ijecc lo attacks of suppurative tonsillitis. (Edema of the glottis is rarely a complication. In simie epidemics there is a iiiarkeil proneness to hypertrophy of the lingual and submaxillary glands, which enlargement almost always subsides without supi)ura- tion. Pneumonia of the catarrhal type is a frequent complication of n'":lected cases and in the very young and aged. \'arious nervous liheiiomena may be present as complications, as evidenced by marked iMcntal depression, hypera'sthesia and neuralgia affecting various branches of the trifacial nerve. The diagno.sis of this condition is readily differentiated from acute rhinitis through the marked depres- sion, the i>romin('nt nervous symptoms, the involvement of the lower n>spiratory tract, and the protracted course. In acute rhinitis the involvement of the pharynx, larynx, and louver respiratory tract when it takes place is in sef|uence and not synchronous. Treatment. It is .ibsolutely essential that patient* sufferii-.g from this maladv should be confined to the bed. Under no circumstances 808 NOSE AND TUROA T. should thpy bo allovvod to inuvp about in the ojien nor ovon within tlu'ir rooms. All avoidance of Ixxlily exertion and absolute n>st is essential to prevent unfavorable eoinplicatimi- and to avoid exhaust- ing the patients physieal streiiKth. The i)atient should be placed upon a hinhly nutritious liijuitl diet. The bowels should Im' well oiM-ned by fractional doses of calomel. Bromide of ijuinine or sulphate of cinchonidiiKC should be given in small doses until the temiwrature has returned to the normal. Should there Ih' evidence of much prostration, strychnine in appropriate dosage, and alcoholic stimulants should b(« administered. The convalescence should be a.ssured Iw'fore the patient is allowed to assume his usual vocation. Should cough prove a distressing symptom it should be relieved by ai)[)ropriate treatment directed to that portion of the air-tract from the patho- logical disturbance of which it seems to issue, as well as by the internal administration of codeia, heroin, or (yanide of potiish. Complications should be carefully watched for, and when occurruig should be appropriately treated. - Asthma. In the discussion of the general c )ndition known as -isthma we intend, under this heading, to consider the subject only in so far as it is a respiratory reflex, and to enumerate the conditions in the upper tract which may give ri.se to it. Asthma is a morbid con- dition, in many of its features closely allied to that of hay fever. Its primal causative element is at our present vvTiting a.s far from solution as is the cause of hay fever. Many authors accept a some- what similar schematic etiological chain for bronchial asthma that they have constructed for hay fever, namely, first, an inflamed hyiM-rsensitive or irritable condition of the bronchial nuicosa; second, a (listurbei! or diseased condition of some other system or organ how- ever remote; and third, a neurotic condition which pennits of the linking of the two other conditions through the vasomotor system. This theory permits not only an explanation of the occurrence of the nasal reflex asthma, but also of all other types wliich seem to be of a reflex character; it in no wise attempts to explain asthma due ti> cardiac and l)ronchial disease-. The attacks of asthma, as is well known, consist of well-marked paroxysms ot difficult breathing, usually coming on at night, and of variable duration. The difficult breathing is excited either by a vasomot'-r paresis resulting in a dilatation of the bloodvessel, or by a spa' , of the nuiscular fibres in the small hronciiioles, either of which phenomenon results in a narrow- ing of the calibre of the bronchial tubes affectecl. Morbid Conditions of the Upper Air-tract Which Excite Asthmatic Paroxysms. Tiic most characteristic and typical nasal condition which excites ])an)xysms of asthma is hay fever and the allied types of vasomotor catarrh. In many cases of hay fever, with its amuiai recurreiice, the asthmatic symptoms become the most prominent INFLAMMATORY DISEASES OF THE UI'l'EB Alii PASSAGES. 809 t'caturp of tin- ens*'. Nasal polypus is stated by many authors to he one of the most p(»t('iit patholo^rical fhaiiKcs witlnii the nasal chanilHT exciting by reflex disturbanees paroxysms of astliina. It is difhcult to explain why the smaller growths eause this disturbanie rather than the large ones, unless it be that the smaller ones irritate the mueosa, while the larger ones obtund its sensibility tl ough pressure, (irowths (il other types apjwaring in the nasal ehanibers may exeite the eon- liitioii under consideration. The condition known ,s hypertrophy of the inferior turbinate is also an infrecjuent etiological factor in asth- matic attacks. A similar condition of hyjKTtrophy of the middle turbinate, whether it be a simple hypertrophy or what is freciueiitly called an (edematous degeneration or myxomatous ethmoiditis, is one f)f the pathological changes in the nasal cavity said to occa!<ion asthmatic paroxysms. Among oth'-r changes within the na.'^al cham- bers which may be mentioin'il as causing asthma are spurs and de- flections of the septum ami purulent diseases of the sinuses comnmni- cating with the nasal chambeis. xVmoiig thos<' diseases of the pliarynx wiiich have been eimmerated as pla\ing an etiological role may be mentioned adenoids, nas' pharyngeal growths, enlarged uvuhe, and liypertroi)hied tonsils. In considering the relationshij) betwwn known existing pathological changes in the upper air-tract and asthma, it is well *o bear in mind the fact that however marked the local changes from the normal may be, and how much the asthmatic paroxysms may appear d< pendent upon the local condition, there may be between t'l'iM no pathogenic relationship whatever. This fact it is well to bear in mind in consideringoiK'rative treatment of diseased conditions of the upper air-tract for the purpose of relieving the asthmatic con- dition, in order not to subject yourself to embarrassing failure and your patient to keen (lisai)pointments. It is well to state the probability of the relationship of cause and effect between the local morbid change ai'd the asthmatic condition, and the probable relief that will be afforded to the one by the removal of the other; no further in the l)romise should one go. I have very little faith in the extreme view taken by Hosworth and others that in a large percentage f^f cases asthma is due to some form of intranasal disease. There is no doubt tiiat in some asthmatics certain forms of na.«al disease which may co- exist may be the local excitant, and their removal may be attended with relief which may be more or less permanent. Usually, however, ill order to make the reliof permanent, it is neces.sary to correct the constitutional condition, which is ecpially at fault. Ie.«t some local irri- tation elsewh( -e after a time cause a r'^'-urrence of the asthma. I have seen the removal of minor pathoh „'ical changes in the mse atteiidei" with subsidence of asthmatic attacks, and, on the otlier liaml, I nave seen the removal of spurs, correction of deflections, and niiioval of polypi in asthmatics accompanied with no result so far as tlie asthma was concerned. Treatment. The local treatment should be the removal of any condition in the upper respiratory tract which is pathological and »10 yuHE AND THROAT. \ ! i lujiy fairly Ik- ropardod as a poxailjlc reflex exciUiiit of the asthmatic state, 'riiere shoulil i)e iiistituteil, at the same time as the loeal treat- ment is heiiij; worked out, that fonii of eoiistitutioiml treatment whieh will aid in the relief of the pan)xysms and restore the gtuierul system to the normal state. Acute LaryngitiB. Aeute laryngitis is an aeute inllanimation of the mucous mem- brane of the larynx. Acute hiflammatioii of the larynx is not so common an affection as simila'- catarrhal inllammation of the nose and pharynx; hut. on account oi the alteration in function that it calls forth, the sufferers from this condition seek medical assistance (luicker than those suffering from iia.sal or pharynj;eal inlianuna- tion. Etiology. Exposure to cold an<l wet, the ordimr I'onilitioiis that are |)roductive of cold-catchiiifi, are potent in tlinr mtluence in pro- tluciii}; acute inflanunation nf the larynx. The form of exposure attf'ix'i'd with the playing of a ilraught of air upon the head or neck is the most common exciting cause of acute laryngitis. Acute attacks are also common among those who profcet their throats with nmf- fiers, l)o;is, and collarettes. The laryngitis produced is not .so much due to the simple wearing of these forms of dress as it is the result of the loosening of them when the neck becom<'s warm ami the su<lden chilling tims produceil while the neck is over-<'X|)o.sed. There is also no doubt that certain individuals seem to develop a proneness to acute laryns^itis whenever subjected to undue exjMtsure, while others terminate their acute colds with an acute laryngitis. The spring and fall seem to be the seasons in which this condition is most fre- (jaently developed. Those who are ex^^osed much to the inclement weather without proper protection are also j redis])o>ed to attacks. The excessive use of alcoholic drinks .«eem: also to 1m' productive of this condition. Inordinate use of the voice, especially in a manner that the individual has not been accustomed to exercise it, as well as its continued and excessive use, as in exhortation, cheering, and louil calling, act as exciting causes. This is also observed in over- exertion of the voice in addn^sing large audiences, and the improper use of it in singing and in nil I <; c speaking. Irregularities in the gastro-intestinal tract act ofttimes as a predispi ■•■iiig cause. The various exanthemata are often accompanic'l by an acute laryngeal mflammation, such as influenza, measles, variola, and more rarely scarlet and typhoid fever. Prolonged exi)osure to ba<l atmospheric surroundings a.'nl the breathing of impure air, the result of over- crowding ami ba<l ven'iii-tion, or of ;in atmospliere containing vapors of chemicals, such as iodine, chlorine, bromine, sulphuric nr nitric acid, are j)otent f.acfors of a semitraumatic nature. Direct mechani- cal injury from excessive cougliing. entrance of foreign bodies, and surgical manipulations jir. .ducc laryngeal inflammation.. .Mlacksarr frequently due to exten.sioii of inllanimation from the ])harynx above ISFLAMMATORY DISEASEH OF TUE "I'KR AIR PASSAaES. jjH or friiin tlic trachea IHow. There is a riiarke<| predis<pi>sitioii to thew attacks in jxTstiis sufferiii>? fnuii olisl ructions in the lasul ehanil)ers. Men are inure fre«(uently affected than woniou, anil ..Julta more fre(,iiently tlian chil(in>n. Symptonu. In descriliing the syrnptoins of acute hiryngitis it would Im' extremely dillicult, on account of the varied ty|M's, to define it in more than a jjeneral way, and then afterward inon- can'lully enuineratc the syinptmns peculiar to the distinctive ty|M's. The const it ulional syni|)toins are usually very mild in the average case of acute laryngitis, the patient simply feeling slight general uncasi ness, with constipation. In some of the more severe inflammation, there may he a slight fehrih reaction with the usual constitution m:iiiirestatioiis that present themselves under such conditions. I'sually the hrst evidence that one h;us of impending inflammation is a feeling of pressure or uncoml'ortaMe sensation in the larynx, which grad- ually hccoiiics magnified into a feeling of s)reness. There is often a peculiar niw s<'nsation in the larynx, ai i he !nsi»ired air is dis- tinctly felt as it j)as,ses over the inflamed sur*'- "c. There is fretiuently a sensation of rawness <ir heat felt extending from the u])per border of the hirynx to tin' middle of the sterman. When there is marked (•; ngestion of the epiglottis or arytenoid we have jijiinful deglutition. The tickling or dryness of the throat at first cans- s the patient to m.ike fn'(|uent efforts at hemming, which is later on followed hy fre(|uent coughing. As the s«'cretion becomes established the cough- ing becomes ;.iore frei|uent and annoying. The cough is of a peculiar iH'llowing, metallic character. The cough varies gn-atly in its char- acter, fre,(uency, and the rapidity of its subsidence, accorduig to the region of the larynx affecteil and the intensity of the inflammation. I h.ive usually ol)s«»rved that the cough is njost distressing when the infi.inimation extends to the subconlal portion of the larynx. The c III itions which intensify the cough are exces.sive congestion of th^ larynx, excessive .swelling or an n'dematous condition of tlie e; "'- glottis and arytenoids, exces.sive secretion of a liquid rharact(>r, '"■ the paroxysmal cough excited by crust formation. Tl ^ 'ici varie greatly iti the extent of its involvement hi different 'acks and according to the extent and seat of the intlamiuation. Thus, when the upper portioti of the larynx is involved the voice may not be affected, or only moderately altered, although it usually varies from a moderate hoarseness to coni])lete aphonia. When the free edges of the cords are congested, or the whole vocal region and the false cords inflamed, the voice is usually intensely hoarse. Swelling in the iiiterarytdioid region is attended with hoarsene.ss or complete aphonia, dependent on the amount of .swelling. Paresis of the crico- arytenoid internus. or arytenoideus transversus, which sometimes occurs, is attended with comjjleto aphonia. (Vu.st formations attend- ••int u|)on laryngitis sicca are .K'companied by alternating aphonia iv d hoarsene.--. The amount of the inlerfeicnce ^^itll respiration is in the great majority of cases only slight and practically not noticed -^'\W 812 SUSi: AXD rilROA'l'. by tlio patient, yet in certain forms, as in the laryngitis sicca, tlic hyixiglottic funn, and in the acute laryngitis of children, it may not (uily become distressing to the patient, but actually endanger the life of the affected one. At first there is an intense feeling of dryness in the larynx, but this after a ju-riod of a few hours gives rise t() the outpouring of at first a semimucous secretiiin which gradually undergoes a change to a mucous and nmcopurulent. This discharge is for a few hours abundant, but lessens rapidly as its licjuid elements diminish in cpiantity. The secretion is at times discolored with little masses of coagulated blood or streaks of free blood. The laryngo- scopic picture obtained in tlu' more frecjuent simple acute laryngitis differs greatly as to the seat of the inthunmation and tlie degree of its intensity. The whole nmcous meml)rane of the larynx may vary from a pinkish red to a most intense scarlet red, and the vocal cords may participate in this inHannnation in the same degree as the rest of the nmcous membrane or appear only slightly discolored. Again the vocal bands may show vivid redne-s, while "the remainder of the larynx is only moderately intiamed, or they may show only an intense red line of inHannnation along their free borders, while" the rest of the cords appear normal. The superior surface of the cords may show areas of epithelial deimilation, and this condition may be mani- fest on the surface of the fals(> cords, aryepiglottidean folds, and lateral walls of the larynx— superficial ulcerations. These surfaces are said to give rise to iKvnorrhage. There may be swelling in the interarj'tenoid region preventing the coaptation of the cords, while intiltration in the muscles themselver* may bring about the same condition. The arytenoid region as well as the aryepiglottidean folds may not only be deeply congested, but also (pdematous. Rheumatic Laryngitis. Hheum;itic or gouty laryngitis is that ty])e of laryngitis that occurs after exposure in one who is of the gouty or rheumatic diathesis. It differs only from the simple acute laryn- giti;* ill that the predisposing cause is the (iresence in the circulation of irritating materials, which are being formed in excess or are not being excreted in normal (piantities. In this form of laryngitis the throat .soreness and pain o:; speaking are very inten.'<e and more pronounced than in the simple variety. The throat soreness is in- creaseil during deglutition, and there is marked tenderness on pressure. The voice is usually very hoarse and often aphonic. The p;itient is depressed, with gre.at lassitude. There is a marked indisposition to work and to m;d<e :iny conlimious nient;il effort. The jjatieiit grows extremely anxious as to his condition. There is an almost constant nervous clearing of the throat. The laryngoscopic picture iiuws a slightly more jiunctated condition of iiitlannnation tlmn in the simple Ijuyngitis. There is p;iiii on p;ilpation over the larynx. Laryngitis sicca acuta is ;i sp<'cial tyiw of l.-iryngitis which is cliar- actei-izeil by the peculiar tendency wjiich the .secretion has to form gr,'iyi-ii-wliirc III |iiip\Mii>ii cnists. The milainmation is tnore intense in the cordal and subcordal region. The crusts, which form on [M.ATt-: XX IV F-K. T y|Pf-. I.I A. uu- CaUiMh; il L.:n\ iKjm ATH XX\' n 1- ,,| 1 A. I.I.- c .,1,11 1 l..ii I .11 \ il.irn- i i.| .-■ I 1,'in. .M h.,.| 1 ..I \ ll.|ltl~ 1-,,| H (,,.,l.l.il 1 I r..ii.. 1 .nvn.nt!- sv : I i i (':.■ ii\.|.- . -t M.- lill.Mli.il ..\IM, I--|,....- M.| i P.,. Ii^,|.-| |,M.. 1 .1. V i.,li- IMLAMM.ITOHY DISEAHES OF THE Ul'Pi MR I'AHiiAUES. 813 a.rount ..f tlic .lotifioiu} in watery clomonts in the socrotion a.lluTO „i,itc liniilv to tlu' c.nls, intcnirytciioi.l r("};i..iis, iMi.l to the suln-on al ,;,„tioMs ..}■ tin- larvnx. Tlu- c.nls ar.> usually not very niarkc. y intlamcl, althoufih the intorarytcnoi.l aii.l subconlal irjiions trcqufntly slu.w coiisidc'ral)!.- iractivc chanp's. Tl.o voice is usually quite aDlionie wiieii the patient awakens in the iiiorniiig, l.ecoining almost n'.nnal as the crusts are removed by rasping and e.)U<,dimK. to become .'laduallv hoarser or aphonic within a few hours as tlu' -nists relorm. (■•ou-diink is verv annoviug. and d(>pendent uix.n the a nount of ob- struction produce,! I)v'tlie incrustation; the breath.nr may b< more or less impaired. CoafTula of blood may be occasionally noted m the ,.xp,.,-toration, as w.-l' as free blood. On inspecti<.n the larynx will |„. „l,^,., ,,..! to l)e sli^dltlv redder, the vocal region will be noted to |„, „u„v or less covered with grayish-white or l)r.Ayiiish crusts and ti„. same condition will be obs.-rved in the subcordal region. This (undition is observed more fre<iuently among females, and especially ai,„,iig those wli(. suffer with atroi)hic changes m thr nose, llie condition resolves within a few days or passes into the chronic stage. Laryngitis Hiemorrhagica. (I'late .\X\„ Fig. 2.) This condition cm hardlv be classified as an in<lividual form of laryngitis, as 1 con- sider it simply as an incident in certain degrees of mHammatioii of the i-,ivn\ In the laryngitis sicca during the separation ol the crust we' may have a littU' denudation of the epithelium, with slight show- in- of l)lo.)d or coagula. Also, in the s(>vere types of .«iinple aryngitis where there is localiz(>d necrosis and d<-nud..tion of epithelu-m with ll,c superficial reduction, we may have slight bleeding. Those laryn- •n-il inllammations seenungly attended with marked bimlmg, varying |,„,n a teaspoonful or more of free blood, are not m my opinion hemorrhages from the larvng(>al mucous membrane, but rather blcMMJing In.m the inilmonary tissue. Several of such cases winch 1 have had und<-r careful ob.seryation have borne out my expectation bv disi)laving at a later period unmistakable signs of pulmonary tuluMculoiis Tnless there is a l<.cal lesion in the larynx sufficient to account for the amount of blood lost, I should advise physical exami- nation of the chest and bacteriological study of the sjuita or blood. Catarrhal Epiglottitis, or Angina Epiglottidea. (Plate X.\I\ ., lig. 4.) This yariety of laryngeal inflammation is characteriz«>d by intense • onp'stionof the epiglottis, which in severe types of mllainmatioii ,,ccasionaIlv shows aivas of localized .e.lema. The dilhculty and pain in swallowing in inilamm;ition of the epiglottis is the most pronoun 1 and ilistressing symptom. We note also a profuse secretion of mucus and the sensation of the pivsence of a foreism body. The voice is only a little rough or (piite normal. Inspection shows the ei)iglottis somewhat thickened anl inleiiseiy conii<>sted. while fre<ii!ently along its tree border will be note(l little areas of (edema. Laryngitis Hypoglottica. This \ariely of laryngitis is ha|.].ily not ,1 very common tyjie of laryngeal inflammation. It usually com- 814 SOSE A XI) Til no AT. il Fig. 416. moiicfs with the syniptom.s of a spvcre acuto laryngitis, cli iracterized b}' iiiarisctl (listurl)aiir(' of tliu voice, severe couj^h, ami iinpainiient of tiie respiration. The interference with free respiration speedily becomes tiie most pronounced .symptom, the breathinj; becoming more and more involved, the stridor being both in.spiratory and ex- piratory. This stenosis rarely becomes so .severe in simple laryngitis liyi)oglottica in the adult as to demand operative intervention. The cough is decidedly croupy in character. In childhood the condition is indeed a much more serious affair. The initial symptoms are the same as in the adult, although, on account of the relatively .smaller calibre of the child's larynx, the symptoms of sten"-!is are more rapid in their developtnent. The stenosis is charact' izetl by laryngeal stridor which is both inspiratory and expiratory, by intense dyspiuKa, marked cvanosis, and extreme anxiety. The pul.se become-s rapid and thready and the whole appearance is that of a child with laryngeal diphtheria. The .stenosis is followed after a tinu; by gradual relaxa- tion and recovery, or becoming more intense, unless relieved by tra- cheotomy or intubation, terminates in death through asphyxia. The laryngoscopic investi- gation of laryngitis hypoglottica shows the upper and midille regions of the larynx entirely free or only moderately inflamed, while the vocal cords may be moderately injected or show no change. It is entirely in the subcordal region of the larynx that the pathological changes are noted. \'\mn deep respirati(Hi two deeply congested immobile swellings will be noted just lx>low the vocal bands, nearly filling up the lumen of the larv'nx. From the sul?- jective symptoms alone it is rxtremely difficult to differentiate the condition from laryngeal (edema, laryngeal diphtheria, and other conditions giving rise to stenosis. In the adult the ditTerentiation from periclKmdritisard (edema is somewhat difficult. In children, v.-here the laryngoscopic picture is difficult to obtain, the difT(>rentiation betwfM-n diphtheria and hypoglottic inf" immation is at times ex- tr(>rnely difficult. The differentiation can only lie made positive through the laryngeal mirror showing the characteristic hypoglottic swelling or the false membrane and the results of bacteriological examination. I have long .«ince been of the opinion that in many of those cases in children wherein we have api)arently laryngeal diph- theria, and in which cultures show the non-existence of the Klehs- Loeffler bacillus we have this condition pre.sent. Acute Laryngitis in Childhood. Pseudocroup. In children where the inflammation involves only the supracordal portion of the larynx. we have a train of symptoms identical with those that occur in the .adult with the sntite <li<i<^as<>. There is hoarseness of the voice, a high, metallic. Iaryng(>al cough, and a slight stridor in breathing at night. .At other tinu>s, and always in children of a strumous type, Laryngitis hypertro- phies acuta in a child live years old. lyFLAMM.iTORY DISEASES OF THE Ul'l'Ell AIU PASSAdES. 815 the laryngeal affoction assumes a more serious phase and is charac- terized by nocturnal paroxysms of intense dyspncua. In this form, which is conmionly desij^nated iis false croup, tiie child during the first day or so may manifest the usual symptoms of a cold with slight hoars' less, a metallic cough, and a mild febrile disturbance. Tliey dispiav during the day their usual brightness of spirit, showing no premonition of the impending disturbance whi( '. may occur during the night. On th(> tirst or second night after first displayuig an irri- tation of the upper air-tract the attack of paroxysmal ditticult breath- ing manifests iti-elf. After a <iuiet sleep varying from one to several hours, the little one's respiration will become audible with a slight res|)iratory str dor. After this condition lasts for u few moments the child becomes restless and is at last awakened by tlie inter se desire for air, with a high-pitched respiratory stridor. The breathing be- comes exceedingly embarrassed, the stridor more marked, the cough sharj) and shrill, the face anxious and cyanosed, the pulse rapid, and the fact> and head bedewed with perspiration. After a few moments tiie paroxysm relaxes slightly, the breathing becomes easier, though .still audible, and the voice clearer. In from fifteen minutes to an hour the relaxation is complete and the littie one falls into a quiet slumber which may continue until morning, or from which it may be aroiised by another paroxysm. During the succeeding day the condition is about the same as the day preceding the paroxysms, although the patient is usually "droopy," somewhat hoarser, and the cough more frequent. Paroxysms may occur on the second or third night, or the attack may resolve after the first or second nocturnal ])aroxysm. The laryngeal picture in pseudocroup is difficult to obtain at the time or immediately after the p.'iroxysm of difficul* breathing, on account of the tender age of the patient. Stiirk, Mol- denhaur, Dehio, Rauchfuss, Krieg, and Rosenberg claim that the disturbance is due to a subcordal swelling of the nmcous membrane of the larynx, practically a laryngitis hypoglottica acuta. (Jottstein, Schroetter, Jurasz, and Schech state that while there may be a slight infiltration of the nmcosa they cannot believe that this condition is attended with the swelling which is present in laryngitis hypoglottica. The last mentioned observers believe the nocturnal paroxysms to be spastic in character, excited through irritation from dried .secretion. This condition can be differentiated from laryngeal diphtheria by mild subjective symptoms, by the amelioration of the syuiptoms during the daytime, by the peculiar nocturnal paroxysms, and by the history of previous attacks, while in diphtheria we have the jicrsistence of the .symptoms with a progressive increase in their ^(•verity rather than amelioration, by the prostration, and through ili(' larytigeal examinations and culture results. The diagnosis of laryngitis can be frecpiently made without any difficulty through the objective and subjective sym])toms presented liy the patient, but the seat and character of the inflammation can only be determined through inspection by means of the laryngoscope. «16 SOSE AM) TIlliOAT. At tiiiK's one will find it cxtrciiicly diflicuit to examine the larynxes of little ones; l)ut care and patience will often enahle us to accom- plish wonders even with them. Prognosis. The simple* acute laryngitis usually Rives a most favorable prognosis. I'nder |)r(iper treatment and can* all cases should resolve. Many cases, even without medical attention, within a lew days or a week make a complete return to the normal. The laryngitis hypoglot- tica }iiv<'~ rise to j^rave anxiety, and in children it may Ik- atten(le(| with fatal i.'^sue. Due care must be exercis(>d in treating these con- ilitions to see that the resolution is complete, other\vise they lapse into a chronic state. Treatment. Prophylaxis in re'jard to proper care of the skin, bathing, and unnecessary protection to the neck, should be thor- oughly in.stilled into patients. Constitutional treatment as directed in aciite coryza is often efKcacious in breaking or lessening the .sever- ity of an acute laryngitis, liest for the voice is ab.solutely es.s«'ntial, and should be insi.sted upon when the voice is at all changed. When the cough is annoying it can be allayed by the administration of codeia in O.O'.i doses, or heroin in 0.01 do.ses every four or six hours. Often administration of one-drop do.ses of tincture of actmite for every half-hour until six doses are taken have an exceedingly bene- ficial result. Where there is exce.s,sive irritability from dryness of the larynx the 0.01 grain tablet of pilocarpine acts very well. Rest in bed, even in the milder cases, brings about a quicker resolution, ail'' in the more severe cas(>s is to be insisted upon. The bowels should be kept well open. Cold compresses to the neck should 1h' employed when nmch soreness and discomfort are present. When tlien> is congestion and swelling of the epiglottis and arv'tenoids and aryepiglottidean folds the ingestion of milk as hot as can be borne gives great relief. Instead of cold applications, counter-irritation in the form of mustard pa.-^tes or tincture of iodine applied from the upper border of the larynx to the middle of the sternum gives great relief. The diet of the patient is to be regulated: it is wise to ]mt them on a liinite(l li((uiil diet. The temperature of the room should be kept at a medium of about 70° F., and it is well to keep the atmosphere moist by the generation of steam, especially during the early stages of the inflammation. The desired effect of steam can also be accomplish(>(l by the inhalation of compound tincture ot l)enzoin, of which a teaspoonful is added to a pint of boiling water. The use of oily solutions and the insufflation of powders in the larynx are thoroughly bad, and I am sure do more harm than good. li mere is evident constitutional disturbance present, which may have some inffu"nce on the production and maintenance of the laryngitn it should be actively treated. Therefore rheumatic and gouty condi- tions, gastro-intestinal disturbances, syphilis, acute exanthemata, diseases of the he.art, etc., .'ihould be a!)propriately looked after \\ henever the laryngitis is due to irritation from dust, chemicals, etc., the patient should be removed absolutely from these sources of irri- ISFLAMMATOliY DISEASES OF THE UPPER AIR PASSAGES. %n tatirin. Local tmitmont forms an essential featuro in the relief and restoration of many eas«vs of laryngitis. At present there is a differ- ence of opinion as to the b«'st and most non-irritating method of mukiiiK these topical applications. Some use them through the medium of the spray, others with a syriiige, and still others by means of the laryngeal applicator. When one pos.s«'sses the necessarj' skill and the extreme nicety of manipulation to make application with <'xactiiess and gentleiie.-is of touch, there is no ((uestion of the .su{X'- riority of din-ct to[)ical applications over the spray or th(> syringe. In the early stages of acute active congestion, (edema, or hypoglottic inliltration the use of a few drops of the .^^olution of suprarenal extract or the adrenalin, repeated once or twice daily, les.sens greatly the (ideiiia, .swelling, and congestion of the mucou:-" membrane. The u.se of alkaline sprays to tl nose, pharynx, and larynx should not be overlooked, and whenever there is ol).structive dlsea-se of the na.'^al ihambers present appropriate treatment should be instituted to relieve it. Topical application should not be re.sorted to until secre- tion is established. The local aj)plication of the mineral salts is (Specially etHcacious in bringing about resolution. The silver salts, on account of their mild astringent and germicidal action, are the most favored lately, especially i)rotargol. The sulphate and chloride ot zinc are also used to meet the same indications in 1 to .3 per cent, solutions. I pn'fer the silver salts in a 1 per cent, solution, or the pnitargol in 1 fK-r cent, solution applied every day. Where dys- plionia is a very (listr>'ssing .symptom, especially li" "tlie patient is a public speaker, singer, or one whose vocation requires the fre(iuent use of the voice, I find that resolution is materially aided by the use of the continuous current applied to the larynx. In the acute larj'n- !litis of children care should be exerci.sed in proper clothing, bathing, rciiulation of the diet, and building up of the general health. These children usually flourish under the administration of iron, arsenic, .iiid (■od-liver oil. When acute attacks occur the child should be kept in a well-warmed room in which .steam is admitted or lime is ;i!lnw(»d to .slack. It should be given a calomel purge in small divided ili)-;es. Internally it should be given one-(iuarter drop doses of aconite with a stinmlant expectorant every two hours, as: Holt recommends- siK — Teaspoonful evei^- twenty rain s until improvement taken place. Internal applications in the form of .stinmlant embrocations ap- lilicd to the chest and neck act very well. I prefer the official soaj) liniment for this purpose. When the paroxysm of difficult breathing 52 Amnintiia; limmidi, 1.00 Ainniniiiic carbon, 1 00 Tinotiir.eaconlttl, .50 (flycerinBE, 8.00 AquiE. ad 62.00 Chloral. 5.00 Potassii liniraidi, ».00 Amtnotii.i' bromidi, 30O .\i](ife(>innan]omi. fii.UO 818 XOSE A.\D Til HO AT Faulty a|>|iriixiiimiiiiii uf the Vftcul oord»4 HN otti'it nbHi'rv»1 la ohnmie hypertrophiu iHryiiKltls. |('OAKI.Er.< is coiaiiiK on, as iiidiciitod by tin- stridulims hrcafhiii)?, if the litflo one is a\vai<«'nt'(l ami n'vcii tlraujilits of wanii milk llu- attacks will !)«• con- siilcrahly aiiH'lioratcd if not itrokcn up. SlioiiM stenosis he very in- tciist' it may In- ncctssary to resort to intul)a;ioii. In laryngitis liy|»o- ^lotti(■a the jieiieral plan of treatment as outlined aiiove should l)e carrieil out. In this ea.-<e the adrenalin, external application of cold, and depletion \)\ tiie bowels are especially ellicacious. The us«' (if a s|)ray of a 1 i)er cent, solution of chloride of zinc or of a 2 per cent. solution of protarjrol is exceedingly iH-neticial, es|>ecially when taken in with ileep inspirations. Should breathing iM'come markedly em- barrassed it will Ix' nece.s.sary to resort to tracheotomy or intubation. Local applica- tion in rheumatic laryngitis is not advisa- ^ ^k I ^« V__ Chronic Laryngitis. Chronic laiyngitis "^•*^^M I IBBkZ?rr- is a chronic intlammation of the mucous membrane characterized by alteration in the voice and tlu* s<'cn'tion. Etiology. Tiiere is no doubt that the larger proportion of c;i,ses of chronic laryn- gitis are due to fre(|uent neglected attacks of acute laryngitis which, through the im- perfect restoration to the normal condition, leave after each attack a certain amount of n^sidual ctmgestion and inflammatitm which, added to l)y recurring attacks, terminates in pronounced permanent changes in the form of congestive hyperplasia or hypertrophy. ( )bstructive di.s- pa.sps of the nasal chambers, causing mouth-breathing, chronic nasal catarrh, di.sea.ses of the nasal sinuses, and chronic changes within the na.sopharynx are all pnxluctive of chronic laryngeal changes. There is no doubt that changes within the faucial as well as in the lingual ton- sillar tis.sues act as exciting .uases. Ofttimes inflamma' w and en- largement of the uvula are secondary to chronic changes in me pharynx or larynx, nevertheless there are times when the engorgement and en- largement of the u\ula urecedes the laryngitis, and its removal aids materially in bringing ^: .out resolution. " The i«<rsistent and ctmtinu- ous misuse of the voice, and the effort to produce artificially a singing voice of greater range than the individual pos.se.s.ses, is frecpiently fol- lowed by chronic laryngeal changes. This is observed in preachers. pul)lic speakers, street criers, singers, actors, and indiscreet young people who think they po.ssess voices of great merit. Persistent and continuous exposure to an atmosphere wtiich is deleterious, as working in rooms surcharged with steam, <lust. lime, or human emanations, excessive use of the voice in overheated rooms, and injurious habits, as the addictiim to the excessiv" u.se of condiments, alcohol, and tobacco, are all conducive to the production of chronic laryngeal inflammation. Most of the acute infectious diseases are attended with inore or less laryngeal involvomcnt which, if not brought to resolution, may pa.«s into the chronic state; the chronic infectious /\FLA.MMATOKr Dt.SK.lSES OF TIIE ll'I'EH AlJi l-ASSAdFU. 8iy <lis.-as.-s, surl, as tulKTouIcsisan.l sy,,},ilis, ..ro almost always att.-n.icd Willi chinin,. arytiKcal iiillanirnatiuns. I n.i.si.l. r it wisr in all cl.n.iiic larynural iiitlaminati..Ms to .■xarniii.. can-fullv for tiii..Ti'ulosis and Mpliilis. DiaLrtrs. >:out, and ti.c iithaiMJc conditions coexist with j""l a|.|.aivnily Millncncc tlu- .•l.anjr.'s which p, to n.ak.^ m. chronic laryn^ntis. I',|,id,.nnc nifiucnza, from its marked proncnc-s to attVct Ih" upper air-tract, especially the larynx, can he considered an a<-tivo lactor III causing chronic larviiKitis. Symptoms. Ordinarily thc^se alTect.-d with chronic Ijirvncitis do not comp am mud. of the sul.jcctiv.- sensations. There mav l.<- n.,t..d ;i sli^'lit dryness or a leelmjt as th(.uKh .something foni^n were in the larynx causing the patient to make fre(|uent and nn.re or less vioh'iit attenipt.s to clear the throat; occa.«ionallv there is dy.sphaeia In son... individuals the fre.,uent clearinR of the throat, known as •'■hem- ming, is often so eoiitinuoas and fn-(iuent a,^ to hecomo distn-ssinc an,| ncrvo-lestroymK to tho.se forced toa.ssociate with one so atTectod It IS the alteration and impairment of the voi'r that are most dis- tressing to the {)atient. Th(. voice varies greatly in different cases as to the amount of change present. In some ca.ses it is only slightly alten'd trom time to time, in others verv hoarse, and still ,gain it may he entirely aphonic. The voice may he clear on arising in the niorning, to Ixcome hoarse as it is subject to more use: or tiie reverse may he th<' case, that is. the patient awakens very hoarse to find that within a short time the voice becomes dear and .strong In public speakers and singers the ordinary conversational voice may sliow only slight alteration f)r no change whatever from the normal .vet when such a jx^rson attemj)ts to address an au<lience, using the voice m Its higher registers, he finds that the muscles quickly tire he becomes conscious of an irritation and a tickling in the larvnx' and his voice either l)reaks or becomes weak, hoarse, and c^ften aph<.mc. The efTort if {x-rsisted in is followed by more irritation which is often attended by distressing paroxv.sms' of coughing In singers the alteration is noticed more deci.lediv than in others, as a more .Idicate and intricate functioning of the larvnx is necessary tor tli.> production of the singing voice. At first singers notice a shor^- '■m"K of their register, that is, tne inabilitv to sing certain m.tes in ' !.■ upper r(>gister which before thev could .strike with ease They ■ilso n;.te th(> (|uick tiring of the voice. If thev do not take timely naming, and still {)ersist in singing, the voice Womes hoarse after ;-linrt eftorts, breaks, and many notes in the regi.ster become weaker n.e attempt to force the mu^^cular stmctures under unfavorable '-nditDns pads to a feeling (,f .soreness or even actual i)ain in the innx. I he degree of hoarseness is dependent upon either the "nount of inhltration of the vocal cords, the false bands, the swdling ni (he arytenoid region, the degree of paresis, or the amount of .secre- '"ti. ( f,ugh IS not an essential feature of chronic lar\-n<riti« u^tiallv ■uw being present when, through exertion, there is excited an irri- ation m the larynx. The amount of secretion varies greatly It is «2<) SOSE AXD THROAT. usujilly iiKMlcTuto iiiul is tlirown out in little jK»arl-liko iikwhom or slirctl-iikt' ^tramls of clear mucus. LaryiiRoscupic itis|M'ctioii shows tlic laryiifjeal nuicous surface swollen and conKesleil. The amount of redness and swi'llinj; is subject to great variation. The redness may U* as intense as is often >)bs«'rved in the most acute forms of acute laryngitis, a saturated ri>d, .s«'ldom, however, involving the whole mucous surfac Most freijuerUly it varies from u delicate ros<' tint to a dirty grayish-red. .\t times the nmcosa shows a dark bluish- red appearaiii-e, with enlargement of the veins. The fal.se cords, the nuK'ous membrane over the arytenoids, and the subglottic region fre(|ueiitly show the most malK<>(l congestive changes, as is evidenced by the murkrd redness of these parts. The vocal bands show most frequently a slight off-coloring, a sii; ' ,inkish-gray discoloration, again a want of lustn\ with the showing it several transvers*- mark- ings of minute capillaries, and still aga.n i briglit-red slight linear injection along the free bonier of the cords. 'I hen' is usually i.iore or less swelling of the nnicous membrane dependent upon the activity as well as the duration of the chronic laryngitis. In acute laryngitis there is only a round-celled intiltration, whereas in chronic laryngitis this condition has passed to one of actual hypertrophy. This liypcr- trophy may expend its force on one of the layers, or may affect all the layers of the nmcosa. The epiglottis is frecpiently thickened, stiff. and almost innnobile, while tortuous veins are noted toward its ba.-^e. On account of this immobility of the epiglottis it is at times difficult to obtain an insjx'ction of the interior of the larynx. The aryepi- gluttidean folds and tin- false cords .are prone to hypertrophic changes. The swollen false bands frequently extend to the middle line, coming in conlact during jilionatinn ;it the .'interior ihird or throughout their whole length, thus obsiiiriiig complett'ly the true cords. In i-nst' of only a partial covering of the true bands we have only a dampening of the voice. Wlu'ii the cords are entirely covered by the false bands i'XteiMliiig comjiletely to the middle jine, they may either interfere with llie function of the voice by preventing the cords coming into apposition, or may take the place of the true cords an<l functionate for them, producing a raw hoarse voice. Tlie most rrei[uent changes are observed, however, in the region of the arytenoid, either along the anterior portion or in the interarytenuid s{)ace The redness and swelling over the arytenoids and the posterior wall are always nm- noiinced. The normal delicate outline of the .'irvtenoid is lost in the infiltnition which takes place in the mucous membrane over tin cartilage. The processus vocalis and imniedintely neighboring por- tions of the vocal bands are congested and soniewli.-it thickened, while the interarvfenoid region is not only congested, bul thrown into irregular folds, indicating a piling up of epithelial cells if not ai; actual hypertrophy of the papillary and .stibnmcous layers. The-' alterations ,'ire .'it first characterized by a tired sensation in thethroaf. witii slight hoarseness on speaking. Slight des(|uamation of the epi thelinm here and ''ere on the mucous .surface gives rise to catarrh: 1 r\l I.AMMATOHY DISEASES Of THE UPPER Alii PAssAUES. 821 ulnrs whicli usimlly In-ill kin<lly with or witlmut treatment. The aiiK.iint ul se<Teliuii is Mlijjhtly in exeest* of the normal, and may he tliih, fluid-like in character, or .show u tendency t(» form in crust.-*. a.ihiTiiiK to the .xurface of the coni or mucosji in the subcordal portion of the larynx. On ohservatioii tin- mucus is s<'e!i in little ln-atl-iike forii.ations a.lherin,; to the upp«'r surface and to the free edjres of the cords, simulating very clos«-ly singers' nodes, while at other times It shows in very tmi irand-iike forms running from one hand to the other, r.-iresis of tiie voc.il hands is very common in chronic iaryn- jlitis, showing itself most frecjuently in tlu' thyro-aryteiioidei inte'rni and tlie tnuisversus. The diagnosii is made throuRh the examination with the laryngo- sc(.|M', and thi.s. with the usual sulijective and characteristic local ihaiifies, should ofTer no ol).stacle to its n'coRniti((n. Marked con- jrisiioii of one or Loth vocal hands, or considerable thickening of the same, should arous*' the suspicion of possible constitutional di.s- Uirb.inces. as of tuln-tculosis or syphili.s. .Marked thickening in the interaryteiKiid n'gion or about the processus vocalis may warrant the diaftnosis of pachydermia. In making a diagnosis care sh.)uld he exercised in carefully examining the nose, na.sopharynx, pharynx, and ' ings in order to .show the iM)ssible corelatioiLship U'tween dis- eaM'd conditions in these parts, if found, and the laryngitis. PrognosU. The condition under consideration is uniier ordinary circumstances not fraught with much danger to the average indi- \iilua! so fur as his loiigevity is concerned. Laryngitis of this type may exist for years without showing much alteration, except that due to occasional acute exacerbations. For those whose vocations are ile|M'ndent on the use of the voice, this condition is indeed a MTi' problem and its relief es.'^ential. Ordinarily a thorough appre- ciation of the factors entering into its etiology, their remcval, and a c.ireful meeting of indications will usually bVing about a complete resolution. The courw of treatment is freiir -ntly a prolonged one. Treatment. First of all, a thorough appn'ciaiion of the po.ssible • tii'logic.al factors must be taken into wmsideration, and means under- i.ikeii to rem .ve these must be instituted at once. If there is disease "t fh( nose f, i-a.sopharynx, such as hypcrtrofjhies, di&v ■ -e of the -iinises. deHecied .'X'ptum, adenoids, disea.sed ton.siIs, or enlarged uvula Irci^'-nent should l)e adoptci! to restore these parts to the ncirnia!. CdiL-^iitutional conditions which may have an influence in inamtair.:!)^' the laryuf-itis should be corrected, and habits that may prejuilice i ..provenieiit should he broken up. Ofttimes a change o'f '•lunate from the s«"ishore to the mountains or from the mountains 'o the seashore works great benefit. A few months s|.ent at o»'- of 'lie well-conducted sulphur springs where a rigid regimen is caniivl ut olfen produces extreme benefit. Great care should be e'r>rcised in fh(> use of the voire. SingefF. actors, and public sppakc^^ should "■ counst^led to abstain from the u.«ie of the voice in singing or in l"ud .speakmg. It is much better if these individuals use the voice d^yW'.'wm^m^.' .-.K^-^T^-- 822 NOSE AND TimOA: as little as pcissiblc, and then in a whisjier. Local treatments are of value only in that they supplement ami assist the restoration to th(> normal after the removal of the cause. The medicament may 1k> ai)plied throufih the medium (if the syringe, the spray, or by a cotton covered ajiplicator. I'nless one possesses the necessary manipulative dext(>rity to make the laryngeal application gently and accurately, it is much better for the operator and the patient to make use of the spray or the syringe. When wishing to reach the supraglottic regions in the use of the spray or atomizer it is best for the patient to have the tongue held out well and at the same time to sound a high note. If it is desirable to reach the subcordal region the tongue should be held well forward while the patient makes deep insj)ira- tions at each time the s])ray or solution is injected. The mineral astringents are far preferable for local use to th(> veg<'table. I have no hesitancy in de|)recating the use of powders in any form in the larynx. The mineral astringents .should be used in acjueous solution, and these |)rcferably at a temperature of about 100° F. In most text-books the astringents are recommended in too strong a solution. Even a 1 per cent, solution of silver often causes considerable smart- ing that may last for hours. The astringent applications or .solu- tions for spraying that I ])refer are: ])rotargol, I per cent, solution; argenti nitratis, 1 to 2 per cent, .solution; zinci chloridi, 0.5 to 1 per cent, .solution; zinc sulphate, 1 to 3 per cent, solution. The above solutions should be used lo more frequently than every other day, and one may be interchanged for the other from time to time during th<' treatment. It will also be noted that as the case j)rogres.ses it will be necessary to increase the strength of the particular drug which is being used. Whenever there is considerable induration ami thick- ening of tissues against whi<'h there is desired more intense action, I prefer eith( the use of puif crystals of chromic acid or the galvano- cautery burner. Laryngitis Hjrpoglottica Chronica. This form of laryngitis is char- acterized by an infiltration of the mucosa and .submucosa of the subcordal portion of the larynx. Laryngitis hypoglottica is not a very connncii affection. It seems to Le more prevalent in Continental Europe, and especially among the natives of eastern and southeastern l-lurope. Etiology. It is said to be due to ex])osure to cold and to follow .severe types of chronic laryn- gitis, and from unresolved acute hyjioglottic infiltrations. It is more freiiuently .secondary to constitutional affections. It is sometimes a sefpiela of typhoid fever: it may be secondary to pulmonary tuber- culosis, or a local manifestation of syphilis, scrofula, and rhuio- scleroma. Symptoms. The thickening and rigidity of the opiglotli.- wiiirh fretjuently coexist with subglottic swelling ofttimes makes e.xamina- Fl.i. 418. ,>A^vfAi IXI'LAMMATORY DISEASES OF THE UPPER AIR PASSAGES. 823 tioii of the larj'nx extremely difficult. The voice is always altered, markedly hoarse, or complete ai)honia exists. The most marked .symijtoni is the difficulty in breathing. The interference is at first only noticeable when moving al)out and making exertion; later it becomes more intense, so that it is pronounced even when at rest, and is attended with both an inspiratory and an expiratory stridor. .\t night the breathing is freijuently markedly impaired, and when tough secretion collects tlu>re may be paroxy.sms of extreme distress; as time passes the obstruction becomes greater and the stenosis more pronounced. On inspection just below the vocal bands two reddish or pinkish maj.ses extending inward and obstructing the calibr>' of the larynx are observed. These mas.ses may nearl\- meet in the middle line, allowing only a very small space through which air gains access to the lungs, or they may show somewhat of a cleft, es})ecially at the posterior border. The mobility of the vocal bands is usually imi)aire(i Cougli i'- present, and is fretjuently of an extremely distressing tyix-. Diagnosis. The diagnosis is not usually difficult. The character- istic picture seen in the laryngoscope is almost pathognomonic. It must be differentiated from iM'richondritis or abscess, from both of which it can be diagnosed [jy the denseness of the liypoglottic swell- ing, the freedom from high fever, and the absence of tenderness on external pressure. The prognosis is uncertain both as to restoration of function and as to lif(>. Very freipiently the ca,«e terminates fatally unless opera- tive intervention is carried out. Thn'e of such ca.«es, under my care, iliat refused the benefit of oj>erative relief died from suffocation. Those of the tuliercuiar tj-pe are the most serious, those due to expo- sure and sj'philis are the most favorable. Treatment. Internal treatment should be administered along the line of the con.stitutional condition which seems to be the etiological factor. In doubtful cases it seems to be prudent to administer the iodide of potash. Those who have had great exi)erience in treating tills condition advise, when the embarrassment to breathing is not ^ncat, the local ai)plication of silver in caustic solution, scarification, and the ai)plication of the galvanocaufery. I would be extremely cautious in advising the use of the two latter. The course I have usually pin-sued and which is advised by Sokolowski is the early piTrormance of tracheotomy, laryngofissure, and excision of as much of the hypertrophied ti.'Jsue as possible. After tlie healing of the Inryngofi.ssure Schroetter's bougies are used, or, as I prefer, the intu- bation tube, until the space is sufficiently dilated to jK-rmit dispens- ing with the tracheotomy. tube, .\fter the tracheal tube is removed it iu'comes necessary to occasionally introduce the bougies or intu- liation tube throughout (piite a long period. Chronic Dry Lar]mgitis. This is a form of chronic laryngitis, also ••ailed laryngitis sicca, which is characterized by a secretion deficient ill wafer elements, which .secretion tends to ailhere to the mucosa and form crusts. 824 NOSI-: AND THROAT. I n Etiology. This form of laryngitis frciniciitiy ensues after ;i nej;- lected attack of acute larynptis sicca. It is more fre(iueiitly tlie result of the extensiim of the atroj)hic form of nasal catarrh anil atrophic pharyngitis. The invoi\Mnent of the larynx is not always a necessary se((uence of the advanced form of atrophic rhinitis, for we freijuently find very old atrophic cases, with marked ilestruction of the soft tissues in the nose without change of any character in the larynx. Nor is the laryngitis sicca always due to a direct exten- sion by continuity of surface, although this method is no doubt a fretpient ini'thod of its extension, for it may he due to the circulatory changes produced by the mechanical irritation of an atmosphere which is thoroughly unfit for laryngeal resjjiration — i.e., an atmo- sphere clHlled and deficient in moisture. Radical operativ.> work in tilt! luLsal chambers, ius complete turbinectomies, results in producing this condition. I have seen the nu)st e.xcjuisite ca.ses (tf laryngitis sicca produced in this way. The condition excited is a change in the mucosa and the submucos:i, with atrophy of the glandular hiyer leading to the production of an altered secretion, from which the mf)isture is further reduced by the inspired air. Symptoms. The accumulation of secretion takes place in these ctises chiefly while the larynx is not b' ing used and when the patient is at rest. On awakening in the morning the larvnx is usually quite choked up with crusts, which become loos(>n(<(l with the restoration of secretion. This usually takes ])lace with the performance of the toilet and the exercise incident thereto. At fin-^t the patient is (juite aphonic, and there may be paroxysms of laryngeal spasm on account of the separating crusts being caught between and irritating the vocal bands. .\s the crusts are removed the voice becomes clearer and may become almost free from hoarseness, to remain so throughout the day, or become hoarse again after a . w hours, due to fresh crust formation, clearing uj) again with the c(;ughing out of the freshly formed crusts. In other cases the voice remains of alternating degrees of hoarseness and aphonia throughout the day, depending upon the freedom from crusts in the larynx. Coughing is a very persistent symptom, and is usually very distressing at night. Violent clearing of the throat at jjcriodic intervals is also present. At night thc-^" ])atients are freciuently aroused by an embarrassed respiration and occasionally by paroxysmal suffocative attacks. The secretions resemble very nmch those produced in atrophic changes in the nose and pharynx, and are occasionally streaked with blooit. Kxamination of the larynx reveals a slightly congested or ana'tnic larynx, having a peculiar glazed appe.-irance. with grayish-white crusts adhering to the interarytenoid region, to the vocal bands, and the subcordal region. The prognosis is not very favorable to a restitution to the normal. .\t times great improvemeni may be gained and great comfort U> the patient afforded. p-^:: fXFLAAnfATOnV J ) IS i: ASKS OF THE UPPKH Alii PASSAUKS. 825 Treatment, The saiiic line of trciitmciit in a constitutional way should Ik> instituted as I iiavc diiwtcd in atrophic rhinitis: the administration of tonics, iron, arsenic, strychnine, and cod-liver oil; tile proper care of the skin, hathiufr and clothinjj; terjiin hydrate, for its seemingly six'citic action on the mucous surface, should be administered in 0.02 to 0.(M5 doses. The local treatment of the nose and pharynx when diseased should not be nej^lected. It is strongly advised before adopting any local treatment to thoroughlv cleanse ihe laryngeal nmcous surface (jf all crusts and secretions by" spraying with an alkaline aseptic solution. .\s a slightly stinnilan't solution an.swering the same purpose one may use a solution of sulj)ho-carl)o- late of zinc, 0..30 to the litre of water. I wish here again to protest against the use of mentholated oily sprays in this tyjM' of inflamma- tion. The only solutions that can be of value are those that will act as active stimulants to the laryngeal mucosa, through which we hope to stimulate the activity of degenerat(>(l glands. Chief amoi;g the agents which we use fc- this purpose are chloride of zinc, silver nitrate, and protargol in strengths varying from 1 to 3 i)er cent. Pachydermia Laryngis. (Plate .\X\'.. Vigs. .'J, 4 : also Figs. 419, 420.) l'achy<lermia laryngis is a chronic inflannnation of the laryngeal mucous membrane which may involve any |)ortion of the larynx, but is esp(|cially jjrone to affect those portions covered normally with liat epithelium. It consists ess(>ntially in a proliferation of the ei)ithelial and papillary layers, \irchow ably described this condition ill 1S,S7, and thereby aroused the interest of the laryngological world ill its existence. Pachydermia had frequently been obser%-ed by laryngologi.sts before this, but had not received the attention and c ireful ilescript ion that it did during the year 1SS7. Etiology. There appears to be a universal acceptance of the idea tliat pachydermia is most freipiently the result of chronic laryngitis, llic overindulgence of spirituous drinks, and the excessive use of to- liacco. Schmidt .seems to think that atrophic rhinitis and j)haryiigitis arc factors through the cough and persistent clearing of the "throat excited by this ecmdition. Among constitutional conditions may be mentioned tuberculosis and syphilis. This condition is more prev- alent among men than women, and is more frecpient during young adult life. The infiltration may be found upon any portion of the larynx where normally flat epithelial cells are present. It is found most fre(iuently about the arytenoid region, that is, in the interary- teiioid space, or on the inner surface of the arytenoid cartilages, and ujioii the i)rocessus vocalis. The })achydernna is usually flat, and in;iy be more or less diffuse or circumscribed. Symptoms. The symptoms which are excited by the presence of l)achy(lerniia vavx greatly. The interference with no"rmal function con- >ists in alteration of the voice, difficulty of breathing and swallowing, riie functions are afT(>cted in greater or less degree, according to the incadon of the infiltration. Where the growth is on the processus vocalis or on the posterior wall there may be marked hoarseness to ^ji. 826 yOSE AM) THROAT. compleU' aphonia. At other times, with pronounced growth on the inner wail of the arytenoid, on aeeount of the depression formed in one of tiie two growths, tliere may be only a very moderate change in the voice. Freciiiently patients complain of a feeling of fulness and of more or less stiiTiiess in deglutition. The amount of difficulty in lireathing depends upon the degree of interarytenoid infiltratioii and fixation of the vocal hands. On inspection th(> ajtpearance will vary according to the region of the larynx affected. In its milder forms pachydermia shows itself in a slight, irregular bluish or grayish-white wavy-like elevation of the mucous membrane in the interarytenoid regidii. The e])ithelial layer seems to be most affected in tJiis type. The same milk-white or bluish-white lustreless thickening of the epithelial layer may be observed also over the processus vocalis. In this latter type the swelling over the vocal processes may show marked increase in growth in every direction, even extending on to the true cord, formnig a growth from 1 to 2 nun. in length to O.o to 1 mm. in width. With Fio. 419. Fli). 4'JO. Flu. aiii-Pachyilerniia larynRis affecting Inner surfaoe of Hrylenoids iiml prwcafus vcx»Us. Fi(i. 41'U — I'HihyiliTinia laryngis of the intemryteiioiil region. this increase in size one or the other of the growths shows a depres- sior on its surface, into which the prominence of the other fits more or less exactly. In the arytenoid region ofttimes the infiltration is very great, forming prominent round or irregularly outlined eleva- tions with intervening clefts which look like fissures; these are covered with hard epitheliimi which h..s a snow-white, a grayish- white, or a yellowish ap|)(>arance. Diagnosis. The diagnosis of pachydermia is readily mad(> from the characteristic find of the laryngoscope. The presence of the thick- ening over the i)rocessus vocalis or both vocal cords, one of whii'li shows the peculiar indentation or the round, irregular, grayish-white .swelling on the posterior wall, causes one to think almost inmiediafely of pachydermia. It is difT(>rentiated from i)apiil,>;na bv the fact that pai)illomata are always superficial. Tlie papilloma is very feebly attached, growing only from the ej)ithelial surface, while the diffuse pachydermia is very Hrmly attached, and retpiin^s the use of cuttinir forcei)s to detach it. The jKipilloinata also have the chara> .eristics of new-growths, while l)achyd( rmia have the r.ppearance of hiflani- .■**^ L\FLAMMArOJiY DISEASES OF THE UPPER AIR PASSAGES. «27 inalury .swellings. When pachych'rniia uffects the cords anterioi to the processas vocalis or the ventricle of Morgagni it is extremely (lifHcult, if not almost impossible, to differentiate it from cancer, an<l lial)ility to error is not entirely avoided by microscopic examination of a portion of the removed growth. The prognosis is in the mild ty|M' of cases a favorable one. Those due to simple irritation and to conditions that can Im- removed offer a very favorable prognosis. Cases after a sh(jrter or longer jx-riod of existence occasionally spontaneously heal. Such a spontaneous resolution is al.so occasionally seen in pachydermia due to tubercular infection, as a result of tlie marked improvement in the general con- dition. The duration of the condition, however, is usually a pro- longed one. extending over a period of sotnetimes many years. \\'ith a due consideration of the causative elements and the proper in.sti- tution of a* )roi)riate treatment good results can be brought about ill a fair pr()i)ortion of cases, and in many the arrest of further exten- sion of the proliferation. Treatment. For all types of the pachydermia the treatment should be dir -d to the removal of the cau.se, systemic and local sources of irriti.tion, and the improvement of the general health. Many advise the administration of the iodide of potash in small doses. There should be restriction placed upon the u.se of the voice. The local treatment of any coexisting (lis(>a.se of the no.se or pharynx shoulil receive most thorough attention, as well as the chronic inflam- malion of the larynx. This i.s all that is necessary in th(< majority of mild cases presenting themselves for treatment. Locally in the more pronounced cases of infiltration it is wi.se to make local appli- cations of silver nitrate in 1 to 4 \wt cent, .solution, or of .salicvlic acid in 20 per cent, solution of alcohol. The galvanocaut(>ry can" be used as well a.s electrolysis in a strength of 10 to 12 milliam])eres applied for three to five minutes. If the growths are pn)nounced on the inner surface of the arytenoid and are causing marked alteration of the voice, it is well to resort to the use of cutting forceps, as through them the growtli can be removed (|uickly and leave a clean, healthy wound. Singers' Nodes or Chorditis Nodosa. A sing(>r's nodule is an inflanunatory growth situated on the free edge of the \'ocal cord at the junction of the ante- rior and middle third. These growths may be single, but are more frequently Fig. ai\. multiple, being situated on vocal cords located identir singers' nodes ' opposite each other. This condition is classed ^-son.e authors with parhydermia, veil as in path- logical organization are entirelv dissimilar they 828 XOSK A.\l> rif OAT. Etiology. The iiixlulo is more frcciiiciit in youiiji adult life. It is fouiiil iimrp often in the fctnalc sex, ami is far inori' ('(iMimon anionji tli(i9(> wiio siiig(.r\vii() arc cuitivatiiifitlu'ir voices. The most eoimiion cause for the existence of the nochile is tlie improper use of the voice eitiier in .s|)eakin<i; or sinjrin<;. It i. in the pnuluction of the tone tiiat tlie injur'- is ilone. that is. tlie stroke or impact is imperfectly placed, so that attrition between the sefjments of the cords is possible. Tlie attrition so |)ro(luce(l sets u|) an hiHunnnatory irritation which results in the pnxluction of the nodules. The greatest injury is done in. the use of the upper middle reu:ister. The condition is said to :iri.s<> during attacks of acute antl i iironic laryngitis, and from vocal fatigue. Symptoms. The nodule is usually characterized In* more or less hoarseness of the spoken voice, the ilegree of the hoarseness de|)ending upon the situation and the development of tiie growth. The voice breaks readily, and singers are unable to tix tiie tone or sing with any degree of certainty as to jjitch or resonance. The patient is unable to carry out any prolonged elfort on account of the great laryngeal fatigue and \)iiu\ entailed. They often present even marked hoarseness of the spoken voice. The diagnosis c;in only be rendered clear by an examination of the vocal cords. The singer's nodes are very characteristic and sliould not be mistaken for any other condi- tion. They an- situated at the junction of the anterior and middle third of the vocal cords, and apjiear as small intensely white or yel- l)wisli i)in-like points on the free border of the vocal cords. They are about the size of a pin's head, sessile, opa(|ue, and usually sym- metrical bodies placed one on each vocal cord. As the nodes come in apposition they cau.se a slight cleft between tlie cords. Diagnosis. The diagnosis is readily made from the subjective symptoms and the laryngeal examination. It is possible for a coujile of ix-ads of mucus vibrating on the vocal bands to be mistaken for vocal nodes. The differentiation can always bo made by causing the patient to clear the voice, which removes the mucus. The prognosis is usually favorable. Treatment. The most important feature in the restoration to the normal condition in chorditis nodosa is the correction of th(> method of singing. .Most sing(>rs so affected are those given to the clavicular method of breathing. Thes(> shoulil be taught the inferior costal method of breathing with fixed high chest. They .should be placed in the hands of a good singing-master who can instruct tlicm in the |iroper method of tone placing. ('om])lete rest from singing othi'r than instructicms given should be insisted upon. Tliis method will usu.ally in a short time bring about com])lete n .-solution. Many authors advise the use of a 2 per cent, solution of silver nitrate, while others favor stronger solution. It is also advi.sed to cauterize the nodes with solid nitrate of silver, chromic .'icid, and the galvano- cautery. Others advise the removal of the nodes with cutting forceps. iR'.W«{ CHAPTER XIX. DIPirniERIA OF NOSE AND THROAT ; INTUBATION ; SYPHILIS, TUBERCULOSIS, LUPUS AND LEPROSY OF NOSE AND THROAT; CHRONIC LARYN- GEAL STENOSIS ; FOREIGN BODIES IN NOSE AND THROAT ; RHINOLITHS. Bv WILLIAM KELLY SLMPSOX, M.D. DIPHTHERIA OF THE NOSE AND THROAT. Dii'HTiiKiUA is iui aeuto infectious and contaftious disease, recurring eiliier endeinically or epideniieaily. eiiaracterized by a hi)rinous exudation on any nuicous surface of tiie Ixxly or wound, heing de- lieiident for its cause on the al)sor|)tion of the toxins produced by ihe Klebs-Loeffler i)aciilus. Tlie ])arts most freciuently affected are tlie cavity of the piiarynx, and less frequently the larynx, nose, nasoplunynx, and conjunctiva'. No age is exempt, although it is most particularly a disease of childhood. When the larynx is involved there is a decided tendency toward extension to the brf«nchi The lesi')n, viz.: the diphtheritic exudate, is the .same in character- istics, both in the nose and the throat; and in a general way we may consider them together. The .systemic symptoms are also about the same. Occurring as they typically do in children, there are one to lwo days wherein they are slightly ill, gradually becoming worse, with .-i rise of temperature and acceleration of pulse and general pro.s- tration. until they show a localization of the membrane in either the iiiise or the throat. The Nasal Tjrpe. The initial symptoms in the iiose are generally those of a ,s(>vere coryza, existing for a day or so, with nasal discharge, which soon becomes ichorous in character, .swelling of the mucous lui'inbraiie, and from the mechanical presence of the exudate very Mioii there suix'rvenes a very marked na.sal obstructum. As a rule, this nasal obstruction is bilateral, and from the character of the secre- lioiis the exterior of the nostrils is very liable to l)ecome acutely ex- coriated, imlicating a more or less grave intrana.sal inflammation. Ilxamination of the no.se will reveal more or less of a grayish-white membrane ([uite well anteriorly, and often that is ail that can be seen. as the intranasal obstruction prevents any der>per examination of the nose. The exudation may be evenly ilistributed over the entire fti. "iC/'-t-l 8;J0 yost: Axi) Til no AT. iiitrniiasal imicuus ii»«inl)r;iiu«, sliowiiiK lui spci-ial point of sclcctioii, and is practically always bilateral. As a rule, the CMnlatidii extends well liack into the nose and naso- pliaryn<;eal cavity, and il' it he possible to make a posterior nasal examination we will lind the nasopharynfjeal cavity cnverecl with an exutl.Mie similar to that in the anterior nares. In the more acute type of cases the cliild by this time Im-comk-s .|uit«! ill, witii more or less j>landiilar swelliiifi in the cervical refjioii. In a certain mimber of cases tiie membrane may extend to tiie pharynx below, and even to the larynx, |)resenlinfr all the symptoms of a jjeneral diphtheria, liut this is'not always the case, for I am led to believe by an extensive observation that" the nasal and n:isoi)harynj;eal exudation may Ix'conio limited, and does not of necessity si)read to the jjharynx nelow, and we may have a purely nasal or nasoi)harynp;eal diphtheria in a class by itsoif. .\lthoufrh, :us a rule, na.sal and" nasopliarynpvil diphtheria runs a more or less acute course, the nature of the trou!)le becomin}; very evident from the outset, there are a certain number of cases, especially where the membrane is localized in the nose, which are very slow in development, the child not becomin.n ill anil the intra- nasal exudate remaining a loiifj while in a latent condition, apparently without very much constitutional manifestation on the i)art of the child. " . . I have known of a number of instances of na.sal diphtheria existmg for a number of weeks without giving rise to very severe sym{)toms, the exudation being present in a greater or less degree the entire time, together with the Klebs-LoefHer bacilli. The severity of tlie constitutional symptoms seems to vary in different ca.ses, and I have often been iinim'ssed with the mildness of the constitutional .'ymp- toins when compared with the amount of membrane which existed in th(> nose and the nasopharynx, wliich would seem to indicate in a certain proportion of cases that when limited to the nose and the nasopharynx there exists a certain immunity from absorption into the general system This may be somewhat contrary to the general belic'^f. but we often .see it illustrated by the little patients who freiiuent our various clinics Diagnosis. The diagnosis of nasal diphtheria, aside from the pres- ence of the Ktebs-I.oeliler bacillus, of which we will speak later, is surmised by the finding of a membrane in the anterior nares, and in arriving atOur conclusions as to the ])resence of the ineml)rane we must be sure not to confound an exmlation with inspissatecl mucus or dense mucopurulent discharge, which often exists in severe cases of coryza, and which is difficult of exjmlsion. The best way of arriving at a positive conclusion as to the presence of membrane in the anterior nares is. after thorough cleansing by a pledget of cotton, to try to dislodge th(> suspected exudate from the mucous membrane beneath, when we will find, if it l)e an exudat(>, it will be sonu'what difficult to dislodge, and will leave a bleeding surface beneath; and if it be considerable in extent a (luitc well-marked epistaxis may be induced. ^F-«r ^mi DirilTllKJilA OF THE SOSE ASD THROAT. ■S.Jl Hut tlic most |)<)siliv(> moans of diagnosis, in fact the only rcliahic means of dctcrmininj; wlii'tlicr the exudate lie (li|ilitli»"ritic'or not is l)y takiiifja ciiltmc, wlicii tlif |nvscnccoral)scnc('of tiic Kicbs-LocHlcr liacilltiswiilsiihstantiatc tliccliaractcrof tlicfxudatc. It has l.,'('n my cxixTicncc in tlic cxaminatiun of a ^rvnX many cases <if mcml)ranf in the nose and nasopharynx t<> find the Klchs-LocHlcr hacilhis prcs^'nt in by far the Krcatcr "proportion of i-ascs, Imwcvcr Iniij; standing tiny may have been, or liowcvcr insifrnilicant the symi)toms, Icadiii); me to believe that nearly all cases of so-called membranons rhinitis are of a true diphtheritic nature, and shouhl be viewed as true (Hi)htheria. doing away with the term memi)ranous rhinitis, wliich Ls so constantly used, and is misleading, and. also, thereby illustrating,' the absolute necessity of making a bacteriological examination in all cases. Differential Diagnosis, The conditions to Im' confounded with nasal diphtheria are .severe coryza, foreign bodies in the no.se. and the sloughing of traumatisms. The first can Ix- excluded bv the ab.^. ice ot membrane after repeated examinations and the siib,se(|uent C( rse of th(> disease. The main point of differentiation from foreign Ixxlies, which often produce a sloughing membrane and ichorous discharge^ is that foreign bodies are as a rule unilateral, whereas diphtheria is bilateral, and a mechanical examination by means of a i)robe will ill the case of foreign bodies detect their presence. Traumatisms are to be determined by the hi.story of their reception. The Pharyngeal or Faucial Type. Pharyngeal dijjhtheria, or diphllwrm, !is we generally use the term in a generic sen.se, is ushered in by more or less constitutional symptoms of nialai.se, rather gradual 111 their ons(>t, which may extend over a j)erio(l of a few days before the jiatient makes a special reference to the throat. The temperature in this initial stage may become quite elevated, the pulse accelerated, and as the .symptoms progress it soon becomes evKlent that the patient is .suffering from some constitutional ab-sorp- tioii. The first symptoms as a rule referable to the throat are those nt painful or difficult deglutition, when examination reveals the presence of a membrane or exudate. rh(> diphtheritic membrane when seen in the early .stages appears 111 the form of a .small whiti.sh patch which mav have its origin in any portion of the faucial region. It is generallv thin at fir.st, and IS It progres.se.s in extent becomes thicker and heavier in its charac- ''•risiK's, changing to a duller or grayer color, with sometimes a dark -oughmg cigo, and from a small origin mav spreatl to cover the "lit ire faucial area. The spreading and rapi«l confluence of the membrane in the ma- i'lity of cases are (piite characteristic features, and ;us the })rocess Aieii.ls the exudate takes upon itself the appearance of an organized 'eini)rane or a true necrotic proce.ss, and if detached bv anv mechani- il means it will be found quite adherent to the underlying tissue, ■avmg, as a rule, a bleeding surface. HJ2 SUSE A.W Til HO AT. Location of the Membrane. Tlii>rc is no siMTial sont fur the itiitial loi'utiim of the iiu'iul)raiic, luit m-iuTally it iiiakcs its apiM-arann- first (III tlu' tonsil, ami spreads ijuitc rapidly to tlic adjaci-iU tissues, and as a ruh- is bilateral. Tlie tonsils themselves may or may not 1m'( .ime eonsiderahly enlarged : that will dejM'nd somewhat upon their ])revious eondition. In seven- eases as the disease progn's^'s then' is gener- ally a very stmng odor, whieh is considered hy some to Ix' eharae- teristie, and then- is freijuently assoeiated with the faueial eonditions a swelling of the adjacent lym|)li glands of the neck. Aside fmni the |)n'sence of the exudate then- is al.so mon- or less marked fauciai n-dness or hypera-mia, Hiving a general angry ap|K'arance. Differential Diagnosis. The main condition to Ix* differentiated fnuii diphtheria is acute confluent follicular tonsillitis. The main clinical points of dilTen'iice lietween these coiiilitions an- that in acute follicular tonsilliMs the ons<'t is more sudden, the exudate is nuicli more friahlc. not a true menihrane, less confluent, more punctate in character, and the tonsils usually mon* swollen and the exudate limit<'d to the tonsils jilone, whereas in di|)htheria the characteristics an' confiuency and density of the exuilate, and not being necessarily limited to the tonsils. It may he said in general that any exudate not limited to the tonsils may be considered as a strong point in favor of diphtheria. Sometimes we are called u|)on to differentiate Ix'tween diphtheria and the mucous patches of secondary syphilis, and the ulceration which attends the early m.anifestation of tertiary syi)hilis. the results of caustic applications, swallowing of irritant poisons, traumatisms, and the exudate following operations within the cavity of the fauces. I ;im becoming mon' and more convinced, however, especially when ditfen-ntiating tVom confluent follicular ton.sillitis, not to n-ly on the clinical pictun', but always to insist on making a culture, deciding the diagnosis on the presence or ab.sence of the; Klebs-LoefHer bacillus, which is the only true way of differentiation. Kspecially is this tin- more important in mild and not well-defined cases. Laryngeal Tjrpe. The i.-ryngeal type of diphlheria ' its general o.Mset and symi)toms, when primary, is the same : the other forms, only varying fnim them by the pn'sence of u,.- memhram' in the larvnx or tnichea giving rise to the set of symptoms which are classified under the term of (Uplitluritir rrnup. Larviigeal diphtheria may be either primary, that is, the membrane forming first either in the larynx or trachea, or it may be the result of extension of the membrane fnmi the nose, na.sopharynx, or pharj-nx. When the larynx is iin.ided, either immarily or from extension, \\v first symptom to attract our attention will be a slight cough whicli soon liecomes U" e frecpient and bra.ssy in character, and as the membrane extends takes upon itself the well-known characteristic i>l a croiipy cough. The row and crij of the child, which at first may be but slightly hoarse, become as the disease extends ven*- hoarse indeed, and almost aphonic. In some instances whore the membrane begins in the subglott;' JSW^r IW^^^-W^'^^^-T-W' JIII'IITIIEIUA OF THE SOSE ASl) TUllUAT. 833 rcjiioii \\\y voice may not Im" interfered with to any great extent, and tliis i.s used as a i)oint of diagnosis in the localization of tlje suli- si'(|iient stenosis. After the cougli and clianpe of vo. ave jjcrsisted for some little tiriie tliire h'^ins to Ik- (h (icecj an interference with the breathing. This, at first, in the majority of ciises is slight, and may Ix- only spas- modic in character, generally \vors<' at niglit. and interfering with sle-p: l)ut as the stenosis progresses the hreathing Ix-comes very much more continuously embarrassed, and in bad j)rogressive cases it ends in the well-known stri<lulous condition of laryngeal croup. In severe cases. esjK'cially when from extension, and where there is much c<.nstitutional al)sor|>tion, the temperature may Ix-come as high as 104° or 10.-)°, the puis.- be rapid and weak from exhauw- tiuii, and the respinitions much increased in fre(|uency, Ix-coming as rapid as m to NO j)er minute. In many ca.ses, however, these ex- tremes of temperature, j, ilse, and respiration are not reached. At this .stage the child iK'comes very restless, tlirowing him.self about the l)ed in a vain endeavor to get sufficient uir, culUng into play the extraneous muscles of resj)iration. with the characteristic talhng in of the ilavicular and epigastric n'gion.s, and only becoming (piiet as cyanosis or exhaustion sujM'rvenes. If at this time tlie child Ix* old enough to a(hnit of a laryngoscupic exammation. tiie epiglottis and arytenoi<l region will be found con- sidiTably swollen and covered more or less witli memlirane, which at once estal)lishes the chanicter of the (liseu.se. \W* =m small children it gf«'s without saying that we are unable to make tiiis examination, and m vaim^s of j)rimary invasion of the larynx we must depend for oin- ihagi.'isis uixm the character of the syiiiptoins and the presence or absence of the Klebs-Loeffler bacillus, as will Ix' referred to later. In all cas<>s of na.sal or pharyngeal diphtheria where laryngeal siihirrtire sipnpiows supervene, it must be taken for granted as indi- cating a downward progression of the diseas*'. Diagnosis. The two main conditions to Ix> differentiated from primary diphtlieritic croup are acute catarrhal laryngitis with croupy symptoms, and spasmodic croup or laryngismus stridulus (false crou])K 111 catarriial laryngitis the hoarseness and cough may become very marked. The cough, as a rule, dcx's not Ix'come so croupy in char- ■I'tcr, and the breathing very rarely l)ecomes .seriou.'*ly embarrassed, and there is a general tendency, either by self-limitation or by treat- ment, toward abatement of the symptoms. In diphtheritic croup the main point for establishing a diagnosis oilier than by the presence of the bacillus is that the symptoms hiroir proffrexsirfly worse, and we may say that in any instance where the croupy symptoms progress to that severity sufficient to warrant surgical interference, we may lx> verv sure that the case is one of diphtheritic en. >, whether we find the bacillus or not. In spasmodic croup or laryngismus stridulus the attack generally comes on verv suddenly out of a sound sleep, and, although for the 53 lliilf.^.2§S H.i4 .VO.s/v AMI TllliOAT. inoiiifiit the rroiipy syinptoiiis may Imtoiik' very .M'vcrc, tlir Jittack is nt'iu-rally I'lilldwcil by a ('cssiliiui of .sympttiiii."*, and tlu- following .lay the imticiit may Im- to all intents ami purposes ixTfectly well, and tlierc is no evidence of progressive eroiip. Another im|M)rtant point is that there is often a history of reeurriiiR attacks of croup in the child, which is fre(|uently manifested in the course of an exist- irg coryza. Sequela. The common seipiehe of diphtheria are o»itis media, from extension, supi)Uiative adenitis, fienerally of tin rvical «''""'"- lironchopneumonia. nephritis, ami postdiphtheritic jiaralysis. This latter neniTally first invades the soft |)alate, and it may extend to a paralysis of the entire muscular .system. It may come on very early in the di.sea.se, orl)e delayed for a varialile [K-riod after the acute symptoms have disappeared. It apparently docs not .seem to de|K'nd upon the severity of the disejuse. This latter fact is (piite frequently emphasized hy the patient pa.ssin>; throush a mild diphtheria, pos.sihiy unnoticecl until we are made aware of it by the . iset of a i)ostdiph- theritic |)aralysis of the soft palate. However severe <ir exten.sive this paralvsis may iM-come, the general tendency is toward recovery, unless it affects the mu.scles of the heart, which may occur at any time during the pronress of the disease, fre(|Uently causing sudden death. Treatment of Diphtheria. I'erhaps there is no disease which in modern times has Imh'Ii so revolutionizeil in its posit iveness of iliapiosis and treatment :is di|)htheria. This has Imh'U hmufrht about by the dis- covery of the Klebs-I.oefiler bacillus as a positive cause of diphtheria, and the use of the antitoxin treatment as its most eflective cure. This latter statement may seem rather strong, and may possibly call forth criticism from some (|uarters: but I think we can safely say from the accumulated ex|)erience and writings at the present time that we have in the antitoxin tre.itmeni of diphtheria as near a sjx'cific as it is po.ssible to obtain. The limitations of an article such as this in a work of this kind prevent the writer from ff>\uii into detail as to its substantiation, so we will have to rely ujton the above statement as beinji the con- sensus of opinion of medical thoufrht at the present time. One has only to compare his experience ■[ results in the i)re-antitoxin days with the present mode of treiitiiicnt in order to emphasize the streiifjth of the forcfioing statemeni ; and the writer considers it the ab.solute duty of a |)hysieian to use antitox'. i in all cases of diph- theria, of whatever tyix- or s(>verity they may be. The efficacy of the antitoxin treatment is l)est obtained when u.sei I in the early stages of diphtheria, before mixed infection with strep- tococci has taken place, that is, in the first three days .)r even before the positive diagnosis may have been made, .so iis to gain time and prevent the spread of the disease. The earlier it is useil, the less liable is the disease to progress, and the less likely will be the necessity for the re{)eatod u.so of the antitoxin; but at any time, even when seen very late, antitoxin should be given. ■naa ■%i- J-^X.>*\-ir ,'£'•.*'■=- • t^-* " DirifTiifjii.i OF Till-: yosi: AM* tiihoat. H35 Tf,(> rrlii.l.ilify of inatuifacturo aiul th<' pr(.|KT fr.>shr„.ss of tlio antitoxin sliouhl !„■ „iir ^n-atrM (•o.isi.|,.ration in tlu- rhoic.. of the particular .s,.rum. Tl... sirrnKtl, aii.l ronmitration nf tl.o antitoxin 11S.MI. ('xpn..ss...| in „„its. will .|,.,M.n.l sonirwliat on .|„. M-vcritv' of tlH- rsi-s,. at tlu. tin,., w.- Rivr it. an.l th.' ag.. of tl,.- patient. H„t, K.-n- .-raliy s,..akinK w.. . ...ul.l .rr on th,- .1.1,. of giving a lar«,. initial .lose. Mi..t..\..r may Im- th.- a^... kui.Iiiik th.. .sulw«,u(.„t Mtrengtli .,f the .l..s,«.. ar.-or.iinK to th.. proRms^ .,f th.. v>m>. This is osiM-.-ialiv so i„ larynp-ai cas^.s. ' • th.. in...!,, of a.ln.inist..rinK antitoxin is hy th.' us<. .,f a hy,K..I,.nnic s nnK... ,„„. R..„..raly ma.!., for th,. pnr,,.,.s,., an.l in using it we sli..ul.lcarry..ut all the. Hails ..f asepsis. '^ Th.- usual lo,.atiori for giviiiR the antit.)xin is ..ither in th.- intra- srapular r,-gion, tl... .■..n.ieetiv,- ti.s.sue over the alxloinen. or th.- .jeep tis.-u.- ol the l)Utto,-ks. ' We may say that th.- av-.-raRe initial .l.,.se when giv-.-n in a nio.l.-rat.-lv M-\.r.. .■a.s,. ol nasal or I'l-arynReal ,iiphth..ria. at what.-vr ag,- .>f the pa ..-nt, shorn, h.- Jm) units. If ,h,- typn- of ea.se 1... .sev.-re at the "..ts..t or 1 It has proRr<..s.s,.,| f„r two .,r thn-e .lavs or m..re, a larL^-r .IO.S,. sh..ul.l Ih- Kiv,-n. heginninR with ;«KK) units, .son,.- authorities |ru i.„. ev..n Aim units. In laryngeal .-ases, .-ither ,,ri,narv„r extel^d- i"« Irom the faun-s, at l.-ast Hm) units sh..ul.| Ik- giv,-n at theout.st-t Dangers of Antitoxin. In com,.aris„n t.. the great etti.-aev ..f anti- t.jx in Its re.sults ,n diphtheria we may say that its poi.sono s ff.-et.s ar.. alnmst ml. an.l tlu-y shoul.l in no way .i.-ter us from using " IH a .•.-rtam numlK-r of eas,.s arthralgia is'mor,- or l,-.ss marke.l j.n.i a gen.-ial ..ruption, r,-.semhling meiusle,s, makes it.^- apm-aranoe l"i: K i< fransi..nt. rhes,- mei,!,.nt- are I(.ss fr,>,,u.-nt s;;,,.,! h.- r„..re .-....•ontrate, pn-parafons .,f .s,.rum are In-ing u-s,-,!, /. . ., large, numher ; t '"- lt> an.l small.-r amount of .serum. Hoteh' ,|uotes in 1,00() (KK) n.|...- ....... ..nly hve cas..s of .leath oceurn-.i which eoul.l in Ty u . I .. attnlmte.1 to the antitoxin. Al.so in 450() ca.ses i„ the Bost.m n> llusj.ital. each n-cen-mgan average of two inj.-ctions. n.. ha.l u^u\u toilow..,!. an.l .)ne jKitient received 2H.{H)0 units an.l ;va.s dis- 'l"'"' '•ff<-ct of the antitoxin on the .liphtheritic i)ro(-ess is gen- ' .; I.v shown .vithin the first twelve to twentv-four Imurs, ami, if a Miff.eient ,lo,so ,s hrst given, it fr,..,uently happens in mil.l an.l early MM-s hat no.sul,..equent tm.,lieati.,n will h,- necessary, an.l th,- .li.s,.a.s;. v.ll piogr.-ss t.. a favorable issue. Tlu- t,.m,H>rature falls, the pulse --|m."s 1„. ter. an.l there is seen a marked absorption or exfoli ii„n 1. - ...emhrane. f th,- .li.se^.se is severe at the time of giying the -antitoxin an.! the sym,>toms ,io m.t abate sufficiently the anti- H b, r!!. ♦ 7"'''''^^'' '" " ?""'^'" ''•"^'' ^^''t'"" twenty.-four hours. I'l >. r. p,-ate,l again m a similar or decreasing strength'according to tliedeyelopmentinthec.<i<w. ^ .umg u. ' Rotch, DiKasea of Children. 8;JG \()SJ-: AMt TlinoAT. Fur ilctails as to the pre) liirai ions of aiititoxiii scrum, its various strcii^tiis. corHciitratioiis, statistics, the reader is referred to larger general works oii dii)!itlieria. Immunity. Not only has antitoxin proven itself of such great value in the direct treatment of di|)htheria, hut also we have in it a strong prophylactic measure wiien given to those immediately exposed to the contagion. The inmiunizing dose should he much smaller, iVM) to KHM) units, and it has hccn jjositively proven that the iimnunity lasts from one to three months. Local Treatment. It is the writer's oi)inion that local treatment other than tus an adjunct means of cleanliness an<l asepsis is not of such great neces.sity as ni the i)re-antitoxin days — and, indeed, in a great many instances where its administration is productive of much objection, resistance, atid disturbance on the part of the patient, it can he safely dispensed with. If, however, local treatment is indi- cated and appears n-cessary, we have at our dispo.sal many of the ordinary cleansing and antiseptic solutions. .\mong them may he mentioned hydrogen dioxide, diluted one to six times, especially used in the pharynx; normal salt solution, bichlo- ride of mercury (1: S(HM)), lime water, boric acid (4 percent.), Dobell's solution. Seller's solutitm, and others of similar nature. The .solutions should be api)lied warm, and should be bland, to obviate any excoria- tions. Irrigation of the nose is often very diflicult owing to the nasal obstruction. This sometimes may i)e partially overcome by first (lro|)|)ing in a mild solution ( '. per cent.) of cocaine, mixed with adre- nalin, wliich w ill cause sufficient depletion of tissue to allow the sijlutioii to run th.rough. ( )ur efforts m:iy be aided, if the child bo old enough, by the |)roper blowing of the nose. .Much m.iy be accomi>lished in ca.ses of nasal irrigation by attaching a small perforated flexible rubber c.-itheter to tlie douche and passing it through the nose to the iiaso|)harynx and the pharynx below. By this means a more thorough ;ij)pli('ation of the douching may be obtainiMl. I'nless there be a competent nurse in charge, the physician should <'ither attend personally to the douching or thoroughly instruct those in charge of the i)atient. The patient, physician, and those in attendance, as well as the bedding and floor, sliouM be well pro- tected, and, if possii)Ie, the discharges should be allowed to flow directly in a large basin held under the chin or over a rubber sheeting to a receptacle on the floor. I think the fountain syringe is one ol the best means of applying local solutions, for by it we can easily regulate both the amount and force, and with <lue attention to tlie details of position of the child, and cautioti in its use. it is as free from danger and will accomi)Iish perhaps more than any other means a' our disposal. .\si(le from the antitoxin and local treatment, it is also necessarv in certain ca.ses to iissist on the general lines of supporting treatmeni and to meet indiviclual iiulications as thr>v pres(>nt themselves. AinoiiL' tlie.se may be mentioned pioper nourishment, the combating of ui' ,^v-*er imt'mmms^i'TmF'^-'^^m^-^m&K"^^^^ iM^^ 'i<>M^\mr^^msde' lyTuii.iTioy. 837 ii.M.allv l.,«li f..,Mi.oraturc. canliar woakncss. all.u.Mi.n.ria. tho various >.'MU..|a. a-Hl att..Mt.u„ to tlir ;:,.,„.ral In-altl,. Al.s„!ut< ' n-st i , d ""..I all uaM«..,. ul p,.s„liphth,.riti,. paralysis an.l .nuscula,- w, kn I liavrpass..,lsli...il.|l,..sfn,i,jrlviiisistc.lup<)ii "<-»Kn(.ss Att«>Mh..M t.. sanitary .lotails is vory import- ,• in ..rcvonting fl„. i-lat.nn ol tlH. pat.,.Mf from otlu-r .n.rnber - of •(.. fan.iiv ,/',,; ^.nt.lat.o,, an.l sunlight of the siek-roo.n, h. v.ari,,^- o, prot mi'L «nwns on I... part o att,.n.la..ts and physid ,,. ,i ,• d-.Li .i | s^ .l.^afon ol rm.ptac.l..s an.l instnunonts of c-.v.,ninat.oo. .- .ts , s S- ra - pu-nsot «an... about tlu- fa., and I.an-Is, wl.ich shoul.l bo n , e- f l> d..stroy..d alt.r us,, an.l. abov. all, personal d,.anli„,.ss on he I . of a I who conje u) nnn.ecliate eontact. These an.l all . t It I et ul .,f hke natun. have an n.erease.i in.portanee when we re.nen er that ,t ,s mostly by .hreet eontact that the eontaj^ion of .liphtheria " Prognosis That the present mode of antitoxin treatment has .■.•.use, I most remarkable .leerease in the fatalitv <.f diphtl, a nus "■ ■•...•e.ve, as an aeeepted fact, an.l by its use a'n.ost f ,vor d « X nos,s may be K.ven. ..speeially is this the ease in larvn^eal .lipl tl e h '• 1. ... obvatn,^. the ne,.essity of ..p^rative proe^.-hm. w e g v! n 'a iy an.l most .natenal y ai.lin^ in briufrins about a favorable ten Man.M. n. those cases where tra.heoton.y or intubation has t. be e - y. m...l. 1 Ins ,s most strongly ..nphasi^e.! in the report of a eolleethr ...^ es i^'at,...-. earr.e.| on by the Ameri.-an Pediatric Association ' A l.nel refcre.ice to the statistics of the Hoston Citv Hospital as |rm.. by I?.,tch,^ w, 11 serve to emphasize the ,uesti..n o fSi;^ OfT. ns,s. „ a state.| rmmber of cases before the ,Iavs of antitoxin i." .lea h-rate was 50 p,.r cent, as con.pared to U ,,eV cent a , !"■ '•;•.„. smce ,ts use. Tlu> ^reat .leerease in fatal ca.ses is her -H. m m.l,v„lual pnvate practice an.l in in.stitutions where the .lis- 'i Th. iTI ' h'' n''n"'' '^'T <'"'.?"■''■' "^ •'^" '^'"""'"f "" authority > l.>latel)r.()I)wycr. wh., .sa,.l. "ha.! he waite.l until antitoxin M b,.,.n .hscver...! he never w.,ul.l have invented intubation " INTUBATION. The Mechanical Treatir ^nt of Laryngeal Diphtheria. When the ,:, ; T\ *'r '" "•" "^ •■>"t't"xi" •>^comes evi.lent, or when Ml Its sev.>rity befon- antitoxin has been piven, the .,u.>stion of I •l.v operative measures b.^omes paramount. To meet this con- :., n'V; ♦;^-'> Prnce.lures viz.: tracheotomy and intubation. I !'.s aitid.. the latter. .nly will be consi.lere.l. as without poirifr into m> comparative merits of the two measures, we can safelv nav tint ' Archiveg of Pedl;. leg. July, 1896. ' Loc. olt. 838 yoSE AM) in HO AT. as a i)riiiiarv (ii«'ratii)ii intubation has cnnniH^toIy superseded trache- otomy. The iiidieatioiis are tiie same for tlie two operations. For tiie tcehiii(iue of tracheotomy tiie reader is referred to works on sur- K'Ty. Aitlioush th(>re have been placed befon- the profes.sion a number of modihcations of the original intul)ation instruments as originated and perfected by the late Dr. Joseph O'Dwyer, of New York, this article will refer )nly to the O'Dwyer instruments, as they are the ones u.sed almost to the entire exclusion of all others. Fig. •l-'i. O'Dwyer s intubation tubes. The figures on the scale denote the age for which a given tube is indicated, the tube being nieasure-l on the scale, the length of the tube corresponding to the age, as shown by the llgures. The instruments for intubation consist of: 1. The tubes, made i/f hard rubber, with metal lining. 2. The obturators, screwed on the iiitroducing-handle. In this respect a recent improvement h;i.s been made l)y Krmold, of New York, by which the obturator is continuous in one piece with the rod, which fits in the introducing-handle, thus doing away with the thread, which sometimes becomes loose at tli • junction of the handle and the obturator, allowing the tube to turn. ;?. The introducer. 4. Kxtractor. 5. ,Scale. f). String. 7. Mouth-gag. The tul)es are of variable -ize«, to suit 'he required age, and are chosen according to the scale. IXTVllATWN. Flo. 423. 839 intubator with a tube in the proper pcltion for insertion In the larynx A Intubation tuh« iLre\rs;reTnirorr'- ^"- ''-'' "^'=''' "- P-- ^--. =- r^ Fia. 434. Mouth-gag. -l^r.te'^L/f'?'''!!!'" T^J °'*,°- "■ '*'*'• P"*"" °° ">"=" '° * downward direction ja«" o^ned " '"^""" "■" ""'" *" ""=" '"^ '*^'" °»y »« "epresaed and the Technique of the Operation. The patient shoul.l Ih- held firmly "I'riRht ..n the left thigh of an ;i.^si.stant whose leg., are tightly closed "M the pat,,.„t ,s legs. The left arm of the a..sistant is thrown around >' < l)ack of th(. patient, holding the left hand and arm of the latter ,:.',;' '^'V' . "^''Z '';""' '"'■ ^'^'^^ hoKis the patient's right "•i"-l. The right sKle of the patient is firmly held against the breast 840 yOSK AM> in. OAT. KUi. 426. To Bbow the method of iutubauug the larynx. of tliP assistant, tlio loft si.lo of the i)ati«-.ii bcinR free. The sccoiul assistant stands l)aclv of tlic patient, holdinj^ tiic licad firmly in a suspended position, anil steadyinj^ the Mioutli-jiaR with the lift hand. There should Ix' no twistiuf; of tlie neck of the patient, who should be held perfeetly straifiht. This cannot be too stronjjly emphasized, as it especially pertains to the successful introihiction of the tul)e. The pro|)er-sized tulx- having l)een chosen accordinj; to the scale, it should be threaded, always using braided silk of a size which will pass easily tlimufih the ojM'niiif!; in the tube, and of a length which will permit of being looped over the patient's ear when the tube is in position, and so tied that the knot is always at a point farthest away from the tube. The operator, staniUng or sitting in front and a little to the right of the patient, at a height which gives ea.-^y access lo the mouth, the patient's mouth being well open and the gag on he i 'ft side, piisses his left forefinger well down into the larynx over the epiglottis until he feels the two small tips of the arytenoid cartilages, which indicate tiie posterior portion of the larynx. The sensation imparted to the finger is the same as feeling the tip of one's nose. Then the introducing instrument is quickly pitssed down over the palmar tij) of the left forefinger until the end of the tube engages in the larynx, gentle pressure Ix'ing continued until the tube is well down in the larynx, when the left for(>tinger is transferred to the head of the tube and the obturator removed by liberating the sliding catch on the handle of the introducer. The left forefinger should remain, gently pressing the head of the fube, until the obturator is well out of the mouth. Care should Ih' taken that the obturator is not re- movi'd in any way from the tube until the latter is well down in the larynx, thus avoiding any danger of stripping oflf or wounding the mucous membrane. Successful introduction of the tube is almost immediately rewarded by relief from the difficult breathing, which becomes more and more maiked as the minutes go by, and the patient pas.^^es into a condition of rest which is in marked contrast to that which necessitated the (>peration. The means of knowing that the tube is properly placed in the larynx are, first, the relief in breathing, and second, the char- acteristic cough, which inuiiediately occurs and is of a moist metallic character, pnxluced by nmcus and air passing through a metallic tube. This cough should always be looked for, and if not present should be provoked by the administration of a te!i.«poonful of diluted whiskey or brandy. The character of the cough is peculiar, and is far belter appreciated by being heard than from any descriplic'. Ofttimes, in moribund cases, the cough may be delayed or be but mMSSSi*'^- ^^"Sfi^Ai^^^V: T^^ lyXVliATION. 841 ffphio whon it is hoard. Th" po'irI. is valuable in cloariiig the traclica ot secretions and as an indu'ation of the firmness with whieh I he tul)e is retained in the larynx. Another way of determining whether or not the tube is in the larynx is l)y |)assin>i the left index hnger down into tlie (esophagus and (eehnfr the tube through the anterior wall of the foriiHT This means IS ot great service if for any reason the breathing is not fully IV leved. and if it is desired to be jxKsitive as to the position of the tube. If, however, after the hitroduction of the tube, the breathing IS not relieved or becomes suddenlv worse, the (lue.stion of having imshed down with tlie tube some detached meml)rane is to be con- sidered 'I'his aeeident may happen, l)ut, as a matter of fart, it is very rare. If it were of frwjuent occurrence it would be a most serious objection to the operation. The reason of its iiifre(|uency is tliat the stenosis is not entirely due to a complete membranous cast of the larynx and trachea, through which the tube has to pass, but also to a lessening of the lumen of the lar>'nx by infiltration of the submucous tissue. This can be easily observed in a cross-.section of a larvnx tniiii a case of diphtheritic croup. The accident mentioned is more likely to occur in late cases of ••roup in which the in(>mbrane has begun to exfoliate, and at anv tiine \vli,.n traumatism has been oer;i..i<ine(l bv the introduction ()f th.' tube It IS accompanied by oxce.s.sive coughing and a Happing x.uiid, cause<l by fh<" loosened membrane. If for this or anv other reason the breathing is not relieved, the tube should be witjidrawn •y til., string and the child encouraged to dislodge the loosened mem- I'raiie by coughing, after which a second attempt at introduction >li<>ui,| he made. It sometimes happens that pieces of detached nienibrane accomj.any the withdrawal of the tube. If it is reason- :ii)ly certain that loo.se membrane is blocking the tube and is not ivailily expelled, a short cylindrical tube (foreign-body tube) mav he ms(.rted. Tlie.se tubes for a given age arc much larger in calibrV than the ordinary ones, an.l allow large mas,ses of membrane to lie expelled. Owing to their larger size they should not be left hi the larynx more than a few hours, on account of the pressure which they cause. Another accident which may possibly occur is the introduction of 'lie end of the tube into one of the ventricles of the larvnx This IS obviated by using the present type of tubes, somewhat bulging on the ('iKl, which thus permits them to override the ventricles, and bv Keeping ,n the median line during introduction. Introduction of the tuhe into t..e a^sophagus will sometimes occur. This can be appre- nated by failure to relieve the difficult breathing and bv attempts on he part of the patient either o expel the tuhe or b^ efTorts to Mvalow If the string is observ. I to be disappearing within the mouth It IS evident that the tuhe is in the (p,soph.agu.^ and it should "<■ immediately v thdrawn. This accident is an avoidable oi ,d tiood not occur if the proper rules are followed. In the cases in m^SiT^fim^ 842 SOUE AXD THROAT. wliich I havo scon the tiilic swallowcil it lias passed tlirouKh the alimentary eanal within from two to four days without any aecident. The tube may bo ooea-sionally .swallowed when eouf^lied up by the ))atient. Tlie strinj^ should bo permitted to remain in place, being passed over the left ear until ([uiet breathing is restored, from hfteen minutes to half an hour, and should then be removed by cutting one side of the loop close to the mouth, taking hold of the long end and with- tlrawing while the loft forefinger is making gentle pressure down on the head of the tube. Never, uniler any circumstances, remove the string without making pressure on the heail of the tul)e, as the string liecomes twisted ii. the mouth and will bo caught in the eyelet of the tube and the latter it.solf withdrawn unless the counter-pressure is made. Another very important precaution in regard to the string is that the person holding the child should never release the child's hand-s until the -tring is removed by the surgeon. Almost the first thing a child will do if the hands are released is to instinctively pull at th(> string, resulting, of couise. in withdrawal of the tube. It is the practice of some, in preparing the child, to tightly encase the arms and chest in a draw-sheet wrapped around the body. While this keeps the hands out of the way, it is open to the objection of too firmly constricting the cliest, and, in case of artificial respiration being necessary, nmch valuable time may be lost. Also some opera- tors fjrefer to introduce the tube wliile the patient is in the dorsal position. I have had no experience with this mode of procedure, and cannot speak of its merits. In extracting the tube the same precautions as to the position and management of the patient during introduction should be followed. The instrument for this purpose is called the extractor. liefore l)eing used it is absolutely imperative that the thumb-screw on the under side of the instrument should I " so set that the di.stal jaw can ojkmi ju.st sufficiently to exert the proper amount of pressure within the opening in the tube. If the jaws are open too widely thero is great liability of lacerating the surrounding mucous membrane in inefTectual att<*mi)ts at removal. It is good practice to test the degree of opening of the extractor on a tube of the same size a.s the one in the larynx. In extracting, after the introduction of the mouth-gag, the left fore- finger shouki be pa.ssed down on the head of the tube until the opening is felt, and then the extractor, closed, is passed down until the point strikes the head of the tube and enters the opening in front of the tip of the finger. When, in the opening of the tube, the jaws of the instrument are opened by thumb-pre.ssure on its handle, and the tube withdrawn, pressure being continuous until the extractor and tube are removed from the mouth, never have the thumb on the lever until you feel sure that the end of the instrument is in tli" tube. The operation for extracting is j)erhaps more dithcult than that of introduction, as it ritjuiros a finer degree of touch to determine ^ S^T?!^^^^^^ P'f^aiP^- IXTitiA Tioy. 843 t .<• ..pHung in th.. hoad „f tho tub.., an.l tho .lifficultv is incn-a^-ed n I.rnp.,r ,.„, to th. s.nallnj.s of th. tul... MoclifiVatioas n,' tn . to t.m,- hav<- h.r„ ,na.l,. in th. hca.l of the tube an.l n tl " <l'^.^ ri^^^^^^^^^ "/ac.htate r.Mnoval; hut th. original promlur. j <l<>mb.Ml. ,s the one ahnost universally employed. Extraction hv |.ush,nK out the tube from below without any Lstru.St n ay su?- eessfully be ,,erfonue.| if for any reaso.i great difficulty is exS, "Jl M the application of the usual method, or in ca.se of emergency when the tube nuis be removed by the n-rse in the alwnce of the „. This .s .one by slightly inverting the pati. .t and, with mouth open' placing the thumb in the episternal notch and pushing tl, tube up .n the mouth and gra..ping it with the fingers of the other and or with a pair of ordinary forceps. This cL be done b "^0^ f <.r<hnary intelligence m charge of the case, and is, under theS^cir cun^tances, a most admirable method of extraction AfU.r remova of the tufx^ the patient should not be left until there .> safteu-nt evulence that the tube will not have to be replace. A small dose ot opiate may then be given to allay cough an.f Stion blight cough ami hoai^eness generally continue a few days to wo .mt inVE""-' ^'^ '"^'^"^^^^' "'"^'h' ^°--'-' Pa-s a^y wlth- Feeding after intubation is best accomplished by having the ild Ile/l ;he'"ft''"f '-'^^ ""r! '-"'^''-v- This is 'commonly he itTf ^'XY'^' "'^^hod. It is be.st performed by raising h! I } }^'\' '•"""^''"K the pillow, and bringing the child t., the e,lge ot the bed on the si.le, and using for the pfirpose of fee ing nn on inarj- duck-shaped feeding-cup. This procedufe ™us in .•nr':7c "7-'^ f-"-"^-"'^' the tube und the actom;rnying F).rox>.sm.s of coughing. However, it is remarkable how n-adilv s..ne children, with a tube in the larynx, will learn to swullow n t*e ordinary upright po.sition. I consider it also very excellent practice to keep the patient in he feeding position during the entire period in which the tube li" mms m the larynx in order to lessen the chances of secretion" pa^ .ng down through the tube, and thus, possibly, causing the deVeC ...ent of imeumoma. The frequent renmval of 'the tube for purS ol feeding h..s been advocated by some, but I think such a practS sh.mid be mentioned only to be conderiined ^ ■ivSe, ""si '''""'' VT ""''' '\^^^^^oM, solid particles of food being i t h t » "t"^ ^" '"" ^^' '''^"S*"'" °^ large pieces being drawn .the tube. In ca^e great difficulty is experienced in the uS of rthlJh thf """T"^ r'°T' ••— « -ay be had to alimen atioii through the oesophageal catheter, passed either through the ;:;;:: ;;: i^rihti """'' "' " ^ '"-' ^^"^^' '^^'^ ^""^^'^ I think it most important to watch the re.^};ir.ition during the m.re period of intubation, as bearing on the progre s of tl^e Sat If they continue about normal it is indicative of favorable pmrrS"; BE^^ •iJw\'^^'iBW'rda&^ 844 yoUE AX1> THROAT. II I i- : if tlicy slum- a tciidoncy to increased rapidity, it is iiidicativo of I'Xtfiisioii of tlic inciiihraiic. rortiiiiatcly, iiowevcr, the latter does not occur as fre(nientiy as it did in pre-aiititoxin days. Tiie ])roj:Mosis of diplitiieritic crou|) under the present coiuhiiied treatment is, 1 tliink, reinarkabiy favorable, especially as compared with the results formerly obtained. A reference to this point in the report of tlie collective "investigation of the American I'ediatric So- ciety, referred to above, fjives the mortality in cases operated upon by intubation, and in which antitoxin \v:us administered, as 27.24 pl-r cent. This is in strong!; contntst to the previous mortality, which raiifred from li!).") per cent, to 75 per cent. I have no d()ul)t that the jirojinosis will continue to l)e even mon- favoral)le as there is gained a better understandin}; of the combined treatment. In a very small numlwr of cases it may become necessary to per- form tracheotomy in the event of failure of intubation; but ^-heii this has been done th(> |M'rcentaRe of recoveries has been very small, and conditions have i)een found which could hardly be reached by either operation. In contemplating the performance of intubation one should not rely entirely upon written description for his guidance, but should aciiuaint himself with the operation by practice on the cadaver. This is, I think, a sine qua mm. The perf(>cted tubes of the present time are made of hard rublMT over metal. This, as I have saiil before, allows the tube to be retained longer without the occurrence of calcareous deposits. These tui)es exert less pressure, and can be more easily expelled in case of plugging with membrane. When to Operate. The (juestion of when to o])erate is always of vital importance, and especially .so if for any reason antitoxin is not employed. We can recall the various opinions which have i)een held on this i)oint, ranging from intubating at the very beginning of the manifestations of croupy symptoms to waiting for the more positive condition of progression marked by recession of the extraneous muscles of resi)iration and signs of cyanosis. It has Im'cii well proven by the report of the American Pediatric Society, already referred to, that in 00 per cent, of the ca.-^es of laryn- geal diphtheria, intubation -^ not refpiired, if reliable antitoxin has been properly administenvl at an early stage of the disease. If, ho\v- ever, croupy symptoms super^-ene and progress, the use of the anti- toxin should be continued, the dosage })eing based upon the age of the child and the amount previously given, .and at the same time the croupy symptoms should be watched, reinembermg that it some- times requires twenty-four hours for the full effect of the antitoxin to be manifested. This is esjx^cially important if the symptoms of laryngeal .stenosis are the first indications of the presence of diph- theria. In either event, and here the initial dose of antitoxin should be a full one. in tiie interval while waiting for the antitoxin effect, if the symptoms of stenosis are progressive, intubation should be inmiediately performed; never, in any instance, is it justifiable t« ISTVliAriOX. «4.j awai th.« appn.aoh ..f the scvror symptoms „f st(>n..sis. After ii.- lu mtmn. th,. ,,s,. ot a„t>t..xm sh„ul.| l„. ,.onti;u,e.| on the priru-ipl.-s al ....ly ^Mv.-n. n „■ d.sc-„ntmu...| as tl„. ,n...nl,ra.H. shows a inarL.I t :M.I,.nry to .xlohat.. an.l tl... r,-spiratory symptoms a t.-nd.-n • to -lisapp.. r. an.l as to the other «,.„eral eo.nliti.ms. ..speeially the puis anJ te„ jH-rature resu,„,. a n.r.r.. nearly nonnal ...n./ition ^ How Long ShaU the Tube Remain In the Larynx? In i)re-antitoxin .ays he average peno.l <h,ring which the tul.e was allowl.l to na n t .. larynx was tro.n s.x to seven full days. Tn.ler the present n.o,le of eoml.me,! treat.nent the ti.ne mav Im- somewhat shorter varyms m .l.tTerent exjH.rienees fn.r., ;hre, ,, five ,lavs The usual' the .\e« \ ork I'oun.lhnp; Hospital three .lays. Porsonallv 'in nrivite |;.-a;'tu-.- I prefer to leave the tube in the larvnx .luring ij; f . 11 ,'^ It tlH.re are no m.l.eations for removing it, on the genml pri ri.le^of av.)i.hngunnecossarvn"intro.luctions pnn(i,m.,i In liospital practice, when, assistance is ahvavs at hand in case of .:."erg..ncy. then; ,s less danger in leaving the tuhe in a shorter me .... should occasion arise, ,t can Ih« at once n.place.1. Wrhal n-ports t m .. the inst. utu.ns mentione.i .lo not show any comparativ im- e so .|t h.. .ec..ssity „r remtr.Klucti.,ns between the ol.ler'an.l the pres -nl ;;■ ....is . eoml,me,l treatment. The .luration of the .li.seise Is nvT.,.e t7"'r', "' **"^I"-*"«'"^ treatment that tmdoul.te.llv in of rSnirhic^i*;;,'"'" ""^ '^^' ""'"^•^•' oanier without the necessity Th.' principal in.Iications for removing the tube previous to its final n.moval an; severe .liscon.fort .,r pain fn.m {.res-sute, esix-ciallv if he '"1. M. en. attacks of coughing, an.l su.l.len .stenosis <lue t.. the l...lire- li;-.. .. niembrane m the lumen ..f the tube. This last-name. -IS- ti. 1 ,> perhap,>, nu.re likely to ari.s,. earlier un.ler the antitoxin .. ...tinent .„, account .,f the earlier exf. ,ion of the membrane In .m.._ .nstances, however, if the membn.n,. be sufficientiv l.,osen;.,l o . 'k up the tube, the latter will be coughe.l up with the mem r ne Is IS esiK^cially th,. ca.se with th.. pn..sent rubber tubes, especially I'-'.tube .Iocs not fit too tightly. If un.ler these circum ta. ceMl2 ..■ IS ..xp,.|le.|. Its reintn.ducti..n may not be necessarv. or at any .1. Vv, "i '"'"''"^•'^ "^ remtroduction will, as a rule, be sufficientiv ^l<' a><..l t., permit remtnuluction by the physician in charge ..f hi! r; '-"'r"^"^" ''^r^"" "^ intubation, after the original cause . n.sis has cease.l to„perate, there occurs a more or less ' nar„.nt se„o..s, necessitating almost constant use of the tube t' •> th.' period of a few days to some months. These cases are cl-iss^l Z^^^;^V''^'''^'ff^''^'''^ Thecou^^eamS • D ( -Dwr !•"" M f''^ r '■^'^"••'^t^Iy set forth in a classical article S oc etv S^)7- 1 'tr '-^^f'^">;f^': ."T-ting of the American Pediatric exposition of the subject, although it requires further experience for 846 yOSE ASD TIUIOAT. its full plucjilation, which will only roinc from a wry careful study of the few cus»'s that will occur from time to time. Dr. O'Dwver, in giviii>? the cause and s<'at of this i)ersistent stenosis, says: "1. The cause of iHTsistent stenosis foUowing intubation in laryngeal <liphtheria can be sunuued up in the single word, trauina- tisin. Paralysis of the vocal cords may |K)8sibly furnish an occasional exception to the rule. 2. The injury to the larynx is done by a tulx* which does not fit projx'rly. It may result either from an imjierfectly eonstructed tulw', or from a perfect one which is too large for the lumen of the larynx, although suitable to the age of the child, or from a tuoe that is perfect in fit and make, if it is not cleaned at pro|x>r intervals. 3. The s<^at of th(> lesion which keeps up the stenosis is just below the vocal cords in the subglottic division of the larynx, or that portion bounded by the cricoid cartilage. Exceptions to this rule result from injury protluced by th(> head of the tul)e on either side of the ba.se of the epiglottis just above the ventricular biUids." Dr. ODwyer sums up the avoidance of its occurrence and its treat- ment when present in a full appreciation of its causes and the skilful use of tubes of projx'r size, shape, and construction, and the us<' of the hard-rubber tube now in vogue, which can l)e worn indefinitely without the occurrence of the calcareous granules which apixmr on the metal tubes, and which may lu'come a focus oi ulceration; further, the rubber tubes at their impinging ints do not produce the same degree of pressure as do the metal tub STPHILIS OF THE NOSE AND THBOAT. Syphilis of the no.se and throat may be either congenital or ac- quired. Whc" congenital it generally shows itself in very early life- although it may be somewhat <lelaved, it usually makes its apiWirance before the age of puberty. It is generally as-sociated with other bo.iiiy lesions, u.id our first attention is attracted bv the usual manifestations of a sy|)hilitic birth, viz. : snuffles of the nose, mal- nutrition, and possibly ulcerations of the skin. In attacking the interior of the nose it usually .shows a preference for the bony stru. tures, esf)ecial!y the septum, but may attack the other bony portions, and as the patient grows, if it outlives the first manifestations it generally results in a lo.ss of the septum and the characten,stic falling-in of the bridge of the nose. Sometimes adhe- sions take place withm the nose, producing more or less complete obstruction. Pharynx. Congenital .syphilis of the pharynx is perhaps more common than that of the nose, but frequently they exist together being s'-uply an expression of the general syphilitic invasion. John iN. Mickenzie, sjieaking of the time of appearance, states that about oO per cent, of the cases occur within the first year of life, and as many as 33J per cent, within the first six months. The usual mani- i'l.AT!-; XXV!. F.-i I r,. F ..I M r.t IN ^\ |.li.li~ ..I T..n, I.,1A --v |,l,ili- ..|- I --. \ -s |.li : h- ..I H.M.I r .h I ..I i T.-Ill.ll', S>|.l.,l,-. ,,f S,,l! (>;i v >•."/'//„. s <tF Tilt: snsi-: a\i> Tin:o.\r. f^^J tVst;.'i..n in tl... ..haryiix is an ul.rn.Iion. griuTally ult!u-kiii« the iH.ny .siruct.in- hrst. viz.: tl... h,,nl palat... |.r.«lu,-inK hTlnratioM w.'ll, an.l wl,,,, thosuf, palat.. ,.n.l la.irial pillars l,<.ru,n.' ulmat...| II iiM.ally .■i„!s Ml ll... pr...lucti.,n <>( a-lhosicns h.-tw.H-n ti.c pharvnK..ai wall an.l suit palatr. Conurnital syphilis .,f the larynx is vm"rar..|v s.'.-ri. Ih.' Kcncra! ty,.." an.l appraraiur „f tlu- l.'siun (Ic's not vary In.ni hr losiui. .,( the a.-.iuircd frtiary f..r.n, which will Ih" .Icsi-ribcd more hilly iinilcrthat heading. Acquired SyphiUs. In its prin.ar>- forn. un.l.T the torn. ..f ..xtrn- j:.'nitai .•hanrr... il„. nntial Icsi.m is rath.-r infnviuont in the noso hut ;"">■'• lr,.,,u<'nt n. th.- lips. fmRu.- (Plate X\\J.. 1%. i,, ,„„| ,;„,„.. times ...r.irnnK on .>i r ctluT nf the tonsils. W h.-n <e,.„ i,, „,.,nv " tliese positions it .io,.s not vary Iron, the general tyjH- <.f genital ;l';"|.Mv. V.Z.: that of .•. localize,! induration with tnore'.'r less sup,"' nml ul.vration. Pron. its rarity in this position it is not infr,..,u,.ntlv nistak..., I..r epithelioma, hut th.- sul.s<M,uent .secondary n.anifesta'- li..n soon estal.l..shes its character. Asa rule, the se,.o„darv . ; ■; •■'";'•••<"""■ '"<"' -vere in their nature than when '„. 'Ii.ii.cie i> o( the usual genital variety. Secondary Syphilis. Secondary .syphilis is extremely rare in the ;..-.; ,n the pharyt.x (l'lat<. XWI.. Fi,, ,>, ;, is e.xtren.ely co.n- mon and oc.-urs ,n a very !,.„ge proportion of those affected with M i T' ;''''"7;"*^ "'""";' ""Vthne within a few we-ks to months .'Iter the initial lesion an.l a.s.sociated as a rul.' with other s,.co.ulary '-ni .'statiotis. It may attack ai.y porti.u. of the cavity o t ."e na th. VIZ. : hps, msides of the ch.-ek. the sid.'s of the tongue, or the 'iiK.s. It ,.. „,,,st characteristic when seen in the faucial region ;M.a b- tuanilestn^ .t^-lf by a symmetrical erythema, having ^^l^: ne 1 ateral fan-shaped appearance, sp rem ling over the anterior . > ol tl... tauces, and u.sually ...eluding the tonsils ..md the posterior "ll-i..^. In a wel-marked vinilent cas<- the entire posterior region .y u"c,.me iniplicated. ami ..nn.timesit spreads to' the m.se, .LJ! - I .n.uigeal .space, and Kustachian tulx-s. In typical ca.ses our II ent,,,,. becomes almost in.n.e.liately .lirecto.l u, this bilateral . r emia of the fauces by ob.s,.rving their sup.Tinr reddened n.argins . c I TT r, "''"'''•"' •■""' '''^ ''"'>■ '*^*'""' ""^ "' '•"'"•f against the M lor o he .superior portions of the palate. W ithi.rthis area ■I l.u.ial er\thema and at various j,oints th.Te appear the chanc- - IS ic ,K.arl-co ored plaques calle.l " mucous patXs," h h -re J- ightl elevate,! fro.n the surface of the erythema, am! frec,uen ly ll. u> an ai,pearan,-e as ,t they ha,l b,'..n flatteno,! out. \\hen small ■; more or ess ,.solat,.,|, they are generally cre.scentic in appeanuiS :t^A:.C^S^%::\:^^^^' -- t., have^/hee„tir; Mthoni^i, .. , " . " '"^ ^''- :"n-i'=, wrtcrrd wnn the mucous patch. Alttmufth a typical ca.se of secondary syphilis as above described - comparatively easy of diagnosis, and whin once sc-en ca.mot very ><48 NO.SE AXD I II no AT. well l)c (•(iiifouiidcil witli any otlicr Ic.-ions, the diaftiiosis of a mild or a I'adiiifi case is ot'tcii very ditiicult of diafriKtsis. It is not infrciiuciit to notice a l)ilatcral liy|M niTuia of the fanccs wliicli is Ix'iiijrn in its ciiaractci-. i)iit tlir liy|MTainia of secondary syphilis is (h'cper and more siihmucoiis in its nature and may Im- paler in color, and usually, '.'. not always, when the free ed^jes of either the anterior or posterior l)iliars have })een afi'ecte(| then' will l)e left evidences of a slight erosion somewhat serrated in appearance. In reachinj; a conclusion in the- difficult and suspected cases I have come to look upon this last appearance as a very .-trong point in the (lia<;nosis. Sometimes the secondary manifestations affect the tonsils only, producing what may bo called a .syphilitic tonsillitis. When this occurs the tonsils become acutely enlarged, of a pale-gray color, and their whole surface covered with this irregularly-shaped gray pla.jue formation. This hypertrophy is very stubborn' in char- acter and yields but slowly to treatment. It is not necessary here to detail the evidences of general .systemic involvement, which, how- ever, must be looked for in diagnosis. The subjective symptom^ of faucial .secondary .syphilis are tho.se usually of an onlinary .sore-throat, but lasting niucJi longer, the pain and intensity of which vary with the severity of the ca.se. When severe, a more or less decided salivation is present. Secondary syphilis of the pharynx is very prone to recurrence, an<l even after being api)arently thoroughly (•bliterated by treatment it may recur often after th<' lapse of months. Diagnosis. It usually lies between herjits, diphtheria, follicular tonsillitis, aphthous sore-throat, and tubercular ulceration, the v; iou- characteristics of which will \m\ described under their separate headings. Secondary Syphilis of the Larynx. This is comparatively rare in occurrence and exists usually associated with secondary .syphilis of the pharynx. Wry rarely does it exist by it.self. There are the subjective symptoms of irrit.ation of the larynx with more or less hoarseness, the hoarseness being of a peculiar raucous character The local ai)pi';trances are tho.so of a more or less catarrhal infection of both the true and false cords, with hypera'tnic spots and .sometime- the .-iiipfviraiice of a true plaque formation, or verv sup(>rficial ulcera- tions, usually bilater.'il. on the vocal cords. Tlie epiglottis is als>' sometimes the seat of thes.ame manifestations, and. in addition to tlir ordin.ar .• secondary .symptoms as described, we may have a formiitici of condylomata of the laryngeal nuicous membrane, which excn- cences may become sullicient to cause considerable stenosis of ih- larynx. In one instance reported i)y the writer the steno.sis w:i • sufficient to warrant an intuli.ation to save the life of the patient. The treatment of secondary syi)hiiis of the throat is mainlv con- stitutional in character, consisting of the administration of mercuiy in some of the usual forms, ami wlicti the character of The manifc--: tion.« seem to be deep with infiltration the treatment is enhanced y ^'»r^ SYl'UILlS OF THE XOSE A SI) THROAT. 849 tlio addifioii of the iodide of potash, rominonlv called the mixed Ireatiiiciit. Local treatment, altliouph sometimes used, as a rule is unnecessarv as the eoiiduion fieiierally responds to constitutional treatment aiid object of the local treatment would he only as a matter of cleanli- the ness. it the mucous patches of the pharvnx are very extensive it is |.ossil)le that their healing may be somewhat hastened" bv the applica- tion ot inild caustics. Among the various spravs or antiseptic Har^Hes which may be used, a sargle consisting of the ordinary black 'vasli, dihite(|. IS of assistance in the treatment. Tertiary SyphiUs. Tertiary syphilis of the nose and throat is very romih.Mi and one of the most frecpient manifestations of the tertiary lorm of the disease. It is peculiarly ulcerative and destructive in Its nature, being the result of a l)reaking down of a gummatous infil- tration, resulting in the nose in the destmction of the septum and other mtrana.sal bony portions, and in some cases producing by the necrosis ot these bones, a falling in of the exterior of the nose, with Its characteristic deformity. Nose. In the nose it usually begins with symptoms of more or less severe intranttsal irritation, soreness and jiain being quite i)rom- iiu'iii, nocturnal pain IxMng very characteristic. When high up external swelling with some nnlness and tenderness on pressure are tnM|ii.-ntly noticed, causing (luite a noticeable broadening of the bridge ot the nose. As the condition progresses nasal obstruction becomes more and more marked, and soon there supervenes a breaking down or ulceration of the induration: this may take place at any point iHit usually lM>gins on the se{)tum. It may be unilateral or bilateral,' ^^ncrally the latter, attacking either the cartilaginous or bony sep- timi. and m its course may include the entin- intranasal bony"struc- 'iirc. I Iceration at the external Uiml orifice is often noticed, and II may extend to contiguous portions of the upper lip. With this iil<'cration there is a.ssociat.vl a bloodv mucopurulent discharge fre- incntiy extensive in amount, with (lislodgement and expulsion of i'.nts ol the intranasal mucous membrane and bony portions- some- "mcs the.lischarge becomes hard and dry. and is "either expelled in m-pissated masses on the part of the jjatient, or retpiires the a.ssist- mce nt the surgeon. After the necrosis has existed for some time 'lie discharge becomes very offensive and charact<'ristic in odor Treatment. Treatment otlu-r than con.stitutional by iodide of potash )^hicli \vi!l !«• all-suHicieiit if th<> nasal invasion is' recognized early' '"•lore deep destruction is established, must \w sui)pleniented In- •li Tough ;u..l repeate.1 cleansing, which is all-important, bv stimii- ■'tion ot tl„. ulcerations by mild caustics and by insufflations of !'"l"t<'nii or by some of its e(|u,illy good .substitutes. ^ When bony necro.sis is present "and the secpiestrum is not as yet "ose. (niretling or trephining may be employed. When .any pnrt"ion "1 tlie bony structure becc.mes loose the secjuestra may be'removed ' \ rong(.ur or traction forceps or by their combined use: when too 64 "T--^ 860 yOSE AND THROAT. large for removal by either of the above combinations it may be necessary to resort to some major operation, among which may be mentioned that of Rouge.' which consists in the removal of the sequestrum through exposing by incision the intranasal cavity by eversion of the upjx>r lip and external nose, thus leaving a mini- mum of ileformity tus the result of ojx'ration. Pharynx. In the pharynx any jjortion may be attacked, resulting in more or less loss of tissue, ancl producing adhesions and cicatri- zation of the various parts affected, with perforations both of the hard and soft palat<'. (Plate XX\I., Fi--. li. 4.) The lesion may l)e unilateral or bilateral. The cicatrix, we nnght say, is always present as a result of a severe tyi)e of ulceration. It is (juite characteristic. ho'mfr whitish or yellowish hi color, and more or less stellate and radiating in shape, and may occupy an extensive area from the naso- pharynx to the larynx, according to the extent involved. This cicatrization is one of the most characteristic evidences of tertiary' syjihilis. In extensive cases the resulting cicatrization, adhesions, and contraction may materially encroacli on the lumen of the pharyngeal space, so as to seriously impede the power of deglutition. When .seen early. l)efore ulceration h:is taken place, there is generally a marked induration (the gummatous formation), the surface of which has more or less of a velvety ap])earance, and is seen mo.st typically when it affects the soft jjalate. The surface of the indura- tion is red and angry in appearance, and . oon gives way to a breaking ilown or ulceration at almost any i ohit. The character of the ulceration is that it is deep and destructive in nature, the edges more or less well defined, irregular in appearance, and the surface of the ulc(>ration, .as a rule, covered with a thick, yel- lowish, ropy secretion. This featun; varies according to the parts in\(ilved. there lM>ing, as a rule, more of the thick .secretion when the {posterior pharyngeal wall is implicated. Subjectively there may be mon' or less pain, with pain and difficulty in deglutition: but severe pain is not a constant characteristic as compareii with the pain of malignancy or tuberculosis, and. indeed, it is (|uite conmion to find quite an extensive amount of ulceration with comparatively little pahi. This will dejM'nd upon the area involved. Diagnosis. The diagnosis of tertiary syj)hilis of the pharynx lies between tuberculosis, malignancy, lupus, traum;itisms. ancf ulcero- membranous angina a.s,sociated with tlie b.-icillus of \'incent. Treatment of ph;irvngeal syphilis is m;iinly constitutional, in the administration of iodide of potash aided by thorough cleansing of the parts and |)ossil)ly the application of mild caustics, as indicated in the individual type and condition of the ulcenition. The resultiiiL' adhesions re(iuire suitable surgical means of uilatation and excision^ to meet the si)ecial ca.se. > Rmie.''" Operation for Remiiv.i! of Sa.ia! Seiii«tr;iin, Hr "' II Knfght, New Vofh. Pbl!«*?' rhlk Mndical New<, January 3, 1H91. ?3S^*(T=— .■-^L-E^V-fT^'. TUBERCULOSIS OF THE NOSE, PHARYNX ASD LARYNX, ggi Tertiary syphiUs of the larynx is of very oonmion occurrence beinc present in ;i large percentage of cases of syphilitic infection Tth2 perl'aps ru.t an fre,uent .s pharyngeal invoK-enien Tn^^^^^ affe<-t..,i m. iefH^n.lently or by extension from the pharvnx The t.: hrVnx' Sr '/" ""f fr^r" "^'"^••''^'^ ^^e entirlTtructure 1 th( Kirjnx. The nature of the lesion is the same a.s in other nor- tions VIZ. a gumma with a sul,.se,,uent destructive ulceration r^t?hi ...g he same generic characteristics, but only varyingTn he Tatu^' iinasion of that kind within the larynx Although there are instances of long-standing lesions of chronic hickemng where tlH> cords lose their color and contour the con .on l«;mg kept in alx-yance by treatment, and theTbcipal vm^^^^^^ benig that of hoarseness, still the ten.lency of terfia^ svph iS^t^ produce an encroachment on the lumen of the larjTix e ther in the formative stage of the development of the induratiranl elrlv £ stmctive ulceration, or in the resulting .leformities of conTractior adhesion, and adventitious tissue, producing not only XTr^iess' but the more serious condition of pr(,gres,sive in.pairni.uit of bre.th .ng due to the laryngeal stenosi-' Perichonclrit^ S t fe c v^h 'es" n ay be produced, and may occur as a n>sult of the necr otTc Smilsbn o vanotis cartilaginoas portions. Pain within the lar^m I n tr able symptom, being more prominent in the early Jt^^e l,;i^,re .i.ronicity is estubhshe.l. and external pain am teSnes. m I-r^sure may ensue, according to the extent of the deeper "nvdv'e- Treatment. The treatment is constitutional in giving iodide of \ lunt and rapid results have been procured bv the combination h bu-hlon, e of mercurv- given hypoctrmicallv. ' For the niechTn- TUBERCULC THE NOSE, PHARYNX. AND LAEYNX. .■xSnns''.?lmo ■' • T'l '-^ '" -^*-:-'-V --are affection, and when tl,„ I • ■ • •) . "K affected. Hill reports one case in whinh •u. >.Kh,s ahso report primary tuberculosis of the .septum ™™"'' It occun., a. a rule, in two forms; ulceration, generally on the sep- iiffH^r-. V-a "T5,'«7r 852 NOSE AND THROAT. turn or floor of the nose ; or the hyperplastic form, either on the septum or the inferior turbinate l)one.' Some authors attribute perforation of the septum so commonly seen, to a tubercular origin. The latter course of the lesion is, as a rule, very slow and indolent in its progn'ss, existing sometimes for many years without giving rise to verj- marked symptoms. The ulcers are painless, rather small, slightly depressed and irregular in shape, with a tendency toward the formation of crusts, and bleeding quite easily, their centre having a caseous appearance. The hyper- plastic form is generally in the shape of small, grayish, warty growths, situated on the surface of an induration, rather soft and bleeding easily, and not unlike papilloma. The diagnosis is generally made on finding the tubercle bacillus. From the position of the lesion, local applications are easily matte, but there is always a very marked tendencj' to recurrence. The local treatment is the same, as will be described elsewhere, as in the local treatment of pharyngeal and laryngeal tuberculosis. Tuberculosis of the Pharynx- Next to tuberculosis ot the nose that of the pharynx is the most rare of the tubercular manifrstations of the upj)er air-tract, and, indeed, until quits recently it was con- sidered extremely rare, but later extensive ii dividual research and obser\'ation have bi'ught pharyngeal tuberculosis into a greater degree of [jrominence It is almost always ;issociated with laryngeal tuberculosis. It may attack any part of the pharynx, including the soft palate, uvula, tonsils, pharyngeal wall, and lingual tonsils, without any .special reference to any one seat of election. When one part is affecteil it shows a rapid tendency toward extension, which in some cases is a very marked feature. Symptoms. In a well-marked instance the subjective symptoms are those of very severe involvement of the throat, pain being a promi- nent ami severe symptom, constant in character, and producing a very marked dysphagia. The general aspect of the patient is one of suffering and emaciation. The local lesion is generally one of ulcera- tion of the type peculiar to tubercular ulceration of the mucoas meni- braiio, rather superficial and having an angry appearance, without nmch. if any, induration, excei)ting perhaps on the edges in the older cases, covered with a variable degree of secretion, ano surrounded by a red, inflamed area, presenting fre(|uently a coalescing tendency and the appearance of bu/rowing or a " worm-eaten " appearance. The character of the ulceration seems deefjer as it attacks the faucial or lingual tonsils, the author having seen almost an entire lingual tonsil rapidly destroyed l)y acute tubercular ulceration. Prognosis. The prognosis is extrem(>ly bad, the })atient succumb mg either to the primary pulmonary tuberculosis or to the star\'ati<iii and inanition produced by dysphagia from the j)haryngeal involvc- ' HerynK, in a reTiew of ninety cane!, found the leaion to occur In lbrt]r^!i(ht u ulcere sod i- forty -two a« tumon. i3ffv«~TT«»'=a-"3»»' y^masoff^ « ^sxm£T^'im,\i. :•■ I'M F^l.A T!-; XXV! I. S. 11 1 II' F ■ .1 1 n- ■ •! I .: 1 1 \ III 1. nl Ti 1 1 rr i i 1 1 1. TUIiKlWlLOSIS OF THE SOSK, I'llARYSX AXD LARYXX. «5;} iiu'iit. Altliniiuli tlic location of plimynjitcal tulxTciiIosis sft'iiis to Im* i('"al for the ap|)li('ation of local treatment, an<l althouKli the iiuli- vidiial areas of ulceration may become healecl by treatment, there is ah» ys a marked tendency to extension. The local treatment in .let..il will he referred to under" Larynj^eal Tuberculosis."' The diafTiiosis lies bet\ve<>n syphilis and carcinoma, and can l)e made |)ositivi' by the findinji of the tubercle bacillus in tlie secretion or l)y histological examination. Tuberculosis of the Larynx. The larynx is by far the most coin- mnti seat of tuberculosis of the upper air-tnict, and it is, as a rule, if not always, secondary to or associated with pulmonarj- tulierculosi.s. Me:irin>j on this subject of the fre(|uency of larynjieal tuberculosis, in tile rei)ort- of the Hromptoii Hospital, Kngland. oO per cent, of laryn- P'al tuberculosis is jjiven as occurring in all cases of pulmonary tuberculosis. Willigk s'ves 237 cases out of 1300, and Kidd gives 20 per cent. This \ iew of hiryngeal tuberculosis being always secondary, is held by almost all observei-s, and is jjroven by the findings of autopsies, there being very few recorded cases of death by laryngeal tuberculosis where pulmonary involvement has not been found. The ojjponents of this view are very few in number, the most prominent of them being Dr. (Jleitsmann, o<" New York, whose researches have been ex- tensive and who rejMjrts two cases of primary laryngeal and |)haryn- jreal tuberculosis in his own practice wiiich were cured. In tiie report of his cas(>s in the Journal of Tubcrculosix, April, 1891, he (juotes Deiiime, K. traenkel, Pogrebinski. (^rl.i, Coghill, J. S. Cohen, Dehio, and Lancereaux in .support of his view. The subject of primary tul)erculosis of the larynx is so imjwrtant, bearing on its }irogres.>^ and curability, that we may digre.ss for a mo- liient by saying that it is almost an impossibility to prove the exi.st- ence of primary or di.s.sociated tuln-rculosis of the laryn.x without .lutopsy. It is possible for the laryngeal involvement to be appar- ently primary to pulmonar}' involvement, by reason of the patient lir<t calling attention to the larynx, or by the preponderance of the i;iry:it;eal condition, or to exist where the pulmonary tui)erculosis may be for the time in abeyance. An examination of tiie chest may iiWc negative results, but this in no wise proves that the lungs are lint inv<ilved, and if we find during the course of the (lisea.s<> that the lungs do become involved, notwithstanding the fact that our attention has tir- 1 been called to the laryngeal .symptoms, we cannoi say that the case wjis one of primary tubercular laryngitis. The a.-;sociation "f the two conditions is very strong, if not positive evidence that tiie hings were first involved ;md the larynx secondarily so, for we know 'iiat it is possible to have certain forms of pulmonary tuberculosis not giving ri.se to many physical .symptoms at first. In wiriie mri' insiiiiirt'soi Uniitizoit iiidiilont formx of pburyngeal ulceraium or induiatloni per- I iiui lit hi'iiliiiK hHs titt'ii obtaiiie<l by local measures. - »Vatsoii-\VilMamn. [ 854 NOSE A.W TUnUAT. \ml iieain if lurvt.Rcal tubcrt-ulosis were primary or dissoeiated to a V sn-at i-xfrnt "tluTe n-rlainly w.ml.l Ih« nun. posmve evulenee of it wlien we c.isi.ler the extremely e..miu(.n occurrem-e o a >..- 1 tulH-reulosis. It is true tluit in .some instances laryn^ea tuber- l^dosis .nay prepon.l.Tate over pulmonary tulH-.Tulos.s for the ^"'IV mth r ha.s seen many e:i.ses of tuln-rcular laryngitis which he ,h, u«h primarv, and whi.-h for a time s<.e„,ed to y.e .1 to reatme ut the" subsequent progress of the ''j-;^; .;;-;; proved fatal through the '^->'-'''''-^^>'7^'''''% ;'.•';' ';-^ nlH-rculosis It is possible in a sus|M>eted mstance of piimarv uIm r . .r lar vngitis wher-' the pulmonary signs are negat.ve that the use of th. -X-rays may disprove or substantiate the presence ot puhnonary '"sySiptol': The svmpt(Mns of tubercular laryngitis vary acconUng to th^ tvp«> of invlvenu-nt. In the- typical ciise the hrst subjective vn'rtonMuay be an alteration of the voice which. "---;-- ^ d'epeu.l somewhat upon the localization of the lesion The oice ecomes slightlv hoars.-: but it may progress to c.inplete aphonia wi t le exum^ion of the disease. The •■haracter of the hoarseness s .ore ..f the soft or weak variety =.s distinguished from the harsh „ualitv of paralvsis or laryngeal growths. This hoarseness is not a-™ due'to marke.l tubercular involvement, but may be due to the general muscular weakness «.f the larynx Cough is a verv prominent symptom which may procee.l either from associat.-d pulmonary tub<-rcul.. sis or from laryngf|iil irritation. IV < also a wrv prominent sympt..m, esp<.c,ally where there is ulceration. The pain is. as a rule, lancinating in character and radiating to the ears. This latter feature when the '-vnx is in- volved is almost pathognomonic ..f laryngeal ulcerati-. jhe 1 fi becom.-s excessive in accordance with tlu; progress of < ,e ulceration until it mav pro.luce marke.l an.l very .listr.'ssing .l>>i.hagia. hx- cessive pain is indicative .)f .l.'ci.l.'d ul.-eration. Dysphagia is .)ft.M. a promin.'.it symptom. es,«^cially n the later .taSslf the .lis,.ase. an.l often to such an extent that patients re use food '«oth from their inability to swalL.w or from the excruc.atmg nain whi.-h th.« latter .-auses. In th<« indurating .an.l n..n-ulcerative vpe ..f tulH'rcular laryngitis pain may not l«- a pnuumeiit >^yinptom. ■ Expectoration and Secretion. i:xi)."ct..rati..n is almost always pre^ ont b.'ing ..f tlu' usual tubercular natur.". generat.'.l either in the lungs or m th.- larynx. S..metimes from the pain ^-'"/'h/^^' "">*";" of th.- larvnx pn..lu.-es. an.l fn.m general weakn-ss of th*- SJ" > th,'« tulK-rcular inv..lv.-ment. ex,>..ct.)rat...n becnu-s v.jy < 'ffi"»lt- '^ <» from its thick charact.-r an.l accumulati.m within the larynx .nay ; ve ris.. t.. s.-v.-r.. fits .,f .■hoking. ..fttim.-s causing great exhau.sti.n Tuter rep.-at.'.l .•ff.-rts at .-xpulsi..n. \omiting .s not infn'.iu.-nt > ;'uJe.l by .-x.-.-ssive eff.-.ts .hie t.. c.ughing and the eiuleavor t« expel the mucus from within the larynx. TUHEIiVL'LO.SIS OF THE XOSE, PlIARYSX ASh LAHYSX. 855 Appearances, l-aryngcal tulM-rculosi.s is cliicHy cliaractcrizod by the ajiiH'iiranfc of iii.liiratioii and uln ration. In the usual variety of tulxT. tilar laryngitis the first change in the niucc.as nieinhraiu" |M'r- ('.■ivcd t.. laryngeal examination is tlic change in eoior. In some instances the larynx Ixromes very ana'mic, which is considered by some to Im- of |)ath()Knom(inic significance, an.l when it is :issociated with otiier Keneral conditions it is sometimes spoken of as the pre- tiibercular an:emia. This aiuemia is not, however, necessarily indica- tive of tubercular laryngitis, as it may Ih' an expres.sion of the general aiuemia of the patient. There are some cji-scs to the contrary, how- ever, where marked redness or hy|)era'mia mav i)e the first"ciiange Ml color, and jx-rsisting to tiie end, usually, however, !i.s.sociated with more or less mduration of .some portion of the larjTix. A localized redness of one or both cords may l)e among the earliest tul)ercular indications. Induration of some portion of the larvnx makes a very Klu, 4L'7. Flu. 4SS. Extensive cliib-iiliaped swelUnfr of arytenoid cartilages, with swelling of ventricular bands. (Cohen.) •■ariy ai)i)earance. and may have its initial seat in almost any portion ol the larynx. However, one of the vocal cords is generally the first part to become involve.l, and, although there has been an attempt to localize this first apfwarance of induration, we may say that it may m.ike its first apjM'arance almost anywhere within the laryngeal cavity. When it attacks the vocal cords thev lo.se their normal contour, becoming .somewhat rounded and nodular or flabbv in char- ■icler. :md, if very much reddened they may at the .same 'time lose ilii'ir identity in the general swelling of the .surrounding tis.sues. This mduiation of the vocal cords may be either unilateral or bilateral. I lie false cords or ventricular bands .sometimes become involved to such an extent that they overlap and obliterate the true cords on tiicir respective sides. When the induration in\oive> the arytenoid cartil.-ige a characteristic condition is established. They lose their .-sharply defined appearance, becoming somewhat club-shaped, and 8.jG AO.VA' A.Mt III no AT. 31 wlicii it cxtt'iitls tit tlif aryt<"ii(M'|ii>;lottic liKaiiioiit tlio iiililtruliuii presents ji coiulitioii wliieli is extremely characteristic of tiiltercular laryiijiitis. A i>yrainiilal-slia|)eil swelliiij; or imliiratioii of one or Ixitli arytenoid cartila>»es may 1m' taken as one of tlie stiun;; p' thojr- iiomoiiic sijins of tiilH-rciilar laryngitis. Fl(i. 4.W. Flu. tVt). Fid. 431. Fkj. 4l"j — TiirbHn-dhaped swelliug of epiglottis. (Cohen.) Fii!. ^:!ll — .\ tubercular ulcer on the left ventricular lionil and left vocal conl. l'ear-i!hai»-<l leiletuHiiiu!! swelling of ar.vepiglottic fohls. more Intense on the siile of tbe ulceration. iC'ohen.i Fio. 131— <ieneral tubercular uleeration of larynx. (Cohkn.) Ulceration in larA-ngeal tuberculosis is of constant occurrence and usually |)re.sent at some stage of the disease. The ulcers iiuiy vary in size from the very small to those coveriiift (|uite an extensive area, they may he single or multiple, limited to one side or portion of the larynx, or they may he bilateral or indiscriminate in their situation, There is no absolute {)ositive diagnostic difference helween tuber- cular ulcerations and those from other causes, other than possibly tulwrcular ulcerations may he more superficial in character, have less indurated edges, and are, as a rule, less deeply destructive in their nature. If the ulceration lia.s (>xisted for some length of time and is slow in its progress and not extensive in character, when taken in connection with other symptom:- ;>f tuberculosis, it is probably of a tubercular nature. When isolated they are generally surroumh-d by a re(| outer border, shading (ttT .sometimes into tiie surrounding tissue, and .are fre(|ueiitly depressed, and if large in extent the ulcerating centre may present a sunken papillary condition, and soUHrtimes the inner eilges niay l)e gray or white. When sif.i.'ited over a large area of broken-down induration the surface of the ulcer presents a very uneven character. In this comiection it may be said -"Afi "^9X7=, or: ssrrgs& >Ji«»MBJj e i E.gyyaiB Wii >a n ar^ TUBEliVlLOSlS OF Tilt: yonE, fllARYSX ASD LAUYSX. 807 that SLiiH'tiiiifs we tiiul a lo-w of tli(> vocal conls wliich sociii to have (lisa|)|M-arc(l iiioiv hy a process of absorption tliaii ulceration, with practically no syriiptoins of ulceration having previously Iwen present. It is not infreciuent to find the suinniit of smooth indura- tions (lotted with line ulcerations, which is (piite a characteristic ap|H>arance. and it is also not unusual to find the whole surface ol the true and ialse cords together in a state of ulceration- and Ireipiently we tnid the whole surface of one or other of the ary- Klu. 432 Flu. 433. Fio. 4;l-.-Tiit«nml«r iiiBllralion of the lnterarytenol.1 space with tuUsreuUr paplllonuU of bolb vocal conls. Charactcristk- .nleirialoiia liililtratlon of the aryeplifloltlo fol.ls (fi.HEN ) Fici, 4a!.-TiiUTcular ulceration of left V(h»1 conl, with swelling of right aryteuol.l cartllaire .('OH K.N.) " ■ teiioid cartilaKcs considerably destroyed by this ulcerative process, and. on the contrary, it is not uncorntnon to find the typical swelling of the ai^ytenoids to exist for a long time, even through the entire period of the disease, without breaking down into ulceration. The epiglottis i.s fretpiently ulcerated in the same characteristic rnaniuT, the ulc(>rations attacking almost any |M)rtion of it. There is some- times (jrii;' a marked destruction of the epiglottis by this ulceration. Flu. 434. Fia. 436. r,,;. m-Swelling a.1.1 hypt-wmia of veiitrlpular bands with tU-H-ttlon of trae cords. (CoHtN ) H... U>.-Siir«^rhcialiilcerau.m of Kuinralt and frie border of i -.ted epiglottis. (Cohk.s.) In-itea.l of pres(>nting a rod or angry appoaraneo, it is not uncommon In fmd but little change in color over the nhole ulcerated area, the wji,,!(. surface of involvement giving the appearance of an unhealthy aiuemic or sodden condition. Perichondritis of the cartilages of the larynx may su|)ervene from the e.xteiisitm of the ulceration, csik- '■i.uly of t!.e arytenoid canihige. in some instances resulting in '•xpulsu.i,. of a F)ortion of the cartilage. The perichondrium in some instances may become primarily aiTectcd in the tubercular process. liai 858 XVat: AM> THRO iT iui.l lint nm's.><arily tin- n-^uit ol an .M. n-^i-n from the su|»rrfici!»l ulciTatiiiii. . , , I Asiilc Iruiii till- ■•(iiidilioiis inclii<i«'l in ti ■• lyinciil form Jiinl cimM- of tiilMTciilar larviinitis thciv an- ■>'\\vr foi -^ ..[ tulMTtular iiivolvt-- iiKMit "f till- larviix. p'n<T,,lly mauiffst^d l.y lo.alizi-d indurations or intiltratinns. fln's<' iiifiltratiuii^ or iiidiiritioiis may omir :i.« tho only Irsioii, and mav W situated at any iMunt williui the larynx; tin y do 'not .i' a n«'(M'ssitv iMMoinc ulft-ratcd I'ot ma, Ix' <'las-.'d as tlu- induratc.l form of tulMTciilar larynKiti^ ' ii'y :.: • quite ire(|uently seen about the arvteiioid rcKi"n, .•ither in. vw the aryMioid .-ar- tila^es tlicins<'lves, ..r a|)|)earinn in th<> .i.> 'iiirv «i">'d ^\<.w^\ and when seen in this location are ([uite rh:ii;t<-t« -i.-i «■ In apixaranee. These iiiterarvtenoid induraiioiis may e\i-.' i.i ;i |. rniiary or corrii- jialed form, (ir the induration may !>• v. n l.irp- uiti, a broad ba^-. the aiM'x of which extends well into t;i( (".:•.. '1.. lary x. This condition whiMi seen in the iiiteiaryt<-ii. m' j-ac. "sci.Ihu by some authors as pathognomonic of tubercular : lyujriti-. Thus is imt inva- riably so, be,-.iuse it is not infre.|uent to find simp, p-inllary corni- fr.'itioiis aitliin the arytenoid sjiare whi.li are appiirei tly Immijiu in their charaet. r: but it i.iust be said that a dirtilnl induration in the iiiten.rsteiioid space, wliH-h projtM'is well mto the cavitvni Mic larynx, is very -i-initicant of tubercular involvenicnt. even wh, it is uuas- sociated with other Icm ms. Thes'> localized indurations may also a|)- jM'ar on the true and false cords. Diagnosis. The (l'::i;iiio>.i-;of tuln^r- cular laryngitis, when lepe-idenl uiM>r the lesions themselvi is often a dillicult pr.Jilem. there b' nfi no absolute characteristics to listin- icuish th.-m whii'h are imt present in other forms of laryiijieal ulceia- '. 1 ins, unless it b^ the tvpical form of uniform induration i vol' uip the arytenoiils and t':»' ei)i<Tlonis and in almost all instances we must look for confinnatioii of our diuir- iKo'is (ither by the jreneral i)roKress of the <liseiisc, its a.ssociutioti with ireneral pulmoiiaiv tuberculo-^is, bv the microscopic examination of the tissue-, or bvthe (indiiifr of the tubercle bacilli in the ex|)e<-tora- tion or scrai)inf£s, and we might add by tiie tendi-ncy to fatal pioji- res^ of the disease, despite all our efforts at treatment. The cmi- .litions to Im- differentiated from tubercu! sis of the hm-nx -^re •^yjihilis, carcinoma, and lupii.s, which will be considered ill dc'ul under their re-pective heail-. Mixed Lesion Instances of association or imxed lesions of 1 . -t- culosis of the larynx with tertiary sypiiiis, Jiavin): ,iiaiact.ristK- .i both, have be<'n described by so-ne writers; i.nl it is a conditi' ■;=« diflicilt of differentiation (if, indeed, it <lo<>s exist, which is jrr iv Iiiltn-iif. iiMiDiil thii ki'iiliiK , ulccmUon of Curd. wBHaiai TlBEItCirLo^rs OF THE SOSh PJU fYSX ASD La, iWX. 85t> •i-nl.lr,| l.y tl,r.aiitl...r), ,(„( „ ,.a„„„t b«. wHId-scnl,. -i uimI ,no„|v 1 tllf i|isc;isr. it is Vf otIi'T iHiitioti- of the u| WduM cxiM-r-t t(i find it ii Tr#<iktment. Tl, tie; -tiiitioiial and local, i wliici, pertain Iw gcticml tiitwrrni . . ail li.<"il irrainicnt shonl.l Ix- .siipf.i, Tfafiiii'iii. In sorm fonn- of far v larviiv ,, Hot .sciiously in\ Ivcd, .1 . ■<iitlii t«. .lire or iv, , ii. al^-vanre ncrtuiii with (h»> gen. ral imi. ,)\cnir h:tvr liif>. i'H(i>' M v'iow 1. 'I'npical •: ilicatiun.s !ur ' 'III' rt. (•(Uljlh, j ,1111, (|y l.najji; 2. Curative nic f- ;r('s, wnh the tultercular h'si.ii. Tlie principles ih.>lve.; tt, '!)< ii"ii to any portion 1 the t; j),-r ill the tnliercnlar pi -<, ,i,„'j »■ ilcpend upon the lo, : , m ar nlweP' iliiin. ^\i' III ! fi 'finhcr tli;it rea: ng iv delicate pi .dure re iiirin^ .dl I'llxMi Frp(niti;tly thi prientsan III' r iroats are render '■ very s<'n^ iiilly (,| "lanipulati^'n. Uie fii-t Ir-adiiifi <>t nil a proiiiioent featu •M pr()[)er application fcretic I I kni'w of n. ' •'• irogen. hirh shouMi ■" I if to six Mog. T' is ' I-'. fhp\ rare. 1nde.1l. to notir-e thJK mixed l.-sion i„ r respmui.rv tra^-t, arid i' it did exist wf iiilff It'KJul.v :w Well ,s ii, the Jarvux nent of Mil-Tcul • arvfirtis ;.. h,',th con- r Ihr f. ri,i- r th- c;, .-r is r. fem-d to works a» » MWiy only In i^iiid he- that lent.- 1 '<y - .rlie f..rtn of rieral 'ijImtc .ir trvtijiifi.s. wl tlie 'dt iMT 11 ;, i.ntiKT c!in;:ite niii v ' '«'^ «'■■' vni[ n con- the 'fulniofiary uiirm. iii fl iitjf. f.H- try lijnti- should 'If Fuiri ind the U'V to }>ove r-trac; '■luiiri Ml'- ■!.jt the '{j loai di- IS. din illOi! the individii; I- appii. 'ecor;ie in\ oivi proi tdure ^nu^5 il Ciuse under rcular larynx is often a tact and skill we can l)rinj>: ■i \V(,ik bodily conditio-', and . adding greatly to the difti- I'nd. -h. ii!d ;iiid i'of is mill' t'\i(j ilted I !li' itii cleansing of the parts onifort of the patient measures. Where there iian the application of Ix' ii.se<i with an atomizer and will have the eflfect of disinte- uei lor t ijiient 111 an*' Hi.. Ill, ,.fji I S'ilor .-..iuti: au-swerine ''.•II ilien,u(-,,!i- .letiibrai. iiefore tn;iki-<: aiiv applica I to precwi. tlieir ii.se I line in . -''i|iien( -y, <.f ;dr. \'U: . lay be further dislodged by the in- -oat and coughing. In order to perfect ■xM. fiMuJd h. tollowed bv the use of ■■ . i,> one no! ieaasii - an.! inti.septic solutions, the Dobell he iH.'pose, in order to completely -Miatever T think it a wise precau- , , -pray of \ per cent. solutif)n of r to render the mucous nienihrane less .sensitive to the iicatn.ns If tiiere be con.siderable hviwrarnia ■, s„h,- . cliioiide may be added, so as to make a strei .'th of •K), with the cocaine solution. The effect of this com- .v grateful to the patient in reducing irritabilitv, sensi- «l>0 xosE Ayn THROAT. tiv.-ucss, ana iviKl.-riiiK all aftcr-ai)l>licati(.n inudi .-asicT of arrnm- lilisllllU'llt. , • r •> I'MN- AM- l)Ysi'iiA(!iA. ('ocaiiic 111 strciiRtlis varyiiiR from 1 i>("r cent to S iKT ffiil. solution, in cotijwnction witli adn-iialin. is jxThaps tli(> ix'st means for allavinj; the i-ain and .lyspli.-'fiia. to l)c aiM-linl imm.-.liatclv lu'fon- eating. Care slioul.l !.<' talicn ti.at tlu- cocamc hal.it is not"f()rm<-.l l.v its contimiai iiso. In somr cases constitutional symptoms of cocaine-poisoning may interfere with or preclu.le the use of the druR. . . , , OiniioKoi'M. When there are ulcerations, caiisMifi |uuii and <lys- i)ha"ia marko.1 relief is nro.luced by the use of ortl.otorm, either m theh.rm of powder insulllations or an egR emulsion wth or without menthol d'J per cent.l. as suggested by Freudenthal,' (t New \ork, to he aii|>iied with an ordinarv cotton applicator or by means ot a larvn<'eal svrijige. The advantage of orthoform is that it is non- poisonous, and its effects last longer than cocaine, although it is slower ill beginning its action. IvniYi, Ciii.oiUDi;. Th(> author has obtahied excellent effects trom the local anr.'sthesia produced by ethy' .'hloride, notably in the pharviiK and at the base of the tongue, when its application is made casy"l)y the glass tube manufactured for that purpose— for local aiuesthcsia. Its effect is not very lasting. Intualakyngkai. AM) TuACHKAL Inmkctions. .Vs a means of applying local remedies directly to the larynx .hikI trachea, I am fully convinced, l)otli for curative and for jnirposes of local amelioia- tioii, we have in intralaryngeal and tracheal injections with a properly constructed svringe one of the most efficient means at our disposal. The larynx !)«■ -omes gently and thoroughly bathed with the s..lution. and it exercises its local influence as it passes down and is absorbed in the trachea amlbroiichi, thus producing a constitutional absorption as well. The number and character of the solutions that may Ih' em- ployed, either oilv or a<pieous, are numerous, and may be chosen to meet tiic indications demanded. The effect in relieving cough, local pain, dysphagia, and producing a general comfort of the jiatient i< sometimes verv marked. The injections shouM be jirecetled by local aiuesthesia, and after the details become mastered the production 1 Journal of the Anurlran Mwlical Aw«Kmtion, M«rih li,. I'.mi I aiipenil the formnliiol the ortholi.rm .•mulsi.m us siitfgeBte<l hy Kt' iiileiithHl. with liirectu'i- for its use It iimv Iw uwil without meiilhol. If •«i ilcsire-l. ••InKllirrilati..iisof the larynx luemliol is of excell.-m service. It reli.x.-- the cough, and «it., this much of Ih.' weretion. This is the Tmmn I udileil menthol to the al*ive emuMon. I use ili- followinn : ■' Menthol. 1. '., in. or |."ij ol nrnvRilal ilnlc, 3D Vltelli ovonmi. -''] Orthoformi 1- > Aiiusedest.. q. ». Kl. 100 Ft. cinulfio. " I commence with 1 per cent, menthol in this emulslcm, and as nuukly ii- ilie loieratioii •■f v- ^ patient iwnnits I increase it U) 10 |«r cent., and it has been In the rarer cases only that I have us. ir> per cent, menthol." TUBERCULOSIS OF THE XOSE, PHAHIXX AM) LAHVyX. g(jl 4if any irritation is roducpd to a ininiinum and the procedure becomes well tolerated by the patient. Dysphagia may become so extreme that it may be necessary to resort to artificial feeding through a stomach tul)e, and in some instances fairly comfortable swallowing may be attained in the so- called " Casselberry " position, being the method used in feeding during intubation. CuKATivK Mk.vsikks. Under this heading are included local appli- cations to the surface of the lesion, and the direct eradication by means of more decided surgical measun' ■ The list of local reme(li( s is, indeed, a \ .ry long one, each having its advocates, and most excellent results having been reported with all of them. A detailed tie.scription of their respective merits would carry IIS too far in an article of this length, and we willcontent ourselves with their enumeration, a partial list, including iodoform, euroj)hen, Fig. 437. ■^yriiiKe used for intralaryngeal and tracheal injections of both a«iueous and oily aolutiuiiK. (Mi'lB.) menthol in oily solution, creasote, guaiacol, ichthyol, parachlorojihenol, .-ulplmricinate of phenol, enzyinol, iodol, aristol, camphor-menthol, and also lactic acid directly to the ulcerating surface or in combina- tion with cun'ttement. to 1«» spoken of later. The author has seen most beneficial effects from the application of lactic acid to the ; urface nf the ulceration, even without curettement. and. perhai)s, there is no one remedy which will give better results when judiciously em- lil(\v<'(l. The lactic-acid treatment was first introduced by Krause, wliK advocates rubbing it in thoroughly on the ulcerating surface by means of a laryngeiil cotton ai)plicator or injecting it by hypodermic ~yiiiige into the deeper tissues of the ulceration. One may begin with a 10 [M'r cent, or a 20 per cent, solution, increasing it to 75 |)er cent., (ir to full strength. It may Iw em{)loyed daily or every other day at first, diminishing the intervals as the caustic action followed by cicatriziition show themselves. The j)arts should lie thoroughly incniiiized prior to the application of the lactic aciil. < M th<' intralaiyngeal surgical mea.sures may 1m' mentioned curette- ment, as !i(|vocated by Heryng and Krause, either by itself or in con- iiiii-'tiiiii with the rubbing in of lactic acid ov(T the curetted .surface, and the excision of tubercular indurations and infiltrations by means 8G'J NOSL AM) THROAT. of cutting t(im>|)s, as recoiuinondcd l)y the above surgeons, witli in- struments bearing tlicirnaMii". We an- in(lel)teil to Dr. (lieitsinaini, of New \ ork, more than to any other Ameriean writer, for a full exposition of the suhjeet of intra- laryngeat surgical treatment, and the reader is referred to his most ex- cellent article read before the American I.aryngological Association, 1S<).") and found in the Trnnsaction." of that societj, for that year, ami published as well in the New York Medical Journal, OctolM-r lit 1S9.">. He enters most especially into the discussion of the merits of and indications for curettement "of tubercular ulcers and excision (.f indurations as carried out i)y Krause and Heryng, with descriptions ( f the instruments usetl by these surgeons, and summarizes the indica- tions and contraimlications as follows: " When summarizing the indications for curettement, it is to be recommended: " 1. In cases of primary tubercular affections without pulmonary complication. ■ • ■ ■ • •• 2. In cases of concomitant lung disease, which is either m tlie m- cil>ient stage or has at h-ast not progressed to softening and hectic conditions. . . ■ ^.i •' :i. It is best adapted forcircum.scribetl ulcerations and mhltration> of the larynx. "4. lM)r the dense, hart! swelling of the arytenoid region, tiie ven- tricular band, the posterior wall, for tubercular tumors, and for affec- tions of the epiglottis. '•,1. In advanced lung di'^ease, with distressing dysphagia re.sultmg from infiltration of the arytenoids, curettement is justifiable as the (luickest means to give i. lief. " Contraindicatioi.s are: " 1. Advanced pulmonary (hsea.so and hectic. " 2. I)is.seminated tubercular diseast> of the larynx, leaving little i)r no area of healthy tis.sue. • ;{. I'Ateiisive infiltrations, producing severe stenosis when trache- otomv is indicated. " We will also not n>commen(l surgical treatment to nervous di.s- trustful patients who lack the nece.-isary perseverance or confi'i.'-'ice in their jihysician. On the other hand, it is f)ften suri)ri.siiig how willingly patients, knowing their precirious condition, submit to tin- opi'ration, how cheerfully they |)ermit the necessary manipulation when the i)iiysician, guided by purest motives, devotes iiis best ener- gies to the relief of the sufferer." For curetting or scraping of an ulcerated surface the single curettes of Il(>ryng are used, while for excision of infiltrated areas the double curettes of Heryng an<l Kiau.se are indicated. These latter in.«tru- ments should more projK'rly be called exci.sion forceps. In porfortninR the operation of curettement or excision the parts should be thorouglily cocainized with a strong solution either bv spra' , potton-ai)plica"tor, intralaryngeal syring'>, or curved hypodcr- !M! wm TUUEHrULOSm OF THE SOSE, PHARYSX ASD LAIiYSX. 863 iiiic syriiipc into the tissue suhst.incp. In order to prevent hemor- rhage, which is sometimes troublesome, we have a most valuable ajrent wiiieli renders the procedure practically i)loodless in a l:o(K)(» solution of adrenalin chloride applied in the same manner, either alone or in combination with cocaine. Inflammatory action sometimes follows the operation, which must be met b> the ordinary means applicable to larynpeal iiiHanimation. \V(> may supfrcst the external apjjlication of ice ami larvnpeal spray- ini; with adrenalin. Fio. 43«. Fio. 439. ~^^ Fi(!. 4;is.— Double rotary curette of HerynR. A. Instrument complete, ready for uk. B. Canulated Shan, with haniile and curettes detached. K. Thnmt>8crew. C. Attachment with rectangular o|>en- iriir. This is attached at K. 1), E, F. Donblecurcttcswhichflt into the rectaiigularojwningC. This nilaiiKular opening prevents the curettes fhim twisting out of proper coaptation, and l)y rotating f ■ri the canula the curelle can lie set at any desired anElo. G. Curi'lte for ventricular band. The inslrumont Is In reality an exclsor forceps and not a curetle ((iI.kitsma.nn.) Fill ^xt —Sot of Heryng's knives and curettes. SiHMi cors I\.iKfT!o.\. This method, both with lactic .icid and with creasote, has been {)racti.sed with considerable succ(>ss, the latttT iibstaiice i)einfr hijrhly e it superficially anil by t! rations with a specially lunation he uses is: d by Chappell, of a'cw ^'ork, who uses ections into the substance of the indu- .ucted syringe and needle. The com- Creasote (beechwood), Olel ESuUhertffi. 4i mj. Olel hydrocarbon, s). Olei ricinl, sly. H(H yOShASI) TlinoAT. i Tho proportion of croasotc iiinylM' chaiigcMl to iiipct the variod con- ♦litioiiH. Incisions. 1 can only loi.K uj'oii incisions into tiic infiltrated areas as practise*' by Moritz Scl.nidt as Ix'ing of service in depletion, and especially where tlicre U ddoinatous tissue present, although radical results have been cUiiiijcd. Flu. 4«. CbappeU's sfrlnKe for submucous laryngeal injections. (Meyrowitz.) Galranoca uteri/ and electrolysis, although having .some advocates, are not extensively practised, the former, unless used very carefully and in selected ctises, being apt to be followed by severe reactionary results. The latter is difficult of application and slower in its final effects, especially over any extiMidod area. Tracheotomij is used when severe stenosis is present, and also with the idea of giving ri-st to the larynx in severe advanced cases. It is a peculiar fact that however severe may be the laryngeal involve- ment in tuberculosis, it rarely produces sufHcient stenosis to call for relief by tracheotomy. Intubation an be recon\mende(! only to meet a sudden emergency of .suffocation, as the constant pressure of the tube in the larynx would cause pain and ulceration, and would not be well borne. Prognosis, .\lthough considerable |)r()gress has been made in the treatment of laryngeal tubi'rculosis, and the disea.se has undoubtedly been arrested in certain ca.ses, especially in the indurated tvpe and in lonilizcil tubercular growths and ulcerations, and, although even when 'hci-e has been extensive involvement of the larynx in advanced geneial tuberculosis, the local symptoms have been ameliorated and a certain degiee of comfort afTordetl the patient, we cannot but admii that the general |)rognosis is very bad, ai. !, as a rule, we nmst look upon the involvement of the larynx as indicating an extension and |)rogre.s.«i of the tubei-cular process which will ultimately eii 1 in flic death of the jiatient. There are no positive means by which we can say how long a patient will liv( after tuberculosis of the larynx has manifested it.self, and the iTiimediate jirogiiosis depends greatly upon the type of the in- volvement, the condition of the pulmonary involvement, and the resistance to the di.sea.se offered by the individual patient. The chances for the extension of life and the arrest of the tubercular process by treatment are undoubtedly lietter where we have to deal LUPUS OF THE SOSE ASD TUHOAT. ggg with !i purely localized condition. All this shr.uld guide us in the ciioice of treatment, uimI shc.uld make us utilize every possible means at our disposal to hrmp about a favorable result, for it is undoubtedlv true that although the process is indicative of a fatal terminatioil much n-hef can Ih' gained by judicious treatment As to figures we might <iuote from John N. Mackenzie, who deduced the fact that from 100 cases death resulted in from twelve to eighteen months after the usual symptoms showed themselves, and that in «) |)er cent, a fatal i.ssue occurred within si.x months. Bosworth' gives iorty-six months a.s the longest time, and three months as the shortest time after pulmonary tuberculosis wjis complicated bv larvn- geal invasion or, to .luote his summary: "The average duration" of lite m an ordinary attacK of pulmonary consumption is three vears the average duration of life in an attack of pulmonary c.msunipti.m' <umpl.cated by laryngeal invasion is two years, and the average dura- tmi. of life aft<'r the supervention of laryngeal invasion is eighteen months. " LXTPUS or THE NOSE AND THEOAT. Two salient points are always to be thought of in the general <'oiisideration of lupus of th<. upper air-tract: first, it is practicallv a ways secondary to or associated with lupoid manifestations of the <kiii. generally of the face, and, .second, it should be viewed as a tubercular lesion. .As to the.se two points, bv far the greater num- ber of investigators concur. Rare instanc(>s of primarv lui)us of the pharynx and larynx are claimed by .some, and in .supFwrt of its .•Mstence tlw subject has received an exteiisiv.- consideration bv I'.nnI Mayer (,f .New York. ^ who re,)orts in detail two cases of his nwii. and refers to others collected bv Kubenstein The .|iiestion of the tubercular natiin> of lupus apparentlv is «„ tlH.roughly proven by the finding of the tubercle bacilli that it is suggeste.1 In- some authorities to dispen.se altogether with the term lii|)u.s a.s It pert.-.ins to the larynx. While from a bactei-i.-logieal standpoint the relation between lupus and tuberculosis is api,arr.ntlv I'lentieal. still we cannot but be impress<.d with the great difference 111 the clinical course of the two lesions. Tuberculo.sis in almost everv tnrm IS more or less rapid, is associated with puhnonarv lesions gives use to more pain, is progressive, and ends fatallv, with some' asso- <-iatcd tubercular concurrence Luims, on the other hand, is verv slow and insidious in its development, not necessarilv as.sociate.l witli [Hilmon.ary tuberculosis, gives a minimum ainount'of local di.scom- t-.rt has a tendency- to heal, cicatrize, and recur, and often dcH's not result ni death from puhnonarv involvement. Lupus of the nose is so associate.! with the contiguous skin lesion tl.at the r.ader is referred to works on .iermatologv for it,s description Twentieth r-^titury Pntciioe. 60 • New York Medloil Journal, Janoary 1, 18W. aE^ 866 NOSK ASn THROAT. Pharynx and Larynx. Ht'lativc to its fiviiuciuv H. Mygind,' in uii cxainiiiatioii of 2(M) patii-nts with lupus of tiic skin, found tlic larynx atTcctcd in 10 jht rent of tho cases. Fifteen of the laryngeal ciuses were f(>inales and five males. Hunt,' in a tabulation of 411 cjises of external lupus, found either the pharynx, larynx, or nose involved in 20 |M'r cent, of the niunher. In I7:i ea.ses of lupus ot the nuicous lueinhrane occurring in the clinic of Doutrelepont only_(> eases were free from cutaneous lesions ami of this same nunilxT ".'> i-;i.ses were affected in the nose-, .il cases in the pal-te, and l:} eases in the larynx. Females are more often att'ected than males, and the lesion is more apt to show itself before puberty. Symptoms. The subjective symptoms at firs* are not very prom- inent, which is a characteristic point: it is only when the lesion ha,s existed a long while, causing sympt(>ms from destruction or stenosis, that our attention is particularly arreste.l. Appearance. The appearance of the lupus varies according to the progressive stages of the lesion, the characteristics Ix-ing the same a-s i" affects either the pharynx or larynx. When the uvula or soft l)alate is involv<M| there are produced in cons(>(iuence. first, a tume- faction somewhat reddened in color, followed by the formation ot nodules over the area of the induration, variable in size, and when dense and confluent producing a distention of the uvula and soft palate, this nodulation being followed by ulceration and subse(iuent cicatrization. The whole process of ulceration seems to be a suc- ces.sive breaking down of these nodulatirns, which in turn may heal a.s new nodules appear. Larynx. When the larynx becomes involved the (lisea.se usually makes its hrst ai)pearance on the free margin of the epiglottis, causing, in some instances, a considerable amount of destruction In-fore in- vading the interior of the larynx: this feature of limiting it.self for a long whih' to the epiglottis is a valuable |)oint in the diagnosis between lupus and other long-standing destructive lesions. The appearance of laryngeal lupus is well described by Breda, ijs follows: "The epiglottis 'is thickened and irregular at its free bi^rder, with slightly raised pale or grayish-red eminences. These we may observe to become whit ■ jit their apices, a slough forming which, on separating, leaves a small ulcer with sloping edges and grayish-yellow l)a.se, but without anv surrounding hypera'mia or infiltration of its margin. These ulcers are slow of healing, and ius one cicatrizes another nodule breaks down or is absorbed without ulcerating. In this way a worm-eaten appearance is given to the edge of the epi- glottis, "which is very characteristic of the (lisea.se. As the process goes on the epiglottis becomes paler initil it comes to have a dead- white color and to the probe is stiff, fibrous, and resistant. Steno.sis of the larynx only rarelv results from lupus, and may be due t<) blocking of the larynx by lupoid tis.sue, to fix.ition of the vocal c<mls, 1 Arohlv f. Laryngol. tl. Rhliinl., Berlin, vol. x. Part 1. < Watmu-WiUiaiiu, 4lb ed. .V TKSOSIS OF THE LA li J'AX .,. , ..r .•..ntracti..,.s msulting fr.„n nciHrhatmi. It is n'markHhlc l.,.«- M.l.lon. lrach.-.,t«..i,y is n".,uir<Mi in lupus " '"arkal.K |.,.w Diagnosis. Th,. diagnosis lies hotwc-n tuhrroulosis, carcinoma s-.r c-uma, a.Hl syphihs. „ ,s pcrl.aps fr„n. so.ne forn.s , f c ," '/^ 't h t" (liHcrcntiatK.n is the ni,.st difficult Treatment. ThouKi. tl„. .iisca.sc is a .slow {jroRrcssivc „nc there is a te,Hlen..y u. son.e ,nstan-es to a spontaneous arrest "hie m.v .'■.na.n lor some tune to he followe.l by a recurrence f r , 7 .M'"t .s .Mainly th.-., of escharotics an.l surRical proce lur " u-tt j'arl". .<•. and chnmnc acid, with Ralvanocauterv an.l Xr ctu ti^ hav.. I,e,.n ..nploy.-d, while in.-isions. curettc-nu^nt a u 'xH^^^^^^^^^ the surK.cal n...asures n,.|ieate.l. Watson-Willian.s men i ..w I e .• ...H-y ..I sui.n.u<-ous „.j..cti.,n of tuberculin, and n-fens , e pol i- iulities ..f the cmj)l.)yment .)f the X-ravs. ^ LEPROSY OF THE NOSE AND THROAT. I.o,.n.sy of the upper respiratory tract in this country is an cxtremelv .a. d.s,.ase. an.l wh,.n,-ver occurring is always s..con.lary to e "o y of the skm - ncv.T a primary disease. It may -itt-ick " l.l . , ' n^^mbnuH. of the nose, pha^nx. or larynx! W shll^M' ,^1:^ V hen these parts b.-ctn.. myohe.l by markcvl structural c. 1' J unng th.> eours,. o gen.-ral leprosy. The subjectiye s^^^^pt,^,^^^^^^^^ U.t are very mil.l. mamly those of irritation. The t c urt «-hanK..s follow the order of cngestion, tun...facti..n. tubercle m .I<-.Ta .on. The progress is slow and i,.t,.rmittent. and reatnS^^ IS by the application .,f caustics an.l sur^^ical rem<,;al '"''""^"* The rem ,T :s n-ferrcl to a m.>st cmplete a.ul exhaustiye doscrip- ti..n ..f th., li.seii.se by Dr. Ramon de la S.,ta y I.ji.stra in Burnett's '-system of Dusensex of the Ear, N„,e, ami Throat, xo] i STENOSIS OF THE LARYNX AND ITS TREATMENT. s,„^!kr,?''' "^ /''^''^'•ynx may bo either acute or chronic. Generally ^ '<"akmg. acute stenosis is r..gar,led ..i.s that ty,H> .seen in the dS .ontic croup „f chi .Iren which h.us been coa^illercl un ler tTu ub J. of diphthena. W e are wont to cla.ssify other forms a.s c Ironic .1 li t, ..r n.,n-n,embran<.us stenosis. The chussification .,f Dr Ch' 1. (Vatrices following the healing of ulcers, or the formation of ^^•^ -n^tituti.nai d.sea..e. .syphilis, phthi.sis, glan.lers, w.)unds, or ' Buck's Handbnok of Medical 8cience, vol. iv. 868 SOSE AM) THRU AT. 2. Inflamruatiiins, acute or chronio, rosultinjr in ()l)structi(m of larynx, (toui), .liplitlicria, (iMlcnm, and iMTiclioiidritis. Clironif sten- osinp inflaninialions arc also alluded to under this head. 3. Neoplasms, hcnign or malignant. 4. Neuroses causing sjuusms or paralysis, iusphyxia. 5. Conipres-sion of the laryux from external causes, which includes fracture of the larynx. Symptoms. The symptoms of stenosis are those of impaired voice and laryngeal breathing, nuThanically produced by the steiiosing cause, the severity depending on the extent to which the |)assage of air tlirough the larynx is iin|H"ded. The symptoms may be progres- siv<' or come on suddenly. The exact nature and extent of the stenosis can only l)e determined by laryngeal examination, which is an absolute necessity in determining the mode of relief. Treatment. The treatment of laryngeal stenosis naturally resolves itself into, first, ronsUtutionnl, as indicated principally in cast's of syphilitic stenosis, by the adn)inistration of potash and mercury; second, mechnnicni. the exact form depending on the seat, nature, and extent of the stenosis. Under mechanical treatment may be iricludi'd: 1. Surgical removal, by external or endolaryngeal measures, of stenosing growths, the liberation of binding' cicatrices, web-like bands, etc. 2. Tr.icheotomy or intubation for the inmiediate relief of impending suffocati.tn. .S. Some forms of dilatation, either iis a single niea.sure or in con- junction with tracheotomy. Tlie surgical removal of stenosing growths and the performance of tracheotomy or inlul)ation for immediate relief are metisures which each instance will suggest, and need no further description either for their indication or manner of i)erformance than has been accorded them under their respective diapters. The subject of dilatation of laryngeal stricture has received the attention of laryngologists for many years, the procedures h-ing based on the same general lines as in tubal strictures of other portions of tiie body. Princijjal among those whose niunes are early a.'^so- ciated with the subject are Schroetter, whose di. ,ting tubes ano, mr- tallic i)lug re(|uired a preliminary tracheotomy in order to be retain<Ml ii! the larynx; Morejl Mackenzie, whose screw dilator was introduced like l.'iryngeal forceps, the dilatation being accomplished by means of a screw at the proximal end of the instrument; Wliistler, whose cutting dilator, the ))ortion entering the larynx, consisting of an olive- pointed [»lug with a concealed knife. , ..s princi{)allv used for the purpo.se of dividing bands or webs and obtaining sonie dilatation at the same time; Navratil, whose dilator, con.sisting of a four-sectioned olive-sh.'ined plug, is i„tr<Hlured closwl. and dilated liy mean.s of .i proximal screw. 'Ihese and other instruments ha.sed on the same principles obtained a measure of success in certain adaptable cases STJ-:X0SIS OF THE LARYSX. 869 I'.'t th.>y wore all „pen to the two ixjsitivp ..bjectu.ns either of re MU.ru.R u primary traclu.ot..,„y or neeessitati. g ..ft"epeat'Tl u t atteiMpLs at .lilatation. The imtt.re „f lurvnReal stVictur s s nf ...gether wth the resisting ,,uality of the larynS b, x ^^t . , t o roduee prop,.r .hiatatir.n s..,nethi,,« „.u«t h?^ .uu.x which u-.II remain there an indefinite time. prcHlueinc c, |".in...s pressure, an.l. if possible, allow breathing o' K cam>d on through th<. larynx without the aid of tracheotomy. " Fio. «l. i Whistler'a cutting dilator. a> «i hmit mneh fear of contradiction that the i.res;nt-<lav treat "'".t ..t aryngeal ster.osis. wliatever its nature, coiLii n £ I nil" •■ation of the principles of intubation. ^ ' N. strongly imbued was Dr. (VDwyer himself with his belief in h- success of intubation for this purpose that he said ' ''Had int Lation of the arynx proved a comj.lete failure in Z trea mem of •rou,. I .shoulc still f«.| an.ply ropaid for the time and exnei^e eon sume,l 11, deyelof.ing it. for I belmve that it offers the mo t ation^i i^ ':;?' r' K ■'" ^^;;'™'' ^- ^Y <'^*ation of ch^cm'S ^ubst^ntb^ln^'o-D^lr^'^rK^ '-e, in my experience, •d';;; tlw" ^'"" '"'"^"''"" '" ''^'•^'"«^«' ^''^''^^'^ "^^y be classi- • necISlvlio!^;? tf '"r '"■ '"" '^'T'^tanding nature, not of V ; '"'"^\"^' <lf'f»aiiding an immediate operation -'.Acute stenosis calling for immediate relief. 'eitt^Mmmarv in .^-nature or an exacerbation of an aln-adv c.isiing con. Sf " •5. Uhcre we wish to produce sufficient dilatation^to dispe^e ^vith ' New York Medioil Journal, March 10, Ifws, .s7(i NUHE ASD TUHOAT. tho wciiritiK of a traclical camila, tlnTchy establishing rcspirntiuii throiigli the iioriiial cliaiiiicl. These three jtroups an- not arbitrary in their (Hvision, and one may at times irierfte into another, ••s|H'('iully ju* far ;us the Hrst and se<'ond are concerned, for we must iihcdi/s remi-mlxr thai all caHfs iif lonimiml or traclital utrnn.-is, hoin-rer ijradital, mai), at atiji moment, takf iiiHin tfnmxflrt's a sudden exaeerlmtinn. before noinji furtiier into any detailed (hsoussion of tlie udupta- bihty of intubation in the foregoing ty|M's of ciuses, and the principles guidi?ig Ifie |MTformance of the same, let me say that the fundamentui underlying consideration which should always guide us is u /»ro/xT diaiinosis. This cannot be too strongly emphasized, for I think that the failures and the disappointuH-nts which may have overtaken us have been largely .'ue to a lack of appreciation of the exact nature of the case in hand. This discrimination includes, among other things, not only an ai)preciation of the original cause, l)Ut also the nature and location of the swelling, density of the tissue involvetl, whethi-r or not then* be ulceration, and whether the imineiliate condition of the patient is such as to permit of the extra exertion necessary for a proper operative manipulation. No one for a moment should think of performing intubation without a previous laryngeal examination, and if a coinph'te examination camiot be maile and we cannot come to a fairly accurate conclusion as to both the cause ;ind nature of the obstruction, the operation siiould give way to tracheotomy, with a view to using intul)ation subseiiuentiv iiearing on this point is .-inotlier important consideration, that <)f always being prepared to do a tr.icheotomy in the event of failure of intubation. It is in the second cla.ss of ca.ses where intubation in compari.son with tracheotomy is |)ut to its severest test, and those of us who may be its strongest a<lvoc;ites niu.st not be s<i much prejudiced in its favor that we (■.iniiot see its impracticability in certain cases, remembering that no one oixTation is without its limitations. It goes without saying that in the second cliLss of ca.ses, where we wish to clioose between intubation and tracheotomy, that intubation .should be chosen if applicable, thus avoiding the cutting operation: but the decision should be made only after due consideration of all till' contingencies. Perhaps it is in the third cla.ss of cases, namely, where wo wish to dispense with tlii' tracheal (anul:i, that intubation has its most posi- tive ap|)li(Mtion in adult stenosis, being closely allied in this n'sjject to the first el.iss. It is here that w«' come into direct comparison with the other and older methods of dilatation. An intubation tube has the advantage .1 l)eiiii; tolerated in the larynx for an indefinite length of time, thus | 'oduring a constant ilegree of absorbing pres.sure. wiiidi is the main p-.^liit !, h.-.- gaiiie<|, i^^n\ Ui'Te is an opjM)rtunity offered for altering the .sizi- and conformation of the tubes to meet the ciiaiigiiig conditions. It has been pi \cn by many cases that J*. mfi/EKLxakifKsi'jfJtriK^^fniPW UTESOtHa OF THE LA K I .V.V. 871 :m intul.ati<.t. tulM- yy l„. w„ri. in,|..finil..|y with a nmitmrativ,. «.'Kr...> of ,■„„,. .rt. tl... pati..nt-s. i,. ,„„.., ,,u^^, |,.ar„i„« to mUust lli.'ms.-lvc.s fo tlic ii.-w riictlicxl (if hrcatliiiij?. Willi thf trarhrotoiny tiilx- i,t .sin, wv hnvv ample time and ()i)tM)r- tui.ity f. .st.i.ly tlu' shaiM. of th.- sfnosis un.l to n.ak.. suHicicnt trial .iinour.t of suffocation or .-xhaustion. It n.av l.«. f,.u.sil,ie in the l..'KinniiiK to make an explorative, introduction wi'th either a Schroctter tul.e or a laryngeal .soun.l of some kind; hut I have alwavs hehl ami Mill do hol.l to tlH' opunon that if a SchnH-tter tulH- can he parsed nn in uhation lul„. o| ,he same or larger calil.re can Im> as w.-ll pasw-d a.i.l lie n-tain.Ml, when w then get the a.lvant.ige of a continucMJ ineZr.'. r'\.""' ;^"''J<'^'<'"K ""• patient to rcp^'ute,] and ..fttimes meH.ctual attempts at iH-rmanent dilatation. It is fre,,uently the .ase that u.tulmtion cannot !«> performe,! as tin- primarv operation, and w,- miL^t depend on it only for s<.cond,.ry dilatation ifter tlK^ .erlorma.u.e of tracheotomy. Inder these circunistati.rs it is weH n |H;r<.r„i the „ach..,tomy as high up as possil.le, as it is much ; I .,.'!. «r '" T'''.'"'"! '"!'•<"''"•.<'<'" a'xl retention of the intubation <l>.' than uhen the tracheal o,.enmK is low down and po.ssihiy beyond tlH- reach of the nn\ ot the intubation tul.e. Intul.l,ti<.n ..hould be |Hrfornu..l as s..on as possible affr th.- tracheotomv. in order to .Mvn„| the .secondary stricture, which is liable to occur at the sinx-rior iMarjrin of the tracheotomy woun.l. which s ,.tim,.s luus to be over- ••-"„. before the intubation tube can be pro,,erlv introdtic-d. The Ini.jrer a tnu.he..tomy tube remaii ^ in ,,n a.lult larvnx th.. more diffi- n. d..es 1, become to reach the larynx with the pnding intubation f.ij.. 1 ,.iMl tube M> the tracheotomy prevents the larvnx from rLsing " P ....lation: this di hculty is increased in a very small patient, wh.-re tl..' larynx is naturally l,ey..n,i the cmtrol of the introduciuR (iiiR,., "> ol the former objections an.l perplexiti. ^ of intubation in •I'lul ,.,ses was th.- uncertainty as t<. the n-tention of the tub«. for M.v length of time, and the probabilitv of its being .je, .ed in a fit '. .•oughing: tins objection, however, h.ns been sMisfactmilv mc-t by urk"S ^;"^""" :'":' •"-li'i'-ati.... of Dr. .Joi.. Uu^.r.. of New ,;Jt 1 • '':'""1"1*^ "^ •' r..taininK arm "l.ich is screwed at f le"!f;"f';'. "/''r'?' "I"'.""'« "• f'-'-'t «'f '<- intubation tul^ ■ t he Mte of the nu-heal op,.nmg. Jt is prevented from unscrewing ^^1" ." Ml position by having a small plug or pin inserted in a gr « "e -n.th" upper siirface of the arm. Thus the'tube is . asilv ct^d • res,,. u,g ...11 ..fforts at expulsion, and at the .same time the su i : "r.ito , •„. the tube subse,|uently removed in the usua n.ann..r ' 'M.ght be thought at first that there would be considerable at g^^^ "•■" the pluggmg up of the tube by retain,.! secretions. hToZ '•'>.ly liapiMM,. M, adult cases, and it there be anv tend.'iicv in th-it . rection steam inhalations may at times be u.scd, oV tt tu o'remo^i^ l'""> litne to tim,. for the pur|K,.se of cl.-ansiiig. remo%cd "^ 872 A'OSt: AM) UlliOAT. TIk' mii'iJkhI (if fiiidiiif; llu- |>..mt in t||.. intulnilinii tulx' f(ir the insertion of Mic iiriii is :i> follow.-, Tlic mtiihatior. ihIm- Imviiif? Im-cii pi.ici'.l ii: the litiynx aflrr llic tnulii'dloiiiy i.iIm- li;i> Im-i-ii n'Miovi-d. a iiiiiik is niailc on the iiitiil)a inn tulx- iluounii tlic traclii'otoniy woiiiiil, liihcr hy a (nic hot .^^tifT niftal |>rol.c \v:!i<! hnrits a tM-rriaiicnr inarkihjr. or liy srratchinK tiic tube will, il..' |,oint of ■< r / liaml iti-triitni'iit: then tlir intnhation 'iilic is rciMovtuI ami tin- iiistriim«-ii»- tinkcr fits flic tlircadi'.l arm at the [Miint of the niarlvinj;. In the Jiiiinuil iif Ihf Amir,, n Maltnil As.'oifialioii. .Iiiiic, |<KKI. I)r. Ijiiil .\ia\cr. of New York, di'scrilns a Imllow intro.iucinjj handle which Kill. Mi. Rogere' Intubation wi f,,r .linnj.i' stenonu. is continuous with tiic intubation tube, a most valiiabi,. device for ...tubat.on m c-rtain ca..... whi.-h has for i,s obj.rt tl,c prc'vcntiou nf till' cutting ofl (,t the iur durmjr the operation Si.Ai-K. The .v/,«/« of the tube use.| in adi:lt intubati-,!, i> the san.e as that used t,.r the rel...f of en.up in children, onlv larp.-r and lone,.r iM.r Kenera convemenr... a .<et .f three lubes willbe f<.u,,d sufficient VIZ. . a .small, m.-duin., and larpe size. If anv special form of stenosi.^ has t(. be overcome whiTein the onlinarv shaped tube cannot h.e use.!, „ w, 1 be ,„.c.e.ssary to chanRo the shape in accor.lance with the ca.-e ;t. hand. I he iiitrodiicint; and cxtractinR instruments should U., HTKyoa/s '//• rnK L.myyx Jh- lirMvicr aii.i stouter than tli<.s4' n.-M with tl., !'• I«TIIlit uf IlKin- fnn-.- ill li.ssili^ \Uo .lin,T.'Mt St ic rn «7;i «'fi, ill ordir may iM-ciihcrof lianl rulihcr itip till ricturcs. The ful.^ atlvaiitanciiiis sdinrtimcf* in Miikinc I rniiial; tin- metal tiiln' Ix-iu^ | ili lU'IlVKT, in IK iii\vi'r(lown in the larynx ami »«•! risiiiK up s<. far in the act ..f (|.-Kliitiii.,M, Tl -Mimcwliat more liaMc ti.ccili.-t n inctal tiilxw, althoiiKli i Inr cither ti> JMroine ohstnier .1 siifHeieiitlv to le seeretitiiis are t IS unusual Altliuutrh then neeessifate reiimval. is eonsicierahle .liir.Teiiee in the weight U-tweeii tl MU'l.il an<l liarii-niltlMT tiilies, they se« t'll.iatetl. The teelini(ju«. of intuhat. the saini :us when ijone fur eroup in child ni to Ik- aliout eipiallv well ion in the adult is. in fheiiiiin c.t fore is to l)e exerted, and wiiere th l)y the left fuietiii^cr, the operatic rer and where a ininiii e epiRi ' can hi Mini ell iiiatianed •n is coinpaiativelv easy for th ulio hav.. had any .•xperieii.e. ( ),i the other hand." wh .imoiiiit n{ force IS to Ix' exerte isily coiiiriille<|, the ojieiation | lere an extra lind this lalt.Tdilliciiltv oxerted and where the epifjlottis cannot 1 inoredilficult. We are apt t( )ecoiiies wi ir in very tall patients and in tl n a IracJHa! ca.iuia for a long whil(>, rend iose who have lad ei certain eircums* anc lering the larynx inactiv \(' where the entrance to the strict > Mnai or situated away In.ni the median line, tl ure i.« liie dilliculty of iiisertiiijr the tul duct I'llliTS I ion with the aid (.f the larvnw'al I ill' In to I le stricture the mirror will have to I lus incrr.i.sinjr it may he well to try its intro- igeal mirror; hut as soon "as the tuhe piickly Iropped ;uid .■.■l.njrer of the mirror h.an.l transfern.l to the head of ',h,. ,uIm. xer. thr profHT pressure and to hol.i it : place while the intro- ■] ir Hi i; 'liiH.ifi instruMHmt is t.ciMg withdrawn. Increase l''l '"'• to advis,. intul.., .,11 hv aid of the niirn -teiinos, ,f possihie to do .. The strinir slwmLI until we art' r no I- tl I. The string should heal' juite assured that the hreathing liangi-r of the tub. hecomi g IS ea.'-' ngocclu<led or coughed ^IH-rieiice ha« ' ■' ■ ■ of adult ^' ' i< 1 'uain ■nd i!'>!.' is lis II. cessaiy wh. e the ealihre of the tul ol uhe IS verA III >ve the pati,nt with the string attache.!, whici an adult tluui in a child, di 11 we can lio lo •ully if we jiiger ,1.11 .>ctions should he given to witlulnw ' - tuhe hj-^ ,„,.an.s of the string whenever the p'th-nt is una It?, should he cautioned, however, not t<. act too hastily eLse it imp-bt HI st introduction. It is well to u.se niedicatcl steam ii.i.da- '.' MS in . rder to prevent drying of .secretions in the tuhe Pnti ,s t ^r:'',.;;;:"iriK' '"' "i"""^ ^^r"^''*'"" '-<'-■"' ''3- ^-!^^ „ ,';. f •' ."'•■• i«.'>f'<''">'«'s Ix'i.er tolerated dav hv dav. The same : 1 c, ; Tl "'^T' *" '''■«'"^"-" «•'"-''. '>- in children, is tt ^ a .d iH having the patient swall,,-v while lying down with the -I ..u d i III ::Z TT^""^ *"'"' '"■ '■"^^••'' '^"""»'='. «-hich means m «74 XOUE ASD THROAT. Tlip removal of tho tube may Im' accomplislied with or without tlie aid of the laryngeal iuirn)r. I think, however, the former way is preferable, ius then we can sec the |)oiiit of the extractor enter the tube, thereby lessening the danger of lacerating the mucous mei i- brane b\ ineffectual attempts at removal. While the tube is in th;' larynx examinations shouhl be made to see that its proper position is nuuntained and that the opening does not become occluded by overlapping swollen mucous membrane. i i FOREION BODIES IN NOSS AND THROAT. Tlie lodgement of foreign bovlies in the nose and throat is of very common occurrence, the articles so lodged consisting of almost every conceivable object large enough to l>e retained in the various cavities. In the UDsc it generally h'ip|Kms in early childhood, and is the result of their being placed there, either by the child itself or by compan- ions. When detected iinm(>diately after their introduction it \)e- conies simply a matter of examination and removal, generally without any resulting harm, but very frequently they remain in the nose for a long while without the knowledge of the parents, setting up sym|)- toms of obstruction, I pistaxis, pain, mucopurulent discharge, and all the symptoms of a decided rhinitis. As a matter of experience, they are so generally placed in but one .>*ide of the nose that it is almost an axiom that a unilateral mucopurulent san^ruineous discharge from the nose is always strongly indicative of a foreign body. When this condition is present it may be recogniz<'d on examination of the nose, wiien. if the foreign body is low down and not covered by .•swollen mucous membrane, its presence is readily determined. If, however, the suspected substance is fiirtlKT in it will !)<> iKTessary to use a blunt met.'il i)r()l)e, passing it well down in the inferior meatus, and then, if undetected, u|) into the higher nasal region, when, if present, the familiar grating sensation of a foreign body will be imparted by the probe. It is best to facilitate the manipulation of the probe by the application of cocaine. Frequently when the foreign body has resid<Ml in the nose for a long while, it may lK>conie encysted or cov- ered with lime salts. Their removal is best accomplishf^l under cocaine and adrenalin by means of a suitable nasal forceps, preferably one with a slightly-rounded olive point, .so tli;it the foreign body may be securely gnisped around its circumference. If the substance is con- veniently situat(Ml its retnovid m:iy be effected by the use of a strong bent |>robe rather bro;id .Hiid in the shap<' of a hook. If very loose in the nose, and well down, the foreign body may he exi)elled by forcibli blowing of the nose with the unobstructed side and mouth closed. It may be necess.-iry in some inst.'mces to push the substance back into the na.'--.opliarynx: bnt I think this should be avoided if possible While, usually, removid may be effected by local aria'sthesia. it mav be necessary, owing to its size, coiiforniatio!!, and the irritability d the child, to employ general aiuesthesia. unixoLirnn. RHINOLITHS. 875 In a cortam number of cts™ f„roign h„lios which lotke in the nose K.m.,u- ,„cru8teci w.th the .alt. „f the .uusal s,.creti„n5, Z L^Z I Hly he,„K the nucleus, an.i the calcareous deposit is supe „ 3 I luT ,„ a sohd mass or in layers. S<,metimes on KiTS tHiik Mtretion. This maybe accounted for by supnosimr fhp or.K,nal nucleus to have bc-n a particle of hard or inspiS«T^ueus' J a ..udl detache,! piece of .lead bone. Rhinoli^hs Ihou^ be FnreiKn substance of various natures may become accidentally TT ".' ?;.' (''"'"'"I ^""' '"'■•^"•^ '» « ^'^"^'tv (.f ways part el?s of ..o. and hsh-bones during th. proces.ses of eating, swailiwi ,1 ,? t'".'thp!ates, pms,aml nails hekl in the mouth in vari,u,s cZ S^ <n.ilklv'yi!'.'t''tl'''.'-V"'''-'*'''" "^ ^''" ''''^'•>'"^ '"• ''irvnx come on so <|ui< kl. ih at the hLstory is very easily obtained. Th'ev varv act rd n*^ to the location of the impaction and the nature ,.f tl .■ f.mU v 1 h l„.,.on.es in.pacted. I„ the pharynx the syn.pton. Se ge .^ eul. those of pan. an.l dysphagia, and in the lArvnx ..f , ai„ n I .l.v aphonia, cough, excessive laryngeal irritati.ui. and impai e I .'.t t .> . xp .|i,.d by either coughing or vonnting. and the patient n.ti us '" '-nplain with p<.sUive„ess that th,. fon-ign bodv s sti It . r ,^ son.e mstanc..s it ,s very difficult to .n,K.s„n. tit- patient ti a tl oreii ..Miy has been expelled. The exact location 'and la n- turn I'.-..;te.| substance can only be .iefinit.-lv n.a.l,. out bv a , ,, per ev. ' J. -n m U,e upper pharynx, by .lepn^sion of the tongu " ^ u': :: W^M 876 XOSE AM) rnilOAT. luxly mijcli iiiorc easy, l)iit it also will allay the irritation caused by the impaction. If the character of the object is definitely known and is lodged in tiie siil)j;!ottic region, the use of the O'Dwyer" short, cylin- drical foreiftn ixidy intni)ation tubes may be brought into reciuisition. The value of utilizing the tiicthod of direct laryngoscopy a:- insti- tuted l)y Kirstein hax been mentioned as aflonliiig assistance in the search for and removal of foreign bodies in the trachea. This metlHMl when practicable would .<eem to po.ssess considerable advantage. In- stances have been reported by Ingals,' F. K. Hamilton/ and olhur.s. = New York M«<lica: Joarnal, .September 17, 18*8. * Auatnllan Medical Uazette, May, 1898. ; i tj CHAPTER XX. NKOPLASMS OF THE NOSE AND LARYNX: THE LOCAI MEDICINAL, AND SURGICAL TREATMENT ' OF THE LARYNX. By W. E. CASSELBERRY, M.D. NEOPLASMS OP THE NOSE. Benign Neoplasms, Nasal Polypus ((Edematous). (Edematous . asal po ypu« ,s :t tunu.r of a gelatinous consistency, m.re ace ,rS .lescr.lK.1 .is <r,len.atou« tibron.a. which originates ro.n tltJ mucosa . nucopenosteun. „. conse,,uonce of chr,M.ie infla.nn.a on espe- ". Il> ..» the ethnuml region. It is .sometimes designated as invxon a • l.u > IS not identica with that neoplasm, as it occuil'l^v 're ^i . t.l.ne s from It in histogenesis.' The form, a.s,,ect, an.i coriiitence ;..,:;. '''"ti;. ';"""",' ''^''"'''.^*» => ^^rape-pulp.bu/ scarcely iZac u- ^'.^. Ihe iKiturai shape is pyriform, but this is often yaried by «...Mt> a.s deyeCpnj.-nt proceeds, and the point w u>re the ,.e( icie ;> n.n.oun.led with the tissues of attachn., nt is known a.s the ''ro t '' 'n ; uiiki!;: r'?;"./" ^•^^^r''"'!"'^'"'- ^^•"" ^' >-"--h";h;e ;; ; , '•" , '" • """' "'^ ""'■^""' ''^ -^'"ooth an.i glistenine It ""'I' tli.it <>t a jK'a to a walnut or larger. When sinde it is !,.«« ..,.f !-vn.raherre„.oyal or recurre,K.e is longer de^;:;:'^^^^^^ may he far ba.-k m the nn.s.ril, „r ..y,. .roject int., the .uts., >,' ry p^ ;■» 't 's apt to be M..,re fibrous, an.i' is then kn.,wn ^^ Xi . al "Nt 1 li.,\, .,i,sery..,| tli..iu fr..n, th.' age of ,>ight y.>ars ui.w.rd .,n, a .-as.. un.l..r ..„e year assume.l ,.. be c.,ngenhal ^ s iZV^ .^ ' ' AI--0 I hay.. kn.uvn th.-m to .l,.yel..p at the a.ly..n,v.| age .'f'^iSlty Etiology. Th<- mo.si f,v,|uent underlying con.liti..n is ethmoi.litis I r... le mHanm,at...n .,f ih^- n>u,.„,,erios,eu,n an.l bone ft hV ' """.M.I labynnth m.,.1 mi.l.ll,. turbinnt.' I b.K|y. Tl... n,,lv, i,| hick ;;;""« a...l gra.,ulati..„ tissue fn.n whi.-h p..lyps .le -1 J ^^ ^ '^ "I >>i.iple ,nflani,>,...t..ry aeti..n which yari..s tow.-ml .e.ie n A, anaivs. ,, the ..yi.lenc..^ fayor. the yi..v that the i::H;un,;^;;Lmbeg(;.^ (877) 878 XOSK ASD THROAT. % } H II ill tln' iiuin)s:i, and tliciicc is lial)l«' to extend to the periostouiii and l)()ne, altlioufili a few' contend that the initial lesion is in the bone. A disintegration of hone, or rarefyinj; osteitis, is often a.ssoeiated. There may he actual curies" of hone; hut usually the condition is iwtter described as a defeneration, in which state it is etusily denuded and it.s trabecuhi' readily broken down. ZuckerkandlV observation on cadavers, that two-thirds of all nasal polypi proceed from »he middle meatus beneath the middle turbinated body, is confirmed by accurate clinical examination. (Fi<;s. 4W and 444.; The polyp buds Via. u;). KepresentlnK the outer bony wall of the left narls, with the mKltllo tiirtiiiiated body iiirne.1 upwani to Rhow Ixjneath the hiatus semlUmaris. to the edges uf which polji* are frcquentlv attached. (Author'KR|>eclmeii.) proceeding from thp ethmoidal labyrinth grow in the direction ..I the least resistance downward thntiijrh the hiatus semilunaris, which is the common outlet, and form attachincnts to its projecting lower edge and to the bulla ethnioidalis above. The point is, that althfiugl distinct polyps ;ire found to be attached to the borders «.f the hiatii- in a^ large firoportioii of ca.ses the initial lesion is a diffuse ethnioiditi- -Next in fre(juenry polyps originate from the free border of tli( middle concha, then from the superior meatus, superior concha, an.; acces.sor>' sinuses. In typical form they are very rare on the iiiferi<!' I lj«mt)ert Ij«k. The Joii.-nal ..f I.«r>-nKol.wy, KhliM.joKy. and Otology, KcLriiary, liUll, p. M = Edmond W<ialce» NamI I'olypu.. etc . in ReUtlon to Ethmuiditta. ' Zurkrrkandl. Anatomic der Nanenholilc, S i'>4 el «eq. SKOPLASMS OF THE S>,SE. Hl[i =t-:;';:;2-;;Si;-l^^^^^^^^^ Flo. 4M. Out«r .VKll o. the riKlu „u.al c.vuy, exhibiting three polypi. iZuckkrkandl.) flu. 445. liv.r may he rppar.le.1 as (.r.p of the prodi.;. l-'sing raiisos of othiiioiditis, for it is a fro- 'I'""' ••<'nr..niitant in this class of cases The v.'r.nus causes of a.-utc an.l chronic rhinitis '" ^^l.lch reference may he made are also <r"rativ... Ohstructive .ieformities of th<. -•pt.imtPay encourage the formation of na.sal t'-lyp.,,, which case they are often found also ''•''.;'■■;'«;■.' ''•••'nl.an.i when in the narrow "•still i,e|„nd the obstruction. (f-V 44^^) A pun. ent outflow through the l.iatas .sen.i- "iiarisfrom ,.mpy<.ma of the antrum of High- "Tc ,s an ...xciting cau.se of ethn.oiditis and l"'lvpus. and the same may l,e sai.i of prim ,v -;;';|""-"""' "f the fn.ntal a,.,l .sp,!,.„oii S ; 'iir '•""' ""'.'""'•' '"•"•^- Kspecialiv in -'""-t.on ..f these cavities seems Lorroft:;;' to'^^s^'fr;;;;;"!; Nttsa! l>olypuslneunJiiiictl..ii with obstructive deformlly of the septum. (Author's oas^ i I i I ■ i i I i i i 880 XOSE AND TUROAT. closure of tlu'ir orifices by polyps which were pritnarily the outprowth simply of an initial non-suppurutivc cthnioitlitis. I "have frcHjucntly obscrvoil simple ethinoidiiis with polypus and, perhaps, asthmatic symptoms, hut without any inus aujjpuration, and years later en- countered the same cases then affect(>d by suppuration in one or more sinuses, or, with bilateral |)olypi there may be sinus suppura- tion on one side and not on the other. Pathology. The pathogenesis of nasal jM)Iypus has Imhtj outlined in considering the etiologj-. It Is further elaborated in the section on pathological histology. Microscopic Appearance.' The epithj'lium is ciliated colunmar, thickened in areas. The stroma is a network of areolar ti.ssue, the size (if whose meshes Is determined by the amount of serous infil- traiion. The meshes contain under higli power granular coagulated fibrin, cobweb-like threads of fibre bundles, and small round cells, which are more numerous in the immediate vicinity of the blood- vessels from which they exude. From the round cells voung con- nective tissue is formed with its branching cells. The senim contains salts in .solution and nmciii Polypoid Cysts. Occasionally a growth which has the external appearance of an (edematous nasal polypus is found to be a cvst, the fluid contents usually (>scaping as the wire is tightened around its pedicle. It may be small or large, single or nmltiple, and exist alone or in association with ordinary polyps growing from the sjimc situation. In one case the c ^t that grew from the posterior part of the middle meatus twice r(>curred, each time as a cyst. Again, polyps may be partly cystic, the spaces containing at "times a yel- lowish purulent fluid. lioth are regarded as glandular retention cysts. Tl»"y differ from cysts of the middh" turbinated bone and from dentary cysts. Symptoms. Na.sal obstructions, excess of secretion, intranasal pressure, and headache, defective speech, aural complications, impair- ment of .smell and taste, and nasal reHexes— <■. 7., asthma, migraine, cough, sneezing, eK-.— are the salient manifestations. The tumors are prone to swell in damp weather, thus increasing the nasiil ob- struction. .Mouth-breathing will result in irritation of the pharvnx and larynx. Tli(> .secretion may be simply mucous, possibly excor- iating, or in case of conjoined sinus su|)pi"iration it will be purulent and may then be fetid. The spe(>ch is "dead" from absence of nasil resonance. Impairment of the sen.se of smell may be the first symptom, as in one patient, a physician, who complained only that he liai lo.st his cu.stoniarily keen olfactory sen.se, and in" whom polvni buds could barely be .seen jutting out from beneath the middle tur- binated bodies. In fact, the di.sease iiresents so many import:. :it phases in connection with its .associated underlying and result!. SI ' Jotuthin Wright. TranMctioni of the American Ur)ngologlcal Aaiocliitloii, 1893, p. 6» liL NEOPLASMS OF THE NOSE. 881 conditions that a clinical cliussification, with brief case-descriptions and illustrations, will best i)()rtray it. Nasal Polypus with Simple Ethmoiditis. Mr. li., aged forty years, coinpiains of pressure far back between the eyes. The bas(> of the nose ext<Tnally is broadened, and there is infra-orbital .swelling which simulates the physiognomy of Hright's di.sea.se. There is great en- largement of the middle turbinated bodies, which press hrnily against the septum on each .side. They hav." a glistening a.xpect and are odi'Miatous, puitaceous to the touch. (Fig. 440.) A compact bunch of small polyps jut out from beneath each middle concha. .Mr. N. .\1., tiged fifty years, liad a few polyi)s removed ten years ago. Xa.sal respiration luis since been free, but of late years hi' has suffered a seiLxe of pressure far back between the eyes, at thnes .so severe tus to induce a high degree of nervous excitement. ICnornious osseous overgrowth, with polypoid degeneration of the middle tur- binated bodies, which together with a small i)olyi)us literally pack Flo. 446. Flo. 447 Fio. 41fi.— Elhmohlltis with nami polypi and polypoid degeneritiim of the middle turbinated Ixidies. (Author's c'a.«i!.) Kri;. 447 — Kepres.'ntiiiit oil one »idi> polyps Rfowing from the ethmoid n.-){ion. visible only after resection of the middle turbinated bo<ly. (Author's case ) the upper channels of the nose. Resection of the middle turbinated builii's was made which laid bare the hiatus, bulla ethmoidalis, and ill I'art the other ethmoid cells, from which i)olyps could then be seen to protrude, and who.s(> walls were in a similar state of polypoid dcjreiicraticii. On the left side, curiously, no true polyps had been visible until after removal of the middle turbinated body, when two, of good size, but of flat s|ia|)e, were exposed, which projected from ilir region of the ethmoid cells. (Kig. 447.) The term "intracellular polyps"' has been given to this type, in which growths imiceeding Irom tli.> ethmoid cells are contained in the middle meatus beneath .111 enlarged and perhaps excavated middle concha. In a study iinbracing a series of forty cases of nasal polyj)us, fourteen were of the cla.ss rejireseiited by these two. In most of them there wa.s Dosworth. Transactlous of the Ameiican Uryiigologioal Ansodatlon. 56 i I H 882 NUHE AM) TlHiOAT. pdlypditl transfonnatiim of the Miiddlc tiirhiiiatcd body, and twn of thciii li.:d each a lar^c typical polyp dcvclopt-d fniiii '"liis process of the ctlimoid, aside from the other jtolyps wliich |,i-oceeded from the tuiddle meatus. Nasal Polypus with Vasomotor Ethmoiditis. This class is introduced itirecosiiitioM of a complex of symptoms which iucludes, with varia- tions, asthma, hay fever, hypera'sthelic rhinitis, intumescent rhi- nitis, and poIy|)us. Tliese. when occurrinj; in the s.ame patient, imlicate a fundamental neurotic lialiit. That the neurosis involves all impairmi-nt of the vasomotor nerv<> control over the affected areas is jiurely conjectural; hut it is a reasonable h.ypothesis, and one which is intended to keep in mind the .-ixsociations and partial dependence of asthma upon ethinoiditis and jiolypus. Miss Mc{". has sutTered from comi)lete nasal obstruction for several years, together with asthma and hay fever. There were multiple polypi which, after removal, would ra|)idly redevelop, jjrowinji in profusion not only from the middle meatus, hut also from the superior meatus posteriorly, and from both the middle and superior turbinated bodies. TIk' (-ntire nii-sal mucosa w;is in a state of (I'dematous tume- faction, as if devoid of vasomotor control. The hiatus and ethmoid cells just alM)ve. when exposed by resection of the middle concha, wore found covered with |)olyp buds and jiranulation ti.ssue which were curetted and picked off by cutting forceps. Intermittent intu- mescence of the nasal tissues contiiuies; she is comparatively but not absolutely free from a.sthma, and the hay fever is mitigated. Out of a .series of forty ca-ses, this case is rpi)resentative of a group of nine. Asthma Wius a universal symptom: four of the nine had hay fever, and the others were es|)ecially susceptible to dust, coal smoke, fog. aroma from horses, etc., which sufficed at any season to excite tumefaction. Nasal Polypus with Suppurative Sinusitis. This class is repre- sented in the series of forty by a group of twelve. Nearly .all had empyema of one or both maxillary sinuses. Two had in addition empyema of the frontal simises, and one of these conjoined suppura- tion of the ethmoid cells. Two others h.id sup|)urative ethinoiditis without involvement of the other simi.ses. Curiously enough, onlv two of these sujipuralive cases suffered from astliin.,. and they, while having polyps on both si<les, had supixu-ative maxillary sinusitis on only one >ide. and in both of them the ethinoiditis |)ulyps anda-sthma seemed to precede the suppuration. .Mr. McC. aged fifty years, has sutTered from nasal i)olyi)i for ten years. < die year ago intense pain commenced over the left frontal siiii'--, then supra-orbit;il bulging and tumefaction, and finally, after months of intense suCfering, spontaneous disch.arge of pus occurred from the frontal sinus. The left middle turbinated bone was enor- mously enlarged and in an advance(l state of jiolyjioid degeneration, the whole mass, together with some small jiolyps, being pack<'d in place .so firmly a.s to obliterate the middle meatus and to press the septum MM .\EOPLASMS Ol- THE SOSb'. ««3 Inwar.l tlic()|)|)(.sitcsi.|c. The removal of lliis mass exposed pulypoid .■\crese<'nres aii.l sii|)piiralioii of the , tliiiioid eells. wliicli were then M'laped ami drained. He Jmd also empyema of th<' maxilla y iinlrum Miss 1'., a;:e.l twenty years. The rij;til middle tiirl.inated l,o,Jv j^ eiilarfr.'d and pres.^ed against the septum. The hulla ethmoidalis is also e.ilarjreil, the two top'ther presenting; the deeeptive appearand • if a double turbinated l.ody or one that has wnd<-rp)ni' apMurenl eieavafre. i !■ ijr. 44N.) From the ii.s.^ure protrude .several small polvps and a jMirulent seerelion. wliieh in the ahs.M/ee of maxilla! v and frontal MiHisiiis musi proeeed from the ethmoid cells. .\ fine piolie inserted iiiio the li.ssnre .leterts denuded hone. |{eseeti(,n ol the middle tur- I'Uiated l)ody and eureliin>i of the bulla and vieinitv resulted in a cure. Diagnosis, It is usually only neee.s.sary to look -vith a good lipid and l-i'l with a probe in order to establish eorres,,.,nde::re with the l.hNsical characters described, but more rarely an accurate knowledge Flu. 44S. fir,. HU <it ail patholojri.Ml states i.s essential to a precise diagnosis. Polypus H '.. be distmjruish.'d from mere Ivperfn.phic rhinitis, and septal ■ v HM-ence by the fact that the turbinated bodies, although sivollen ■ nul the s-ptum. althou.iih deformed ( p.ui'v their natural po.sitions' \Uiile a polypus occupies one of the spaces beneath, between or beside tliese structures. . Fig. 4 K). 1 It i>. moreover, movable, and jrenerallv "f .1 paler color. Sarcoma should be carefully exclud. d by micid- -■■'•I'ir .'xammation m any case in which the clinical aspVcts ap- .''■'.icli malignancy. i li.-nv obser\ed polypus .and sarcoma side by side in the same ii'Mnl, .-md I ••im mclmed to share the widespread belief that ordinary pnlypus m,y m ceriam subjects become the site of .sarcoma, although it i^ditiicultol absolute demonstralion. So-called '■ i,je,>di.,jr tuiiiors of the .septum,- if not simple vascular iivpertroi.hy oi svphilitic gumiuata, are usually angioinatti, telaii- i^i'ctuiMata. or s.ircoinata. t^^ur IM4 SaSK AMf TllHO.iV. Progi 4ii. Tliif i> •.ctlliiit if tlic di^iiw 'm> crtcctivcl trcatfil otherwise rcciiiTciKM' is iif<uai. Treatment. The Im'sI means fur tlir r(iii()\.il nf ty|)ical polypi is the cold wire simrt', suppit'iiicntcd l)y sharp cutting forceps, aiii! ix-ca- sioiially a sliarji curette. Tiie tcdiiiijUe is di scrilM-d in another ciiap- ter. I.ocai tnediciiial measures, ^Mcll as the injiTtion into the polyps of perchloride of iron solution, chromic or IrichlorMcctic a<'ids. are inferior modes of treatment. \\Vakcn( il alcohol, etc., to di.-' an i;e their growth, is of i|uestionalile utility. \\KiT\ from the removal of the polyps an important part of the treatment consists in the estab- lishment of free nasal passages for respiration, drainap , visinn. and instrumental manipulation, for otlier\\i.<e the polyps can Ik- hut mi- perfeclly removed, and are certain to recur. To this (>nd hypertro- jihied turl)inat<'d liodies and septal .spurs should he reduced and wcriou.** detlections of the .septum straightened. I iirthermore. in iSiM, in a piiper liefore the .Vmerican Laryiipological A.ssociation,' I i>r()posed :i.s part of tlu' radical treatment of iia.sal polypus, the resection of the anterior part of the middle turhinated hone in order to facilitate acc«'8s to the jioints of development, liiRli up in the middle mcatas. The method has al.>*o Iwen advocated hy ( Jriinwald,' Haji-k,' and others. .Vssociated sinus supi)uration should receive appropriate treatment. Intranasal and Retronasal Fibromucous Polypus. This nra- plasm, al.so called myxohhroma, contains a variahle, often u large proportion of fibrous tissue which gives it a firmer con.-iistenpy, denser structure, and somewhat darker color than the onlinary mucous polypus. It is more .ascular, and the intranasal ;;rowth remains sessile longer. It is |iroiie to originate toward the rear of th<> na.sal fo^su, the median and posterior a.-in'-ts of the mi<ldle utrhinated body or adjoining ;';'rt.- iif t'nr cilimoid and sphenoid bones being .-^cat- of att;;clinic!!t. Tlicnce it m.'iy project forward or backward. It is attached fa.iiin Kirward than a regul.-ir nasopharynge.il fibroma. In diagno-is one should be c tri'fiil to exclude sa''.'oma. The symp- toms and treatment of the intranasal growth are the sanu' iis for ordi'iarv nasal jxilypus. The symptoms and treatment of retntnas:il fibri.nmcous polypus cannot be better described than in relatiin: the follow inu case: Mr. M., agcil about forty years; increasing nasal obstruction for years. The ;:;!M\vtli actv like a valve, permitting a slight ingre.ss of air. but closing the clioana' upon e\])iration. an action which is par- ticularly noticeabl(> and distmbing during sleep. ,\t first, if he won! 1 lie upon the right side the tumor would gravit.ate so a> to free tin' other side; but iatterlv it has growii {t^> large to afford even tlii- relief. On examiualii n po^teriorl\ the tumor is seen to project fro'i ' Oih^'lberr)"- TraiLsartions of the American Ijiryn«ol(«;ici"! Asaoolatlon. 1X91. - (iriinwiilil. Iiiu I^bre von ilen Niuenel'tTiingvn, 1S9,1. Milnohcn und Leipzig, Verlag ^ a J. f. I.shmMi: « H. Ji'l. ..:. hlv r. Lar,. n;?ulogle und RbiuoloRie, VS\ Band It., Heft 3. SEOI'LASMS OF THE XOSK. 88S the rijriil nostril inti) Hit- iiiis<.|tliaryn.\, whicli it nearly fill;*. ( Fin. 4.'»<).) It i- liarfly visihlf liy anterior ins|)cciiun, iM-cause adi'tlcftcd wptiini limits the vi.vv. An cfTort tu nnarc I'roni in front failiMl. A loop of No. ."» piano win- carricii l>y a curved catiula through the niontli and lias. .pharynx enveloped part of tin- Krowlli, hut Im-mI the caiiulu Ix'foro \\un {Urmifrh, and had to Im- .1. laclM'd. A cautery snare siini- no mo lariy a.i; isled ilivided part of the tuiiior, permitting the reiimant to >lip forwanl so iluit it could he snared anteriorly. Intranasal Fibroma. rnderthi> title it is proper to include only jiwre or nearly pure tihroinata which orijiinat!" in the musal fos.sa- anterior to the nasopharynx. They are rare. Schmidt' oh.served two _ among .'J.'MKH) palients. The UU- Uetronawl nbmmucoup polypiw. (CoHlN.) tlior has re|iorted-' a typical case ol strictly na.sal hhroma of dense cnn.«istpncy. niicroscopipally pxani- iiied, which originated from the vault, and -.vhicli. pri'.ssinR the" septum to ihi' o|>positc side, had cau.sed absorption of the middle turbinated i" y, the trahecuhr between the ethmoidal cells, and part of the anterior wall of the sphenoidal .sinus, the nostril after its removal presenting a large cavernous juspcct with smooth walls. It was re- iiiovi-d in fragments by the galvanocautery, and has not recurred during tliirte<'n years. Iti the nasopharynx pure fibromata an- coiiip.-irativcly conmion. and some of the nasal cases have originated from parts bordering upon the iia.sopharynx— c. »/., the walls of the posterior ethmoidal cells and .sjihenoidal sinus, the posterior edges of the septum, and the rear ends of the turbin:it<"d bodies, since here is foimd in greater .abundance the fibrous stratum from which they ■lie assumed to develop: but no part of the no.se is exempt, for welf- .■iutlieiitic;it''d cases are recorded in which the origin was from the .•Ulterior wall of the sphenoidal sinus," the rear of the vault* as demon- >tratrd by an jiutoiisy: the middle' .and inferior turbinated bodies, I'le n.of uf the nasal fossa," the cartilaginous sepfinn.' and the na.sal Etiology. ( )iic ca.se. involving the septum, was directlv attr;buta'>le to a blow on th.- nose: in another it followed some years after the leiiioval of a mucous jiolyp from the same site, and hence is attrib- ' .Sohmldt. Die Krmikhcltfn deroln'reii Lunwegc, 1S!V|. S. 4'4ci • ( mwll .-rr)-. NNsul KiliroiimtM. Jdiimal of Ameriraii Medical .A^sl«■iallon, April 21, IHiw, ' I'luwelbcrry. .Inur:^ 1 uf Ameriean Mollcal As.xx'iatlon, April ■.'!, Isw. ' lieMy. (iiixi by .Muckenzle. I)i.-e«M>« of the Tlirout aiul S.w, vol. il. p. 37.>. Am. cd. ■■ e. II KniRlit. .loiirnal of I,ar> ngnlony, Rhinology. and Otolosry, March. 18S«, p. l.V! New- '•niiib Tliv UrynKiisco|>e. July. I9()l. p. TO. ^ ^;«ckeii2ie. l)ioi«p« of the Throat and No«e, vol. II. p, 376, Am. eU. ' BuchaiiHn. (ilaairow Medical Journal, 1S82, p. JU. MICROCOPY RESOLUTION TEST CHART iANSI and ISO TEST CHART No 2' 1.0 I.I If ■- I— 1^ I- 1^ IIIIM [1 2.2 [ 2.0 1.8 1.25 1.4 1.6 A APPLIED IfVVIGE Inc "fe) .-flS '■^.^■i ■-609 ■wi* : I 8«6 A'OAi,' AXD THROAT. utal)lc to ii porvcTsioii of the cliroiiic liypcrtropliic iiiflaiimialory jiroccss similar to tliat wliicli rcsuits in iiuicoiis polypi. Both scx('s and al' ajri's sccin (Miwally liahic. Pathology. Fihrous tumors in this situation present the ordinary pathological characters of hhroniata in general. In con.sistency they vary, heing sometimes very dense, and at other times softer and more succulent. The fibrous tissue which constitutes the chief part of the growth is grouijcd in Innidles of various sizes, or is simply do.selv interlaced and devoid of <lefinife arrangement. A few minute cells, either round or spindle-shaped, may he |)resent among the fibres or in large numbers around the bloodvessels. A smooth fibrous cap.sule usually envelops the whole. The following is Dr. .Jonathan \\'right's description of sections from the author's speciiTien: The sections are largely made up of fibrous conne<-tive tissue whose outlines do not show very clearly, owing p'robably to the long time the six'cimen has been kejjt. I presume you are justified in calling the growth a fibroma, although thei > are a number of (edematous areas in it. as well as the evidences more commonly regarded as those of chronic inflanmiation. " (Fig. 4.51.) Fio. 451. IntninaMil tibnima (.\utbor'H s|n;t*imen.) Symptoms. The early symptoms are tlioso of a catarrhal nature, followed by obstruction and distention of the fos.sa. Its develo])ment continues, to th • deiriment of bones or cartilages that mav be in the rhes *ay. L'se aie absorbed, enveloped, and rent asunder, the neoplasii yiyjPLAS3lS OF THE yusE. 887 p.-notrating into fissures, accessory sinuses, and neighboring cavities. Tlif l)riilf;e of the nose is ffatteiied, the eyes bulged forward, and tiie (•lieei< swollen, th(> whole constituting: the hideous deformity known as "frog-face." Fre(|uent and dangerous attacks of e])istaxis may |ii()ceed from surface ulcerations. Kxiension upward may open the cranial cavity. Diagnosis. A ])robal)Ie diagnosis is not diliicult. Its appearance //( f^itii differs mucli from that of the mucous polyp. It is not mul- tiple, but may be lobulated. The ba.se is broad. Ihe color is tlark red, tliere is no translucency, and it is firm and resistant to pressure by a i)robe. It is more difficult to distinguish it thus from fibro- sarcoma. Microscoi)ic examination is the only means of positive diagnosis. Prognosis. There is a tendency to recurrence after removal, although, if thoroughly extirpatetl and ihe base cauterized to the bfine, the prognosis should be good. Intranasal fil)roma, like fibro- iiuicous polypus, appears to form a fa\'orable nidus for the develop- ment of sarcoma. Treatment. If small it could Ix' removed in lolo by the galvano- cautery snare. When large and confined by adhesions it is necessary to resort to the author's expedient of dividing it into two or more tongues or fragments, over which tlie snare may then be more easily adjusted. Repeated sittings may be necessary, and if profu.se hemor- rhage be excited an iodoform gauze packing sliould be inserted. In cutting operations there is great danger from hemorrhage, Grrdy's' and HeilerV cases having termin," d fatally from this cause. Never- theless, in long-continued neglected cases, wl'Pre the neighboring cavities are encroached upon, it may be necessary to make an external operation, such as von Brun's, OUier's, or Rouge's, or a resection of the sujierior maxilla. Intranasal Papilloma, (a) Fibroma Papillare. (6) Adenoma Pap- illare. The true papilloma or i)apillary fibroma, conmionly called a wart, is often found in the vestibule of the nose at or near the jimctiou of th(> skin and mucous membrane, and is then usually of ti\e hard, scpiamous variety, as it develops fron> the cutaneous struc- ture. Strictly within the nose true papilloma occurs but rarely, but still it does occur. It may also be of the s(iuamous ty])e,'' as are the w.trts of the ])harynx and larynx, or it may he soft, ((uite va.scular, and composed primarily of colunmar epitheliiun* which, however, nay degenerate in places into Hat cells. Whether the ephhelium is of tiie columnar or s(|uamous tyi)P the branching ])ediclc or central tissue is fibrous and without glands. It may be pedunculated or ' 'iertly. Loc cit. - Soiler, TraiisHirtloiis of the PRtholiiglcal Society of Philadelphia, 18*4, p. 126 : cited by Bosworth, lMsea«es nf N<mh; and Throat, vol. i. ' Hillman. Archiv f. Uryngolruie und Rhinologie, Band Ti., Heft 2, 8. 171 ; Douglass, New York Mnlicai Journal, J.intiary 7, ISini. p. 6. ' Jonathan Wright. Transactions of American Liryngological Association, 1896, p. 177. 888 yoUE AM) Til HO AT. i"i 1 1 H ! J I ■ I I (liffusoly sessile. The favorite sites are tiie cartilaginous septiini and the floor of tiie nose. Sjmiptoms. The salient symptoms ,••'•'> nasal ohstnictions and epistaxis. cither of which may l)e ahscn* > the jrrowth he tiuite small or not vascular. Dia.H'nosis. The jjapillomata would he distinguished from malig- nant neoplasms, especially epithelioma, hy microscopic -xamination coupled with the clinical aspect and course of the disea.se. Prognosis It tends to recur unless thoroughly removed: but complete removal is usually i)ossil)le in the nose. Treatment. They may he removed hy the cold or hot snare, or, if accessible, iiy knife or sharp forceps. Hemorrhage, if persistent, may he controlled hy an iodoform gauze tamjion. Chromic acid is best adapted to the cauterization of the base, which is oft(>n indicated to prevent recmTcnce, although unnecessary irritation by repeated aj)plications of caustics or inefficient operative measures is to be avoided. For inveterate recurrence it is said the local and systemi" use of the tincture of thuja occidentalis,' ajjplied on cotton for enty minutes twice daily, and a tcasjjoonful taken thrice daily is .if service. Adenoma Papillare. In addition to true i)ai)illoma or papillary fibroma there are not infre<|uently found in the nose glandular over- growths, ])a|)illary hyi)ertrophies, and inliamini.tory thickenings which present to tlie naked eye a papillary surface, and some confusion has arisen by naming these also ])apillomata or warty growths. Ho)i- maim's" so-called ]iai)illomata, which are implante(l usually upv)n hypertroiihied turbinated bodies, contain glandular elements sulficient to .justify till' term "adenoma papillare." Others are mucous |)<)lj'])i'' with a papillated surface, and still others are to be regardetl merely as localized inflammatory overgrowths. Intranasal Angioma. Bleeding Polypus of the Septum. Si/notuiws. .\ngiotibroma, fibroangioma. fibroma angiomatoides, telangiectoma, {■avernous angioma, bleeding |iolyi>us of the .<e|)tuni. Tlii> I iimor is probal>ly not so rare as li:is been represcMited, being de- scriiicd under various names. S<'ver;il papers' have recently aitjjearec I in (ierman literature under the title of "bleeding iioly])us of the sep- tum," and I'tliers in .\nierica under the titles of telangiectoma'' and cavernous angioma.'' The detailed pathological description of all these tallies I'loselv with each other and with the case below described. ' K F. Ingalls. Transactions of AinerM'Hi Laryiiijolonioal ,\s<<i)Ciaiion. 1**'.J0. p. .'»J. > UopiiuiiMi. Arihlv. I'. i«th. Anal., rhysiol. niul Me<l.. ISKl. Nci. ',i:i. p :Jl');eiteil by Joiiullmu Wrinht, rraiisaction" of Aniurican I.aryiiK"IOKicai Asscx-iution, 1>*91, p. 14. = Xo.iuet. Rev. de laryiiBolORic'. etc., July, iswi. ami June, 1"*91 ; citeil by Jonathan Writjhi. loo. ('it. * Victor Ijin;re. Internationales Centralltlatt fur Laryn. und Uliinot.. June, lsy;i. p. .V.HI , Schadewaldt. Arehiv f. i,arynifol., Bani i. S. 'ii'A) ; Alexallier. ibid. : Sclieier. iiii'i ; Heymann, ibid. f" Cierce, 'I'ransaction.'s of Ameneau Medical Association. Section of lAryntfology and UtoloKy Ju.ie 1, Iv.iT. ' Cobb. Trausactioiu of the Paii-Amvrican Medical ConKren, 1X93, vol. ii p. I.MO. NEOPLAHilS OF rilK S</>,E. 889 111 tlic cMily' litoraturo sovorul cases are reported uiulcr the name ansiioiiia, Imt some of them ar<> eoiifused with other neo])hisms, c. r/., anjiiosareoina. angiotihroma, etc. About thirty oases in all are re- |iiirteil. The exact site on the se])tum hii-s varied, hut all were toward the anterior part, and several at the l)as(\ Tlie size is from that of a pea tip a hazelimt; if much larger, one should strongly suspect sarcoma. The siu'face is no(lulat(>d or furrowed, !)ut may he smooth, the color a mottled l)lue or red, and the pedicle either narrow or hroad. Cavernous anjiioma is also described as occurring on the anterior and median portions of the inferior turbinated body. In this situation dill' mu^t avoid confusing mere hyi)erplasia of the normal cavernous structure with a neophism, although the latter does occur, the illus- trations^ and pathological descriptions siiowing it to conform closely to angioma, as it occurs on the sei)tum. Etiology. They are more freiiuent in females than in males, in the proportion of three to one. The lymphatic temperament seems to be a I iredis] losing condition. Pathology. The vascular tumors whicli grow upon the septum iiarium do not conform exactly to either the tj'pical amjioma mnplex iir the (Uhiioma ravcnwsum. They contain both bloodvessels and blood spaces, thus far representing rather a combination of the two ty|>es, and they contain also a larger jiroportion of reticular connective tissue, with either round or sjiindle cells. In some this reticulum has a lilirillary "liaracter, justifying the term angiofibroma. If composed entirely of dilated pre-existing vessels rather than newly formed vessels, the term relaiigiectasis or telangiectoma is by some preferred. .Mil noscoi'ir Ai'i'KAKANCK. In the ca.se below mentioned the tiinmr was compo.sed largely of bloodvessels and blood spaces. The bloodvessels vary in size, and most of them contain more or less blood. .Smieof the v^'ssels are collapsed. The blood spaces are partly lined with epithelium. Hetween the.se ves.sels and blood sjiaces is connec- livf tissue ill which are lumierous round cells and young connective- tissue cells. ( )n one side of the tumor is a remnant of mucous nieni- lirane. Symptoms. Attacks of bleeding are fre(|ueiit and severe, especially if the tumor is located near the orifice. The degree of obstruction dr]iends ujioii the size of the tmiior. The condition is exem|ilitied in the following ca.se: Mis. T., aged about thirty years, married, pregnant. Has been .iniii .I'd for the past few months by fre(|ueiit bleeding from the rigl.i ii"-tiil, and gradually increasing obstruction. Kxaminatioi. d' I'l ised :i soft, reddish, irregularly nodulated tumor, the size of a smail bean, .ittached by a rather broad pedicle to a small excrescence of the se])- tiiiii at the point of junction of the cartilaginous .segment with the I lloswiirth. Discuses of the Niise atiii Thrmit. vol. li. p. 431 ; Schwager, Archlv f. l.ar)'ngol. und ia.ni.ii., r>„u.l i. ,>. lo-'i. - Jurasz : cited by Scbwager, lac. cit. 890 XOUE ASD THROAT. 1. w ■ Kio. I5i septal process of the suixTior maxilla, therefore just within the nostril and dose to the Hoor. It bled ejisily on contact with a pro!)e. I re- moved it with a cautery snare, and cauterized the l)ase with chromic acid. Three weeks later one small vascular i)oint, still unhealed and disposed to bleed, was again cauter- ized with chromic acid. No recur- renc(> during three years. Diagnosis. The tumor may j'ulsate if connectt ' with an artery, and the color is tluw more red; but if chiefly venous the color is bluish. Sarcoma should be excluded by careful micro- scopic examination. Prognosis. If well removed it shows little tendency to recur. Treatment. The growth may be rei.inved by the cautery snare, very slowly by a cold wire snare, by silk ligatures, or by electrolysis. The ba.se should be cauterized, preferably by chromic acid. Intranasal Adenoma. A pure of gland structure, having its type Obstruction of tii(> ducts may lead u ^vstic formation. More often it contains considerable fibroas conruH tive tissue, when it becomes in reality an adenofibroina. Such a neoplasm occasionally originates from the glandular structures in the posterior surface of the velum. In the nose i)ure adenoma seems to occur but very rarely. Certain mucous polyps may contain adenomatous elements, .\denoma pap- illare receives reference under intranasal ])apilloma. It is usually imp-lanted upon hyi)ertroi)hie(l turbinated tissue, contains glandular elements, and has a jiapillated surface. Adenosarcoma is encountered in tiie nose, and is included in the chapter on sarcoma. Rarely, the sarcomatous element has Ix'cn so slight as t'l induce the reporter to cla.ss it as adenoma, in accordance with the i)renonderating tissue, for. while semimalignant, it is less so than the average sarcoma. In Harris'' case, after six years' suf- fering from asthma and nasal polypi many times removed, he expc- ri>nced an inveterate rapid recurrence of the poly])i, which finally became soft, necrotic, and friable, packed the maxillary and ethmoid sinuses, and terminated fatally eight years after the commencement of the asthma and poiypr-. The structure o' this growth a.s described by .lonathan Wright- may serve to exemplify the class: Comi)osed principally of glandular 1 Harris. Ijincet, January, 1896. Reprint. • Wright. Quotsd by Uarris, loc cit. Intrana»l angioma. (Author's case.) atlenoma is a benign hyperpla.'^' in the acinous or tubular gland: SE0PLAS31S OF THE XOSK. Sl»l culuninar opitlu'liuin regularly formed into acini and ducts, in some pints involution of the epithelium wjis surrounded hy a framework of new connective tissue, which in a few places is ma(ie up of spimlle cells, and in considerable areas is densely crowded with round cells, some of both the rounil and spindle cells being so arranged as to suggest sarcomatous tissue. Adenocarcinoma receives reference under carcinomata. Symptoms. These would depend upon the exact character, situa- tion, and size of the growth: but the symptoms likely first to attract attention would be those incidental to lui-sal obstruction. Diagnosis. Adenoma is prone to develojj in middle and advanc(>d life, ttbroma in the scond or third decade. A careful micro.scojjic examination, considered in connection with the clinical aspects, may be necessary to exclude sarcoma. Prognosis. This is favorable when there is an entire absence of malignant elements. Treatment. When strictly licnign there is little difficulty in its eradication by the means enij)loyed for other nasal neoplasms. If there is a malignant tendency the treatment would be in accordance with the principles enumerated in the .section on .sarcoma. Intranasal Osteoma; Chondroma and Odontoma. O&teoma. Sipi- (imims: lixostosis, enostosis. The term exostosis hius also been aj)})iied to excrescence of the sejjtum, but is not now generally so used. .\ form of exostosis which constitutes an osseous tumor somewhat rarely develo])s from the walls of the ethmoidal cells, frontal or max- ill.'iry sinus, and, while occupying to some degree the nasal fo.ssa, it u>ually encroaches upon surrounding parts, especially the orbit. ^\ hen it develops in the diploe the cortical substance ex])ands and envelo|)s the osteoma, and \'irchow' draws a distinction between these which he names enostoses and exostos(>s pro])er, which originate from the periosteum. Bornhaupt,' in reporting a case of frontal siinis osteoma, gathered from the literature .'iO cases, "i.'J of the frontal sinus, 12 of the ( *hmoidal cells, 10 of the antrum of Highmore, and •") ot the s])h(>noiil, sinus; 87 per cent, oi the whole number occurred before the thirt eth year. Osteomata ar • described as living and dead, the latter when they li.ive undergone spontaneous loosening from their point of attach- ment. In btein's'' ca.se the osteoma wa.s .symmetrical aii<l double, causing the a])pearance of "frog-face" and complete nasal obstruc- tion. In FengerV case thi' large osteoma, partly living and partly deail, s]ir;ing from the ethmoid bone, filled the na.sal chamber, and en- croaciv'd upon the orbit. It followed a fracture of the nose, trau- ' Virchow. Cited by Fenger, Journal of American Medical Association, 188S. p. 185. ■ Bomhaupt. I.angenbeck'8 Arehiv f kliniache Chirurgie, 18S1, Band i»vl. p. 5S9; cited by Feuifer, Inc. clt. ' ". J. Stelii. IjirynKOScnpe, July, 1900, p. 2:*. * Fenger. Journal of Americau Medical Awociatlon, 1888, p. 186. mi yosi: A^ rnito.iT. w ! I (I inuiisin l)cin^ rcfianlfM !is !i (•oiiiiiion cxcitiiip cawso. Nassil poly])! (•(M'xistcd, (loiilitlcss excited l)y tlic irritation and supjuiration inci- dental to the |iresence of tiie osteoma. Chondroma. Intranasal chonilronia is rare if the term, together with its synonyms— enchondronia and echondroma— he properly restricted to a real neopla.-m t)f cartilagi', and not loosely a|)plie' to inflammatory sjuirs and deflections of the septum. A true dion- dronia usually ilevelops dininp adolescence, springinfi from the .sejjtal or alar cartilages, or at the inferior junction of the two. It varies in size from that of a hazelnut to an orange, and is round or nodu- lated, closely resembling a dense fibroma. It is composed of hyaline cartilage with perhaps tihrous tissue near the st'rface.' The diagnosis would licst he confirmetl l>y Toscop'c examina- tion, for which purpose a segment could he .cd by means of a rotary knife trephine. One would wish to .de chondrosarcoma. From osteoma it is distinguished by its peneirability by a needle. Chondroma, if not too large, can be removed by a cold snare; the iiemorrhage is slight, and it .shows no tendency to recurrence. Hence the importance of ;m early recognition, for when (juite large an exter- nal operation becomes necessary." Odontoma. Odontoma is a neo])lasm which arises from the germs of teeth, and which is composed of dental ti.ssues, cementinn, dentine, and enamel, one or all in varying i)roportion. The tumor may contain a mniiber, even as many !is Hfty denticles or tooth-like bodies composed (if either cemeiitum or dentine, as the case may be, or even ill-shaped teeth comjiosed of all three elements.-' The number of such denticles in the human may reach fifty or more. Odontoma involves the no.se only by extension from the alveolar process. It encroaches first u])on the antrum, filling and distending that cavity, thence possibly 'Vojecting into the hnnen of the nose.* It arises only in youth, before dentition, a ])oint of value in distinguishing it from osteoma. It shows no tendency to recurrence if well enucle- ated, for which ]iur])ose a subperiosteal partial resection of the maxilla through the mouth may be reijuireil. Lipoma. While lipomata are not uncommon on the external surface of the nose, they are not encountered within the nares. Malignant Neoplasms of the Nose. Intranasal Carcinoma. Carcinoma occurs less frequently in the nose than sarcoma, but many well-authi'nticated cases are recorded. It is rarer in the nasal cavities than in other ]iarts of the upper respiratory tract, the larynx, for instance; hence the more dotailcii ' Mackenzie. Piseaso nf the Thnwit ttiid N'ose. Aiit. e<1., vol. ii. p. .3S0. - Veriieuil ; cited by Boswnrth. PiaeaRes of the Nose aurl Thix>at, vol. if. p. 4:l'>. 'J. lllaiid Sutton. Tumors. Innocent and Malignant, IH93, p. .W: cited by A W. de Roa'.dcs, * A. W. de lioaldes. Tran»actinn8 of Ainericun Laryngological Aitaociation, 1894, p. 91. NEOPLASMS OF THE yoSE. ^J3 (l('S(Tii)ti(m of tlio (lisoiiso will be found under i-urrinonia of tlic larynx. Si|\iani()us-c('ll(>(l raroinoniii (cpitliclioinai, cylindrical-celled caicin- oiiia, and glandular carcinoma, soft (encephaloidl and hard {scirrluis), appear in point of frequency in the order nanieil. Favorite sites are the vestilnile, cartilaginous septum, middle' and inferior" turbin- ated bodies, ethmoid'' region, anil posterior edge of the vomer.* It oiijjinates more often in thi' antrum of Hifrhmore, and extends thence to the no.se. It develops usually aft(>r forty years of age. Hilhotli has described a "glandular carcinoma" or "cylindrical epithelioma" of less disposition to recurrence, in.stances of which occur in the nose. The .same is known also as adenocarcinoma'' or malignant adenoma, and con.sists of a stroma of young connective-ti.ssue cells, lying in which is an aggregation of tubuli lined with a cylindrical non-ciliated e|)ithelium. Symptoms. In addition to nasal obstruction and distention pain of a lancinating character is a prominent .symptom. Invasion of the orbit will cau.se exophthalmos and blindness. The diagnosis, especially from sarcoma, will depend upon micro- scopic examination. It does not always involve the neighboring lymphatic gland.x. The prognosis is exceedingly unfavorable, excjit in "glandular carcinoma." The principles of treatment are the same as for sarcoma. Intranasal Sarcoma. Nasal sarcoma is rather frequent. Nine cases have pas.sed under the author's observation, mo.st of which have terminated fatally. Each had long jjersisted in the hope that ill' suffered merely from a polypus. A better comprehension of the disease in its early .stages is to be desired. The cartilaginous septum is a fa\orite site for sarcoma. Of 41 ca.ses tabulated by Bosworth in 9 ii originated on the .septum. This fact is the more important since >n this situation, if recognized early, it is accessible for thor- '•■ -ition, even by hitranasal methods. This was exemplified uthor's ca.ses, a man aged fifty years, who.se right nostril ■ed by a rather firm neoplasm which projected slightly II ..is and .sent tongue-like prolongations backward into the »;■ the nasal fossa, but which on removal was found to l)e attached only to the upper jjart of the cartilagincms septum bv a pedicle 2 cm. in diameter. Its i)rojecting lobule w;is abraded and Med freely on slight contact; but its larger part was covered by a thin, smcoth, capsular membrane. After complete removal I cauter- ized the base with such thoroughness as to produce a large perforation of the sei)tum, and, although metastasis in the ethmoid region iiccurred, it did not redevelop at the original site. The microscopic findings are given under pathology. Other points of origin are the ethmoid region, the turbinated • Robert Crieu. Atlas der Nasenkrankhelten, 1901. Plate XXXVI. = Krteg. Loc. clt. 3 Kriee. Loc. cit ' schmirtt. We KraiittheltenderOberen Luftwege. ' Thoruer. Medical Record, September 10, 1898, p. 367. or. ii. ' i'niiii CK '-ice S<J4 yo.SE ASO riUlOAT. Iiiiilics, and (lie iiaMiil llimr. Tlie aiilniiii is pniiif t" involvciiu'iit, I'df it is an avaiial)lc spacf into wliicli llic tumor expands midcr the pi'i'ssuiT ol ils ^lowtli. Less often the nroplasm urijiinates in tl.e antiuiu and e.Npands into the nose. In advanced e.i.-es it may be dillienlt lo determine which course lias l)een pursued: l)Ut the aiitrinn and the other acce-sory simises should l)e kejit in mind in connection with |)os>ihlc reineihal ineasun- Cases reporteil include all af;e> I'roin four' to seventy-<'ifjht years,- although, in comjiaiison with carcinoma, e;irly afies preilominate. My youngest case was a hoy of ten years, whose rijriit nostril was packed with a fungoid mass of a few months' development, which proved to Im- rouiul-celled sarcoma. l']xteriial o|MTation was declined, and the patient, witliout treatment, had still survived, hut was fast falling, a year afterward. The oldest of my series was a man, a>;ed sixty-hve .vi :<. who had an imm(>nse growth of three-ye.'irs" development, wilii )jronouiiced exoplithalrnos and swelling of the whole side of the face. It pro- truded from the anterior iiari.-, projected somewhat into the naso- pharynx, and involved the aiitnuii. Etiology. The still unsubstantiated microhic, that is, the protozoan infection tlieory of carciiKJina, isapplicahli' a' > to sarcoma, the organ- isms supi)osedly exciting a proliferation of coimective-tissue cells. .•\lso the Cohnheitn theory of an excess of emhryonic cells in pre- viously ((uiescent ej'elets ma.v he U'entioned. Schmi<lt ascribes sar- coma to a perverted or atypical syphilitic iiiHuenee. Trauma i^ re))Uted to Ih- a pre(lisposing condition to sarcoma. Without implv- ing a change of type of tissues, it is clinicallv observed that benign growths occasionally become the site, that is, furnish a suita'^le nidus for the development of malignant tumors, and the same is true of inHammatory tissue. Tims is explained the rare development of s.arcoma in connection with UMleniatous nasal polypi which, for want of a better name, is termed "myxosarcoma." This tyjie usually grows from the ethmoid ri-gion, since that is a favorite site for (edematous polyps. It is exemplified by 2 cases in my s(>ries, one a man aged hfty years, who had been subject to nasal i)olypi which had iK'cn periodically removed during several years, (iradually they assumed a cauliflower aspect and a mottle(l hemorrhagii hue. Bleed- ing liecame continuous and at times profuse. He persistentl.v de- ferred external surgical measures and ))asse(l tinally from observation, being then in an advanced state of exhaustion. Pathology. Both the round and sj)indle-celle(l ty])es iire encoun- tered, and either may be of the small or large-celled variety, tin smal! rouiid-celled nas,-' sarcoma beuig es|)ecially malignant. (!iant- celled or inyeloiil sar .aa also occurs in the nose, one of the writer"-^ cases being of this form. When truly pigmented it is known as 1 BlisB. Transarti.-.ns .-.f '.tnsiiror, [,Hryngol.-igica! .A=50clat!t>n, I".*, p. 16. • ButUn ; cited by H.swDrth, loc. <;lt. yEOPLA.SMH OF THE AOAA'. 8!)o tiictaiinsarconm.' also a very inaliu'iiaiit type; hut iiasal cases dc- s(iilic(lasiii(laiMiticari'n()talwa>> n-ally such, the discoldiatidii Ix-inj; ilui' to l)lu(»l cxtravasiitioii. An .ihcr couiltiiiatidti is lilirnsam.tiia, uhirh is(.|ic<)uiitcn'<l in all (ic};ivis of Mialij;iiancy, In.tii the tiijruuia uilh which there are mixed only a few round ci'll.s, and which may not he malijrnani,' to the sarcoma which has simply a larger amount than usual of tilmius connect ve tissue minjricd with it. Angiosar- coma' is encount<Ted es|M'cially u|)<)n the cartilaginous -.ptum, where It constitutes one of the forms of " 1)1. -ding polypus of tJie septum." Microscopic Appearance. In the author's ca.se 1. ahove mentioned, small round cells i)redominate(|. In case 2. " my.xosarcoma," tiu' M'ction showed, ui addition, areas of ci'deinatous p(»lypoid tissue. In i-ase ;{ the .-ection showed large nuinlH>rs of small multimideated round cells lioiuid together hy hhrous connective ti.ssue, also an aliiindance of mucous ti.s.sue. Symptoms. Nasal obstruction and distention, leading to headache and other pre.v-ure manifestations, .such as exophthalmos, "frog-face," and local par. lyses, an- .symptom.s wliich vary in degree acconlii'ig to the extent of the growth. To these is commonly ad<led re|)eated, easily e.xcited, and s()metimo,s severe l)l(H'<ling attacks and discharge which may he fetid or excoriating. The cervical lymj)hatic glands are not usually involved until late, and cachexia al«) mav be absent until exhaustion is manifest. The growth is originally encap.sulated and pedunculated, although the parts which i)resent anteriorly are oft.-n .so broken down and excoriated as to a.ssume a granulated cauliflower a.sjject, and with closely packed large growths it may not he possible to distinguish the [MMlicle until after removal. More than one point of attachment may he anpiired. or the growth may become a diffused fungoid mas.s. The surface, if unbroken, is a mottled bluish-gray or yellowi.sh, and thi' consistency soft, although in two of my ca.s^'s it was so firm as to suggest ti!)roma. Diagnosis. The presence of the symptoms deserilK'd would Ije ■strongly suggestive of sarcoma, although confirmation should inva- riably he sought by microscopic examination of a fragment removed tor the purpose. Kven then, for diagnostic pi poses, a degree of harmony between the microscopic findings and the clinical aspects should he established, for micr()scoi)ic errors do occur, and in the nose the normal lymphoid structure, inflanunatorv and svphilitic infiltrations, and adenoma, may all sinmlate sarcoma. Carcinoma, .■iltlioug!i more rare, is also encountered. Proposis. If early recopiized and thornughlv extirpated, the prog- nosis IS fairly good; but if long established or "incompletelv removed < IS very bad, for diffusion • the cells to a distance in surrounding > Mlphael. Annaies des Maladies .le fOreille. du Larynx, etc., 1890, p. 6S8; Lincoln. New York \lu<lical Journal, October 10. l)«i. - Schmidt. Die Krankheitpn der .".hprpr, T.uftwege. ' Scndzlak. Journal of Laryngology, Khinology, and Otology, March, 1896, p. 104. Hi»G so.si: A\j> riiii'iAT. H \ ; t I 1! tissu.'-i :m<l inctastiisis occur. An iiiiiilysis of sixty tiiluihitnl cases woiilil s...|n to iii.licatc that al.uiit lialf tin I>alicrits ,i|M;ratc.| on rccovcriMl, vet if one cxclutlcs cases in wliicli no report is jjiven alter six months or a vear, the minilter of rec.iveries will Iw rediice.l to abont IV) i>cr cent, lioun.l-celled sarcoma ami true melaiiosareoma are es|KM-iallv malicnant. iM'inji liahie to very rapiii growth ami .lii- fusioii. yet one certain recovery from the former ty|M' ami one trom the latter are re|iorte(l. Myxosarcoma is much less malignant ami furnishes a numl-er of recoveries. The ihiration of life in unoix-rated cases ami in those which recur is from two to six years. Treatment. First must Im' deciiled whether it is an oin-raMe or an inoiH-raltle cas«', and if o|M'ral)le whether inlraiia.sal or e.xti-rnal methods should In- pursued. To aiil in the determination tif the first iM)int .su< lata may Iw (livided inio Inur jjroups.^ The first Lh that of pedunculaled tumors. The .-second >;roup, which comprises tumors with a limited hase ..• implantation, is less fa^•or!ll)le than the tirst for surgical intervei.iion : but when situat<'d near the anterior nares their ablation is relatively ea.sy. DiH'use tumors, on the con- tniry. which form the third griaip, when they extend either sui>er- ficially i>r deepiv, perhaps sending prces.ses into the underlying iMuies, necessitate ftrave and ditlicult optTations. Only a (|uestion of degree .separates tlxMu from lho.se of the fourth group, which are situated in immediate proximity to vital parts, and so far-rcachinn fis to Im> (luite iiioiM-rahle. To decide iietweeii the third and fourth group may call for judgment. It may Im- impos.sil)!e prior to an oi)eration "to determine the extent or attachments of the growth, in which case an external o])eratioi\ may he justified in the hoiK' that it inav prove to he erai'.icahle. The decision between intr.anasa! methods and an external op-ration will deixMid upon the accessibility of the base of the growth through the natural pa.s. , ges. When circumscribed, and esjiecially when originating from the cartilaginous sejjtum, thorough intrana.sal mean> are to be preferred. If i)edunculated and iilion the external wall, the same mav be s;iid: but if difluse and rimning n\> Ix'neath the mi<ldle turbinate(l bo.ly into the ethnioitl cells or into the antrum or si)henoi(lal sinus, the only hope of eradication lies in a formidable external operation to give access to tlie parts, ''"'le nature of this will depend u])on the site. i'.vt-n f '• circumscribed easily accessiiile tumors it is sometime- urged that extirpation w.iuld be more certain through the simpler external incisions--( . (/., -.'w reparation of the ala by an incision in the nasogenal fniTow with or without temponiry resection'' of the nasal bones— but, by reason of convenience or prejudice agair\st faci:il <lisHgurement, intranasal methods are usually giv<'n a first trial. The incandescent snare, wlien it can be caused to envelop the growth 1 Biiylan. Transaclions "f American iJiryngolopMil Association. 1S'J6. Bosworth, loc. cit. : Plicqiiu. Aniialea des .M»l. liu ion-illf, tlu Laij ..a, etc., Murctl. in'JO. s Maekenjle. Discussion, American Laryngological Association, 1«9". KEOPL.f^lS OF THE LARYSX. 807 with amiracy, is to Ik- pn-fcnrd, hut the cold wim Hiiare catj 1«' used and is often iiKiri' coiivctiiciit f(ir fniKiiifntiil n-movul. I huvc IdiiihI I'riiicf s turliiiiiitoiiiy f(irc«'|w wTviccahlo f. the rapid clearing away i>l' large caiiiiHower-like niai*^^. Hemorrhage is controlled hy i.MJotorni-gauw! |)acking. For destruction of the l)ii»«> I have used llic gaivanocauter\ <ui)|)leniente I liy chromic acid, and if preventiil i)y bleeding I have deferred this procedure until the next Hitting. NEOPLASMS or THE LARYNX. Benign Neoplaanu of the Larynx. U'ith reference i he symp- toms, diagno.-is, and treatment, the ()enign neoplivsm: . the larynx have so much in comnum that they may Ih> considered collectively under the heading of their chief repn'sentative, {)apilloma, leaving only liricf individual descriptions for the rest of the group. Papilloma. The most frerpient and clianicteristic type of jia))- ilioma in the larynx is that v..' h resemlilcs to the naked eye a cu- taneous wed-wart. The neoiiiasm with its hy|)ertrophied papillie may In- plush-like, foliated, i 'mhlhig a cock's cotnh, of a cauli- t'owi r aspfct, or nmlherry form. The growth as a whole is of ru'lier tirm consistency, although the surface is soft. It iscommonly c. . .il or scmiglohular, but may be irregular, e\<'n angular in contour. In size they vary from 1 to 10 nun. or more, in long diameter. The color grades from i)ale gray to pink, and they may l)e single or tnultiple. T!ie smaller growths are usually se.ssile; hut with greater develoijment they are prone to liecome jiodiculated. The |M'(licIe may jxTinit considerable moliility, as in a n-cent cii.se of »he author's, in wh'ch a papilloma the size of a bean attached to a vocal cord hung below the glottis during (juiet respiration, but rose between and alw the FlO. 4V) "n -IM. PHpllloma of the larjuz. vocal cords on phonation. The site is nearly always the vocal cord, • ■■specially at or near the anterior third. I have observed the warty U'luwth to spread around the free edge of the cord, involving both till- u]ii)er and lower surfaces, also to spread from the upper sur- iace into the ventricle, and from the anterior commissure dowTi the tracheal wall. (Figs. 453, 454, an<l 455.) The vc) 'ricular band, ft" %^-'><J« «!I8 XOSE AXI> TiriUKlT. I ; Flii. 4'm, Papilluinu of lilt' Iiirynx. aryopifllotlic fold, ami cijislottis arc rarer sites. The iiiterarytenoid folil is stat('(l to he exempt from true pai)illoma, hut 1 have notes of two cases in wliicii it was involved together with the vocal cords. .\ .second form of laryngeal papilloma is characterized hy a more ditTu.s'cl distrihution, wide areas, any or all parts heing covered hy till' growth which may lead to ohliteration of the lumen of the larynx. This diffused ty]K' is prone to affect young children; hut the author has oh.served some |)ronounced instances of it al.so in adults. In the case from which Fig. 4.55 is drawn tlie larynx at first sight was fillecl withamassof papillomata, \\'iich on Ix'ing in ])art cleared out, were i> aid to sj)ring like a fringe from the entire length of the vocal cords and the iii- terarytenoid fold. A third type of laryngeal ])ai)illoma is descrihed' as ijuite small, .sessile, and smooth : in fact, indistinguisli- ahle from a lihroma, I'xcept hy inicroscoi)ic examination. Etiology. Little is known of the etiology of this and the other henign n(>oplasins of the larynx. I'redi.sjxisition is evidenced hy papillomata apjx'aring on various surlaces and at times hy a family tendeniy thereto. Males' are affected in the i)roportion to females of three to one. Chronic laryngitis and the congestion which is incidental to overu.se of the voice have heen apparent causes in a few of the author's cases. Two were singers, one a hoard of trade operator, one a campaign orator, one a lawyer, etc., yet in most of them the voice was not overtaxed and the larynx not independently infiamed. Four were young children, a much higher percentage than is indicated liy Fauvel's'' ;J0() cases, of which only ") occurred in the first ilecade of life. Pathology. The essential elements of a papilloma are a connective- tissue stroma, hypertrn|)hied iia])illa'. and prolifer.-ited epithelium. The stroma may he soft and sparse or the compact form may pre- dominate, the latter conditicms especially ju.stifying the term papillary fihroma.' The hypertrophied pa])illa'may he very few and simple, each composed at thi' has(> of a central core of connective tissue containing a vascular loo|) and covered hy layers of epithelitil cells; hut usually the pajjilhe are multijjle and hranchecl, each terminal rep'-esenting one of die small hulhous or jiointed jirotrusions of the surface of the tumor. The epithelium is stratified, hut may he thin or very thick, often constituting much of Ijie growth. It hoth covers ;t"nd dips between the papilhe. It grows kihui. hut not. as in carcinoma, ititc ' Oertel ; riiwl hy Jiirnpz lleynmiiirs lliuvltjiich, Haml i , s syi. ' .Inni«7 HpyTt!H!!!r< !lsi!!!'!ieh. ■I Kaiivtl ; oital by H<«uiirtli I>iK<>ii»'s iif Ihe Tlirdiil nilil N\«e. * Zli'gler. Lvbrbuch iler palh. Anatomie. Xi:orLA^.M^ OF THE LAItYXX. 81(1) the iiiiilcrlying tissue. In the ilcpths the of)itholial cells are polyg- <iii;il. hut near tlic surfaoe they assume the pavement form. tlie tcnii pnrhijdrrmin rnrurosa (Virchow) is applied to tliis tyj)e of papilloma iti coutradistinetion to imclii/dcrmio diffusa, in " which there arc ehronic inflammiitory changes in the deeper sulx-pithelial layers. The res|)iratory trad heing derived from the epihlast its papillo- in.it.t are classed with skin warts of the hard type in contradistinction 1(1 soft warts of organs, like the bladiler and intestines, which are derived from the hypoblast. Symptoms. The disahility occasioned by any benign tumor of the larynx consists mainly of an interferen e with the functions of phona- linii and resjjiration. The voice first iires easily, then grows st(>adily hnarse, and finally is reduced to a husky whisper as the growtji impinges more and more upon the glottis." Kfforts at talking when the larynx is thus disabled are ajit to maintain congestion. Dyspncea iiccins when the neo|)lasm attains .-JufHcient size to occlude the glottis. It i-< common in young children from laryngeal papillomata, because the larynx is |)roportionately small. It usually necessitates tra- cheotomy. Diffuse papillomata may interfere with res])iratioii also ill adults. Other benign neoplasms which may grow large enough to obstruct res])iration are fibromata, chondromiita, lipomata, adeno- mata, cysts, and thyroid tumors. On the other hand, any (tf these growths when small and favorably situated may be devoid of symp- toms. Cough is rare, but may be severe and lead to suffocative attacks. Laryngeal .spasm is ob.served, especially in childhood, in the form of nocturnal exacerbations of tlie dyspnu'a. Diagnosis. The differentiation of benign pai)illoma from carcinoma of the larynx, which may present a papillom.atous surface, is dwelt u|)on in the section on carcinoma. Papilloma occurs at any age, favors the anterior }K)rtions of the vocal cords, is not painful", does not bleed, and is distinctly superHcial, not impairing the motion of the cord. 'aicinoma favors mafin-e age, often begins on the posterior part of i; cord, may ulcerate, bleed, and infiltrate the depths of tissue, im- pairing in l.ihty. \ microscopic examination of a fragment from ill'- depths of tSe neoplasm should be conclusive: but it is a safe mic to insist upon harmony between the microscopic findings and ilic cliiiical aspects. SiiKin-s iKules (lifTer from ordinary pajiillomata in being svmmet- iic.illy i)il;iteral, usually (piite minute, and of simple in'lammatorv origin. They consist of a hyperi)lasia either of th<> epithelium o'r '■'■niicctive tissue, which forms a minute nodule on the free edge of each vocal eord at about the middle or near the junctitm of the ante- rior .and middle third. l-'ihmmn is distinguished from papilloma ))v its smooth -urface. "icimisciilxMJ form, firmer consistency, redder color, and bv inicro- ■^copic examination. ii( yoo yUSE AM) THROAT. i i { I \ti Myxoma, so-culled, in the hirynx is probably an (Edematous or degenerated tibroina, and its exact nature would be determined only by niicroseopic examination. Cynts also have a smooth surface, and their litjuid contents may be (lemonst rated by i)uneture. Lipoma is rare, occurs usually on the aryepiglottic folds, falling into the pyriform sinus, and not on the vocal cords. Amiioma may have a rough surface not unlike a papilloma: l)ut its vascular or red raspberry aspect will usually indicate its nature. Chondroma is dense, hard, anil immovably attached to one of the cartilages. Adenoma is very rare, but when it occurs it might readily be mis- taken, without microscopic examination, for a large papilloma of the mulberry type. Prognosis. \Vith respect to the voice, the prognosis is good in the circumscribed type of papilloma, provided the tumor be skilfully and promptly removed. Recurrence is freiiuent, but is due only to the (lifhcuity of thorough extirpation. Dyspncea is an evident menace to life, and tracheotomy should not be too long delayed. This is especially true of children who are liable to die, as in two ca.ses of the author's, through nocturnal exacerbation of the dysj)n(i>a, perhaps excited by crying, temper, and fright. The liability of a papilloma or other benign neoplasm to become the site of a malignant growth is also a consideration. Treatment. The treatment of laryngeal ])apilloma and ol the other benign neoplasms of the larynx is mainly of a surgical nature, and the techni(|ue is considered at length in the chajjter on intralaryngeal o|)erations. A few principles, however, may be heie expressed. Nearly ;ill benign neoplasms of the larynx in the adult are amenable to intralaryngeal methods, which should be skilfully and persistently attempted before resorting to an external oj)eration. Laryngotomy, however, exceptionally may l)e justihed. even in adults, for instance, when till' throat is very intolerant, the larynx very deeply placeil, and the neoplasm very imfavorablv situated — r.'j., at or Ix low the anterior coiiimissure, a combination of conditions which has occurreil in the author's experience. Thyrotomy has been many times resorted to for papilloma in childhood, but is not in as much favor as it should be, for the reason that re"urr(>iice of diffused growths is the rule, while cicatrici;il stenosis has occurred, and there is an appreciable risk from jineumonia (.'{.o per cent.).' Delay may be afForded by a low tri- cheotomy, and in rare instances spontaneous recovery has thereafter •■nsued, encouraged by enforced rest to the larynx: but indetinite delay becomi's far more dangerous than tliyrotoniy. becau.se of tli;' many accidents which liMj)peii to traclie()t(imy or intubation tube^, and the liability to sudden death before assistance can be rendere'l. In botii children and adults with obstructive iieoiilasms tracheotomv ' M»nierrc. etiicBuo Mclii'iil Recorder, January, 1895, p. 35, XKOI'LAHMS OF THE L.lHiyX. 901 m;iy Ix' an csspiitiii! a'nl n ♦ only to respiration, but to subspciucnt inlralarynfical removal of tlu L'rowtli. Fibroma. 'I'lie coMneetive-tissu *'bres may be closely interwoven, constituting; the hard fibroma, or they may Ix- loosely arranjiei I, with spaces containinf' serunr when it is known as a soft or (edematous lilimnia. iietween the two are found T degre<'s of consistency. wise W iiich approximate the former ty])e are most connnonly de- sciiiu'd under the name of fibroma, while the latter are collo(|uially spoken of as polyps or incorrectly named inyxomata. In the larynx fibroma occurs next in frequency to paoilloma, the usual location lieinj; one of the true vocal cords, pretVrabiy its anterior i)art, aldiouph any feature of the larynx may be the site. The author has recently observeil one on the arytenoid eminence, which was large and firm, beini; distiiifjuisluMl from a cyst by puncture. On the vocal cord it is usually small (2 to 5 nun.), semiftlobular or oval, broad based, circumscribed, single, smooth, and of a reddish color: but there ■Iscwhere it may become ipiite large, lobulated, exceptionally mu lti|ile, pedunculate<l, and gray white in color. The .sym[)t( )nis. and treatment are considered in common with those o nillon Fig. i'il. Fig. Vo\ Fiu. 4. j»i.— Fibroma of left vocal cord. (Cohen.) Flo. 4.'»7.~Fibroina of right vocal cord. (Cohkn ) Fio. 4V*.— <FAlematoU8 tibmtna or polyp {tnyxomu) of rijrht vot-al curd Myxoma. Certain growths which spring usually from the edge ( f the vocal cords and resemble nasal polypi in their lustre, seinitrans- hiccncy, and .soft consistence are variously termed myxomata, polypi, oijematous fibromata, and degenerated fibromata. Like iia.sal poly])i they may be of inflammatory origin, yet they assume the distinctive characteristics of a tumor. Whether they can with propriety be separately cla.ssed as myxomata would seem to deix-nd upon whether their gelatinous or mueo.s(>rous intercellular sul)stance is the same as the gelatin of Wharton, which is \'irchow's prototyi)e for myxomata. Tiie tendency in recent pathology is to regard them as crdeniatous libroiiiata. (Fig. 458.) Cysts. Cysts of the larynx are usually of the mucous retention t>|ie. They vary in size from that of a millet seed to a walnut. Ihey are apt to be semitransjiarent when possessing a clear li(iuid cont(>nts, but may be opatiue from thickness of the wall or opacity ! 1 902 yosi: AM) TlUiOAT. of tlic (•(intents. TIloy tire niuiid. ov:il, or siiiiidlc-sliapcil, anil aro located ill tlie (inlei' named on the epifilollis, especially its anieiinr siiil'ac<' and I'lee ed<;e. vocal cords, ventricles, aryepifrlottic folds, and arytenoid region. When projeetinf; from the ventricli they may lie mistaken for Mi-calleii prolapse of tlie ventricli-. A cyst is not always a mere distent 'm of a previously e\istin;t structure; liut its wall may aci|uire a <;riiwih of its own and its multiplied endothelium continue to elahora '• the contents. Such a <'ysl is a veritable neoplasm, and may he properly de-;ij;nate(l cystoma. Lipoma. Stricdy inlralarynjieal fatty tinnors are exceedingly rare, iiut a few c;i>es are recorded.' - They frrow more often from the aryepijrlottic folds' ;ind epifjlottis anil fall uiitwardly into the larynx. However these may attain a size sullicient to ohslruct the larynx. Thev mav lie sin;;le or multiple, smooth, lirimched, or loliulated. Ang'Oma. The characteristics of ihis .uiowlh are descrilied in connection with intranasal anj;ii>ma or lileedinjr polypusof the.sejituni. It is comiiaratively rare in the larynx, the author's ex|ierience iH'injj re]iresented liy a siii<;le case. In this, as is usual, the <;riiwtli was located on the vocal cord, (iverlaiipinfr the free eiljre: it was bright red in color, .•uid i's surface was roughened liy tortuous l)liiodvessel>. It was raised liut little above the sinface, and would be clas.sed as angioma simjilex. It was destroyed by a single ajiplication of the gai^anocauterv, tin patient's singing voice being restored. (Plate XXVIII., I'ig! 1.) Angioma cavernosum apiears more like a raspberry, either sps.sile or pedunculated. I'lither lorni may occur at any other site in the larynx than the vocal cord— c. </., the ventricular band.* Kithcr form may be nuiltiple. or indeed ijuite diffused, perhajis involving other parts of the throat and moutli. .\ laryngeal tumor described miller the name of cunriKiiis pdpilluuKi is doubtless an angioma' with a thick epithelial covering. Lymphangioma eavernosim of the larynx is I'epresented in literature by a single case." Chondroma. Chondroma ajijiears '.n the larynx as a conical, round, or nodulated hyperplasia, usually of the cricoid cartilage, which forms a sessile tumor, sma.ll :it l:r-t, but of slow, pei'sistent ilevelo]iment to the point of occlusion of ihe larynx. The thyroid cartil.-ige is a rarer site, and still more larely are the arytenoids and epiglottis the scat. The structure is that of hyaline cartilage, in which will be spots of chalkv degeneration ;uiil ossJIicMiion. In diagnosis it may be dis- tinguished fiom perichondritis by its circumscribed t'ormation. abseiiir inflammatory conditions, ;mil ledeina .and absence of the usu.i! cau~es of jiericliondritis. The priigno--is is go(,,l if well removed. 1 Bruiis ; liti'c! li.v ScliniclkT, KmiikliclliMi ili's KiOilkuiiles, l*'.':i, S. iw. - K'tiilor St'ifert : ritt^l h.v Jiini>z, MeyinHiid's HaiKlhiich. Itutul i., s. s!0. ' J(H».'^: (Mti*"l by hirasz, !<«■. rit. 1 N.riii- \v..ircri.liii. .I.rfuiia) ut I..iryni;nloBy .iHil Itnin.ihcy, I-<m. p. ■-->;. Fl'ioiwr. r. n. TmiiBiictidiis of Anu'ricHii l.nryii(!nti.i:iinl .\sscici«tiiin, iss|. p. 6,3. • K.wehler; cited liy Junsz, Ileymann's Uandbueh. llHinl i . S Mil. ~'?S.:lilli LATE XXVIII. Angioinn or the LpM Vo.al Cord. lAuUior's Case.) H.'i.urrenie ol Smiomu in ilio Larynx. f^r-rM-'^w I I XEOI'LASMS OF THE LARYSX. yoa When not tod largo iiitralarynp.'iil iiiethodrt arc hoiH'ful. 1 cautrrizatioii by chromic aci(l= liavo each been suc- Treatment. The snare' anci cainfiiiimvni •>.. i... - ••■,-:•. — , ... ., c-sfullv uscl. (iulvan<.caut(>rizati..n an.l l-Uinj: f<.rcc])8 inij?ht b.' utiiizc.f. If of nn at bulk larynK.)toniy may be p.ec«"ssary Adenoma. B.-niKn adenoma of the larynx i., represen e.l m l.teu.- ,„n bv l>ut three well-..ubstantiat,..l ca..e..-; I.. -'•IVl-J;':;;:;: ,.,aine.l a size ..utlicient f. occlude the larynx, luul a p-anu ar sur a.-e, a,..| clor varying In.n. gray to r.,1. The type of nasal neup asnj ;ics.Tib.-.l as adenonu. papiUare" po.ssibly ..ccurs n. the larynx cloaked under the name of i)ai)illoma and carcinoma Thyroid Tumors of the Larynx and Trachea The ,«« rec.r. ed instances of thvroid tis.sue in th.- larynx' have been subglottic, h „„„efac.i..n exiending from just bel.w the voca! cords to th'" ^••j;-' '• ■ ,l,inl, or fourth tracheal ring. In two .t occu,>H"d t'''' I'- ;; chcal wall. The thvroid tissue enters the larynx not b> abenation „f ,l„. eu.hrvonic elem..nts, pro.lucing an acc.-ssory thyroid gland .u.i. a< is f.mnd at the base of the tongue, i.ut. as demonstrated m ,„„. case by post-mortem dis.section," the thyroi.l tis.-^ue grew mto and between the traclu-al rings, fornnng thus a ^''''''^j''^'''" l";;';!;^ 1... intralarvngeal tumor an.l the ti.yroul gland. The author has iS'served o,.;. ca.se, reporte.l by Freer," in which there was .pronoun-l subglottic inhltration surroun.ling the .nter.or of he cnco.d ca t.l, ^e and a large tumor on the posterior tracheal wall at about he tlnrd ,i Microscopically this ma.ss, after removal by a snare an.l cuttmg- i;.p; prove.l f.be tvpical thyroi.l tis.sue. Nevertheless I am m- for.n.'.V that symptom's uulicating malignant disease subse<iuently ' ''prolapse of the Laryngeal Ventricle. The mucosa which lines the vntSes ..f Morgagni is attach.-d t.. the inner surface -t t lie thyroid til i. Looseniiig ..f the attachment gra.lually ..r b> violent cough n'uiv iH.rmit an evers^.n or turning outw.ml ..f the pouch. Thij^ s „.,f a' ne.,plasm; but is considere.l m this sect urn a.s a ->«'-; ;f ,.„nv..ni.>n.r with ivspect t<. .Iiagn.is.s an.l treatment. It is s., r. re ,l,at its <>xist<'nce is ,l..ubted by .-ertam autlmrs wh.. '":">';>'"<''•»' v.Titabl.. nc.plasms, as well as syphilitic an.l tubercubus mf.l rations l.ave !......, mistak.Mi for it. The latt.>r are certainly predispos. ,g !; .ditions. siife most .>f the rep..rte.l cas..s- " have b.;."n either syph- ilitic ..r tul.ercul..us. Lefferts'= ma.le a thyrotomy m his case, abscis.-.l . Asch Traii«i.-tir.ns of A.nericai. LarynKoloxical Awoclalion. 1SH4 p. .56. « insals. Transar.iun.s or American I.ar.vnKol<«i..al ,||H«H.l,.t.on 1««.^. P. U6. . PaLuf. /.legler's B..,.r.K.. 1S9-.'. Band .v.. S. 7, ; oited by Bav..»v.c,. !.«_ cu. ■> Freer Journal of tl.e Araeri<».. Medical A9!«ciatlon, March 30. 1891. P-i*? ■ .'. Mai.ir. Tran«.ruon!.Americ«..I.ar>„«.,logical.\sHat:mtmti iw.,p II. n ,i„iKenhelm. Inleruat, .cntralblau f. Laryngol , Rhlnol., etc.. vol. Till. p. 127. 1= l.ca'ert». Medical Record. ISTti, p 3.W. !»(I4 sunt: AM* TlIltU.lT. r- ! ; llic priiji'ctin); iin'inbrMiic, and fouinl it Id he an everted ventricle, so that tlie |i(issil)ility tiiiist lie admitted. Mlsl'erj;' and Colien- also report cases. l)ys|ilionia and moderate dyspiid'a are the salient symptoms. Temporary replacement of the ventricular membrane by a probe, and its rounded, soft, smooth contour jiroject in j; from tiie position of the ventricle are the chief diajinostic features. The treatment is by ab.scission, evulsion, or cauterization, the same a.s for a real neo|ilasm. Malignant Neoplasms of the Lar3nix. Carcinoma of the Larynx. Caicinoina. win ii orijiinatinji and confined strictly within the frame- work of the larynx, is termed iiilriiisir or endol;iryn>ieal cancer. When it attacks even the superior border of the larynx, so as to in- volv<' necessarily p.arts of the lower pharynx, and when it extends from the tonsil, lin>;ual base, or pyriform sinus, it is termed exlrin.-^ic or pharynpilarynjieal carcinoma. This distinction is of im])ortance, because the intrinsic type is more amenable to ojx'rative treatment. It is much slower to inv(»lve the cervical lymphatic fjlands. ( »f Hutlin's' 14 cases the frlands were affected in but 2 at the time of operation. This is explained by the fact' that the lymphatic ves.sels within the larynx, while present, are much attenuated, so that at the level of the ventricular ban<ls, and especially the vocal cords, it is difficult to inject them. Etiology. As with cancer elsewhere, the direct cau.se is unknowni. The microbic, that is, the protozoan infection theory, while plausible, is not y(>t wholly substantiated. (Jeneral pre(lis])osin<i conditions are iH'redity, which is traceable in about one-fourth of the ca.ses, the male sex in the i)riii)ortiop of four to one, and mature ajjc, an analyses'' of 4S{\ cases showing 40 per cent, between fifty and sixty years, and S4 per cent, between forty and seventy years, with but 1,) per cent, between twenty and forty years. Larynjjeal sy])hilis, tuberculosis, and chronic laryngitis, includinR pachydermia laryngis, by maintain- ing Ideal irritation seem to act slightly as pi-eitisposants. Tobacco and alcohol figure only ina])preciably. Witisout implying a change of tyjie of tissues, it is clinically observed that benign growths and inflammatory tissue occasionally become the site, that is, furnish a suitable nidus for the development of malignant tumors. Thus is exi)lained the so-calle<l transformation of benign laryngeal neoplasms into malignant ones." which, however, is so rare that the alleged influence of intralaryngeal ojx'rations must be practically nil.' Pathology. The most fre(|uent tyjK' is sciuamous-celled carcinom.n (epithelioma), although cylindrical-celled carcinoma" is encountered ' Eblwrg. Arc:hlvi'« of l.aryiiKoloKy, vol. ill.. No. 1. p. 66. - Cohen. Archives of LaryngoloKy, vol. ill.. No, 1, p. 67. » Butlin ; citiMi liy Bosworth, Diseases of the Nose and Throat, vol. 11. p. 7.'S1. < ."appey'a Atliis. Valswaiix Lyniphatl(|iies <hez I'Homme. Paris, l«9.i; cited by Lennox Browne. '■ s<'ndzl»1(, i(.isiiriiKe(!i.«chw«l«te'1e! Kehlkojifs. « Ward. M. K. I'itlsburK. ■ Seraon-Sammelfcin.chiiii|{, nuernatioiwlw Cenirulblati f LuryiiKologie, etc.. Idlilt. " Seudziak. Op. ell., S. I». L yEOl'LAfiMS OF Tin: lmiysx. Jt05 witli nirity. ( )tlifr types about in the onlcr tiaiiicil an" soft ulaiulular irciiioiiia (<'iicc|ilialni(l) and hard n'!"idular carc'moiiia (scirrlitis) \\ licii intriiisic, favuritc sites, prii irilv. are tiie vocal nird, veiitrie- iilar liaiid. and ventricle. It is primarily un'lateral, l)iit may JM'come asymmelricaily bilateral by contact infection or otherwise. Symptoms. \'ocal impairini-nt, a sen.se of laryngeal discomfort, and sii};iit couffh are tin- tirst and perhaps the only symptoms for months or years. Later dyspiuia and hemorrha>;e ensue, the latter when the ulcerative .stap- is i-eached; at the same time the secretion, [kt- haps previously aufrmenteil, becomes more cojiiows, thi<'k, \iscid, and U>\\\. imparting to the breath the peculiar odor of malipiant disease, bi extrinsic cases |)ain, e.'^pecially on deglutition, and reflected toward the ear, is a prominent symptom. 0/( (wamiruiti'in in the more common difTused form, the carcinoma is ol)ser\ (I to spread over and through considerable surface, at first a mere thickeniiift of the ti.ssue, later becoming irregularly nodular, .iiiii of mottled reddish-yellow hues. Kxceptionally the surface appearance is ])ai)illoniatous, chalk-liko, or snow-white,' or it may lie (luite smooth, londhig to a tumor of reddish hue the apiM'arance of .1 fibroma. Fill im. Flu. 4.')0,— Siiiiamims celliKj carcinoma (epithelioma) of the larjriix. iCuHis ) Fill, -ifii).— MtHluUary can'iiioina of the larynx. (Cohen.) The so-called cnrcinnma pnlypnidts^ primarily affpcts the vocal cord only, and, while not circumscribed nor sujjerficial, like benign neo- plasms, has a broad-ba.sed elevation of more or less limited contour, bate cases which have extended from one part to another present advanced degrees of distortion, tumefaction, and ulceration of the parts. Diagnosis. Renign neof)Iasms, especially papilloma and fibroma, if not pedunculated, are superficially situated, not interfering with the free motion of ti.e cord, while in carcinoma the substructure is infil- trated and swollen, causing a "lazy" motion of the cord, which, how- ever, is not invariably observable. It may be situatcMl at any point, but is the more suspicious when, in an elderly individual, it is found upon the posterior third of the vocal cord. The carcinomatous sur- < <•' ^mann. Transnctinnn of .\merican Laryngolngical Aiisociatlnn. 1896. ■ Fi iiikel ; cited by Sendziak, op. clt. IKMi .\USi: AM) TltllOAT. i I t i fact' wIk'I) siiinil;iliii<^ papilloma is softer ami inoro vascular. A microscopic cxaniiiiatiMii of a frajrm<'iit removed when it exhibits a positively careiiioiiiatoiis structure is conclusive, hut a nejjative result does not with certainty exclude carcinoma, for tin reason that tin- frajiment may represi-nt only a papillomatoid >urface of an under- lyiufT carcinoma. This is ohvi.ated hy sulimittin;; a fragment from tliede|)tli()f the neoplasm: hut still other histolojiical' - errors are po.s- sihle, so tliat for a final diagnosis it is a safe rule to insist upon a dejjree of harmony hetween the microscopic (indiiijrs and clinical as|M'cts. I'lichililiriiiid is usually synnnetrically bilateral and af'IVcts the vncal processes jiarticularly, witli an oval-cupix'd infiltration. S!ii>lillis, when not characteristic or distinjiuishalile hy concomitant symptoms, may Iw clitTerentiated from carcinoma hy the thera|K'utic elTect of |)otassium ioiliile, it Ix'iri); remetnhered that cancerous infil- tration will also recede at first under this dru^', hut only sli<;htly and for a brief ]M'riod. Tiihrmiliisis enters the (|uestiori only in atypical cases when devoid of concomitant jmlmonary symptoms, bacilli, .and local pallor. It may be unilateral, but is prone to alTect lirst the arytenoid eminence ami posterior part of the vocal '•ord. Tin ulceration ajJiH-ai-s earlier and is of the mouse-nibbled type. It is possible for ciircininia to d<'velop in a tuberculous larynx,' al.so in coimection with lonn-standin}i chronic laryngitis' and in syphilitic .subjects,' conditions wliich render the diagnosis the more diflicult. Prognosis. The natural course toward a fatal termination is com- paratively slow. Kijiht years is not an unusual jieriod. An early (liajiiK'i^is and promjjt operative interfv rence afford a chance of recov- ery, but at the expense of deformity of the throat and some imme- diate risk to life. Treatment. Xotwith.standinj; occasional cases reported" favorably, endo'.'rynjreal operating is suitable only for diagnostic and palliative |)urpoM's, tlu> exception being v n the tumor is strictly circum- scribeil, "•polypoid" in formation, superficial, and accessible, very rare conditions, even in the earliest stage. It is justifiable to remove -egments l)y the cutting-force])s or double curette for microspo]iic (•x.amination. and in inopenitile cases the hm.en of the Larynx may be kept clear in like manner, but, as a rule, one of the ext(M'nal vipera- tions should be urged early. It is inipossible to determine b^- the mirror the extent of cancerous infiltration, certain recesses are inac- cessible to intralaryngeal methods, and, besides, one is without means of controlling possible hemorrhage.' .\ false hope is engendered b> repeate(| in;id<'i,-iate removals which delay radical measures uuti! 1 rhlari, O. Archiv f f.arynj^IoBie unrl RhinoUtRie, Bund viii., Ht'fl 1. S. t'A. s Frnnkel ; citetl by clilHri. (ip. cit. 3 Chiari. A-chiv f. LHryrmolOKie und khinoloRio, Banil viii . Heft 'J. < rhiarl. Lw. cu.. Fall \\. ■ Cliiiiri. I.oc. cit.. tall xl. » Krknkel, B. Areliiv I. I.aryiitfrilcmie uiul Rhiiiologio, Band vl., s. 3«i. : Ndltenin!. Op. cit., llanil viii., S. lin. .\j:i)rLAsMs or rni: lauysx 1K)7 tfxi l;itc or until, lii'.'iii-iick hy liopr drfcrrctl, iIh- imticiit rcjciiH further opcrjilivc aiit. Tlnintlonn/, tin- least fDriiiidalilc "f the external niMTatioits. is the hest when the earcirKinia is wjinlly within 'lie larynx, cdntihed ehielly |(( one vocal eurd or ventricular hand, and without extending so d'-epiy ••IS to involve the cartil.'ij:''- Also as a iliaj;nostie nietlmd it may ininiediately precede total or partial larynp'Ctomy whenever there i> the least (joiilit of the necessity of such upeiations. Modern statistics'" an- favorahio to this o|M<nitioii for early cases limited to one Mn-al cord or ventricular hand. showiuK U to 14 per cent, of ahsolute recoveries (thu.. years), i;{ to 4:.' per cent. aililition:il of relative recoveries (one year), with !> to IS per cent, of d( aths from the operation. I'liiiiiil risirtiiDi i>j Ihi' Itirj/iix, meaning the removal usually of a lateral half of the thyroid and cricoid, is ad;ipted only to strictly ininilarynjiejil and iniilatenil carcinoma. It has heen soufrlit to suh- stitute it for complete laryngectomy when these conditions jiermitted, JH'cause the risk of .-jeptic pne'.nnoni.-i is le.-;s. .•md dcfihititii'M. respira- tior nd I'ven voca Ii7.ati( 111 are resumed It can he iitilizeil for case: slifthtly more extensive than those suitahle for tliyrotoiny, hut should not he relied ujion where there is any suspicion of invo^-einent of hoth sides or in larynfiopharynp-nl ca.ses. One hundred and ten cases tabulated* since iNTti show 9 [mt cent, recoveries (three years), \2 per cent, relative recoveries (one year), 2S jxt cent, recurrences, and ■Jfi per cent, of deaths in conseiiueiice of the op<'ration. Two latci series, one of 57 cases'^ and one of .50 c.ises," since 1,S((0, piv<» an improvement showiiif; 12 to 1(5 per cent, recoveries, :i2 per cent, ri'lative recoveiios, 3<) per cent, rt'currences, and 16 to 28 ixt cent, of operative fatalities. Liiriiniitrtomj/, or complete oxtirjiation of the larA-nx, is indicated when the carcinoma, while confined to the larvnx. involves so much of that orjran that no part can lie saveil w'»hout risk of recurrence. If the epiglottis is |)ositively he.'ilthy it can he retained and utilized hy Swain's' methoil to form an anti>rior wall to the (I'.sonh.'ipiis aid close the pharynx from the windpi])e. The greatest danj;er of lary- Kcctomy is septic pneumonia from the inspiratioi; of discharfjes froi i the wound and secretions of the throat, and this is prevented hy leaving no openiiifi: hut, as a rule, the retention of the epiglottis favors recurrence (2() cases, 2 recoveries)." and the same end can he accomplished as in Cohen's ca.se" and others'" hy stitchinjr the upper ' St-iidziak ; cited by Chiari. np rit. - schinleKclon , iMe<l by ('hi«ri, op olt. ^ lielavan. Transaption;* nt" American IjirynenUiKial Associalion, liHH), p. 71. * Seiiiizirtk. Kiisartige (icfichwiilste ile.s Kehlkoples. ISIIT. '- IviavHii. Transactions of American l^tryngological Aosnclation. 1900. p. 71 ^ SclnnicKclow : cited by Chiari. loc, cit. ■ Swain. Transactions of American Lan-n(Coln«ical Association. l«tt|. p. U.i. ~ rxMuizialc. BnsyirtiKe tieccltwulfte <ies Keiilkopfs. S. 171. " 1. Soils Cohen. Archiv f. Laryngitlouie nnii Khinologie. Band i.. S. ;*7S. "' i;iuck. Berliner klin. Wochenschrifl. 1S97. 9. 1K2. iXM .vo.na; .I.N7) Tiii;o.\r oikI of tlu' tniclicii. slit (i|Mii ill Innit, l<. tlif xkiii i.f the neck iit the hotldiii of the iiiiisioii. This |iicclu'li's rt'-piratifin liy tlic iiioiith iiiul Ihi' 'vcariiiK of jiii arlilici;il larynx, Imt If.-scns tin' ilaiip-r and condutrs t.i ( ifoit Ity iioii-iiitcrfcri'iicc with tli'Klutilioii. A luiccal voice is ptotic to (l( vdop. which ciialiN H the palicnt to make hinwif uinl«T- stood. Till' stati.-itics of total extirpation of the larynx have improved with iiiodeni iiielhods. Kifly eases talmlaled' since ISiM) ^ive it) iht cent, recoveries (three yearst, fs per cent relative reenvcries lone vear), Jl» jx-r eeiit. recurrences, and 2'2 per cent. o|H'rative fatalities I two inoiihs). Delav.'iirs- >eiies of .U ca.ses from seven operators sii IS'.M) -jives *> per cent, of recoveries, mid -'(> |x'r cent, of o|M'ra- tive deaths. Sources of danp 'dier than pneumonia are shock, damaKi' to luaiiches of the pneriii i>r;istric nerve, alTectinj; the heart and cirni- lalion: exhaustion, and ,ieiiiorrliaKe. It is still a hazardous o|M'ration tln' advantages nil disadvantages of whieh sliouhl be; fully explained to the patient. Siihli fluid i>liiiriin<iiiti»n!i is indicated only for tumoi's of the cpi- fjtottis, iiyriform sinuses, or lower pharynx when not properly re- movalile throujili the mouth. Tr<ulni>li)tn>i alone serves to proloiip lift- in iiioperahio cases, those in which the pathological process is too widely distributed, or the patient in an enfeebled state, and in those in which a radical opera- tion is declined. ( )f six cases seen by the author, in four, two intrinsic and two extrinsic, this la.st resort was the only suitable remedy at the time they Hrst a]>|M'ared. late in the course of the disea.sc. It is often thus. Usu.'illy the canula should be insi rted Ix'low the isthmus of the thyroid gland, in order to escape the descending laryngeal infill ra I loll, and f"r permanent use a tnichiHitoniy tul)e of soft rublier is iietter tolerated than the customary metallic one. (lastrt)st(iiiiii may prolong life a trifle when exhaustion is iimninent because of dysphagia. I'nllidtirc Mtiistii-fs. .\n alkaline antise|)tic spray may be prcccdc'd by a 1 per cent, cocaine spray and sii]ipleniented by additional sedatives and emollients. Orthnforni applied as in laryngeal tuber- culosis gives the most enduring relief from pain. Fotiussium |)ernian- gaiiate in 1 per cent, solution is an ethc' 'iit deodorizer. Sarcoma of the Larynx. Much that has been said with reference to carcinoma ajiplies also to sarcoma of the laryiiX. The c'lnical course is similar. It is more rare, in the proj/ortion of one to twelve. The com[)arison with all other laryngeal iiei .iilasiiis'' is three to five hundred and forty-eight, nevertlieless. a series of .jO ca.ses or more is readily collected from modern literature. The author has observed but one <'a.sp, that of: I RchmM-Kclow ; oiled by O chlari. liic clt. t DelBVRn. Tr»t!sHclion« nf AmcrioBH Ijir-ngnlnglcal Aaaoclatlon. 19U0, p 72. " McriU-Schmidt ; cited by Sendilak. op. clt.. p. 194. yKOI'LASM.S OF Tilt' LAHYSX. 9W Mr. (). H., of Seattle, WoxhinKton, forty yean* of age, ujwn wl.nii Halm liail jHTformed thyrotoiiiy in Kurojx' six months pn-viou-ly tor the puriMiM' of extirpating a malignant growth whieh proved to Im- spiiuile-eelled nareomu. At the time of my examination, while on hi." way home, a reeurn'tice had already taken place, a graimlo- M'atous ma«M oeeupying much of the lumen of the larynx. He < '••(lined anoiK'ration in Chicago, and continueil hi.«t journey in despair. (.'ate XXVni., Kig. •-'.) ^'nrvimit may originate in the order nanunl from the vocal cord, epi^liitti>, aryepiglottic fold, false cord, ventricle, and pyriform sinus. .\lso from the subglottic region and trachea, or it may l)e extrin.sic, having ext.'iided to or from the pharynx. The usual tyiK'san-spintlie- filled, ngmd-celled, and alveolar .sarcoma, although every possible .su'comatous combination has Imh'ii reeorded. For a further drscriji- tion of thes<^, and for the etiology of sarcoma in g.-neral, references I'lay 1m^ made t(» the chapter on intrana.sal sau'oma. It is more litciuent in (•••irly life than carcinoma, but tho.m' of mature age, thirty til >ixty years, funii.sh the majority of ea.s«'s, projKirtionately increa.s- iii); ill each decade. -Men are affected in the ratio of three to one. The sjilient .symptoms, such as cougli, hiar.seneas, and es|M'cially pain, are less pronounced than with carcinoma, ami the glands are <'vcn less likely to Iw affected until late. On examination one finds u.sually a diffused, smooth, nodulatetl or warty tumor. .More rarely it is circumscrilK-d, even |M'dunculated, and tlien proceeds from the vocal cord. The color runs from i)right red through yellowish tints to gray, and the consistency varies accord- ing to the tyjH', fn)tn a creaking hardness to a cauliflower-like for- mation. It is usually single, but may Ik' multiple. Diagnosis. Carcinoma can l)e excluded only by a microscopic examination. The polyjM)id or jjcdunculated type may simulate tihroma. but can 1k> differentiated in the same way. Not so, however, with syphilis, for gimunatous infiltrations in section resemble uid- i'flled sarcoma. The effect of pota.*.sium indido should be noted and a degree of liiirmony esta' 'ished iK'tween the microscopic ftndings and the clinical course and as|)ects. The prognosis is less unfavorable than with carcinoma; but it all di'lK'iids u|M>n the |K)ssibility of an early and thorough extiq)ation. .\ii analysis of 50 ca.ses' shows 12 f)er c : t. recoveries (three years), and '1\ ])er cent, relative recoveries ((me year), with fewer immetliate fatalities from tli,' various operations than with carcinoma. Treatment. The principles underlying the selection of an opera- tiiKi and the techni(iue are the .same :i.s for laryngeal carcinoma, to wliich subject reference should be made. Medicinal means esjH'cially adajited to inoperable cases are there mentioned. In addition injec- tions of mercury bichloride, 2 [H-r cent, solution in olive oil, and 1 per cent, pyoktanin cxtrnially have been co:. u'tidcd. Sendzlak. Op. clt., S. ii 910 AOA/v AXJ) THROAT. i THE LOCAL, MEDICINAL, AND SUSOICAL TREATMENT OF THE LARTNX. McdiciiKil substances may 1»' aj)|)lio(l to the larynx in the form of sjiray, medicated air, vapor or t'nmes, pigment or ))aint, powder, syrinfjed (luid, and suhmucoiis injection. The larynx may i)e sprayed hy tiie ordinal y straif;lit-tip|)ed atomizer by taking; forced inhala- tions while the head is thrown backward, the tonjiue protruded, and the nose closed. Nei)uli/,eil oil is readily inhaled thus, while a(iueous s]irays soon excite coiifih which, however, is evidence that th(> spray lias actually entered thi' larynx. The short aiiKtilar downward atom- izer-tip is sometimes of sei-\ice, but l'"reer has devised a cnrvecl attach- ment for the Daxidstin spray tulx', suiliciently lonf; to acfuMly enter the larynx, which in skilful ham Is is still more useful. (Fig. 4()1.) Vh,. 4f.l. Shitwin^ KrytT's liiryngeiil sprHv-tnte atlached to ft Davidson atomizer. For a decided emollient elTect the actual atomization of oils by means of a powerful double-ball hand atomizer of the Davidson tyjM', or one operated by machine compre^-iil air, is prefer.able to the more finely divided oil vaporization which is furnished by sjK'ci.Ml "oil atomizers," "oil nebulizers,"' and "inhalers." The latter cla.ss of inhaler of the <;lobe |)attern is now arr;ui>;ed in multiple for attach- ment to the com|iressed air tank. Its actual usefulness seems to me (juite limited, perhaps beinj; beneficial in acute larynjiobroncliial intlamm.'itiou and as an occasioii;il means of inducinj; respiratory frymnasiics. (Fiji. 4fi2.) The "atomiziiij; vaporizer" of Thomas is more efficient because the spray is more copious. (I'ifi. 4().'{.) The steam .atomizer is at present little used. A hot laryngeal spray is objectionable before froinj; out in the cold, but may be serviceable for the first stajje of acute laryngitis, when the patient is confined, MEUICISAL AND SURGICAL TREATMENT OF THE LARYNX. ()H iiiid for cvciiiiif; a])|)lic;iti()ns. Till' same may be said of iiicdi- ciiially iiiiprcftnatcd hot-water (ir steam vapor inhalations. The latter can I)('('Xtem|)orized liy tlie use of a friiit-jar half tilled witli water just short of a i)()iliiij; temperature, and covered with a glass funnel. Tiie sedative properties of tlie \apor itself ill tlie e.irliest stage 111 an acute inllaniniation of tlie liirynx and contiguous ]»arts will he intensified hy the addi- tion, for instance, of thirty ^'lains of hipuliii. Swahliing the Larynx, that is, the application of a pig- ment or medicinal paint, is made hy a pledget of cotton lirmly secured to an applicator. Hruslies are no longer used for lliis |)iirpose, l)(>cause they ean- niit he rendered aseptic. The applicator should he sutti- cieiitly ^^trong to maintain u fixed angular bend. Cohen's t'orcv'iis (Fig. 404) and Freer 's Fill. 462. Traux multiple nebulizer. Fia. 463. Tlionius' utouuzing vtiiKtiizur 912 NOSE AND THROAT. steel rod are satisfactory. The hitter's firmness is an ai'vantage in applying lactic acid with friction for laryngeal tubeicnlosis. There is less resort to painting tlie larynx than formerly, since it is recognized that the impact of the swab is in itself an irritant; nevertheless, the process is very useful, with astringents and re- i I \ ■ I \ Coben's laryngeal cotton-ii Ming forcep*. solvents, for certain forms of sul)aeute and chronic laryngitis, also with lac'ic acid, etc., for tuln'rcu'-i'^is, and witii cocaine for the pro- duction fit local aiue.-ithesia. Tin' swab is applied under laryngo- sco[)ic ob.servation at the moment when the epiglottis is raised by phunation. FlO. 465. Shurley's powder-blower. The insufflation of powder into the larynx is accomplished by means of a])owder-l)lower. ( Figs. 4G5 antl 466.) Itshould have a detachable end for sterilizatio". The insufflation i -nade under laryngoscopic ol).ser\-ation and while the patient phonates to raise the epiglottis, the powder being blown FlO 166. fireene's powder-bUiwer. from behind forward and downward. This method is useful, amonr other conditions, for persistent subacute laryngitis, alum diluteil with an e(|iial part of acacia being insufflated. Oils, especi.'dlv "oil v.nseljnn" jind other petroleum products, c.-m be slowly syringed into and through the larynx without provokinr much spasm. From 2 to gin. of an antiseptic or stimulating einol . MEDICINAL AS It SURGICAL TREATMEyT OF THE LARYNX. 913 licnt inixturc iiiay be thus injected at a dose. A syringe with a long aiigiihir hiryngeal tube is requisite. (Fig. 467.) The larynx should Fio. 407. Moreau Brown's laryniieal syringe. first be sprayed with a 2 per eent. cocaine solution. Even afjueous solutions, i" bland, can be injected after cocainization. The method is useful ioi chronic tracheitis and laryngitis sicca and for fetid bron- chitis. Subimicous injection in the laryn.x is employed for the production (if thorough local ana-sthesia by cocaine preceding certain endolaryn- fieal oi)erations and to promote absorption of tuberculous infiltration by creasote, guaiacol, etc. ChapiK'H's .syringe is well adapted to the latter purpose. The needle shank is six inches long, and may be given suitable curves; the needle itself is half an inch in length, with the opening close to the point. The piston can l)e disengaged byathumb- button when it is automatically pushed home by a .spring. A set- screw regulates the do.se, usually one droj). Heryng's sjTinge is an excellent instrument without the automatic piston. Fio. m,. Anthar'8 laryni;eal pnrte caustlque adapted to Schroetter's handle. ChrmirnI Cnuteriznfinn. For the application of either chromic acid or solid nitrate of silver to a circumscribed spot in the larj'nx these 68 914 SOSJ-J AM) TIJJiOAT. sul>stiinc('s sluuiM he fused in a small ix'ad upon the cikI of a shicldoil applicator. The tubular shield should cover the head during; the introduction of the instrument, heins; withdrawn to exjxjse the caustic {H>int only when the latter has reached the exact spot to bo cauterized. (FifTs. 4i)S and 4()!).) This method is properly available only in a tolerant locally ana'stlietize(l larynx and under perfect laryngoscopic oi)servation. It is exceptionally u.sed for the destruction of small benijrn neoplasms or for the cauterization of the base after tlit- removal of a fjrowth by force|)s. Ingals' reports favorable results in a case of chondroma. As a rule, the galvaiiocuutery is a liettcr means to the same end. Fvj. 401). Mc('(iy'« laryngeal potte cuusti«iue. Surreal Methods. l-jidolaryngoal surjiical procedures include scarification and incision, curettement, evulsion and abscission by forceps, ecrasement, jrah'anocauterization, and electrolysis. The appliances are most employed and best described in connection with the treatment of benifjn neoplasms, larynfreal tulx^reulosis, cicatricial stenosis, foreiii?) bodies, etc. Local Anssthesia. Before the introduction of cocaine it was necessary to train the larynx to tolerate instrumental manipulation by a course of daily contacts with a ])robe. Cocaine amesthesia obviates this necessity, if not wholly, then in part. The degree of anaesthesia obtainable depends in a measure upon the nK'thotl of application. The cocaine solutions, it, 10, and 20 per cent., should he freshly prepared. The '■) per cent, solution is sprayed sparingly first from a straight tij) through the ])harynx, being forcibly inhaled into the larynx, and after an interval of three inimites again sprayed din'ctly into the larynx by Freer's nozzle. The 10 per cent, solution is a]>plied by a cotton applicator after a second interval of about four minutes, and the 20 jwr cent, solution is used in like manner after a third interval. Including a fourth period of rest, the whole time consumiMl aggregates about fifteen minutes. The patient pre- viously should have been tested for supersensitiveness to cocaine. Very strong solutions will occasionally irritate more than ana'sthetize, in which event the limit sl;:Mild be from o to 10 per cent. Swabbing also must excf^ptioiially Ik- avoided ff)r the same rta.son. For dvc\ ' Tmnsaclioris of AmtTloaii Ijiryngnloglcal AwDclatioii, 18S.S. p i;.Vi. Mi:iin/.\AL AM* SVIKIIVAL TREATMEST OF TIIK LAHYSX. 91,j (■iircttciiiciit and for I lie excision hy tlio double curette of tuixTcuIous sites tile iii!inediate area is further aiuestlietized l)y sui)niucous injec- tion of a dro]) iiere and there of a 2 to 4 per cent, sohition. The Removal of Papillomata and Other Benign Neoplasms. Foreign Bodies. Singers' Nodes. Pachydermia. Tlie patient pro- trudes iiis tongue and steaihes it witii a nai)kin between the tiiunib and first fiiifier, while the surgeon, seated soinewiiat iiigher tlian ti;o patient, hoi<is tlie tliroat-tnirror in position with one hand, and with tiie other passes the forceps, snare, or cautery electrodi' around tlie epiglottis without touching it, and well downward and forward to tlie site of the growth. The forceps is ([uickly o})ened and the growth lirnily grasiM'd. .lust at this inoinent or before the larynx is apt to close. If the force[)s is aln'ady in exact [Hisition this spasm will not prevent the gras|)ing and withdrawal of the neoplasm, but if not, one iimst desist and try again: the attempt niaj' be made either during respiration or on phonation. I have been more successful in the former position of the larynx, l)ut an overhanging epiglottis must often be pres.sed forward by the forcejjs. The latter position is adapted to growths which ri.se well above the glottis on phonation. The forcejjs are of two general types, bladed pivot forcei)s and tubular forcejjs. In the former the laryngeal bend may be ajiproxi- inately a right angle or a curve. Hlades are constructed to open both antero-posteriorly and laterally, the latter motion being very important for growths at the anterior commissure and for foreign hiidies in certain positions. The grasping ends are made with cutting ¥'.!.. 470. Hackeniie'ii cutting forceps. edges and with simply serrated surfaces. Dundas Gratit has modi- lied the j)ivot forceps by hinging together the distal ends of the rutting blades. fFig. 472.) The obstruction to vision by tubular forceps is less; but the move- ment of the blades is limited and they are suited rather to (juite small i 1 916 XOSE AXI) Til HO AT. growtlis. TIkiso of Sclii" cr, Stoork, Soilor, and Krause are most favorably known. Seilor's tube is flexible, and is therefore adaptable Fia. 471. Coaco'a laryngeal forcepa. Fig. 472. Dandas Grant's guarded forceps. Flu. 473. SchnHjtter's handle, contAining serrated forceps. Two stienthed kTiives and a sheathed caustic api'Iicator are also shown. Mi m MEDICISAL ASD SURdlCAL TREATMESr OF THE LMlYSX. 917 for i)r'ii<'liial and (rsophaRoal uses— r. f/-. the removal of a foreipn body through a tracheal oix>ning. (Fig. 474.) Fia. 471. Seiler'K tubular forcepi. guillotine, and lancet. A small guillotine which forms part of the tubular outfit is suitable for the removal of readily encircled tumors. A laryngeal lancet also convenientlv forms one of the tubular attachments. The tube acts as a shield within which the small knife is concealed during passage into the lar-nx, to be protruded at will when the desired spot is reached. It is employed for scarification and puncture in a'dema of the larynx and for the division of adhesions. The '■ double curetten " of Krause and Heryng are in reality sharp- cutting and punch-forceps, which operate on the tubular plan. They are availalile foi the removal of neoplasms, although they were de- .-^igiu'.l for the eradieation of areas of tuberculous infiltration, a subject which is considered in another chapter. Laryngeal forceps are emploved also for the removal of foreign Ijotiies both from the larynx and laryngt>pharynx. These objects, Foreign bodies in the larynx. including coins, fish-bones, pins, tacks, cockle-burs, buttons, nutshells, beans, jackstones, teeth, etc., being of all shapes and sizes and in varying situations, one selects whatever implement seems best adapted yi» snsi; .[.\h rmioAT. t" the individual case. The iiictlmd ;is r<%'irds local aiia'sthcsia and the introduclinn of ilc forceps is the same as for tlic removal of neo- |)lasiMs. I.ivinj; objects, such as luiubricoides. hydatids, and leeches, occ.'tsionally \p\\u access to the air pas- sap's, Larpe ohjects, such as apple- cores, pieces of meat, and tooth-plates may occlude the larynx i)y hecomiuK impacted in the pharynx. Tiiey can usually he dislodp-d hy the hnjicr, hut laryn<;eal forceps may he re((uired. In children extraction, e\-en from within the larynx, may often he made, puided hy the tinfjer, under jjeneral ann'sliiesia. Foreijin bodies which are lodjjed in the trachea or in one of the main bronchi can usually be j;ras|)e(l by straii;ht or slightly-curved forceps introduced throufili a low trache- otomy wound. JM'rasement or the use of a cold wire snare is best adajjtod to pe- dunculated neoplasms of good size, especially jtapillomata, fibromata, and cy.sts. X camila with a laryngeal curve can be adapted to a nasal snare. (Fig. 47S.) Flo. 478. Kiiri-i|{h Uiily til thi' Ihtviix. Cas8e'.t«rry's mudilieil Allen > When a papilloma is broad-based and deeply inserted in a situation rather m;icce.ssihle to forceps, as in part beneath a vocal cord, it may be destroyed in sllii by the galvanocautery. The author's experience nicluiles several cases of this sort in which the forceps oper.atioii seemed like pulling pieces from a cutaneous "seed wart." The more one pulled th(> faster it grew. The accompanving figure -epresents an electrode which is well adajited to this purpose. Its j)latinuni loop is turned to one side or the other, which renders umiece.-sary a shield to protect the opjx.site cord. The p!;itinum tip while cold is pressed l.'iterally ui)on the growth and then c;msed to glow for a .second only Sajous' handle, which is light and has the cords su.speiided from i"t.- middle, has the best b.alance for laryngeal u.se. (Fig. 470.) Sc.-,Mle aiigiomata. small iibromata, polyps, cysts, and tuberculous granulomata can be destroyed in the satue way by an expert han(' Persistent singers' nodes, especially tho.se which air too miimte and Mi:i)l(l.\.\L A.\l> SVRdlC.XL TREATMEST OF illE LAUrSX. !»l!l tdii iiitiriiatcly l)l('ii<lcil with the .''uljstam'c <if the vocal cords t<i he (Ictaclicd l)y forceps, may Ix' treated by the cautery electrode, althougli extreme care is recjuisite. Tliose nodes which project siiliicieiitly and tlie larjjer iioihiles of cliorditis tuherosa can l)e detached by ciittiiift-forceps, esiM'ciaily tJrant's guarded forceps. fffiilVnittaiii Flo. 479. iiiiiitiiiiiii'lliiiiiBi Casselberrj'B laryngml electrode KiiU Sojoiis' udle. Curettement of tlie larynx is employed chiefly in the surgical treat- iiH'iit of tuberculosis and receives ai>])ropriale mention under that heading. Heryng's single curettes are suitable, In'ing well made, sharj), and of varyingsizes. P;i])illomata, when diffused, and when in- accessible to forceps, ean occasionally be effectually curetted. Simple inflammatory and .syphilitic infiltrations, and p'lchydermia laryngis ■AW somewhat rarely amenable to the same treatment. In pachy- ijirmia, curettement is usually supplemented by chemical cauteriza- liiiii. either by lactic acid on a cotton swab or chromic acid fused in a bead on a porte causti(|ue. Salicylic acid, 10 per cent., in alcohol anil water, is also comtnended. Electrolysis by th,' bij)olar method is recommended by Chiari for pachydermia diffusa (JournnI of Lari/nnoldi/i/, May, 1S94). The irido|)latiinnu needles designed by the writer for nasal use are suitable if given th(> laryngeal angle. A current of from eight to twelve niilli- aniperes is adcfjuate. ("upric electrolysis applied by a bulbous positive electrode of cojjper with a current of five niillianip<Ves is advocated by Scheppegrell for laryngeal tuberculosis. Oxychloride of copper is liberated in the tissues. Injuries of the Larynx. Injuries of the lar^'nx may occur in con- s(i|uence of either internal or external violence. Traumatistn from witliiii can result from extreme muscular action, the ini])action of I'nreign bodi(>s, the application of surgical ap])liances, either inten- tionally or unintentionally — c, r/., the false ])assage of an intubation tube, the swallowing of corrosive li(|uids, and the inhalation of scald- ing vapor. Injuries from without include gimshot wounds, incised "(lU'ids as in cut-throat, punctured wounds as in sword and hay-fork thrusts, fracture, dislocation, and contusion as from throttling, hang- ing, and accidental blows. »20 A'UHE A.SD THROAT. \'i()l«'nt couRliiiiR and shouting sonidinios injures oiif or tM)th vocal cords in such a manner that thry present an ecchyinotic and paretic app«'arance. U»'st and .la enioHient spray an- indicated. Sharj)- cornen'd foreign l)odies occasionally lacerate the interior of the larynx, cs|)ecially during forcible extraction; such wounds usually heal n-iulily under antis<'[)tic and einollieni sj)rays, hut it is jwissihle for an abscess, |)erichondritis, and (rdenia to Ih- excit«'d in this way. Bokay' re|)ort8 that out of 12(X) cases of intubation of the larynx obs<'rved by him there were four cases of false pa.-wage, all in the ventricle and all fatal. The false pa.ssage nmy also Ik; forced through the membrana thyn)- hyoidea. (Kdeina, suppurati(m, and perichondritis are very prone to follow. Tracheotomy should Ik» immediately substitute<l for mtu- bation. The ulceration and pressure n«'crosis which occa-sionally results from the j-rolongtnl use of intubation tulx's merely re(|uir(^s mention in this connection, h is rarely serious, but very exception- ally may he followed by cicatricial stenosis. The same is true of high tracheotomy when the tub' is so placed that the upper curve impinges u[K)n the inferior surface of the vocal cords. The author hivs recently observed a case in which a web extending largely across the glottis and an ankylosis of the left crico-arylenoid joint had resulted from this cause. In the swallowing of corrosive li{]uids the epiglottis and aryepiglottic folds would be the only parts of the larynx directly affected, but ol)- structive cedema is likely to easue. The inhalation of steam is fraught with the same danger. Gunshot, punctured, and incised wounds from without vary in gravity according to their situation and extent, yet most of them do well if the hemorrhage is check(>d and the i)arts are cleansed and care- fully coaptated. To avoid stenosis by the formation of a diaphragm, the divided cartilages should l)e deef)ly sutured by silkworm-gut. Emphy.sema of the neighboring connective ti.ssue is sometimes a troublesome symptom. Fracture of the larynx may be caused by a fall upon a projecting object, i;.y a blow, and by hanging and 'loking. For instance, a man while riding a bicycle carried sus[x>iii round his neck the diamond- shaped frame of another bicycle. 11. iell and compressed his neck in the angle of the frame, which fractured the larynx in such a way a.s to result in immediate death from asphyxia. Fractun' is rare, owing to the natural resiliency of the cartilaginous framework. The ino.st serious symjjtom is dyspna\». which is usually due to odema of the glottis from laceration of the soft parts, but which may be caused by a disMlaced fragment encnwching upon the lumen of the larynx. It may .set in at once or at any time within a week. <)t! er manifes- tations are cough, bloody exfx'ctoration. impairment of the voice, emphysema, and pain both on talking and swallowing. Hy digital > Bokay. Trauoatl'im during latubatiou. Juurual uf .\mericaii M«(iicul AisociaUoii. Jauiury 'J6, IWl. MEDIVISAL ASD SUROIVAL TUE.XTMEST OF THE LARY.SX. 921 cxaiiiiiiatioii, (Icfomiity. in()l)ility, and crepitation would Ik' iwrccivcd, ami tli« diagiioxis thus ccrtitii'd. Laryiigoscopic cxainination will ilisclosc .swelling and di m within th«' larynx. Th«' fracture may lie linear or coni'iiinutcii ..u. may involve one or more cartilage!*. The |iroj;iiosi.s i.s very seriou.s, tliree-fourth.>< of the recorded ca.s<'s having; terminateil fatally,' either immediately or from subsinjuent pneu- monia, al).-<cess, and septic; 'mia. The treatment should Ik' directed toward the promj)! n'lief of dy.sp- iKi'a hy low tracheotomy, provided then- is time for a deliherate o|M'ration, or, if necessary, hy a hiusty high tracheotomy. Intuba- tion as a substitute for tracheotomy is not suitable in these cases. Vavw if asphyxia is not at once imminent the j)atient should be kept under close surveillance, for it is liable to develop .suddenly. Prompt replacement of the fragmentK, cold applications, and absolute rest, including f(>eding by the n-ctum, are indiwited to ward off (I'dema. The hyoid hone Ijeing in clos<> proximity to the larynx, may l)e frac- tured conjointly or alone from the same causes. The superior cornua if the thyroid cartilage are loosely articulated to the gi-eater cormia "f the hyoid bone through the medium of the thyrohyoid ligament. .\ di.xplacement in the nature of a dislocation of this articulation occa- sionally occurs by muscular action in sudden movements of the neck. \ return is usually effected in the same way by nuiscular movements, but digital manipulation will hasten it. Seve;e contusion of the larynx would suggest in part the same ciire as actual fracture. BcMworth. DUeaseM of the N(Me « ' .' Throat, vt>t. il. p. 712. i! CIIAPTKR XXI. DISKASKS i)V rilK ACCKSSOllV SINTSKS. Hv StCLAIU THOMSON. M.I).. M. U.C.I'. I-<>m>.. I'.K.C.S. Kno. Introductory. With the cxcoptiDii of that part of the niof of the nasal chanilHT foriiicd hy the crihrifonn plate, the up|H'r and out^r wall.-* of the nasal cavities are ncciipied hy the accessory pneunuitic .sinuses. Contiguous to the outer wall of the nose are lodjfed the nia.xillary and ethmoidal ca ities. while |)ortions of the ethmoidal, frontal, and sphenoidal chamlx'rs help to form the na.sai roof. It would Im' a natural presumption that these cavities, communi- catiiifi as they do with the na.sai fos.sa', exposed to a variety of possible etiolojiical factors, and in clos<' relationship with sucii im|H)rtunt parts as thi" lirain, eye, e.ar. and throat, woulil not he exempt from disease. Thi'y ;ire indeed suhject to disease just as the nasal fos.se are, hut it would he a mistake to think, as some authors state, that since atTections of the |)itiiitary memhrane can he |)ropafiated to the accessory cavities, the latter manifest just the siime diseases. A little reflection would show that this view cannot he correct. The provision in the nose for (ilterinj^, warminji, and moisteni-iir the in spired air necessitates special anatomical arrangeiuents, which, i.hi'ii disordered, are suhje- 1 to particular pathological changes. At the same time this continually renewed air stream hrinjpi with it i)atho- penic j)ossihiiities from which the acces.sory cavities are nmch more exempt. The nuicous lining of the li'.tter has not the same fui'ctions to jK'rform, and is therefore difTerently iirranged. On the other hand. .-dTections of the simises require individual consideration ' \vin<; to (a> the shaix' of each cavity, ih) the >ituation of its orifice, i.'<l (c) its relation to neighhorin}; organs. It will he noted that all 'h.ese three factors ]>ertiiin to anatomical chanicteris- tics. and hence the great importance of an exact practical ac<iuaiutance with the surgical anatouiy of this region. It is .seldom t.augiit ado- <iuate!y in the dis^i-ctiiig-room, ;ind the consideration of the surgical point '. in the anatomy of the sinuses hardly a|)peals to students sufhciently at an early jM-riod of their career to conmiand nmch atten- tion. A rorrert idfa <>f the top>gniphir:\I anatomy of the arct--s.=on- sinuses can only he ohtained hv the study of hoth dry and moist sections. I'A'ery surgeon who aspires to a profound study of tln' diagnosis and treatment of nasal suppuration should lose no oppor /'/.n7;.|n7-,.s itF rilK .irrK'S'iliy SIMSJ-SS. !ij;j I unity of cxjiiiiiiiiiiK :i ^n-nvx of coroiml, j<!i){itt:i!, .'irul horizontal xciioiis of the lic;ii|, wliicli lie should, if iK)s.«.il(lc, prcparf with liid own h.'iri'ls. Those who have not tlirsc op|)orttinitics can to soin«? fxtcnt siippicnicnt thcin hy the stinly i • phistt-r casts,' while much can Ik' ffaincd from the iiuincri)Hs atlascH mid s|x'ciai tn'atis<'s dc- voti'd to the siilijfct Surgical Anatomy of the Accessory Sinuses. Matiy of the itn- |)ortant points of the lopojiraphical and surjjical anatomy of the accessory sinuses are shown in the illustrations, an<l othi-rs will he referred to in treating of the diseases of the individual cavities. It will therefore lie sudicient here to briefly refer to a few of the jioints which deserve s|M'cial consideration. I'roin lioth anatomical and clinical considerations it is conveniriit to dividi' the accc.sHory sinuses into two groups, a'Tonling as to wliethi'r their ((.s7/rt o{M-n (ii) aniiriorli/ into the middle meatus, Im'Iow the attachment of the middle turhinal, or (/)| ittisttriorltj into the ■superior meatus and ahove the middle turhinal. Thus: .Vnterior group. Maxillary sinus. I'rontal sinus. .\nterior ethmoidal cells. I'osterior group: Posterior ethmoidal cells. Sphenoi<laI sinus. I i'rt'|«rp<l )>>- nr. Bull, nt ilvilbronn. and nld by Inilniraent (lealen. - John Jmnw Walt. Anstumlcu-thlriirgi™! Vlewn of the Nine, Mouth, Larynx, and Fauoa. Lmiloii. IHU. /Mtkirkaiiill't .\n«tomlo Nnrmale et l'«thol<>glque dos F <iiies Nasalis et de leun Aiiiu'xt-< Pneu- iniiiic|iiin, Tniilin'iioii Kmtv aise '||. i,|..htw(tz. l^irl«. O, ?.; ixm IH'jrv onmliii Atlas of the Safwl Cavit) ami Sluuse-, tr«i>«i .twi by 3i<'uir Thum*)n. London, U. K. i.f«is, i<<n. l)r» K. (inuirenhclm et J. Olover. Atlas de I.aryn(tologfe et de Rhln«l(i([ie. Parin, (i. Ma»on, ISW. Aritiur Uiin iiann. Atlas der Anatomie der Silriihiihic, dervotdereii Siebelnielluii und den Ductus Nasofrontal!,!. Wieohaden. J, W. Horxmann, 19()0. Or I', ri (terrier. Atlaader Krankheiten dcr Na«e, Ihrer Nebenhiihlen uud desi Naaenrachenrau- iimis. IUtH 1, S. Kanter, 1901. Iir Robert Krie«. Atlaa der Sasenkrankheiten. Stuttgart. Ferdinand Enke. 1901. I.oKrtii Tiiniir. The Aece»«ory Cavities of the .Nose. Edinbunth. fireen, imil. J. H llr an A further Contribution to the Study of Snppuratitre Diseases of the Accessory ■Minuses, with lieport of Cases Transactions of the American Ijiryngological Association. wj:>. j>. 7'.. and New York Medical .lournal. llnwar.1 A Ijithmp. The Anatomy and Surgery of the Frontal Sinus and Anterior Ethmoidal 'Vlli. HeprinttsI from Annals of Surgery. Hmdc'i Kvie The Relation of the .Vasal Chamber and Accessory Cavltien and Dental I.eslons JonmHlofthe American MellcJil As«,K'iation, October", 1H99. Ki!it'liptwTi. Ititernational Dental .lounnil. 1«<*7 Kiiifc 'c s. T'llhit. Jounuil of tile American M-'dlcal Association. Noveralier2l. !*.►*. McHiuKn Douglass. The Pneumatic Sinuses In the Sphenoidal Wings. Laryngoscor>c, l<i«l, vol x No, -'. .1. Mouret. Anatomie des Cellules Ethmoldales. Revue hebd. de I.aryngi)logle, is;i8 xlx 2 No •n. !,. M:'.. A Onndi Des Rapports du Sinus Maxlllaire avcc le Sinus Sphenoidal et Ics Cellules Ethmoi- ■ iftle*, Anterieiires. Kevue hetn! de I.Hrvngologie. F.'V. Irt, I'lOI. sxli I. N'o. 7. p, 177. M II. Crv.'r. siuilies of s...ne Facial Bones .lournal of the American Medical Association. I'urtyeigh.h meeting, \'<:n. and Frftieih meeting, ITO:i. I 124 SosK AM) Til 1:0.11: The maxillary sinus, or aiitiuin ni' Iliiihnuirr, li.is (il'tcu liccn coin- part'tl ill shape Id a tlifci'-siilcil |)yrainii|. Sniiic autliois ili'scrihc it as all iiivt'ilcd ])yramiil. the basr lii'iiitj t'lirmcil iiy the floor of the orliil and the apex siliiatcil over the loots of tiic molar tcctli. Others place the base of the pyrainiil at the ou!i'r wall of the nasal (•!iaiiil)er ainl the apex towanl the malar process. In that case the three sidi's of the pyramid arc formed l)y the facial, orbital, and zyirom.'itic walls of the sinus. The temporal or posterior wall is loriiied hy tlie holly of the superior maxilla: it is concave and laces toward the zyfioniatic fossa. This is the thickest wall. The thin, orbital Flc. ISO. Corunal section in the anterior thir<l of the iiO!-e \ u .vt-l trom the front. Shows the inferior anil tnidille tnr)>inHlK : |iol.vpi Krowlli^; Iroin the ethinoliliil leKinii in eaeh Mile; ami |><il,V|>iiiil tleKelieni- tion ot the liiiitii; i>l the lelt inuxillary sititls. A prolie is |iasse<l np into ihe Iroiilai Minis on the lell siile. (I'reparalujii h>' "^ri'i-xiu Thomso.s.j wall forms the roof of the sinus. The anterior wall corresponds t the lacial surface of the superior maxilla and is always very mucl thinner over the canine fossa. Here it may only measure "_' mm. ii thickiies.s. The ba.se of the pyramid corres|)onds to the outer wa! of the nasal fossa, which is markedly convex toward the sinus. Th anterior and posterior jiarts of the base are formed by the su|)criii maxilla, and a referenr-e io a dried skull will sliow how relativel stout they are. The central area of tlie base— formi'd chicliy li; parts of tlieethinoid -is very thin, and in certain points is closed oiil; l)v membrane, 'i'lie natural openiiii; of the sinus which is fount i>isi:asi:s or riii: Mcrssajn' si.\i:si:s. »2.5 nil tills wall is iiiiicli iii'arcr In tlic ninl' tliaii tu tlic llnor (if tlio caxity. Il iipriis iiitDtlit' iiiiilillc meatus (if the ikisc \)y t\ic nslinnt tiiiixillnre, at the |i(ist('i'iin- cxtrciiiily nl' the hltilH.< si'niihiiiiin.'i. line or more aci'css()rv(ii>ciiiiijrs arc somctinics met witli, also in tlic iiiiildlc iiicatiis, iri'iicrally posti'rinr to the nsliiim. Above the level ol' the o>^linni ni'ifilliin- \hf' inner wall of th • • ,•'!■, "oines into relation with the eiliiiinidal labyrinth. The . . ('iii. ni 'iic iMiterior and posterior walls forms what is fre((iientl; refi.reii ti as •(i( floor of the sinus. It »'nr<i!ml st'ciiou aboiii the centre of the nose, viewe*! 'loni the biu-k. The seetiDii shows the hi- liTior. niliMle. iiii'l Mi|ieMiir liuhiiials, hikI the ii';i\illttry, cttitnoiilul, un-l Iniiihil >iiiu^'s. The rrlalioti of the elhmoiiirtl cells to itic fronlal --.mi-. mii-I ot Uitli to the ortut tin<l (Tiiiiiiiin. are well 'tMii I'oh pi are se*.li tit the tlliiMIe itivatll>* on eacll ■•i'le. ijrowltit: man the elliinoHlat region ; an J 'iKTe i!t |i.-ly|)iii.I -K'neiiei^tion cM the iimeoii^ iiieiiihratie ol the laaxillary sitius on the left Hi<le. A |ir<ilie i> iiu>M-'l throtiiih the tell o^tiniii tiiHxlllare. tl'reiMiiatitin by STt'l-Alti Tit iMvin.) i~ really a riuiiuletl ansrle. It lies above the alveolar liorder of the -iiperior ' \illa. ami the roots of the teeth— particularly the second iiiriis|)i,; I the 'irst molar— are only separated from tlie cavity by a thin lamella of bone. Th(> nnico-|)eriosteuni is fret|uently arranged ill folils or ritlijes, which form sd many pouches, but it is very rare liir the sinus to be divideil into two cavities |>y a comulet(> septinii. .\ larjie aduli mavillarv sinus will holil one ounce of fluid.' The W A. N. catlliii Tran««itiotis iHoiit. Swlely, Lomlnn l«'o, vol. jrlx. p. 31. \)2i) yosi-: AM) tiiudat. avcrafjo capacity is 14.4 c. cm.;' hut of cniirsc iiuicli variation exists, owiii^ to the numerous irrejiuiaritics met witii in tli:' configuration of the sinus. Tlic cavity may i)i' ri'|)rc.scnti'(l hy a narrow ciiink: more rarely it is entirely absent.- Development. Tlie maxillary cavity exists at birth, hut in a rudi- mentary form. It reaches its full ilevel()|)inent about the a^e of twelve years. The frontal sinus lies b(>tween the two lamelhe into whicl'. the frontal bone sepaiates in the re<iion of the superciliary riiljie. As a rule the cavity is decidedly smaller in young ])e()ple and in women FIO. 482, Citninal st'rtiiin nl the ptwterior thirti of the lutse, viewed from the front. Ttio section shows the inferior, iniildle. ami iiui»erior tiirbinals. Tliere i.** ft i>c»ly[«ml. inullK'rry hy|iertlMi>hy of the po«;terior end uf the riKtit inferior turtiinal. A very hhihII (Mirtion of ttie nitixillnry untriitn i.<l seen on each side The relations of tlie fronuil vimi-ies and etttmoidal cells lo one Hnotlier. and to the orbit an<t erainnin. are well seen. The si»eeiint. i stio.\s the roof of llie (Mislenor choana. the front wall of the sphenoidal sinus, and the sphenoidal oritiee on each side. (Si»eeimei» pre|>aretl by StCi.aibThomw>s.i than in men, but there is t > nece.s.sary relation between a promineni su|)er('ili;iry ridge and a capacious frontal sinus, or the rover.se fZiick- erkanill). Hut from an <>xainination of 12") preparations Lothrop formed the opinion that ''in g(>ner.il it is fair to concluile that tin- 1 Hrainii nnd I'lasen. Hie Nebenliohlen d menschl. Nasc, etc. Zeitsehrifi f. .\ii»l u. Entwlik lunitsitesch. IS77. Hand ii. ' MfirKAKni. lie Sedibtisel cansiii niorhornni, )77'.>, DIS^A-StS-S OF Till: .WVESSOKY SIS USES. •dT, more proiuiiu'iit the sijpni-orbital arcu, iiifliKliiig tlic sii|)crciliarv riiincs and nasal cini iitr, tlu; greater tlie probability of the ju-eseneV (it well-defined .sinusi s."' The anteri()r wall is the tliickest. It is about 5 to 6 nun. in thiek- ness, but varies considerably in different skulls. It contains a good deal of diploic tissue, and this exphuns the How of blood which may take i>lac(> while ojjeiiing it, v ' also the pos-jbility of se])tic infection ulien 'he diploe are exposu.. The posterior wall, su])porting the anterior lobe of the brain, is thin and brittle. The floor of the cavity is irregular and often marked by the elevations of the fronto- etiiiiioidal cells. It overlies the roof of the nose and the orbit. Tlie cavity of the simis extends upward on the forehead for a variable distance— sometimes for one and one-half inches or more. Backward it may reach so far that the entire roof of the orbit is divided iiy th • frontal siiuis into two plates. Outward it extends in the direc- tion of the eyebrow, sometimes as far as the external angle of the orbit. It is separateil from its fellow on the other .side by a septum. This is very irregular, and is so seldom in the mesial line that the two sides are often very irregular. Indeed, an opening made on one side of the middle line will sometimes expose the cavity on the ojjposite side of the body. The cavities are very irr(>gular .and unsymmetrical. They may lx> very small, or even entirely absent. Logan Turner found the sinus ab.sent on both sides in SO out of ,500 nmseum skulls— '.('..in Ki.l per cent. ),M)ut Sieur and .Jacob examined loO s])ecimens without once failing to discover both cavities.-' The sinus nuiy be present only on one side. The sinus becomes fuimel-shaped as it jnisses downward between the ethmoidal cells, to open into the middle tiieatiis of the nose at the upper end of the hiatus semilunaris. It is noteworthy that the ostium of the frontal sinus lies at the most 'lepeiident f)art of the cavity. It is foimd at a short distance from the septum and further from the anterior wall than might l)e imagined. Tilley found that ihe infundibulum may lie as deep as -'Slum, from the anterior surface.' It leads into the frontona.«al duct (l.J cm. long), which oiH>n.s into the anterior end of the hiatus -semilunaris. The surface of the cavity is .seldom smooth, rece.sses of various -hapes and sizes being present. One long narrow pouch is apt to i)e met with running toward the outer extremity of the eyebrow. The nuicous membrane is thin and closely adherent to the pcri- oslium. It is scantily s'!|)plied with glands. Development. The frontal sinus is absent at birth and during infancy. It is .seldom evident before the seventh or eighth year. ' l.<ithr()p. The Anatomy and Siirsery nf ihe Fronul Sinus and .\nterl(ir Ethmoidal (Vila, p. IS. - I'-riM'h Vr^II.-rtl Joiirim!. 0!-(fl«T li i-:n Iti-ciircht's Hniitomiiines. plinii|ues el oiwralolres sur leg fosses iiasales et leur ulnus I'urls J Kiieir. .itit VMM. < Lancet, September 2fi. ISOti. 928 yisi-: AMI runo.xr. \\'\\A |iii!)crty it imrcuscs raiiidly. iind icaclics its full size aliout tlic twi riiicili yrar.' The ethmoidal cells (Icsitvc sju'cial considcratidii fruin tlic iiii- portaiipc of their topofirapliical relations, the fre<[iieiicv with whicli etiimoiiiitis is assoc-iated witli ptis-foniiatioii in otlier accessory cavi- ties, and their irreijiilar and coinphcated anatomical arraiifienients. The system of cavities in tlie etiimoid hone is iod'ied between the nasal cavity and the orhit. On the outer side it is closed in by a thin plate of hone which forms the fireater porti.m of the inner \va'' ' the orhit {lamina jKipi/raccn or as j)la)inm). ( I'ifl. 4Sl.) As : of arrest of development I Zuckerkaiidl) and in old jicople, th. _ ' .-■ may i)0 defective in parts, and the se])arat ion from the orbit is then only maintained by memi)rane. On the iimer side the ethmoid cells form a part of the outer wall of the nasal chamber, from which they are separated by a frajiile lamella of i)one. The su|)erior and middle turbinals are in connection with this surface. A study of coronal and horizontal sections will show that the cells increasi? in size from before backward, and from above dowinvard. They are divided into two groups, an anterior and a posterior. The anterinr open into the upper jiart of the hiiit:'^: ."cmihinan's by one or more openinijs, and therefore |)our their sect 'tion into tlu^ middle meatus. The ostia of thi' posterior fjroup are situated above the middle tur- binal, and therefore o])en into the superior meatus of the no.so. Development. .\s a rule, the ethmoidal labyrinth is not apparent in infant skulls, although Laurent states that the cells are visible in an eight months' fcetus.- It conmiences about the age of four or five years, and is not fully developed until about the twentieth ye: .'. The sphenoidal sinus is an irregularly (piadrilateral cavity situ- ated in the body of the sphenciid lione. |)art of the an1"rior wall being formed by the ethmoid bone. The orilice of the ca\ity is situated ill the th'ii anterior wall, a few millimetres below the roof of the n.asal cavity, and therefore comimnneates with the superior meatus of the nose. The two sinuses frei|ueiitly do not correspond in shape and size. One or both may be entirely absent. They are separaleil by a septum, which is seldom (piite vortical, being bent to one or the other side. They are not often symmetric.d. The average capacity of the sinus isti.tlT c.cm. (('. R. Holmes).^ Development. 'Fhe sphenoidal sinus is not present at birth. Its appearance is given by ditferent authors at the third Steiner). seventh (Laurent), or twentieth vear iTillaux). ' For fiirlherdotaiN oti the iinatnmy cif the fnmtal 'iiiiu-o.'s, rirtr Lotbrop, loo. cit. Tilk-y. Lancet, Sopti'inlKTi'tp. lv.«i. Li)>;an Turner. Ktlilibiir«h .Me<litMl Joiiriml. .\|'ril iiri.l May. IsiWi, KtMlmoivl W, Piiyiiu. Atiinnalk»< of the Fnmtal Sinus. Junrual iiftlie .Amcrlraii Mcliral Asjocia- tlim, .luly JT, l:"il. .-..•;ir. N'pit- rrliitivc .1 r.initMTnie (U-:^ '■■inns frnntau.^. itLv;:.: ijcbd. tie l.Aryiigt.ltigie, lUtil, iiii.. M.. Nn. ^s. p :l;s, anil literalurc on pau''' I'--!- ' ,Annal.'« .ti- mal. de rurfilli'. !<:«, xxv ii. p. IJ.l. • Arrhivesof nphthalmnlojy. IVW. xxv. p. 4fiO. disi:asj-:s of riu: accessory simses. 92y The Mucous Lining of the Accessory Sinuses. Tlic acccssory cavitics arc lined by a mucous iiii'iiihraiic. which is so thin and so closely adherent to the periosteuin that wiieti a heahliy cavity is ii|icned in the iivinji subject the bony walls are seen shining throuph with ivory-like whiteness and with all their ou "ines and ramifica- tions clearly (l(>fined. The nuicous surface is coated with ciliated epithelium, which |iro\ides for the removal of >ecretion, and the importance of tliis function is realized, when we recollect the disailvantap'ous |)osition for drainaf;e of most of the ostia. The imicous membrane is coii- rto. 483. Kn>zeM section of anierior half of hcHd. cut Initneflidtely in front of I'liiasma. ViewtMl from be- liiiiil P. Orbital roof of Irontal pinna, o. Ostium splienoiilaie. Y Y. Right anrt litt sphenoidal ■ aviiles. J M. InfiTlor ami miihlle tiirliiiials 1 (iptie nerve with ophthalmic artery, a. Thini iKTve. 3. fourth ntrvj. 4 First ilivision of tlfth nerve. :i. Sixth nerve. 6. Second division of lillh nerve. 7. Ophthalmic artery. «. Ophthalmic vein. (C R. Hoi..me».i ^iilerably thinner than the nasal mucosa: the mucoii« glands are much scantier. Sappey,' indeeil, only found them on the fioor of tlic maxillary sinus. Zuckerkandl- says they are distributed on all I lie walls, but that they ar(> neither so regular nor so numerous as in the mucous membrane of the nose. Physiology of the Accessory Cavities. In the history of medicine v.irjiius theories have had their d.'iy .-is to the function and ptirjiriso ' Trait,'- d'anatomie, tome . '.le partie, Je fasc, p. 741. ' Aiiatoinle aormale et pstl..loglque de« foaaea naaales, tmduit en Fmn^aia, IWi. tome i. p. 310. ."lit s 9;jo yosi-: AM) ruuo.iT. of tlic iiiicumalic cluinil/crs of the face. ( )iic ancient tlvory was tliat llicy served for tlie drainafje of the hrain, eonveyinp tlie iniieus and secretion of that or};an into tlie nose— the "clo;-.ca del cerehro" (San- sovino). Anotiier view was that they served for the ins|)irati()n of air which went to tlie elaboration of tlie " animal spirits." At one time they were regarded as resonating spaces for the voice, while at another it was thoufjht that they served for wariniii)i the ins()ired air. .\t times they have hi'en reKarde<l as serviii}; for the secretion of mucus to lubricate the nose; as assisting in directing tlii" inspired air toward the olfactory region: as accessory organs of smell; or as Iielping to diminish the weight of the bony cranium. That they can hardly contriluite toward the secretion of mucus re(|uire(l for lubricating the nose is evident from the poverty of glands and vess(>is in their mucous nicmbrar.e (i.uschka), and from the position of their ostia. That the hollowing out of the chambers would render the cranium less weighty appears at first a feasible suggestion; but if the cavi- ties were rei)laced with spongy bone the difference in weight would be so slight as to be insignificant. .\ more jilausibh' suggestion is that the hollowing out of the bones gives a wider attachment for the ))lay of jiowerful muscles like the temporals. Against the theory that they are connected with olfaction we may |)lace the facts that no trace of the olfactory nerve can be found in them, and that not only animals with the jioorc'st seii.se of smell have the best developed cavities, but certain apes and children ~ whom one has no reason to think are devoid of the olfactory sense — are practically wanting in sinases. The view that the sinu-ses help as re.sonating chanibers for the voice has again come into favor lately.' Etiology of Sinus Suppuration. The causes of sinusitis are not well-determined. They may be jirimary or secondary. By most writ •••< the majority of cases are regarded as secondary to some intranasal alTection. By others, such as Killian, they are considered to arise (irimarily in the majority of instances, and he appeals to E. Fraenkel's pathological researches- as sup,|)orting his views. rndoubtcdly many of th(> acute infectious diseases give rise to purulent intlamiiiation in the accessory sinuses, the most common being iiiHuenza. pneumonia, enteritis, measles, scarlatina, smallpox, and cerebro-spinal meningitis. Dijihtheria ami erysijielas may also he inentioned, and among the rare causes are glanders, mumps, and gonorrhcea. It has Ikhmi attributed to acute rheumatism, acute peritonitis, an<l also to contracted kidney. .Mercui'al ptyalism and phosphorus |)oisoning may cause suppuration in the maxillary and ethmoidal cavities. I'lumbism has been found to be a causative agent. I W Xrtvlor Siiclrtnth. The Aitmm <it lliKhnii>re iii «» Keiaiiou lo Vo'al ReaouuiHf. Jmiriial >• AmtTictiii Medicrtl Awm'iRtinn. November 17. 1^W. " Virrhnw's Arcliiv. I*"^"', Banil cxlill. ' WKgner. .New York Mo<lic«l Juiinml, Aiigu.it l'>. 1S9«. lH6t'ASi:s OF THE AViESSOUY SISrSES. 931 Aiiioti^ till' secondary cases are those wliicli are coiise(|iieiit on ciiryza, altlioiigh many of tliese doubtless orifiinate primarily ainl conleniporaneoiisly with the infection of the Schneiderian membrane. All processes in the nose associated with pus formation may induce empyema in the accessory cavities. Tiie relation of oza-na, how- ever, is still a vexed i|uestioii. There are numerous traumatic ctuses which are instrumental in conveying pyoRenic matter to the sinuses or in diminishinjj the natural resistive power. As examples may be mentioned the use of probes and canulas which may carry pyogenic organisms from a diseased to a healthy sinus, t'" em|)loyment of the galvanocautery, tiie misu.se of the nasal dourhe, the adoption of nasal plugs, the pre.scMice of flies and larva-, and even of vomited matter (Harke). Diving info water feet foremost is mentioned by Luc as a possible cause. Accidental intrusion of instruments and dressings will some- limes be responsible for the continuance of supjiuration. Occa- sionally the mucous lining is extremely tolerant, as is shown by the c.ise of (Jerard-Marchant, in which a piece of forgotten drain.age- tul)e remained in the antrum for tw(>nty-fi\T years. I'ortions of instruments, canulas, gauze, etc., may gain access to the cavity in tlie process of treatment, and (louly, in relating a case,' recommends the ;ido|)tion of forcible douching through an alveolar opening before having recourse to a larger opening. In this way he succeeded in driving the broken end of a canula into the nose tin igh the osliiim iiia:.-:ll(irt\ Baratoux" extracted through an oj)ening in the canine fossa one and one-half inches of laminaria tetit, which had slipix I into the antrum six years previously when being used to dilate an opening in the alveolar border. Fnin another i)atient he extracted a mass of cotton-wool as large as a small orange. It ajiix'ars that this material had been used by a dentist to stuff a hollow tooth: he did not realize that the carious cavity conuiumicated with the antrum, and the disa])pearance of the daily i)lup of cotton-wool was thought to be due to the patient having lost or swallowed it. I'xternal violence will sometimes sot up a sinusitis — c. g., blows over the frontal sinus — and when several siiuLses are affected with ch.ronic suppuration, operative interference on one cavity may, by obstructing the outflow of the others, produce in them acut(> symp- toms. The presence of nasal polyi)i occluding the natural ostia is often considered a cause of empyema: but the marked manner in which polypi cease to form when the dis(>a.se(l cavities are drained compels us to view them as usually the result rather than the cause of sinusitis. \ malignant growth, :us well as tviberculosis and syphilis, will give rise to purulent processes in an acce.ssori- cavity. Most of the chronic suppuraiions in the sinuses result from .""ute attacks, either from the intensity of the primary infection, or from Arrhivex luternat. <le Laryngol., inah. No. 1. ! Le ProgTbi MM., Avril «. 1»95. 032 yoSE AM) TilliO.iT. sccniidary iiifcctioiis. or tnnii luc-il or ficticml coiKlitiniis iiiit:iviifiil)Ic In rcsdliitiDll. Bacteriology of Sinus Suppuration, i'liis lias Imtii carcfullv stiidicil In- W. T. Hciwanl, Jr., and .1. ^[. Itificrsoll, and sumniari/cil as follows:' Acuii' and cliroiiic inllatnnialion of the accessory sinuses ot the nose are not caused by a sin{;le inicro-orfianisin, norCven by a single jiroiip of niicro-orj;anisiiis. It is, however, demonstrated that with a few exceptions (asjierjcilli and verin.si. inllaniinations of the cavities are caused hy hacteria. The bacteria found are those tli;it .ire coinnioMJy present in the buccal .'ind nasal cavities: in the fornier in health, and in the latter occasionally in healtlj, and usually in disease, such as acute and chronic rhinitis i lioth atrophic and hypertrophic), nasal tumors, and the like. It is interesting to recoirnize that the common aRcnts in the causation of infl.immations of other jKirts of the air pass;ij;es (the diplococcus lanceolatus, the pyojrciiic staphylococci and streptococci, 1 r b.acilli of the firou]) of Friedlaender's bacillus |H. mucosus capsulatusj, the H. diphtheria", and the H. influenza') are the most important and the usual micro- orfianisms found in iiiHammatory processes of these .-idjuncts to the respiratory system. The relation of the infectious diseases, both local and general, to these intlanuTiations is of j;reat importance. There are two jrroups of these cases: the first in which the acces- sory sinuses are invaded by a direct extension of the inflammatory |)rocess, as in acute and chronic rhinitis, corvza, influenza, dii)litlieria. pharyngitis, tonsillitis, tuberculosis, sypliilis, na.sal tumors, erysiiielas, and injuries: .and .second, those ca.ses in which pa.rts of the body remote from the simises are primarily afTected, ;is in ery.sipelas, articular rheum.iiism, |)neumonia. phthisis, meningitis, and suppu- rations in general, or diseases in which the whole system is involved, as measles and .scarlatina: in all of these the normal resistance of the simises is .so lowered that bacteria which read, them from distant parts by means of the blood, or from neifrhborinK parts by the spreadinjr of inflammatory i)roce.sses. set up inflammation. Fr.aenkel is the first to sufiRcst that inflamm.atorv proces.sos of distant parts of the body may be the sources from' which micro- organisms may reach the acc(>.s.sor\- siiiu.ses by means of the blood. Somi .f his cases .strongly support this view. Luc records the ca.se of a medical student who was attacked with acute fronto-maxillary sinusitis after making a post-mortem (m a case of pneumococcal meningitis. He had no dental caries. \ cul- tivation of pus from his empyema showed a pure culture of the pneumococcus.^ In the serosanguiiiolent na.sal discharge of an acute sinusitis which did not go on to a chronic .supjjuration the pneu- inococcu.'s has been found in abundance.^ In tiie post-mortems of I America i Jo\irnal of the .Medical Sciences, May, 1«98. • Liic. Revue heW. dc Ijirynnol.. July !,■), 1899. » R. Beniani. Ibid., IXiW. xviii.. i. .Vo. aj. i>ist:Asi:s or tiik avvehsohy sisvseh. D.-W many aciiti' iiitVclioiis Wciclisclljnuiii dclcctiMl ilic (liplix'occiis |ni('ii- iiMiiiia' ill the (liscasi'd accessory cavitii's.' I']. I'raciikcl. [)iiiu('hi)\vski, ainl ntlicrs have foiiinl various or;;aiiisms in cniiiycniala • luit tiicir siniplc cniiincration ilocs iioi assist the iiui'stion in;it('vial!y. More intcrcstiiisr arc tlic researches of Staiicu- Icanii and Maun, who found that th<' organisms of sinus supjjuration i,iij;ht l>e ihviiled into two ^roujjs: (1) Those of nasal origin, such usual organisms as pneuniococci, streptococci, and stapliylocorci, were chietly a('rol)ic, and the pus was not fetid: (2) those of dental origin, such as hacilUis raniosus, perfringens. thetoides. an<i stapliy- lipcoccus parvulus. were r.udnlv ariaeroliic. were found to i)e (hie to dental caries, and produced a fetid pus. In two cas<'s tlie fetor was attril)iital)lo in part to tiie hacteriuni coli.- Morbid Anatomy. The changes in the mucous membrane arc of a similar tyjH' in the various cavities, though in certain sinuses one |)articular form may he more marked and more fre(|uently met with than in another. They are es.sentially of a chronic inflammatory (■har.icter. and the changes in the tissues leading to a round-celled and serous iiitiltration are descrilied el.sewhere. Following on this tlure is polypoid and cystic degeneration, ))eriostitis, rarefying osteitis, and caries. In the maxillary sinus the mucous nioml)rane is genentlly swollen, -oft. and gelatinous. (Vsts ;md hemorrhages are met with. In rlironic ca.ses cheesy pus is found ui the villous and fungus-like pnices.ses of the degenerated mucous menihiane. Carious spots iiiMV he met with, especially on the nasal wall, where X\wy may lead to communications heing estahlishcd witii the etlmioidal cells, and through them with th(> frontal sinus. Zuckerkandl, however, iuis never ohserved caries ;is a result of empyema. In the ethmoidal lahyrinth, on the other hand, osteophytes are very rre(|uently encountered, and their jiathology has given ri.se to much discussion since W'n.ikes drew particular attention to them.-' (inmulatiiig osteitis, cari' ~ ilestruction of hone, and jiolypus for- iii.ition are all met with \'iy fre(|uently in purulent ethmoiditis. In the frontal sinus suppuration ap[)ears to have a special tendency lo produce grave secondary changes on its posterior wall. In the sphenoidal sinus erosions and necrosis of its anterior wall m.iy ( iccur. Polyi)i are rare. Acute Inflammation and Suppuration. Etiology. Acute in- llammation of the cavities forms a part of many acute catarrhs of ilie nose, from which it may spread l)y direct extension. Or it may • irise through the sw(>lling of the na.sal mucosa hlocking the cf)m- inuiiicition of the sinus with the nasal chamher. The confined .lir hecomes absorbed, and a hijdroiis ex vticuo takes place. This, ' wiener meil. Wix-l.i'iiBohrift. 1H90. p. -."-i:! ; IN93. pp. :v.>. 3S. - Ari'htvos Intenmt de Lrtryni£i)!'Hcit». I'.HH), xiii., Xu 3. p. 177. » BriU.-li Meill(Ml J:iiirnal. nt-crniUT IT. 1S',I.>. 'J.i4 SOSL AM) TllUo.lT. If il with a coiincstcd linini; iiii'inlinirii', is .i very suif;il)l(' niiliis anciit the arrival of any iiilVclivc uriianism. Kiit acute ititVctions riiav arise pririiarily in the sinuses, and (iri<;inate fmni any of the caiisi's alreaily enunieraleil. Acute exacerhaliDUs are not luicoinnum in the eiiurseipfchrnnicenipyeniala. Symptoms. The symptoms complaineil of are so fre(|uently asso- ciated wilii acute nasal coryza tlial reference sliould l>e made to the cli.apter dealinj; with the suiiject. The occurrence of a rijior or rise of temperatui; would indicale more than a simple c.itarrh. The symp- toms which chietly i>oint to the implication of a siruis dmin); an acute "cold in the head" are d;) pain in the region of the cavity, f;enerallv descriix'd as neuralgia, and i/() tenderness oii pressure, f.acrymation and photophobia may occur with acute inflammation in atiy sinus, althou;ih more conmion with affections of the frontal ami ethmoidal. Facial neural^'ia, ie(|ema, sliirht conj;estion, and tenderness are most often met with in the maxillary and frontal simis. A ileep-seated. • lull, heavy headache, with a sense of oppression ix'tweei! the eyes, is more often encountered when th(> siihenoidal sinus is involved. .More th.in one cavity may of course he aifected at the same time. Relief is obtained hy the discharge of mucus which forms part of the usual evolution of a cold. .Vs it is impeded it fre(|uently Ih-- comes jiurulent. The di-char;;,. ,v l)e bloodstained, and an acutely purulent inflammation i^ ,; relieved by ;i fn-e ^\A\ of pus, fro(iuently very otTensive both to shiell and taste. Oil examiniiiji the nose tiie usual evidence of acute rhinitis will be visible. If the anterior ^roup of sinuses is affected, the middle turl)inal will be p.articul.irly conj;ested, infiltrated, ;ui.l pusheil against the septum, while the meatus below it will be cloj^fred with stringy mucus, ami later on with muco-pus or jms. This discharge may terminate the acute stage: but occasionally the How lessens. an<l the .symptoms recur until relieved by a fresh gush of matter. When the posterior group is affected the rhinoscopie mirror will show a deeply congested .and velvety appe.anmce of the fornix and ;mterior s|)henoidai wall, and muco-pus will ultimately be vi.sible above the superior turbirial. Transillumination, to be describe<l lati'r, is often of much service. Treatment. The chief indications are to facilitate the e.scaiM> of the l)ent-up mucus or pus ;uid to soothe the pain. The principles of treatment are ( 1) rest in beil, I'l) very w.arm, moist compresses on the forehead or affectecl cheek, (.'{i fre(|ueiit inhalations of steam, medi- cated by the addition of a few drops of a 10 per cent, .solution of menthol in alcohol, ( I) antiseptic gargles, (it) anodynes, and (6) the (•areful u.se of warm no.se lotions. .\ sjiray of adrenalin may reduce the congested turbinals, and the same effect can be obtainecl by a spray of 2 per cent cocaine. If the maxillary sinus is affected any carious or suspicious teeth should at once be dealt with. i>/ii. ISA'S '>/•• Tin: .\<(:essory sisvsi:s. !(;t:» Ft llMS Im'CII rcCUllltllCllllfll toUtlClllpI tllCI'\|llll-i'l|Mit' till' <'(lllt('nt.S ul llu' ravily hy the iuliMinistratiDii of a rolil/d- iiillali< f air. Slid' a |irtn'i'('.rm« is of dimtitful ctlicary, ami '-vcii if it 1ic1|mm1 t«i ,iii|>lv one ravity it would risk scattering the cxiii'llcd cuiilriits in llif iniildlc rar <"ir clsfwlirrc. A Ix-Mcr plan would he tliat siip- (icstccl liy adopting llic Toynhcc in- lod for cniptyiiif; tlir inidillc rar of air— swallowini; wati-r while tlie nose is tirniiy held -so as to Mick liciuid secreted in the siinises into the throat. .\s Mion as free secretion takes place from the no.<e it can lie en- conraned liy the usual nie'liods. The neural};if pain is l>est relieved hy keepin-i the patient warm in bed. with tiie head well wrapixyl \\\^ in tlannel. A fi-w doses of antipyrine, or other coal-tar anaifresic or a hvpoderinic of morphine, will hest secure relief. The treatment otherwise is that of the accompanying coryza. and in the majority i.t cases is sullicient. If very urgent symj-toms are present the an- terior end of the iriiddle turliinal should be removed and an attempt may l)e made to catheterize the atTected cavity. An exteriial opening >iiould be reserved for extreme cases. Chronic Suppuration in the Accessory Sinuses. This form is (ret|uenlly referred to as an empyema, .ind has been described as • latent. ■' in order to distinguish it from the acute type-, which makes its presence known by the foudrovant symptoii.s, which indicated to surgeons of a former age the only form of empyema they recog- nized." The study and g<Mieral recognition of the latent form dates from the year ISSt;. wiieii attention was |)arti(nlarly directed to it bv Ziem. although an e.urly appreciation of sinus disease was mam- toleil i>v Spencer Watson in bs7.").' .\ chronic empyema occurs inudi more fieiiuently than was for- rnerh thought to be the case, and its diagnosis ami treatment call for much study and care, and tliis for tlie following reasons: ili There is often some as,sociated atfection (if the nose; (2) several simises mav be affected at t!ie same time: Ci) the symptoms are fre<|uenllv not characteri.stic; (4) direct evidence of the atTect-on or of its localization can sometimes only be arrived at by indirect methods: (.")) the etiology is not well established, and most of tiie cases take a common origin from the nasal cavity: fd) the prognosis has to be verv carefully con.sidered : (7) the indications of treat- ment varv considerably in different cases: lience (S) the impor- tance of a comjilete diagnosis of all the sources of nasal suppuration: il») the aHVction tends in certain cases, as yet not well-determmed, lo fatal seiiueke: tinally (10) the treatment retiuires considerable si udv and skill, and is mit devoid of danger. Frequency of Suppuration in the Accessory Cavities. It is difii- cult to determine what proportion of patients are atTected by em- pyema. Fein leporl.- that among 22S() private [lalients of Chuiri 1 W. Spencer Walaou. iJiKjancs of ihu Nose and lt» .\cctiSMor)' Cavities. LoudiMl, H. K. Ij^wia. \)M yttsi: .iM> ruiin.ir llitTf well' I") ciiMs uf acccs.-".'v sinus siip|(iii;itiiMi. Liclitwilz' i-ii ciMiriiiTcl -.'l.l caws aiiKiiin l_',(KK) patii-iil-.. ' Kuih ilicsc sialistio tuiiiciilf ill ^iviiijt ail avciaKi' of alHiiil 2 |mt rent of tlic iiaticnl- prcsciitiii); tliciiisclvcs at a tliroat i-liiiii'. I'Viiiii posl-iiinrlciii uliscrvatioiis we liavr several sets uf statistics in rejjard tu empyema: lUrki' r.iiiMil 111 cuMiifalniultli . ... in tKi csiUvvm.' E, KrHviik.l loun.l •« •• •• In Urtc«.laviT.'' I.H|ii'llfi>n<l Manlh t'linnil 71) •• " In 'Jiiii rulitvi'n.i '<''"■'■ f"'""l *" ■■ inl;i,-.c«.lHv.T!i.' Tliesc fijiures give an average nf over :«> [x-r cent, uf sinus ili.sease in all sui>jects cominji t" the deail-liuuse. The hrst idea suggested hy them is that we must, in the living suliject, overlook an immense numlKT of cases: but a critical study of the ahove reports shows that many slight changes are recorded as sinus disease, and hesides we have no means of judging how many cas«'s originated only in the last lalal illness— often some infective alTection. The conclusion is. however, ilouhtless justihed that a fair number of cases do escape detection during life. Tliese post -mortem observations agree with the majority of clinical observations in showing tli;it the m.axillary sinus is the iiiost com- monly di.se;i>rd. Killiaii is of the opini<Mi "that the alTectioiis of this smus only unilateril or bil;it<'rai -form one-half of all the ca.s<- we have to treat.' The distribution of l.ichtwitz's 24;{ ca.ses -aUo showed that the ;iiitruin of Ilighmore headed the list. His figures give A Mniflo inaxlliary suiiL"* 1'* tltii "i Hcilh ■• ■■ . . '^ ..' ' A ultiKli' splu'lKiidul " . . . . . . ' 17 " B<i(ll ■■ ■■ . . ! 11 •• A single frmlal " r, ■■ """' " " ....!.]'.,'.. Slt-.;le fliiuioid '. .. Ikjlli ■• ......',.. In the remaining 22 cases the sinuses were mon mi.xed, but the following Were .atTected: Maxtllttr.v !iimi« iQ,i„ Sphemiiilal • n •■ r'rr)ntal " . . . . iii ■> Ethmohl ■.....!]' 7 .. l'ansinti>iiU!4 ' I .. It will Ih> noticed in these figures of Lichfwitz's that the sphenipidal sinus IS, next to the maxillary, the nio.st frei.uentlv disea.sed. This .sc-iiuence is supported by Criinwald. wl- . has ojjeiied .ll sphenoidal sinuses and has only found it necessary to do the external operation on 14 troiitals.'' I Wi'jner k!in. Wi>ehi.-n.ii'hrif( MM V.-. '^ ,. 7^.1 ' (Jnntol by F Martin. De la Kr.-iiufnce ile lEmpy^rae. Bonleaux, 1911O " (inoie.1 In Thiso of F. Martin. < The Unnuiw-oie. '\im. vi.. No, 2 p 81 ' Heymanns llanilhuch iler Ijirynnoliigic. Wien. liHHJ, Band iil. • Urilnwttld. Nasal i^iippuratiou. insE.ishs Oh' rut: AcvEssouy simsks. lt.)7 To show liovv (lifTcrcht schools aiid oltsi rvcrs vary on this |M)irit It is siillicit'iit to i|Uotc Hoswot'tli, who is of the opinioii that true [iriiiiaiv ihscascof thcsiihfiioiilal sinus is vi-ry ran-. Hi- hail (in ISil'ii only seen two uni|oiil)tci| cases of it, to one hnndriMl and fifty of cthnioid troiil>lc,' which he regards as "iiy far the most frt<|Mt'nt of all diseases of thi' accessory cavities."- In this he is >ii|i|iort('il hy -nine recent statistics of John Muckie, who found "lOof his cas<'s dis- triliuted as follows:' l-.llimiilil 41 ilmw Maxillary - . 11 ■• Kmtital ...... II ■' S|ihciii)idHl * ■• I'vidently. from the divergence i>l the.se opinions, certain ("avities wlieii diseased arc more apt to he lliagn"^■'d liy .some oliservers than \>y others, ami therefoO' we may conclude that a fair numlx-r of cases -till esca|K' detection in everyone's practice. Symptoms. .\n em|>yema in one of the acces.sory cavities of the nose is often only referred Ui hy patients as a "chronic cold in the iicad. " if ins|M'ctioii lc I's to the discoxcry of pus in the nose, e--pecially if it is one-sido <he prohahility of an em. "m;i is at once manifest, r, \ the aj)plieation of certain tests will r i i' ' s presence iriiaiM Hut in a large numlwr of cases the .sympto. . v Im- more reiiiiiii . .iiid attention may only Ih' direcli'il incident.aily, if at all, lo nasal tronhle. It is imdoulited that a Large numhcr of cas«'s are ovcrlooktij in practice in conse(|ueni'e of ;i want of knowledge of llie niim<i'ous results which may follow on chronic suppuration in 'ine of the pneumatic chamliers, Ahhough tliese se(|uela' should, -trictiy speaking, l)e considered as complications of the atTe<-tion, it ,i|ipears more |)raetical to consider tliem as sym|)toms, and in the liist place to p'view such of them as may occur with pus in any cavity. Symptoms Common to Empyema in any Accessory Cavity. Presimiptive Evidence of an Empyema, The one constant cause lit the symptoms is the presence of pus in one of the accessory cavities of the no.se .•uid its slow outflow into the n.asal chamhers. The syinp- iniiis this condition will produce may \>v grouped in three cla.s8«'s, ■IS suggested by Lichtwitz:' I. Symptoms in iieighl)oring regions — the nasal chamhers, pharynx. eyes, ears, lie.ad, and face. II. .Symptoms in more distaiii organs — lower respiratory tract, digestive tube, etc. I!!. Sym[)toins of interference with general healt!! — prostration, loss of Weight, fever, ete. I. Symptoms in Neighboring Regions, 1. N'.ks.\i. Symptoms. The two most usually complained of are f«) ohstruction, and (7)) discharge. ' Transa^-lions nf ttu' Americnn ljtr>'nfrnlogical Assuciattoii, .Stvfntuuntb Congrew, lfl9.'>. - IWil,. si.xteemh Congress. 1M94, p. HH. ' British Molical Journal. September js. I9(i!. and Journal of Ijtryngology, 1901. ' Aniiiil|.m1es niiil. .Ii> I'oreille. etc., IXidi, Uimc ixii p. 113 h' ; P 'j;i<s .YO.SA' AM) TllliO.W. Tlif iilislrKcliKii may be uiiil:it( nil or hilatcnil. It varies according til the MiiMPiiiit of cxcrctiini. tin- position if till' hcail, tiic time of dav, tl ic genera ral licaitli. tiie weal lier, tlie cavities afi'ected, and any recent increase o: owin f "cataiTli." It is usually worse m ( tlinioidal affections <; to the develoiunent of polypi. The discharge is more marked to accumulation having taken place in in the mnrnnig hours, owni the nigiit : and also w hen the heail is In-nt forward, and during cold dam| ) weather. The ili.-<rli(irtir may tlow forward when the front group of cavities are a ffected, or backward when the po.-terior arc concerned, lint there are exceptions to this, and the outHow may take place hi both ts maiiv varieties of luuco-pus and pus, Ix'ing directions. It preseii vellow or green fluid or (Irving into crusts, and it also varies in amount the aine wav as ( Iocs the obstruction. Mriijihii of the nasal mucosa occurs in so many instances that everv case of atrojihic rliinitis should Im' reganlecl as ])o.s.sibly Ik'j due to accessory sinus sup] iiiration. Ciriiiiwalil is even of opinion that it has not lieen established that oza'iia rejiresents a pathological entitv. and. although many are not prejiared to accejit this view, it i ited that in jiroportion to the greater fre<|uen iindouhteii Iliai in |iro[)oriioji lo me nuan-r in-,ni,ii. y with wliich .sinus disease is now recognized in our clinics, cases of true fetid atrophic rhinitis have become proportionately (liminished. H;ipvrtn>i>lnc rhinilix i.s 1ps.s often met with, but is found in early stagi's. Sometimes the two conditions are present togethei fihituhs cisrosii is so frciuentlya symptom of shii'^'i-. chiefly of the antrum of llighinore, iliat Luc is of opinion tu..i it does not exist as a separate |)atliological entity.' Xasdl jutliipi are so suggestive of disease in the accessory cavities lliat Criinwald has stated hat "polypi in a majority of all ca.ses are almost as good as |)athogiioiiioiiic of einpyeniata of the acces.sory cavities, or focal suppuration in the nasal jiassages."- Disiinlrrs iif siiirll and UiMv are often indicative of the disease. There may be parosmia or eoinpiete aiiosniia. More fre(|uentty the complaint is ni an intolerable cltliough intermittent cacosmia, always worse, as the patient puts it, " \\hen the discharge comes away." Thi- sinell is seldom |M'rceptible to the patient's entourage, and this helps to distinguish it fn.m the smell of true oza'iia which can Im" p'l- eeived at s<inie distance, lilthongh undetected by the patient herself 2. is Nasopiiakvnx and Pmai{V.\x. Postnasal catarrh is .sonn - times the only symptom a jiatieiit will coin|)laiii of. Tornwaldt's disease, or bursitis pliaryngea, is considered by Ziem to be merely a symptom of suppuration in the accessory chamber- nyiMilH' e( (It'R CBvitu^s s('rcsw>Irej* 'les fn-^ - I l.uc. Ix'viins Hir le» niipinimtioiisile" I'lireilli.' tia.'iuli'S. Paris. I.lhrairii' .1 H. H«illiin>ol Ills. lilOil. |i. ■-'-'T. - (iriituv.i!;!. NttyH! stippnr**'"*" Tf'in^lHltHl l,y I.iiiilb. Londnli. I'.KXI. It. M7. ' >;iein. IVNt ri'tnmasHl Kiilarrli imd wnft'iiimnli' Tcirii\v«MI«cli Menials.. l«!m. N" 4 /iem. NcK'liiniiN die wiircnimnli' Tiirinvnldt''«'lii No. !■.. Krankhelt. rhemin Kraiilihilt. Wiener klin. W<icheniichrtfl , I- DISEASES OF THE AVVESSOHY SISLSES. 939 IaH.u,uation. suppuration, an.l J^^^^ ^ ^ .S^^J'S' u^k „,,atiuo tonsils, tlj. P»f=-y:-;4^; , f-.n S^^u t1u>^inusos. ,„av 1..' symptotnutic of tl.e '';^^"; ''' th.MUsolvos in the first ,ZX\^%^ZCi. ^""^^ '" •"' »^« --"" ,vtro-..cular phlcfinion. etc ' '^,, ; ,/'. "^.."^ (ti/,Un.inuti..n of the ;;,";t „,„«• n-n-,. l,,. l.,.., .....n; 'X'"S^^ .....■.' ■»»' -«- :i»^7^'' fit lEEfe;^^^^^^^ .vinptomsofan cmiiyoina. Thk Larynx. Unox- H. symptoms m More f;»°** J"!f 't/ i^^vn-ritis and hronchiti., ;:;:::;;!; ™";;;;;i;s, :;r.«n:ii;^"'r»:;: ««... .. ... ...ryn. i< nii't with. »u..,„t;,. ntt'ipks ami rocurrpnt out- Cliroiiif l)roiu-horrii(va, asthmatic attaoKs, an. f It. .,. .,„,,,,..,..,.».■...,,,.„» ■|;;'i-|;„'>"»;;i ■■',*, tmST .» puliiionarv tulxToulosis havo m Nariou. .vini.ton.atic of al .sorption of nasal pv^^ stomach ul.stinatc voiniliiiK and (harrhita. , .,„.,.s„en. ...e,.U„„„n...K.„..,S,nu.wU.ca«.. .ua.e.y Me.c„U„ur„.. O.U..r. -T';r^r ";;:;'i;:::r ..rt^v ':^:.:u. u.«.., or .« «.. .o„n.. . .^ AiiKTlcan MwllCHl AMOclatl.iii, Sovcmber 11, 1ks». ^■nr I'^K^w; MJit 1 ^'j^'^^w^i': ^^ ^'W^ ?s*."^» . 940 XOSE AXh THROAT. I \'ti!<i'ulfir Sjislcni. I'lilchitis and l)ra(lycanlia liavt' l)oon foiiinl associated with the affection uniler consideration. HI. General Affections, .\nioiij; the conditions which have in some instances JK'en traced to a sinus enijivenia are tliose of jjeneral ill iiealth, loss of weight, and feverish attacks simulating typhoid or malaria, with or without septicemic metastases. Insonmia or, on the other liand, marked .somnolence durinft the day have been traced to this cause. Various cerebral conditions are not infre(|uently traee- .'ihle to it, sucii as irri'-d)ility, loss of memory, lanfjuor, weariness, stupor, aprosexia, neurasthenia, melancholia, and weakened resist- ance to the action of alcohol and tobacco.' .\t the meetinj; of the .\inerican Larvn<;oloj;ical .Vs.sociati()n in 1S94, Mosworth relat<'d tiie C!is(> of a patient who was restored to health by treatment for eth- moiditis after ten years of suffering from ajjrosexia and m(>lancholia so profound that he had meditated suicide. The case is interestinjc from the long li.st of medical and surj^ical measures which had pre- viously l)een resorted to without effect.^ Intracranial Complications. .Most of the complications wliicii may follow on su|)purati()n in the sinu.ses have already Iwen referred to in coiisideriufi them as symi)toms of tjie unreco}!;nized condition. It i.s sufficient here to direct attention to the most serious of all the possible se(|ueUe of na.sal su])puration, viz.: intracranial complica- tions. These may arise secondarily to suppuration in an_\ cavity, althoujjli with a simple case <•' 't-axillary sinusitis it is a comparatively rare continjieiu'V.' Extension to the base of the skull has been demonstrated in many instances, and |)().ssii)ly takes place more freipiently than is sus])<'cteil. These serious complications occur in both acute and chronic atTe<'- tions. They may arise (1) by infection of the diploi'; (2^ by in- fection throujih the venous or (.'J) lymph channels of the bone, with- out any palpable trace of the route of infection: (4) by caries and destruction of the sinus wall, so as to allow of the pus coming into ilirect connnimication with the meninges: and (.">) by mischief-spread- ing along the oplith;ilmic vein to the cavernous sinus. When the bone becomes infected it may give rise to a slow and apparently irresistible septic osteomyelitis of the cranium. If tln' infection traverses the l)one, leaving the Latter int.-ict, the result ni:i\' l)e a cerebral abscess, or thrombosis of the superior longitudinal, cavernous, or petrosal simis. When the duni mater is exposcnl the result is an extradural or cerebral ab.scess. or a jiurulent basal >>y general meningitis. .\ny combination of these complications ina\ be met with. I'ntil the acce.s.sory sinuses are examined .systematically in po.-'- ' Wnlter A, \\\'Vs. Si)iue Nervous and .MuiitHl Manirit<tati>inH 0<-currln(f iu Connection »i:li N"-j' [*ip4?MMr. AliKuIcMii .ItMUlitil ,ir [Iio McIiCul ;-M ieliotK, Dvcmabvr, 1S9S. » New V'Tk Me<tlral JournHl, October M, IsiC. I K. Dreyfus Die Krankheiten dea ilehirnii iiml 3einer .^dneia im Folge von .Nasenelliniun' <i. Fixher. Jena, 1H96. ,UU41.f" DISEASES OF THE ACCESSORY SIX i'SES. 941 nu.rt.MiK (111 all fcrchral (■:is<-s. the true source of nmny inf«'Ctioiis must .■si-ii|)<' (Ictcctiou. Those which have been revealed have gen- n-illv had attention directed to them by some antecedent nasal ,,,'„.rition It is not fair to at once attribute the fatal result to Mir.'icai int<Tference, for cases have been recorded m which some Mlhcr coincident latent affection has been the true cause. Still the tHtil issue in some cases has U-en apparently precipitated by surgical inatinent which has interfered with drainajte from other sinus(>s whose diseased condition had jM.ssibly not Ix'en susiM'cted. These (ciisi.lcrations explain the importance which lias already bwi laul mi makiiijt a complete diafjiiosis, if possible. l)efore initiating any ndical measures, and of following a certain seiiuence in treatuiR mVix.mI cases. It is liardiv necessary, in addition, to emphasize the uiipurtance of strict asepsis on the part of the surgeon so as to ,v..id the imiiortatioii of anv fresh infective material, the avoidance nf n.i.sal ')r other plugs which might interfere with free drainage, and ilie iiromjit recognition and treatment of any of these coniphca- Treatment. It is onlv possible here to n'fer to the importance of ■it oiice relieving all tension in any suspected case, and, where neces- s.ry. of opening the cn-iial cavity. With spreading meningitis little is to i)e expected, and septic osteomyelitis apj)ears to be a jia icu- laily malignant form,' but in other cases it may still be possible to 'prognosis. The majority of primary acute cases tend to complete res„luti()n, although the progress may be irregular and the attack hist for a few davs to, with relapses, a few weeks. it is the acute attack sujjervening on a chronic affection which proves most intractable. These very acute cases are less freciuently lui't with than formerly. Still, if unrelieved, the acute suppuration nnv lead to acute distention of the a.'fected cavity, which may ulti- un'telv riiptun-. Thus an acute maxillary sinus abscess may burst thn.u'-'li the cheek below the orbit, the canine f< sa, an empty tooth socket, or even through the hard palate. An acute collection of pus III til th( ital sinus may point anteriorly beneath the inner part of "yelid: or it "niav rujjture into the cranial cavity: or by ,e veins of the diploi- give rise to spreading septic osteitis velitis. The roof of the sjjhenoidal sinus is not likely to ' . recent acute attack. Retention of an acute formation of in ethmoidal cells niav also burst into the orbit or the cranium, from their anatomical connection these cavities are more likely to I'liiutv into the nasal fossa-. When more or less complete obstruction leads to threatening symp- toms the dominant one of pain generally points in good time to the iMcessity of intiTvention, and secures its acceptance before dangerous !!iii!p!jc:itioiis arise. ' Luc, J..urn»l of Ijurngolow. September, liiW. Tilly. Ibid. vu pus llllt 1142 A'OSK AM) rmtOAT. Ill tlic clirDiiic fiiniis tlicrc is littli- tciuloncy to spontaiu'ou.s rc- CDVcry. Jonathan Wriglit lias expressed tlie opinion tiiat many cases must tend in time to natural recovery. Tiiis view is unsup- ported l)y clinical reconls, and most observers are forced to the con- clusion that an estal)lished empyema shows no disposition to dis- ap|)ear, hut, on the contrary, tends in time to infect other accessory cavities. Slow and insidious changes in the diseased cavities are often only revealetl by the sudden development of (jrave intnicranial coin|)lications. Temporary alleviation is very common, and the symptoms in some cases will almost entirely dis;i])])e;ir durinj; fine weather and when the patient is in jjood health. Such improvements are often attrib\ited to climate, and ;ire apt to be deceptive. The dangers to health vary very much in ditTerent ca.ses; in .some a lifelong; "catarrh"' causes little more than a trifling local incon- venience. In others existence is rendered almost intolerable by a suppurating focus. The dangers to life are saiil to be lare wh(>n we remember the small proportion of fatal cases to the freciuency of the disease. The prognosis will depend on I'laiiv general considerations, such as the patient's age, temperameii' , general health, and occujiation, as well :i-- on the cavity or caviti( s atf'ected, the indications of secondary (iianges, etc. In all c.ises a guarded prognosis should be given ;;s i.;;ards .hiration of treatment and completene.ss of cure. Final diagnosis is often only jMissibie during a course of treatment, as after one cavity has been dealt with it is found that another calls for investigation. In many cases, while decided improvement can be promised, the necessity for continuous treatment should not be denied, and a certain amount of mucopurulent discharge may have to lie tolerated. Chronic Suppuration of the Maxillary Sinus. Si/nditiims: iMupyenia of the antrum of Higliiuore: maxillary sinusitis. Symptoms, ''hronic sujiiiuration in this cavity may follow on an acute attack, or may develop as a "latent" affection. When any of the iiresumptive symptoms of an empyema are jiresent th<' discover' of decayed teeth . houlil attract attention to the antrum. Mveii win;: the teeth api)ear sound, careful examination by |)ercussion ami transillumination iiia>' reveal a root .ilTectioii. ft has lately been suggested that if the tuning-fork is applie(l over the upper teeth ii will -lot be heard by the patient as distinctly on a diseased as on ,i healthy side.' If the secretioti of |>iis is so slight that it only occasionally over flows into tiie nasal chamber the objective syini)toms are projwir- tionately slight, ami the diagiiosis the more difficult. In such case- the patient may coin|)lain chii'fly, or only, of a haunting cacosniia. I''aeoachp or neuralgia may Im' the only complaint. The j>ai!' ■'■ 1 D A. Kuyk. l.:ir}llKi«ic)|ie. IWU, x.. N" J. l> 106. DISEASES OF THE ACCESSOKV SIM'SES. y4;i tciidcrncss is ftcncrallv over the facial siirfacf of tlic sii|)<>rii)r maxilla: l.iit it may 1m' rcfem'tl entirely to the frontal region. It fre(iiiently presents a" certain periodicity, increasing for son!" hours after nsmg in the morning, and then disappearing as the day g(H>s on. This is explained by the accumulation of the night escaping from the cavity (luring the earlv working hours. A colleague who liad lived in the tropics had diagnosed his own ca.se as one of "hrow ague," and was unconvinced of tlie correct diagnosis until a fearfully foul col- lection of pus was exiM>lleil from iiis maxillary sinus. When the >,^ifl()w of pus into the nose is more decided and eon- liiiuous, other svmptoms are added to those already d(>.scribed. Sometimes the secretion i)as.ses so rapidly backward that it may be readily overlooked, or mistaken for postnasal catarrh, or an affection of the po,sterior group of sinuses.' In doubtful cases the patient ■ihould always be examined in the morning hours, as after midday the s'luis has often become so emptied that no pus overflows into the nose during the rest of the day. Fio. 4M. TransilluminiUng lamp. The lower fl(?ure shows the removable Rlai* cap. The upper figure shows the vulcnnlle (u»p as U!*<1 with ihe fruiiial sinus. lu^]wdion of the nostril on the affected side will generally reveal pus in the mid.lle meatu.s. It may liave accumulated in the lower meatus, or bv capillarv attraction may have travelled up between tiic middle turbinal aiuf the .septum into the olfactory cleft. It is seen ill the posterior choana lying below the end of the middle turbinal. The origin of the pus can be i)artially determined by carefully wiping away every trace of it from the na.sal cavity. If done with pledgets of clitton, moistened with a lOjjercent. soluti(m of cocaine, the in- spection is more complete. The detection of a swelling between the concavitv of the middle turbinal and the outer na.sal wall— so-called •cleavage of tiie middle turbinal," or Kaufmann's swelling— lias been considered as in<licativ(> of an empyema: but it is found with pus from the frontal sinus, and has i)(>en seo.. when no (Miipyema \v;is discovenible. It a})i.>ears to be due to inflammatory thickening I Brady. Journal nf Ijiryngoluiiy. ovember. ISW, xlv. p. 6M. i!i }t44 yoUE AM> rilROAT. ovcrtlic jiroccsnus iiiirinaliin — the lower lip of the iiiiitus scniili.ii, ris - and iiiifjlit hr iiiiliiccd hy any irritation. After waiting a few minutes the nose slioulil again Ih' ,ii: jvc'ed, and if pus lias reappeared in the middle meatus it would :ai-e »ne suspieion that its origin was from the frontal siiuis or aiiterio'- eih- moidal cells. I'osfiirc Tcfl. SupiMisinjt the pus does not siKH'dily make its re- appearance, the patient should lay the head well 'orward iM-tween liis knees, with the atTecteil side uppermost. This test (known as Knienkel's) brings the ostium maxillare into the most dependent point of the simis, and so facilitates tiie outflow of any liijuid con- tents. When the hi-ad is niised and tlie no.sc again ins])ecte(l, a stream of pus will Ix' found in tlie middle meatus. Although, in the ;il)seiice of other sym|>toms, these points may indicate the maxil- lary sinus as the source of the pus, we unist proceed with our ex- amination before we can speak positively. I'olypi and granulations in the middle meatus are often st.ated to he suggestive of antral disease: hut in uncomplicated ca.ses they are rarely met with, ami their presence generally points to infection of the neighboring eth- moidal cells. KlG. 4S,'i. Fig. 4»6. Flu. 4S.'> -TrHiisllliiniliiation of Iho frontal sinus. Shows how the niiius on the right side i» lit "p. while the left remains ohncure. (StCl\ir Thomson.) Fiu. 4«(T.— TranBillunilnatlon of th' maxillar)' sinus. Shows on the right side how the cheek ie lit ii|i. a stmiliinar t)and of llglil apiit'ars bilow the eye. ami the pii|iil is ill\iminate<i. On the left slil.' these results are absent. (StClaik Thomson, i The /c.v/ 11/ tranyilluminnliiin. chiefly develoiMvi by Heryng, will sometimes afford strong confirmatory eviclonce. It is applied in the following way: It retjuires a small o-candle electric lO-volt globe, of about 1 amp("'re current, enciseil in a glass cover which can be detached and disinfected. (Figs. 4S.") and 4S(>. ) 'I'he examination must take place in a completely darkened ch.-uiiber, or else the head- of both patient ami |>hy.siciaii .should lie envelojieil in a thick black DISEASES OF THE ACCESSOHY SIS USES. 1)45 I'Idtli, such as that used by i)h()tORrai)h('rs. Any dpiitiirc present liaviufi been removed, tlie lamp is intr<HUi(e<l intc the eentre of tlie patient's mouth, an<l the current switched on. In normal condi- tions tlie rays of lij;lit pass upward and outward unopposed through tiie iioliow cavities of tlie face, produciiig the following results: 1. A ditTused glow of light over the lower part of the cheek and iH'tween the separated jaws. 2. A semilunar patch of light immediately below the lower eyelid, caused by the jjas.sage of the light-rays through the anterior part of the orbital wall of the sinus. ;{. .\ subjective seii.«ation of light by the patient, as the current is switched on, sometimes more marked when the eyes are kept dosed. 4. Illumination of the pupil by the rays penetrating the sclerotic. so that the centre of the eye is lit uj) and glows like an animal's in the dark. In a healthy subject all of these may be present, but some are of more freijuent occurrence and of greater value than others. Thus the third and fourth points are freciuently wanting, and the second is the most valuable, and should be most carefully looked for. When jius is jiresent in the antrum of Highmore the passage of tl.( rays is so obstructed that all these phenomena are diminished or abrogated. Tliis transillumination test renders more .service if only the siims on one side is suspected, when positive results are easily contrasted with the opposite side, and would lend strong contirmatory support. On the otlier hand a negative result would tend to indicate that the pus seen in the middle meatus came, not from the maxillary, out from the frontal sinus. Transilluinination may give positive results in the absence of an empyema, owing to — 1 . Small size or complete absence of sinus. 2. Abnormal thickness of bony tissue. 3. Permanent thickening and opacity sometimes remaining in the lining of the cavity after complete cure of suppuration. 4. Presence of a malignant or other neoi)lasm. Transillumination may give negative evidence, although the antral cavity is diseased, owing to — 1. The cavity hapi)ening to be more or less empty at the time of examination. 2. The bones being particularly thin and translucent. The test must not, therefore, be too much relied on. If positive, it may arouse a suspicion or confirm other symptoms. If negative, it may point to other cavities as the source of the pus, or inayonly indicate the necessity of seeking for other signs. Thi' onlv conclusive evidence of a maxillary sinusitis is the ex- pulsion of pus from the cavity. This is done by exploring the cavity from (1) its na.sal wall; (2) the alveolar border; or (3) from the caiiihc fi).s.sa. Kxploratary Puncture of the Antrum. This can be carried out under .adrenalin and cocaine. A good-sized pledget of cotton soaked 60 11 I 946 XOSK AXn Til II OAT. wilh a 10 |)or cent, solution of coraiiii' is tiiri<cil well uinlcr tli<> inferior tiirbinal, so as ♦(> aiuustlictizc tin- outer wail of tlie inferior meatus. The anterior part of tlie septum sli..ii!il also he anu'sthetizcd. as the hilt of the nee<lle may press jiainfully against it. .V stout hollow neeille. eithe'- sir.iicht (Liehtwitz) or curved at the extremity (Sclurdt, .Myles). is ftuideil hijfh ui umler the con- cavity of the inferior turbinal. It is then pressed apiinst the antral Fill. 4K7 ■«#= k*»»*i.tktH Hollow needle for explonttor)' puiictun; of the ra«xill»ry ptliius. wall at a point which is judged to be about the junction of the middle and posterior thirds a point much further back than is penerally sup|M)sed. The patient's head being steadied with the left hand, the needle is pushed gently in a line directed toward the outer angle of the orbit. The shaft of the needle is gnusp'd about half an inch outside the nares, in order to prevent it plunging too far into tht; Fig. 4»s. MyleK' trocar ami canula. sinus, and so traversing the cavity and p(>rietrating the orbit. The point of the needle being felt free in tli.^ sinus, a llustachian catheter bag is now attached and air pumpc ilirough the cavity. If the na.sal cavity is kept under observatii i. jnis and air bubbles will be seen making their exit from the Pinion of the ostium maxillare, while frequently the foul odor of the .secretion will be only too per- FlQ. 4»9. r^J;^^Jfc=a=^ -^ Curved hollow needle for explomtory puncture of the maxillary' sinus. ceptil>le. This is followed by syriiiging a tepid solution of sterile normal saline fluid or of boric lotion through the hollow needle. This should be |)ropell<'d with some force, as the secretion maybe very inspissated, the cavity very tortuous, or the natural opening obstructcil. The pus ex|K'lled is goierally fetid and freiiuently Hocculent. \ small amount, or even a decided turbidity, of the lotion is sufficient inshAsES OF Tilt: AccKssoRY sisrsjis. 1)47 ,„ «.ttl.- tl.r aiapiosis (.f oininvnm. Who., tho l..t.on c.m.'s away ,.|,.ir thr Kuslachiu.. l.:i>;shou!.l iMjai.i !«■ coi.iM-cto.l w.th tlu- oxplor- ,„.' ...■.•,11c. !i...l air fr.'.-lv i..s..lIl:.t.Ml t.. .'XIH'I any ro...a.i..i.K luiu.'l. '"«;ho.il,l thcs<> ..ru.-.-(vii..(rs fail t.. nvcal a (M.ll.'ction of pus a small ,,„'.,„titv ..f a 20 ixT .•.M.I. >ohiti..n ..f 10 v..l. hydrogen iM'r..xulc is ,,„V,..l.ir.Ml ...to tho simis. wl..'.. tl..- ..iTerv.'scM.c.' with a..y pus will |,iil>l)l.> out into th(> meatus. , , , „ ^v, ,„,i Hrnloration oj the Antrum from n Tooth Socket. If. on the susix-cte.l .„|,.' wo fi...l a carious bicu.spi.l or Hrst m..lar, or if tho tooth sockets .,,,. "..niptv w.> can not oiilv explore the cavity from the alveolar |„,nler hut at the sa...o time initiate the troatn.ont by .Irainage. If nocossarv the cario.is tooth can In- remove. I im.lor tho san.e ana-s- thcV.-i .,r.-ferahlv that of nitrous oxi.le gas. A large-size, han.l- .Irill is employed". ( Fig. 490.) Some prefer to employ a .iontal engine PIO. 49a AckUnd^B h»nd-drtll for opening the n»xiUar>- »lnu. from a tooth socket ora..ol.^ctromot<.r; but th.-y are "»f f^«\2^ '^^V £ Z t of „..l 1..SS certain tlian an instrument guuled by the han.l. The pou.t o th.. drill is .lirocte.1 vertically to tho alveolus and in a plan.' with ,1... .•.-ntn- of th.> patients eye. Firm pn'ssuro, with a f.>w rotator> ,v. .-nts, is sufficient to quickly p-rforate the fl..or ..f the antrum^ 'n... drill is prevented from plunging in too far by the operators tlnin.b tixe.1 about half an inch from the margin. [ pr,.liminary ins,x>ction v !1 h.-lp to a...ure the success of t ns „n...a i..n. Thus, if the facia urface ..f tho superior maxilla is ^er^ ! ." the hanl palate arch 1. an.l the nasa chamln-r o.. the sam.> . wi.l.-r than usual, greater care must be taken in scnng that le , , 11 d...-s ..ot .niss tho antrum In- passmg (.) outwanl Ix.neatl. 'k (h) inwanl thro.igh tho Ho..r of the nose, or even <■) int., th. ,;;!.; of tl... .....uth. it i. rare for this simple o,K-rat.on to be attende.l with a serious hemorrhage.' Fin. 491. Mailllary sinus drainage-tubes. .\s th.> .Irill is withdrawn tho escape of pus will often confirm the diagnosis. When th.- patient has roovercl fro.n the anirsthos.a the iotio.. a.i.l air should b.- so... through the cavity, a. already .lescnbed. 1 -ichcppcgrell .lournal of ..Hrynsology, im. ii.. No. 9. p. m. (! It4« SO-St: AM) riHtn.lT. opciiinj; and a i)oriiianfnt ilniitiaKf-liihc slimild Im- inscrtcil. If tlic result til' the I'xploratiuii is negative, iii> harm is iliiric, and if the is left aliini- it will clos*' up in twfiity-foiir hours. Exiiloratiim Ihritnijh tiw Citnlitr Fossit. Thi^ route is unsatisfactory, as it is more painful and not well suited for estahlishiiiK treatment. !t need on'y Im- adopted when no tooth socket is available, when attempts to explore the antrum from the iio.se have failed, and when the diagnosis eaiinot otherwise he fully estahlished. It ran he carried out under nitrous oxide >jas. as local ana'sthesia is not suffi- cient. A .-;ma!l incision is made down to the hone just ahove the prominence of the canine fang; with a nispatory the muco-j)eriosteum is turned up and down, and a drill is employed as for the alveolar (>ik'h- in>t, but directe(| vertically to the surface of the canine fossa. The exi)loration of the contents is carrieil out lus already directed. Diagnosis. Cases have been refM)rte(l of maxillary sinusitis in children.' This is surprising when we bear in mind the rudimentary condition of the cavity in early life, and it may Ik- suggested that the above cjises were in.stances of acute osteomyelitis of the superior maxilla— an atTection describe<l byseveral authors'— or of tuberculosis. Obstructed cases have more than once l)een mistaken for malig- nant disease of the antrum: and on the other hand, the association of suppuration with such growths has le<l to the nature of the case l)eing overlooked. The age of the patient, exploratory punctuit>, and careful examination lx)th of the canine and nasal walls will generally prevent any error in diagnosis. Acute suppuration in the. sinas might Ix" mistaken for dental perios- titis. The latter is an external affection, whose progress can be watched. The teats given will .show the freedom of the antral cavity.' Treatment. In all cases attention to the teeth should precede all other treatment. Treatment of a maxillary sinusitis can l)e carried out (1) through the natural orifice, or (2) through the nasal, (.3) the alveolar, or (4) the facial surfaces of the cavity. 1. ThroMjh the .Watural Orifice. Daily irrigation of the cavity by this route has been recommended by a few rhinologists.* Garel hiis succeeded in irrigating twenty-eight out of forty-four antra through the natural orifice.' (Fig. 492.) It is not usually ea.syto catheterize th(> ostium maxillare, and the manipulation is generally facilitated by removing part of the middle turbinal. 2. Cases have been recorded in which a single exjiloration from the inferior meatus has been followed by apparently jx'rmaneiit ces.sation of suppuration. It is, therefore, wise to always defer 1 BAny Power. British .M<,1i<«l Journal, September ij, 1S97. Alex. DouglM. Ibid., February .'>. 189K. Emll Mayer. TranMPtions of the Arnprioan LaryiigoloRlcal A-Bociatlon, 19UI. • Schmlegelow. Archly f. l*ryii(colo(fle, 1S96. Rand v. p. IJi. Ropke. MUnchener med. Wochen- schrin, .lanuarj- i'l, 1S9S. Llohtwltz SoclitA de Ijiryngol. de Parta, 1897. A. Caatex Bulletin d<' l*ryiig., !30I, IV. p. 171. • G. Avelllii. Revue hebd. de Laryng., 1899, So. 2, p. 48. < Oaiel. Journal ol LaryngolnRV, August, 1894, vili. p. .MO. » Nerval B. Pierce. Laryngoscope, September. 1901, xl. p. 197. DISEASES OF THE ACCESSOKr SISUSES. y4S) turllicr trciitiu.-i.t after an .'xploratDry lavage, until |)Uh is a^ani .viilfiil in the nasal chanilxT. Tlu> siicc-ss of a su.kI." tn-atnu-nt K iHThaps du.' to tlu' fact that the cas.- was rrally a r.'<vnt one und.-r- .rciii^r spontaneous cure. Such fsises in fld.-rly (x-oplr should Ix- viewed with suspicion, as thoy are sotnetitnes found to Ik- owuik to Mippuration in connection with a nialiKnant growth. V Throuqh the Snxul Wall. It has Ix'en prop<)s«'d by Mikuin-a ,„(! Krauso to niak.' a larger oiMMiing, w.-ll forward (Waiter Iree- „n,0 ' un.ler cover of th.' inf.Tior turhinal with a large tr-ar and .••inula (Fig 492). so that syringing an.l other treatment can l>e d)== Method of calhilerlzlng the maxillary !<imis. riie method inav I... carried out fmin the inferior meatus |,l(.vcd ill patients who hav<' an intact set of ui)|)er teetliou the side Mtf.rted and wlio decline more aniuous treatment. It is jideqiiate l,.r Miiii>le rec(Mit cases, i.iit does not allow of the removal of patho- lo.'ical products in the lining inenihrane. The opf-ning also tends lo'close and is sometimes dillicult totind hi.ld<'n und<'r the turhmal. Access to it, however, is faci'=; 'e.l l>y removal of the anterior end (lithe latter. , . \ TImmih the Alrcolor liordi-r. The method ot gaining access t.. the maxillarv sinus from the alveolar border dates fmm the time of Cowper, in 1707. The .-laiiner of drilling the oiieiiing has already 1,,,,,,, .i,.,,,.ri!«.d It is irenerallv recommended to introduce a dram- age-tulje HtU'd with a siud which can he inserted cluring meals. The 1 Jrairiiftl of lUe Aiufri.-an Me,llcal Association. November M. 1"S5. •j.y) \J.SK .l.\7» rilliOAT Flu W. .iiiiniiiit (if (Iriiii.ie'- tlin UL'ii -ucli an npfiiini; is -in -ilijflif that it i- 1>. tier to (IciM'inI (ily .n -ynii);iiij;. ainl In irisiin- as far as [iKssiltlc the soparatinii ■ ciiiil tiinatioii fmiii the tinmth by intrd.luciiijj a solid stciii ol)t iialor. i ;,is laii 1h' fitted on a denture. In liiK4|>ital practice [Mirfinns of i;ilis' sjiinil wire are cut in suitaiile lengths. I'lie iihturaiiir ordraiii is reii'o,-ed and the cavity washed out with a I Ii>r(;inson syringe. A pint of epjd sterile fluid Imuld hceniployed «'a'h line, ni I the medicament used with !t ijix's iifi I I . ar n most cases to Im- of jrreat im|x)r- ta'if Siir lal saline solution is generally -'tis- facli'i . aiiii 'II cases of fetor we may add jier- II :iii.;Mati oi lotasli. listi-rine, sanilas, piiennsalvi, eui'uaii'l, or in*' of the nnirriti'Mnj; compoMnd !iiit •' plies. At ( rst the wasliing-out sjiouh' .ke pl;.i'( ;. , I :ii!(! e-. linjr. the obturator l-euij; th)-' anhl_\ ' insed .nd replaced im:iiedi lely afl> I > ard. K th^s is n.-irlected. ;rranulations laay sprin-r up win .n ..•: hour or -n !m|H'ilin)i the re- plareiiienl \\ lu'. the :ii|Uid escapes froi:; the nose in a clear stream the washings are diminished to •■nee a day, then )■■ every other daN iid so i;radiiaily to on, <> a week When thecaxily on several oc( inns is I lund to '■ofrce !roin Ellis' «)n> tnh<>'< for ilraiiittiK tlie uiuxillitry jiiiilH fnun tbc ahwtliir Meth'i'l "f wa«liinKi tltt' liiux:!!arv Ills {Torn tht' ■ilvi.-.jlar Imnier, secretion aftii remainiii<,' n-cleaiised for a week we niav considr! the I'ase cureil and allow th- alveoi ir . (K'ninjr to cl-^'— which it doe- StlOntanCOU'^lv "V. disc^.'!!ti!!':il!;» th'- dr:tin <:!• :>}>t!:T-t,-'r If the secreti<in persists we may iry the use oi 'ntnger antisef)ti(- or astrinj^ents diiniodi !!• of morcurv. chinosol -tarjiol, sulphaii IK res. of zinc. etc. -before re^ortiiiL' to m:>rc radical i i,isi:Ast:s "F Tin: .uvEssnRi ■lyunEii. 9.>I Ursul: . Mv "wn .'x,Hri.Mu-r is that, .. lui-. cum wh.cl" ;.n. ..,.inir t.^ V..-M to till iM-th.«l -tiuv* .iki.. >i .l.-mj. s.. ..url.Vyu mi. ; i..w w.,.k whil.' tnu-.. whi.ii .-I...W 1" >en..l.nrat...M w.thi.i n ive : ,.„.th- an tHTuilv m^ -tmit... A Iti-fory uf |M„«-stan.l.nK sn,>,m- ,lu,, tion 1 ivr iH^-n ,«-n uinentl> '...al'v! with thn- month. n.R- '"whon ih.T.' is n. -uunWr ...^. aai tooth or .•nn-ty s<K-kH i th<> , ,uT jaw o|- 111.- an. . i.,l mu, it i. n-t juHnllahl.' t. Haonii.-.- a souiul „'„ th t- it.iiiat.. u i.K.h.Kl of tr atn..-nt which is . .<-ertain ... its n- M.ils Hon.. i.. all . .-. of .., .xill rv si.n.H.t.s - a scni.,. sot .f li-cMi .'I'l ill thos«> whi.ti luivc TO' 1 MitrMcta treat.', "lit aln-. Iv lo^' i. tn '.V um !!!; il . (iiiiii '"ssa KTfo' '!mg V nal the (a .Iwi ! I »• o|-ra ii. -, Tin- ("III,,' h'o.'<sa (): -niim. Uh--'ie»i ; lo th nu'i <m1> ' irricd out liy ojh u- uciitly ix'fprretl to ill 1! /-.not sii|i rallli ... N,., ..i.i <l. ati' 111 rcc >! lion lo ll the <lfah Iniu llO! " cavil} lueiplfs !ih puoil. •ii:i\!ii.ir> ■V cai. '•■ !h. froi: tic wi aci's tills . MiT nicthi York/ i It^'i rilx-d u. l.'^OT t(. ihc suhj " ■..(,■ lie Th. r'liii ■an'fii III! anil ,1^'inally designed by M wa.** imlo|K»n(lpntly nivcii con- xNlicd in a the cxpcu- -iich access fossa that thoroughly as sM ■<'i.i<.' olv ir curi.i}. il the C!l. ts conten .i princiiMi' is the cstablishiiicnt of free iito the nose, on a level with the flc-r of ■ seen that the realizatio.i of these two rat ..'11 at a great advantage in coi.i|)anso" of treatment. In thos». which have •rp is either inadoiiiiate >r takes placf "■tioii readily takes place!, while the i il< -; to the exact pathological conditi. ;„| I ffon- in ignorance ;us to what prosiw^ thods i reatment may s^x-ure. .igj! the ■ai.iiie fos.sa r<-.|iiires a general ana^s- should h.ve tlie usual preparations made, and ve the teeth put into good order and the mouth ...p, IS jMissihle. The nsv-sal chaml«^r of the same side louslv IK> cleared of any polypi which ..!,ay be present, ent having Ikm^i a..a'sth.>tize.l the hp and cheek of tne . :.| side are n .-acted -. as to show the , .>;rne fossa. A mouth- „i. ij,t. ....l .-tween the molars on t.v. side affected will be iread\ -crilK'l •!,, nio; wlienr ■ia. is ciilirel; '' ,f • ,(• disea.sed it>ui ics,shisn The o|MTati' •hetii i"he p:.nf IS di'- Me t'l 1 ier as<'i>t He i, u,m«..!ihcCllnic«ls.K.ic.ty. l^.ndon, May 12, !8«. „1 Novt.n.l*r4. .s.«!. The making of a .Ic.ble ..penlt* tbr'-'W' h"'" .alls ol the anlnim ««« designed by Seances Spicer in 1»M. British ■ -.tciiitr 'I iu.u. N.-v Yi)rli Me. tit. canine and tt.^ Mmiieal Juiiiiitii. U* . cn:r:v- r •. I'liris. l^KX). 952 A'O.VA' ASD THROAT. •■ I found us(>ful in al)si)rl)iiijt blood, which niiftht otherwise trickle back- ward into the throat. .\n incision is tiien made at a distance of a few niilhnietres i>el(.w tiie «inKivodabiaI furrow, and extending from the level of the first molar tooth forward to the canine prominence. (Fig. 495.) This incision passes at once straight down to the bone. Flo. 496. Oreiiini! the frontal and maxillary sinuses, shows the point on the sltull for exposing the tVonUl sinus; tlie.lolle.louilim- indicate the directions in wiloh the opening may have to b-- extende.1 ,, .,, openinii may have to b"- extended over the ma.illarj- sinus the dark line marks the situation and extent. ,f the in<i«ion through the Kingivu- labial fold. which is rapidly disjilayed by reflecting tiie muco-iH>riosteum with a raspatory or |.eriosteiim detacher. With the cliisel an.l mallet the canme fos.sa is broken down, and the entry into the sinus is often .signihed by the escajx' of pus and sometimes of a foul, penetrating odor. Ill many cises profuse bleeding takes place a.s the cavity is entered, but generally ceases as the o|)eniiig is enlarged, so th:it a small sponge or plug of g.-uize can Ik- inserted. The sjK.ngc placed iM'tween the p.-ttient's back teeth often nvpiires n'liewal at this time, anil the h(;d slioulil Ik- well tm-ned to one side. The opening intti the sinus .should Ik" enlarged wiili the chisel. l>one forceps, or burr driven by the hand or eleciromoi..r h is important to rememlH>r the exact direction in which this (>iil.irgeiiicnt should take [ilace. It should be both .lowiiward, so thai the (.pnijng is on :i level with the alveolar floor of the sin.is, and forward.. so that it approaches closely to the n.asal wall of the cavity. This situation is preferable, as the n|>.-n!!ig i« (n\ distant fr.-in .l.-mgernus regifms; ,7,i giu-s (he iiesl view of the cavity: (r) is in the most favomble situation for drain- ace, and (d) is most suitable for |«'rf(>rming the s<>cond part of the tm DISEASES OF THE ACCESSORY SIS USES. 903 oiHTatioii, viz.: tlic cTcation of the ()j)oninR into the iiiisal chamber. Tlie caiiinc oiM-niiiK is ciiiargwl sufficioiitly to admit tlif> oiK-rator s little tiiipcr. Till' marRiiis of tlio o|X'ning in tlic t)t)nc arc kept as ^mootli us possihie, any spicules which may have iH-en .Invon m with the chis«-l ar(> carefully removed, and the reflected nuico-iK-nos- teum is carefully pres<>rve(l. Care should be taken to avoid injury to the infra-orbital branch of the trigeminus nerve. ( )ther\vise tn.u- i)l(>s()rne neuritis may be set up.' riie lileeding from the lining of the antrum is carefully stanched with lengths of sterilized p ie, and the walls are then carefully in- -pected with a frontal electric searchlight. The diseased mucous membrane is now dealt with, and all redumlant or polypoid tissue lirUuwald!, forceps. is comi)letelv removed. This can Ix" done by Crimwald's forceps iKig. 4iW')), which will only embrace any hypertrophie<l tissue which priijects above the surface, or by sharp s|M)()ns or some form of ring knife, preferably such as that of Myles. (Fig. 497.) It is often adviseil Fia. 497. MjlM' riiiB knife, used for cureltlng the sinuses. lo curette the walls vigorously and fn-ely, but it is difficult to imagine liow a good ri'sult can be exiM>cted from entirely denu<ling the sinus of its mucous lining and then rubbing a strong corrosive on to the bare walls. On the contrary, care should Ik- taken to remove only Mich tissue ;is is diseased. In some cases the antrum will be found ajnio.st completely filled with jKilypoid masses of hypertrophy. (Fig. \\)S.) In other cases the mucosa may 1m' found to be thickened only ill parts. The rejjions which slmuld l>e most carefullv <'\aniii!e<l 1 I)e Ri)«l<le». TreniiacUonii of the American Urynitoloflcal Amoctatlon, ISM * i y54 yont: A.\D TiiRo.ir. are (a) the (loo|x»st part of tlic internal or nasal wall — /'. c, near the natural opening and in the ncijihborhood of tlir cthnioid bone; (b) the irrcffularities on the floor of the sinus, especially between any |)ro- jeetions of the dental nH)ts, and (r) the outer part of the anterior or facial wall and the tnalar fossa. Fig. 498. Life.«izo drawing nf polypoid hypertrophies removed from a maxillary sinus. (StClaib Thomson, i Caries of the walls is much less fretiuently met with than some l)atholof;ical investifjations would lead one to expect. Once the toilet of the cavity lias been conipl"ted we proceed to the second stej) of theo|H'ration.' Cmiliiiii of a Xtixal OfHuimj. During this part of the ojx'ration blood is very apt to find its way into the })ostnasal s|)ace, and it is a useful precaution to insert into the cuvuin i)haryn<teum a small s|)onp;e attached to a tajx'. The na.sal cavity on the affected side is first well ijluininated. and the anterior third of the inferior turbinai is amputated in the following w;p : With a stout pair of Panzer scissors (curved at an angle and als<i on the flat) the attachment of the anterior third to the outer na.sal wall is cut through, and this portion is then removed with a cold wire snare. This proceedini; may, with advantage, be carried out undiT cocaine some time liefore the major oiK-ration. It gives us fre(> access to the partition between tile !io: ,'md antrmn which we wish to break down. This is done with the chisel and hammer through the canine ojK'ning, working i'lose to ilie floor of the sinus and as anterio: i-; possible under cover of the severed attachment of the inferior twrbinal. .As soon as the chisel has p iietrated the wall a Krause canula with pro'he-pointeil trocar should be introduced, to define and increa.se the oj)ening. b can then Ih- enlarged with tl;e cliisel and hammer, or suitable burrs, until at least the anterior third of the outer wall of the inferior meatu- has been resected. There is little fear of resecting this wall too freely, as it always shows a remarkable tendency to contract afterward, ami many ca.s<>s of failure are due to the inadecpiacy of the njusal ojx'nintr. While tliis upfiiiiig ir^ being (iiade i-,ire slumlii be taken, either b;. ' The ortKiiml canine ojieni'ion icnown tis DewiIt'H or Kuster's terrnlnated here, and subaeque' ■ treatment w«.s carried out through ihis opening. l)ISEASt:S OF THE ACCESSUJiY SIM'SES. 955 u\u!iii\utl the iiMsc on that ^i.lc with fiimz>' or by introducing the litti.' tlnwT into it, that the septum is not injured. ,, , i-i The n.iixiiiarv cavitv is now onee more .Ine.l of any blood which „nv have accmnulated. It is fnH,uently advised to pamt the wails with -i U) or 20 IKT cent, solution ..f chloride of zmc: the cavity is well powdered with io.loform, and is then firmly packe.l with one l„„tr 'trip of drv i.Kloform ribbon gauze, which shou.d l)e about one ui.l a half inches wide and with selvage on both sides. The end of the ttiuze ribbon should be led through the na.sal oix-ning until it .„)|M"irs at the nostril. The inuco-[K'ri()steum reflected from the ;..,,' ine opening is carefully lifted buck into position, and any sponges in the postnasal space or angle of the jaw are removed. Fio. 4W. Panzer's ticiMon. It is recommended bv Luc and others to carefully suture the buccal xvuund with cat-It. This ste)) is not only te.lious and (juite un- necessary, but the insertion of stitches apix'urs rather to retard rapu union Tiir sides of the wound fall into coini)lete apposition, and if a pad of cotton-wool is placed externally, .and mastication on that <ide avoided for a few days, union is both rapid and complete. »/,. -f^ratmrnt. There is seldom any marked general reaction •liter ti . . operation, and the physician need not be alarmed if the .•lieek on the same side iM-comes so swollen as to partly occlude the eve Tlu< feeling of distention is relieved by a firm compress ot cotton- wool, or by hot fomentations. For a few days the diet sh.mld be fluid and should be swallowed through the opposite side of the mouth. The mouth slmuld »)e rins,-.! out fre.piently with some cleansing alkaline lotion. . ^, , -p, Th(> ribl)on gauze is removed on the Hfth (Luc) to tenth day. Ihe extraction is easy if the resection of the anterior end of the inferior .urbinal and of the antrona.sal well has lu-en adequate. Otherwise it i. apt to be s:. i)ainful that it is well to administer some nitrous oxide ga- The gauze is g..n.>rally fn>e from fetor, and m its removal it ci....r . ■ .X any debris left from the operation. The large opening into th. ^'M )r meatus is sutficient for natural .Irainage, but it isas well to . ! (iie antrum out through it for a few weeks imtil after an interva. ,,f a f.-w ,lavs the loti.m used return? clear. Th,. cWns.mg is easily carried out with a short length but full-bored silver I'ustachian cathcU-r, and some sterile salt solution. For some time the 1 i 956 XOUE AM) THROAT. iiuiciisof t'i(- iiusc is apt to (irv into crusts along thn irrofiular bonier of the ar* ilcial hiatus: Init this ihsapjjoars iis tho margins heal over, anil, as ulrca i\ stated, the large oix-ning shows a remarkable ten- ilenc.\ ;(> n-i'l i ontraction. The cure is generally coint)lete in from three to siv wwks. Indications for Treatment. Surgical treatment of the maxillary simis is not a-ssociated with the possibility of any di.sfigurement of the face, and is so free from risks that our ainbition should Ik> to obtain a complete and lasting cess'ition of the discharge in all uncomplicated cases. Treatment through the antronasal wall may be tried in patients who have intact teeth in the upp-r jaw, and who pn>fer to essay a simpler method l«>fore submitting to the canine operation. When a suitable tooth socket is available the method of washing out through the alveolar opening may be given a trial of a few months. If either of these methods do no more than reduce the secretion to a tolerable inconvenience many p-itients may decline further interference. Whenever the teeth are inlact and when the patient is anxious to have a radical cure effected, the canhie operation should be carried out. Chronic Suppuration in the Froatal Sinus. Symptoms and Diagnosis. In a large imniber of ca.ses of frontal sinusitis there are no subjec- tive >ymptoms which point particularly to that cavity. Whi-n the oiitHow of pus into tne no.se is obstructed we may get local symptoms of \)a\n, tenderness, lacrymation, etc., .siniiljir to those met with in acute cases. Mut in the chronic, "latent" cases it is seldom that any of the sui)jective sytiiptoms an' at all trustworthy. Thus pain and even tenderness over the suiM-rciliary region or frontal headache niav 'm" ilue entirely to pus in the maxillarv sinus, while the frontal cavity in jinother ca.se may l)e full of pus "without there Ix'ing either frontal headache, pain, or neuralgia. In .some .such ca.s(>s the headache m;iy even be referred to the occipital region. Still, in .all suspected ca.ses it is well to note the presence of frontal pain or lie;idache, and to t(>st carefully the s(>nsitive!iess of the region, i'ressure should be ap[)lied first to tile apparently healthv cavity, so that the (lifTerence by contra.st will be recognized. The siipra-orbital nerve must be avoideil. .Vnother extern;d method of ex.amination is the test of Iransilltimi- nalion. The same preparations are re<iuired as for applying the test to the maxillary sinus, bu the electric globe instead of being enca.se.l in a movable gla.ss hood (Fig. 484) is fitted with an oi)ai|Ue vulcanite cap which directs the rays in one longitudinal axis. This is pres-ecl firmly against the lower wall of the simis, under the inner third of the eyebrow. If there is nothing to interfere with the pa.ssiige i.t the light rays the dear frontal sinus will be lit up with its extensions upward and outward, and in some cises the sei.ituni an<l partial dissepiments will be defined. If one sinus only is ob.structed tliesr }X)ints become nion- evident by eontnisf. It is imjHJSsible to compare the two .sides simultaneou.sly, ii.s we d' UlfiEASEa OF THE ACVESSOBY SISCSES. 957 in applviriK 111.' t-st to th.- maxillary sinus. Hciur, Lulu-t-Harbcn MiJe.sts that the rul)l..>r c-ap coi.tainiiiR tho lamp should \w pn-ss.Ml m ,inst the mi.l-linc of the for(>h.-a<l, two or three cent i mot n-s above tl„' root of th.' nose. On switchinR on the current a comparison ,,,,„ l„. ,na.l.- of the way in which th.' lipht rays traversi- each sinus to iiiiht up the antero-suiK-rior allele ot the orbit.' \ form of transillumination lam|) Juis also lK«en .lesigne.l by which both cavities can be transilluminate.l at once from the:- orbital wall, so that the results can be compared.' „„.,,• i i „ Objections to the TransiUumination Test. This test is much less, sitisfactorv for the frontal than it is for the maxillarv" sinus. The ,.,nat..micai arrangements an.l relati..ns of the cavity lend them- .clv<>s less rea.lilv to transilhimination than do those of the max- illarv sinus. Pus mav bo present in the sinus and yet the test mav fail l)ecausc it mav be slight in amount, lymR only on the floor. an.l the bone may b.- particularly translucent. Pus may bo^absent uu.l vet the test mav fail to light up the cavities owing to the great thi„u..ss of the walls, or even owing to their entire absence, or to the presence of a solid new-growth, such as an osteoma It can only be regarded ivs a subsidiary aid and as confirmatory of other tests, to be shortly descrilied. Pio. 900. FronUl ainus canula. Nasal Examination. The discovery of pus in the mi.ldle meatus of tlH^e should prt^are the observer for finding that its source is the ntnl or m..ixillar; sinus, or both. If the pus ts seen high up an- . ■ f it is acVompanied by polypi, if it recurs rapidly when i H. awav, if it flows more freely when the middle turbmal is pres.sed ; d the Septum, and if then- is no marked cacosm.a. the evidence points to the probability of the upper cavity tang its «ource^ Grun- w.ld has s-.ggested that by cleaning the mid.l le meatus, and then • n ullv packing the region of the hiatus semilunaris and waiting r:.w miimt, we can I whether the pus -^--^.^^-.-^^fX tlu- plug The method has not met with general auoption and th. evidence obtained is still pn.blematical. More certam evidence can l>e ul)taiued by washing out the cavity itself. . Bulletin de U 8ocl«t# r«..9.l« rt'Otologie. »«»• W"* "T-P^^ = Furet. Archive. laternat. de Uryng., .^an et Avrll, 1899, p. 1». JioH XO.SE .l.\0 TIJUOAT. Sounding the Frontal Sinus. I lie iil)S(iv:itioii.s of Lnthntp on the (•:ulav<'r show that in the majority of instances it is iniixissililc to pass a probe t'rnni tlie nose up into the frontal sinus, ami it must he still inoreilillicult to do it in the iivinj; subject. The care with which this attempt shoul,| be carried out is U'xt impresseil upon us by beariii}; in mind the case recorded by Merrnod.' This ex|K'rienc('d rhinolo>tist diagnosed an escape of watery fluid from one nostril as .rifjinating in the frontal sinus. lie tried to catheterize the cavity, but wasarri' ted owiiif; to the pain the (irocoed- inj; induced. The patient died some d;iys afterward, and at the post- mortem it was found that he had no trace of frontal sinus. The Huid had esca|M'd through a .small openinfr in the anterior f()s.sa of the skull and mu.st have In-ei. cerebro-spinal fluid. This hati Iw- come infected, although the attempt to sound the postulated frontal sinus had Imh-u carrieil out with ev(>ry a.septic i ecaution. AmpuUlion of tlio iinltrior mil of the mlddli' turbinal, lilvliling the Rttarhraent to the outer tci^itl vvnll. It is wiser to secure free access to the Irotitonasal duct by amjiu tilting the anterior end of the middle turbinal. This proce.lun- will in any cas(! Im- re(|uired as a method of treatment if the sinus i~ found affected. The sinus can then in many ca.scs Ik' catheteriz>Ml Amputation of the Anterior End of the Middle Turbinal. Tin region is rendered ischi-'mic with, .•idrenaliii. !!!i>l cucnifiixed. !?i thi- way tiio p.art to be removetl is generally well exposed and stainl ' Annul, rtea Mul. de I'Oreillc ut ilii (.nrynx, April. 1«<.«, xjll . .No. 4. DISEASES OF Tin: ACCES'<OIiY SIXi-SES. 959 ,,ut from th<- ncijrliboriiift imrt<. Witli a stout pair (;f Gninwahl li.rn-ps or I'aiizfr scissors the anterior attachiiu'iit to the outer \\;ill is cut tiirougli, so as to free a licad arouiul wliich ti colil snare ,:iii lie passed and the extremity removed. In cjises where it is litlicult to introduce tlie forceps alonjj the aftger nasi to the attach- ment of tlie middle turl)inai the h'.a.les may 1h' applied to the lower laarfiin, ahout half an inch from the anteiior extrenuty, and hy theii liitinj; out a portion the loop of the wire snare can Ik- passed around the head of the turl)iiial, which is easily removed. Diagnosis by Exclusion. If the sounding of the frontal smus iia.s fiiled all the points already rrferred to are uncertam, and we are still in doubt iis to whether the discovery of pus in the middle meatus .•riuinates from the frontal or maxillary sinus, or both. This point can really only Iw positively .settled by a process of exclusion, which is done iis follows: Auii.uiatlon of th.. anlcrl.T end of the middle turbinal. Kemovlng the «p.rat<!d extremity with a wire snare. The maxillarv sinus must be exjilored in one of the two methods ,,ln"adv describVd -cither through an empty tooth socket, or by imncturing the inferior meatus. The antrum is then thoroughly ,leare.l bv svringing through it air, st(>rile salt solution, a teaspoonful ,.r two of hvdrog<-n jH-roxide, more salt solution, and then air. In this wav we can .lelermine ili if ihr cavity ct.ntams jm=, and <1) iliit if" present, it has been temporarily thoroughly ex|K'lled. it r,ov. we let the patient wait f.)r from ten to thirty minutes, anil again 9«U h XOSi: AM) THROAT. <m .".ViiMiniiiK hill, fin.l pu. i,, the liii.l.ll,. „i,-alUH. w,. vau \w (rrt'iiii that this can ..riKii.at.' in no ,.ih.T than tiu- fmatal siniu or untcrior ('thiiioiilal cflls. In carrying out tliis test it is im|«,rtanl to avoi.l cnusiiiR anv hh-t-.l- iiig 111 tlic nasal chainlMT. as this inihtatcs against th.- r.wult Th.- nasal chaiiilHT should als., Ik> scrupulouslv d.-an-.l ,,f anv purulent matter first, as othcrwis.. we cnil.l not say that anv (liscov.-rod then- later had eoine from an am-ssory sinus. It is hanllv n<'ee..,sarv to do i.H.re than refer to the method of exploring th.- sinus l,v pun.-turing Its door from the nu>^'. This nieth.xi is s.. dangerous that it is ,,uite unjustihahle. It will he referred to later under the hea<l of Treat- ment. CompUcations. Many of the.se have alreadv been touohp<l on The most common an« suppuration in the anterior ethmoidal oell.s and the corresponding maxillary sinus. According to Luc it is excep- tional to find the frontal atTected without participation of the maxil- lary sinus, although uncomplicated .suppuration in the latter cavitv IS trequontly met with. Treatment. Intkanasai. Tkkatment: Puncture of the Floor of the •yniis. The method recommended hv Schaeffer' of puncturing tlic t^oor of the frontal sinus from the nose is only mentioned to l)e con- demned. The anatomical irregularities which render such a proceed- ing much too dangerous have already been referred too It is com- iimn knowledge that a rhinologist in Pari.s, believing that he was affected with an acute frontal .sinus suppuration, attempted to thrust a trocar and canula from his nose into this cavity. He died shortly afterward, and the instrument wa« found to have penetrated the anterior fossa of the skull. Catheterizimi nnd Wnshing-ont the Frontal Sinus. Observers differ a^ to the frequency with which the fmntal sinus can l)e explored from the no.se. Some authorities believe that thev .succeed in catheteriz- irig the .sinus in .50 {)er cent, of the cases, but most of us acknowledg.- that we are not so frequently fortunate. In any case the operation IS greatly facilitated by amputation of the anterior end of th.- middle turbinal. (Fig. 502.) In those cases where the method is feasible ;• IS best done with a Hartmann canula. which has a double sigmoid ""r ?■'''■ •!;''■?■ •^'■^•' ''''"' '" '"^'•"'luc'^'l i"to the middle of the centiv of the mid.lle meatus and f n gently .lirect v| upward and forward until the ,)omt is felt to enter a free caviu', and is found to h' h to 7 cm. distant from the nasal orifice. It is often impossible to .sa\- whether the canula has really entered the frontal sinus or wheth('- the point IS nier»'ly engaged in one of the fronto-ethmoidal cell- It IS in this method, and in such cases, that Spiess' emplo^Tr.er of the Roentgen rays is .so valuable. With the shadow thrown up,-, the screen it is extr< mely ea.sy to follow the pa.ssage of the poir' ' Otutwb. med. WochenKhritt, October », isao. p. 906. DISEASES OF THE ACCESSORY SISUSES. y«l of tho instrument through the n..s.' until it enters the fr.mtal sinus, ,,f whicii the '.valis are well detineil.' ■. i i i i>.. When the ruvity ean Ik- catheterized fnMn the nose .t should Ik- w.'le. nit .lailv with li.iaids similar t.. those m.l.cate.l for suppu- Ui he maxillary antrum. Whether a cure w.ll he effected m •n prohlnnatical. tilley pave the meth-nl a careful tnal m fou •uses without any pennanent result except m one cas,..- "';«'•;'••" , ,.es where the cavity can be easily reached from the "".'^ »'> ' « „;,,l,od the patient is to a great extent n-heved of any r.sk of the dangerous complications which might otherwise ensue. Fig SOS. Method of catheterlan» Ihe frontal slnui after removal of tbe anterior end of the middle turbin.1 The drA«.;n,- >ho*. the lu.tus semilunaris, with the edge of thi- pnH>«».m uncii.atui. below it, and tliffthiuoidal bulla above. The ln<llr,-tin,u for the einplovment of the proceeding are thereforo Iff) a« a tirst .step in all treatment, and (b) as a precautionary measure ill Midi patients, especially young women, who decline an external "'m Eternal Operation. This metho.! of treating the frontal sinus^ l,v .M« ration through the forehead, was first described by Ogston, Init it was indeiH«n.lently conceive.l by Luc^ who has given consider- uhle attention to the method. The patient is prepare.l for operation m : r'""; i'':"::';l^^"'""^^ """" o:.ir- The Me..lcU Cb«.nic,e, December, :m. ! ijiuTOt, Jiiiy H. i««i ~ « Luc SockHi Frani;iil»e d'OUilogle, eti. Paris, MM, 189B. 61 t>()2 yoUK AXD Til HO AT. the usual way. and in addition thooy«'hn)W on the .sninr' side is cntirclv slmvcddffjinil fh.' skin of the forehead on that side imriHeil twelve hours iH'fon-hand ;ind an antiseptie dn'ssing applied. A general ana-sthetie having U-en adininisten-d the skin of the eyebrow on the affeeted side is drawn wel| up on to the fon-head so that tiie part lying inunediately Im'Iow is I'liled up on to the edge of the forelieiul (liryan). A eurved ineision is then made down to the Iwrne along the inner third of this n'gion, reaching from near the middle of the eyebrow to op|M)site the anterior paljicbral ligament. (Fig. 504.) The'imier extremity of tlie ne. 6(M. Eilenial operation on the frontal slniu, Showing the eituatlon for making the skin Incltlon whllv rtrawing the eyebrow up ou to the forehead. inci.-iion will terminate ()|)|M)site the suture of the nasal bone with the nasal process of the frontal, while the outer end will Ik- internal to the supra-orbital foramen. In the latter direction it can 1m> extended, if recjuired. At the end of the oiMTation, when the .soft parts are allowed to fall back into place, this incision will Ih" almost entin'ly concealed. With a raspatory the soft jiarts are turned Ufjwarll and downward so as to expose the anterior wall of the frontal sinus. A half-inch treiihiiie applied at the jxiint indicated in Fig. 495 will never fail to expose the sinus, if one is present. Instead of a trephine, however. I recommend that the cavity Ix' ojM'ned with a chi.*l ami liammer. It may present considerable thickness. Throughout the ojK'ration great care mu.-t lM>t:iken not to pn'ss on, disiibce, or other- wise iiijiiiv the eyeball. As .soon as the sinus is {)enetratod careful ex- j)ii 'atioii should 1k> made with a blunt \)To\yp to detorniine not only the direction ande.xtont of the cavity, but to positively ascertain that DISEASES OF THE ACCESSOHY SISUSES. !Mi.l iIk' liniri)! incinhraiic of the cavitN hii- Ikh-ii cxiM.fwd aiid not the uiiKT surfac- of th.> tlura maUT. Tin- pyojri'iiic m<Miil.ran<" filling till- siims soiiH'tiiiK's pivrtonts an cxffnial siiioolli, dark, piiiplish- cray surface which at first diaiicc ininht !«• mistalvcii for the (hira mater. In sonic casJ-s a.s soon six the sinus is o|KMie(l yellow pus makes its escajH'; it is never possessed of the same putrid odor as that from tlie antrum of HiKhmore; it is never hirge in amount, and m «..me cases no j)us mav Ix- encountered, although the cavity may 1)0 mor.' or less complctelv ftlled with funnoul. papillary, myxomatoits- like hviHTtrophies. In order to n-move thes«' the (.iH-mng mto the -^inus inav have to »>«• enlarged with chisel and hammer or Imwic f<.r- ceps. upward on the forehead and outward toward the outer margin of the eyebrow. This orbital arm of the sinus is much more concave than the asrendinp frontal. In securing this access to the cavity, it is not by any means neces.sary to remove the entire anterior wall, but only so much a.s will allow "inspection of the contents. The cn- larirement of the f)|)ening shouM lie chiefly on the antero-mferior wall. Ih'Iow the glaU'lla and above the suture of the frontal with the maxillarv and lacrymal bones. This gives the freest access to the part which nnpiirt-s most careful tn>atment -the frontonasal c-iinal— and it is here that the scar is I)est hidden by the eyebrow. W hen a sutficii^nt oiK>ning has Ikk'Ii secured th.> depenerated mucous mem- brane should be carefully removed by plucking it off with Oninwald Kia. 806. Fuu' probe forexplorinK the ftonliMmsal duct. forceps or a Hartmann conchotoii: The further recesses of the villus esiM-ciallv the outer angle, imi.^t \ie carefully cleared with t le curette but this instrument should be us«'d with great can', especially on the thin posteri.ir wall. It is {M)ssible tiiat .some of the fatal ca.ses <,f septic osteomyelitis, which have followed tiiis operation, have been partlv due to too "iree curettage." The part of the sums winch dcnuinds the most careful toilet is the floor and the frontouiv-sal .luct. When not evident this latter c.in readily be found with Paiuus curved- eved prolie (Fig. 505.) For rea.sons already given no attempt should be made to pass this upward from the nose; but with the tip of it in the sinus the ostium is rea<lily found, and by imparting to the prol)e &(>l XO.Si: A.\l) 111 Kit. IT. a <^<'iitlc ciirxiiisr iUMion ilnwtiwm I, backuanl, and then forwnnl flic I'vcd cxtii'inilv will a|>iM-ar at ; !m' aiitcrinr naris, Thf <)|M>rati)r slioiilil iiitn- Im-f hi- little tinpT into tlu- tioilril lo niift tin- proJK' h> it ilt'sci-Mils, mill he iiiiiy I" MUpriscd in his carlitT cases tn lind that it is ciicuuntorfd in tlu' nn ;.l i avity ii!U"!; .' irthcr hack than ho would have iniafjiiK'd. The jirolx' is chrcaiifu wi li .•• stout silk liiratiin* and withdiawn. To thv silk end mow projecting from the sinus a strand I iodnforni rihhon Kauz<>, one to one and a liilf inch wide, and with a M'lvMttc is attacht d and drawn down into the nos<' and out throu-zh the nostiii. The surucon s' /les the up|XT exth niity of the puize rihiion prujcctinji from the frontal siruiswith one hand and the Iowit end with the other, and hy s.'iwinj!; it upward ami downwanl he will not only dehne the frontonjLsal duct, but l)reak down some of the friable ethmoidal cells along its track. These c«'lls should Ix' further cleared away t>y the use of a ring knife. <ir sharp s|K)on. from above. Once the frontonasil canal h;i.s Imh'h iletined there is practically no danger in working along it ilownward, inward, and backward. Kven if directed too iniich outward, the only risk would l)e that of damaging the OS planum (Fig. 4S1), and entering the orbit when? the capsule of ihe orbit would pievent any injury to the eye. It is with the up|)«<r |)osterior wi.ii 111;;! cxtreiue caution should b<> us!>l. .\s the success of the operation ii< !i large oxtvn* deix'iids cm the complete removal of the anterior ethnmidal cells tli - part of the oivration should Im- carried out with care. With the liitle finger introduced from aliove into the funnel of the frontonasal -luct as a guide th(>se cells may also Ih- cleareil from lielow by working arrmtKl the tip of the fingc'r with a pairof (Jriinwald force|,-. When the parts have Ik-cii salisf.ictorily cleared it is recomm-ndeil to swab out the cavity with a soluHou of chloride of zinc, forty graiii- to ttie ounce. This is uimeeessary if the toil(-t of the sinus lia.s been well carried out. The remaining steps of the o|K'ratioii arc; varii-d by ditferent op<'rators. I.uc formerly (>in])loyed .i rubbenlrainage4ulx> with a fuTinol-sha|M'.l extremity. The latter was hxiged in the sinus, while the tul)e passed down the frontonasal duet to ap|)ear at the anterior naris. The ex tiTnal forehead wound was closeii at one", and any sub.sei|uent treat- ment was carried out through the ilrain, which wa.s generallyVemoved at the end of eiiiht or nine clays.' He has lalterly- abandoned the niblxT drainage-tube, and now. after dusting the cavity with iodoform gauze, he jiacks it with a rit)iMiii of iodoform gauze, which he leads dow!i into the nose. The extern;!! wou.id is cio.seil ;it once and the gauze is removed on the second n' third day, by which time it has ensured the pateiicv of the frontona.sa! du-t. Walker Dowiue' does not attempt any irrdnage jnt^* the nose. U packs the sinii.s tirmly with a strip of gaiizc which he leads out througl Archives Inlomat. <le [«r;iii;ol , lS9fi, tome Ix , Nii. ,1, p lfi3. 1 i.lB-giiW .M'.'dlcal Journal, M«y, tVM. hoc. cit. DisEAiEs OF rut: AccKii^iont' sisuiks !)(».'> Miuv ihf ftriRiiml svtiuml, which i-* (•nrn|)K'Hy |,,s<m1 The Rii izf ir" I'-ft in pluci! for sovcri i.. f'.iirtcfii Aii\>*. ami till liruufili tho poiinNT-ojK'niiiR the wouiul w found to whi'n oxtr:i< Ih' ri<'atii/,i'(l. ...... ..• 1 h.ivi" ;ilrcailv ri-ffr-<'«l t<> the aurigcr ol inihsornmniiti- curi'ttuiR. \ii,.ih.'r risk is' that attni-linc iiiim.Mliat.- clnsim' of ih.' .'Menial ' Kr^'atly WIMIIII 1. ami «1h- ptcntinn in ai. iiiiyiclilinii. Imuiv Ciivity \vi Ictuiilnl walls of s.-cri'tion wliicli couKl Imnlly havr Im-cii cMinplPtely -ii-ri lizf'il, in .•<pit<'<>f cvi-ry f arc I have, thcrcfon', always iiv ■oidod imincdialc pomplcto plosnrp o S ihi- lori'lu'ad won nd. MU'r drying tho t-avity we I have timily iki'd it with a .iry strip .f io ; form rihlxin >taiiz<', of wliich the t-x in-iiii IV W!i.s left proji'Ctiug fro... c internal anR i.f the WOUIli 1. thp ulcrixirtion i f which inavlx' dosed with a few silkworiii-KUt stitches A few lavers of cvaiiide jiaiiz« wruriK out of iioracic lotion, and covor<-d \y\ th a sui)i)rtiiiR l)ad of aleniliroth w<m) il is then fixed on with a liaiidap' like an ey Ire.s.sini'. No ruliher or Rauze drain is in.sc ited ihroURh the coinn iiunication with the nose Honc^" there is no ri: I if a "dram pa actint: its an o teiu'v oi" th- .nlarfp'd fmntona.-a V ii,i.sses off in a week he forehead on the . •■':K hi's of tlie supra- .■■ .-nd of twentv-four ibturator, instead of as an outlet. The ,1 duct is demonstrable in most , IMS afterward ix'th hv the eas«' with which the lower part of the Minis can U. washed out from the nose, and also by tlie fact that patients can force ail from the nose up into the sinus. Not only 'lues the patient feel the distention of the cavity, but the impact of rhe compressed .ail can, in some cases, be l«)th .sirn and felt against the I niiital cicatrix. , . , ■• , • Progress. For some time the p;ttient may complain of diplopiti, particul. K- if the pulley of th.- sup.ri.. bruiue was int«-rfered with diirinp; ti: ijieration. This diplopia (. . or two. I'atients may also iiulice a m.' atTi: 'ed si-le. due to division of some ..ri)ii 1 division of the Hfth nerve. The external dn-ssinR m.ay in- chaii;: . . h.airs. s,, .as to bathe the covered-u]. eye wilh Ix.racic lotion. I H' packing of tlie sinus can be left in jilace for three, five, or iiion- days, according to the absence of anv supi.iiratioii or reaction. .\n\- ten.siou can Ih. reli.-ved bv Reiitlv puUiiiR out and cuttinR off an inch or two everv secmd or thinl .lav. When tii.' whole <•< this tirst packiiiR is nmiove.! at the en.l ..f five t.. ten -lays Ih. 'Mside ot the sinus sh..ul.l be can-fullv insiK'cte.! and syriiiKe.l out lih sterile salt solu- tiun or iMiraci.- aci.l, which should p:i.ss down fively iiito the nose if the l"ronto-<-11 iuoi.lal cells have l>een adniuately dealt with. Any .Irbrisor firan.ilation obstructing the na.sofroutal duct can Ik> cleared awav with . .airved, silver, luistachian catheter. Tl >ackinR may have t(. I>e renewed at inter\-als until about two or thi-», .veeks from the oiH-ratiou, when Hw cavitv will .apin-ar so healthy, ai;.- -.e tarfje ,luct into the middle . .'atus so permanently patent, th.at '.ere need IK' n.i hesitation in allowing the external wouii.i to close. A hrm Hi 9m .vo.va: Ayi> THROAT. compress is applied over flic Inmy defect in the anterior wail of the sinus, so as to partially ol)lit"rate the cavity. Any sul)s<'(|uent ivashinj; out can 1m' conducted from the nos<'. Unless an extensive amount of the miterior wall has Iwen removed then is very little (hs- figurenipnt, and the scar in most cases is trilling. (Fijjs. 5(W) and 507.) Km •«•.. Flu. .107. Ffo. 'lOrt.— Frontal sinus n|>erati(in. riitoiiched photocrdph, showing how the sciir is eonceali'd below the eyebniw. i A in horn cast*, i Flo. .V»7.— Frontal sitms o{ienitton. rritoti^hed photoRraph of the same jaac seen In Fig. .V!t'>, showing the situation i.f the ttcar when the patient raises his head and elevates liis i>ye*)rou-. Va^it siipiMiratioii was completely arrested after o|ieration on both antra, both ethmoids, and the right frontal sinus. Tlie latter cavity was o(>eiied twice, owing to a pouch t4>wanl the e?tternat orbital angle having been overlooked at the flrst operation. I Author's case.) Ktihnt'x Operation. In the above operation a considerahie amount of the cavity is ol)literat<'<l hy the coaptation of healthy graimiatiriir surfaces, hut it is not entirely ohliterated. Hut siim.ses arc occa- sionally met with which are so cafiacious. extendinp hack to the optic foramen and out to the frontosphenoid suture, that tlie extensive granulatim; surface fails to cicatrize over and continues to secrete pus into the nose. It is in such ca.ses that a radical cure can hardly he liopeil for except hy Kuhnt's method, which consists in chiselliiii; away the entire anterior wall of the simis and then pressing the soft parts covering it down into the cavity until they are a|)plied to the posterior wall. There can he little douht as to the satisfactory result in regard to nasal suppuration s(>cured by this plan, but the resultin;: disfigurement is so marked that few |)atients care to submit to it Possibly it migiit find its application in |H'i'sons wtio are pre^"pnteli froin earning their living by the sufferings or inconvenience entailed DISEAUKS or THE ACCESSORY Siy USES. mi hy the |M>rsist('iu-(! of the sinusiti^■. aiul to whom appcaninces are of little inonu'iit.' Suppuration in the E'Junoidal Cells. .S//m>/(//m. hthiuoKlal ^ Etiology The (lir(>ct inaimor in which the ethinoi.l is exposed to e\t<Tiial iuHuena's. ami its anatomical arraiiRenient, n-athly exi.Iiin the fmiueiicv with which suppuration is eiicounteix-d m the ethinoi.l hibvriuth. "it is probablv attacked priniariiy in a large num- ber of eases; and, owing to its position in the centre of the accessory system supDuration readilv extends from it to the other snmses 'Pliat it may'become s.'condariiy infecte.l with discharge from any of these cavities is also very possible, and Luc has suggested that m the treatment of maxillary siimsitis by washing out through the alveoltir ...MMimg we rim the risk of driving infective matter into the ethmoid c'lls However, in the inajoritv of cases it is probable that tlie ethmoiditis is prinurv. for we ohm get pus in these cells without encountering it in the frontal or maxillary cavities, whereas it is very seldom we find the two latter attacke<l (and esix-ciallv the frontal) without implication of the ethmoid labyrinth. The external sources alnnvlv n-ferred to are the most common causes of ethmoiditis, but owing to its '.x,x)scd position it is doubt- less more commonlv infected by the conveyance ot sentic m.ection by the surgeim from other cavities, from the reckless use of the galvanocauterv. or fnim incomplete oix-rative interference. .Sec- ondary suppuration mav also reach the ethmoid region from the orbit," aiul suppuration in the anterior fossa of the .skull has been known to make its wav through these cells into the nose. Symptoms. It is well to recollect that the posterior group ot ethn.oidal cells are smaller an.l their mouths are much more open. Ilcnc- diseas«' in them is less commonly met with, less trouble- some but more .lifficult to treat than that of the anteror group Tli<- interior group of cells increase in size from above do-. nward ami from before backward One of the largest is called Uxo oulla eth- moidalis It is generallv concealed just Ix-low the aii.erior extre-mty uf the middle turbinal, an.l somewhat overiies the cleft .;f the hiatus s,.inilunar:s. of which it forms the upper .an.l posterior lip. just as the prominence of the processus uncinatus forms the lower hi). Ihe '.pening .)f the bulla is on its upp-r an.l posterior surface, close un.ler the attachment of the mi.l.lle tuH.inal. Other cells oiM>n above the hiatus, int.. which their secretion nat'.irally trickles. .\in.)ng the most important is the frontal bulla an.l the fronto- etlimoiilal. . , , ,..11 Vcconling to this anatomical division of the ethmoid cells we can first of all divide the stu.lv of ethmoiditis int.) suppuration in (a) the anteri.>r ethmoidal cells, and (h) posterior ethmoidal cells. ■ W MllUga... Etiology and Treatment of Supimratlve Dlsewe of the Fronttl sinuMi Un<»t, Febnary 19, 18«8. K. J. Moure. LeTraltiment de.31.iiuit«t Rev. h«M. de Uryngol, 189H. ^ 968 SOSE AXl) Tiniit.lT. The Anterior Ethmoidal Cells. Adopting the ("liissification of Oriin- wulil we iniiy divido siipptiration in those ciivitics into (a) closed sup- piinition. and ih) <>|)t'n suppuration. (n) Cliisnl Siiitimmfion. It is now ostahli.sh. d that the orifices of a cell may iK'conie ohstrueted by inflammation and its cavity dis- tended witii suppuration. In such a case tiie distended portion of tlie middle turhiiial will caus(> symptoms of pain and obstniction accordinj; to its situation and the ihrection in which it tends to expand, eitlier toward the na.sal cavity or toward the orbit. In tiie former case tlie chief complaint will be of increasing nasal obstruction, with a feeling of distention referred to the bridge of the nose. Weight and opi)ression toward the forehead, with a feeling of tightness and heat in the nose, leail to ins(X!ction of the na.sal chanilK>r, when the normal situation of the middle turbinal is seen to be n-placed by a 8mooth, rounded body, impinging on the septum and more or less com- pletely blocking up the middle and infe-ior meatus. To the prol)e it fi'els firm and resisting, som, 'times decidedly Imjuv, and sometimes like eggshell, but frecjuently its true character is only discovered on puncturing it with the prol)e, or cutting it across with a wire .snare. It is thru found to 1k> a hollow, bony cy.st, with a smooth lining mem- brane, sometimes containing j>o!ypoid mucous membrane and 'illed with mucoid contents, or with \mx. which may 1m> strikingly fetid. The ci.^es in which the contents of a cystic dilatation of the ethmoid, w'th or without suppuration, make their way toward the orbit have long lH>en reco-nized and have generally come under the notice of the ophthalmic surgeon. Fiefeded by some darkening of the lower eyelid, or by some congestion and inilltratior, a swelling makes its api)earance at the inrirr ::ngle of the .rbit, displacing the eyeball outward and downward. This may lake pl.ace (piit,- pa.iiilessly. Son-etimes this d-ise.| cthmoiiial si:;)puratioii pointing toward the orbit may develop suddenly, with intense pain, fever, Hgoi-s, swelling and (edema of the eyelids, and a lliictuatlMg swelling to the inside of or below the eyeball. If such a case is umclicved ii m.iy g,, rui to suppunition within the cranial civity and f.at.il meningitis, .\lthougli .ippaiently primary these acute cases .ire ijnubtlcss in tlie majority of instances exaceriw- tioiis of a chronic < liiion, ai'd if ^s wi-ll to remember that they may siipeivne on a chronic manifestation or be induced in uiisusijected ca.ses by surgical ir.auiuatism. Treatment. The circnni-ciilHil ithtnoid.al empyema found in the tind.ilc 'fi.'atHs should Im' ivmoved with ;i cold snare, forceps, and eunite llic iv.,iaining ethmoid region .shoulil then Ije carefullv ill |K'cted and treated .h con lingly. When tlic direction is that of the uibii ihe swelling may have to 1m' df.ilt with by sternal incision, but communication with the nose .should be established as soon as possible, so as to .s(>cure gooil drain- age and enable further treatment t.. Im' carried o'l from the inside. (h) O/Mii. L'ltcnf. "I- MnnifrsI Kiniii/rma. Tins is the most common form of affection of the ethmoid. It is frequently ovi-rlooked. and DISEASKS OF TUE ACCESSORY SISVSES. ytjii the actual patholopical affection is apt to bo mistaken for nasal pulvj.i <.r atrophic rhinitis, which ire but two of the con.se(|uences, ilthou^h often the most prominent symptoms. Symptoms. In this form of nasal sui)puration the patient may ,.,„nplain of almost any of the symptoms which have already been , I, .scribed as a>sociate<l with affection of the sinuses. Still there is .rl.lom the faceache or neuralgia, although a dull heaviness at the n,ut of the nose is often noticed. A general sense of mental hel)e- t,„l,. apro^exia, and disinclination for mental work is more oiten ,„inplained of. Depression and melancholia are more often trace- .,1,1,. to this form than to suppuration in the larger sinuses \ foeling of distention of the bridge of the nose may l)e comi)lained ,,r and acluid enlargement may even l)e noticed. Tendernes.« can ,,,'mctimes Im' elicited, esjx>cially by pressing on the lacrymal bone •,t the inner angle of the orbit. The discharge from the nose is .sel- ,l„ni so ■< •)ious as with other sinuses. The patient rarely complains „f liu- <A\\w cacosmia, but o'l the other hand he is much more apt to l„. a!!ect(>d with anosmia. Although he may use fewer handker- niirfs he often has greater difficulty in clearing the nose, owing to the ..(•(•iction <lrving into crusts. In consequence of the tendency to .Irvness of the s(>cretion, and the turbinal atrophy, the secretion tends to" be inspired toward the back of the nose, and so, in some cases, to un'seiit it.self in the form of atrophic or crusty postnasal catarrh. I Aainination will n>veal pus in the middle meatus. In many cases it is ac( ipanied bv ixilvpi, and it is in such instances that the pus m lluid and vellow. In certain cases the pus tends to dry int adherent .rr....nish-vellow crusts, the ei)itlieliu. i gets eroded, and the turbinals ;,tn,phy.so that the appearances an- much like those describe<l under the ii(.;iding of < )za'na. . , , „ r \lthougli pus fi:>ni the anterior ethmoidal -ells must of course ,uak(> its es(.aiH' in the first instance into the middle meatus, it is often tumid Iving <.n the Hoor of the nose, and a.lhering to the margin of til., ini.ldl.- turbinal. whence it i.a.sses ui)ward mto the olfactory clelt. Ill delennining the origin of the suppuration it is a go(.d plan not to wa>h out the nose \v: l\ a cleiiiising lotion, but to careful y lift .jr wiiH. out the crusts with nasal dressing forceps, cotton, and a little ,.,„.Mine. .Mrefullv avoiding any blading. In this way any pei't-up pu^ iiiav sometimes be (liscovere<l and traced to its source. 1 lie use „f tl... nasal prob(> is essential, and \ len carefully used it will m many .-.Kes. es|K.eiallv those a.ssociated with jMilypi. detect canoas bone. \tler ihe middle meauis has Ikmhi cleansed, a me.lium-sized blunt i.K.be is insinuated between the outer nasal wall .and the middle lurbiiml. which is then pre.ss.-a inward. This will sometimes allow tiie ,..s,.ape of llui.i i-us. Tiiis pus might come from the anterior et i- in..idal cells or from the frontal sinus. If carious bone is felt in the nei<:hborhoo<l of the ethmoid it {>oint.s to ethmoiditis. although this does not exclude the pn-seiup of a frontal .sinusitis which often ac- companies it. The mere .sensation of " bare bone" is not sufficient to 970 XOUE AXD TUROAT. found a diagnosis of caries. The iinico-ixTio.stcum is so tliiii and closely adherent over the parts in tiie concavity of the middle turhinal, that the hone can Im' felt in many cases where there is neither |)us nor any symptoms sugfjestive of ethmoii litis. It is otherwise wlien the l)rol)e meets with rouphened and readily hreakinp-down spicules of hone, or on slight firm jMcssure enters small cavities in the ethmoid. The diagnosis of ethmoiditis can also lx> arrive I at by the method of exclusion already descrilx'd. In all cases it is a pood routine plan to commence by excluilinp the maxillary sinus. When the symptoms already descril)ed jis indicative of ethmoiditis are j)res»^iit it is sometimes dilFicult to say if the frontal sinus is also affected. The methods suggested by (Jriinwald of damming up the various ostia might l)e tried. If it is p<)ssil)le to catheterize the frontal sinus, and pus can be washed out of it. the diagnosis is facilitated. In most cases, however, it will first be necessary to do the typical amputation of the anterior end of the middle turbiiial. and there need Im no hesitation in taking this step, as it is the first one necessary in initiating treatment of the ethmoiditis. (Figs, .")()! and .t()2.) Once this is done the frontal sinus can l)e washed out in a majority of cases. In ,sf)me the involvement of the frontal cavity will still remain uncertain. In .such cases we should i)roceed with the treatment of the affected ethmoidal cells, and the persistence of pus from high up anteriorly in the middle meatus will indicate that the up|)iTmost simis must be dealt with. If there .in" no other means of determining the coutiiuied escape of pus the urgency of the .symptoms may justify an ext<'rnal exploratory opera- tion through the incision already descril)ed. If the frontal cavity is found healthy, !i.s in one of my cases, the wound can l)e clos«'d at once, and no perceptible scar is left. Treatment. In many of the slighter forms of ethmoiilitis only pal- liative^ treatment is called for. These are the cases in which a small ((uantity of nmcopurulent .secretion takes place, sometimes ilrieil into " films," •'casts," cru.sts, or merely into ''pieces like goldbeatn's skin," as I have heard patients describe thein. These fre(|ueiitlv forin in the night, sometimes in one no.stril <iiily, aiid .'ill that the |)atient reipiires is a cleansing alkaline lotion tou.se in the morning In these slighter forms the .secretion is .seldom s.i dry. or -accreted in such i|uantity, as to form obstructive collections. It i- a|)t to be the only thing the patient complains of. and it is therefore wi.se not to <)|)en up the < thmoirhd labyrinth mon' completely, when infectiem might only si)read and rr(|uire more or less co?n|ilete removal of a!' the cells. Sometimes in such cases the patient is subject to reijeatel violent "colds in flie head. ' with profu.se nuicopurulent secretion and the prolonged iliscomfort of acute coryza. It is then to I" considered whether more active measures should not be nroceede^ with. ' I'olypi .should be removed with the cold wire snare. When sufli cif'iitly cleared to enable a complete di;ignosis to be maile the ethmoid DISEASES OF THE ACCESSORY SINUSES. 971 MU must Ix- fnH'lv oiK-ne.i up, :uul this will entail roinoval of luuch o....(.u.s tissue. Iii iK'iirly every ease the typical a!ui.utati()n_..f the interior eii.l of the niidillo turluiu'l must he performed. (Iigs. Ml and -,() > ) If this enables a diagnosis of puK in the frontal sinus to be nnde rnd it is decided to o|)<"n the latter from the outside, the cells rm Ik' cleared from above through the floor of the frontal sinus. If thi-; step is not agree.l on, and if the frontal is not attected, the .MMMiiiiR of the dis«'as<>d ethmoid cells can be i)roceeded with. The -interior end of the middle turbinal havinp been removed, thi< i-xposes the bulla <-thmoidalis, the hiatus s<>milunaris and the interior cells The diaRiiosis can l)e now confirme.l by the caretul us,. ..f the prolK', which should always precede each subse.iuent step. \s a .liseased cell, or an escaix> of pus is definitely locate.l with the i.n.be the punch forceps of (Iriiiiwald or Hartmann should ein- bnce the diseased spot und(>r the control of the physician s eye. and in tlu- i)ortion removed at each bite carious bone, -.ms, and myxoma- tous-like tissue will Ik- found, liefore introducing the f<.rcei)s again the parts .should Ix' dried, an.l the prol)e shoul.l define clearly what the next step is to Ik'. In some ca.ses where the patient has »)een carefullv prepared, an.l resp<.nds nuarkedly to the ischa-imc action of Mdivnafm, the chief part of thedisf>ase can be remove.l at one sitting In ..tli.-r cases the fr.-e bleeding soon limits further oiK-ration ami treatment can onlv be c.rried out at intervals of ten to fourteen days. Next to careful use of the prol)e the most important ixtmt is to proceed alwavs in a direction upward and outwanl. A reterence o the topographv of the reg^.n will show that this w.,.il.l Ix- toward ,he orbit, and this is a .lire-tion of stifety, for little harm is do e ,.v..n if the cavitv of the orbit l>e ix>netrate,l. The capsule ..the e>e W..U1.I limit th.. progress .f the sprea.l of any mischief, an.l the acci- d,.nt might lK> revealcl ..y a "black-eye ' incident on the effusio, of l,loo,l below th.. lower li.l. It is otherwise if the .lm>c ion Im upwar.1 an.l inwar.l. The surgeon must av..i. most carefully an> approach to the ..Ifactory cleft. f.,r it is here that th.. ' anfrl.es .,f ,v.;„„,ling the cribriform plate. Still. I canno think that there is „„icl, .langer if the above a.lvice is carefully followe.l. viz : It niak.. r..p..at..<l invliminary expL.ration with a prolx;; (2) rem..\( .mlv what falls within the grasp of the f..rceps and avoi. twisting or „„tli,ur anv portion .iut. an.l Ci) work always upwar.l .and outwanl. It ha^ been reconimen.led to place the F>atient un.ler a general ana'sth.-tic an.l scrape away all .lisea^-'-d tissue with a ""f 1^'1'^<;- \lthough th.. little finger can be intr...luce.l into the nostril fn.m tin... to time t.. -letect carious areas, still the proc.H..ling mus 1„. „i..n. haphaz.ard than that ab.we .lescribe. , since hea It.iy an.l ....-ful parts arc ai)t to Ik- remove.l with the .lisea.se.l, nn.l when a . W K '-.swlberry. New York MerticaUournal. November 24, 1S91 A. B. Thrasher. Necrt-Uof the Mi.ldie Turbinal Ibiil., December 7. 1X9V , .^ „v„ J U. L. Lack TraiiMCUons of the Laryigological Society. London, 1901. 972 yoUE A so THRU AT. portion of l)oii(> is ripped out wo arc not assuml that thi" fracture of it may not extnul to the (•ril)riforin |)lat(' In an unconscious |)atit'nt in tlic jmir" position, ami witli 1)1 1 often flowinj: freely, it is more (lillicult to iM.'iintain anatomical laiulmarks, and I have known of a case where the rinj; knife had broken through the floor of the iiuterior I'oss.i of the skull, with, of course, fatal conse<|U''nces. Kxternal operation of the anterior ethmoidal cells has already been descrilied as part of the o|M'ration when the frontal simia is o|M-ned from the forehead. It has iM-en recoiTUnended to treat ethmoidal suppuration by this route in any case. Kntry is obtained by makinj; an incision similar to tiiat already describee f for reuchinj; the fr intal sinus, but it is better to chisel throujih the frontal bone on it.^ orbital aspect, .so as to jjain ready access to the ethmoidal cells. In ex|)osin<; tliei/i, care nuist Ix' taken not to displace and injure the eyeball, as ca.ses of iwrmanent blindness have occurred from doinp so. Prognosis. In many cases a complete cure can.iot be looked for, and if. with the removal of the anterior end of the middle turhinal and the openinfr up of the larjte ethmoidal cells, the patient's chief symptfims .iiv relieved, he probably will be well advi.sed to put up with a certain amount of muco-pus from the nose, and possibly the use of a daily nasal lotion. .\ glance at some coroiuil sections of the skull will show how impossible it is to o|)en up the very hij;hest cells without perilously approachinf; the floor of the cranium. tFifr. 4,s_>.) Combined Cases of Suppuration in the Anterior Group of Sinuses. Siiniiniinis: ...axillary, ethmoidal, frontal. Diagnosis. In many cases where it is difHcult to determine the "ri<iin of pus seen in the miildle meatus it is safest to begin bv settlini; the condition of the maxillary siiuis. Rajiid recurrence of pus will then |)(iint to disease of the frontal cavity, and in.xpection and the probe will determine the amount of involvement of the aii- teriiirethnioidal cells. Treatment. .\ maxillary simisitis eatmot be radically cured so lotid as it is M'Uu<i as a reservoir to the frontal sinus. Tri'atment of the frontal simis will be unsati.^actory if the ethmoidal cells con- tinue to secrete pus. Therefore in initiating treatment the maxillary sinus should, if |)o,ssible. be (irst drained through ;i tooth socket. The anterior ethmoidal cells should then be restored to as healthy a conditi.in as po,-isible, an<l a radical operation on the antruiii shoul.l not be undertaken until a frontal source of re-infection i< eliminated. Indications for Treatment. The frontal is the only one of the ac- cessory cavities whose ostium is situ.-ited in the most" favorable point tor natunil dminage. Hence in the absence of obstruction there is not the same tendency to accumuLatioii. .-md the cavity can rarely Ixronie tilled. With certain easily ajiplied iTieasures this tendenc'v to obstruction can Ik' further obviated. Besides tiie necessity of any radical operati(;n being i)erformed through the skin of the face rai.'ses IHSEASES OF THE AVCESSOHY Sl.\UiiEii. 973 the i.ussil)ilitv of s.)in.' (lisfiK„rpiu.'nt. while llu- proximity of tl.o „„st .'riur tl.in" wall of the s'mus to the anterior fossa of the eraniuin Ivinl.Ts all surnieal procedures much mon- .lann.'rous than those ..n the antrum of Hislmiore. . , While thes<- consi.h-rations induce a eertam difhdence in eml)ark- in.r „n ra.lical treatment, there are two oth<'rs which raise the .|uestion ./attempting a complete cure. The first an.l most imiK.rtant is. that nedect.Ml su|.puration in this cavity has midout.tedly iK-eii l„ll(,w..l 1)V s«.ri<.us results. The .second is that neglected frontal Minis supiiuration is verv likelv to infe.-t the other cavities iK-longiiiK to the anterior uroiip, viz. : the anterior ethmoidal cells and the maxil- lirv sinus In such cases the amount of pus secreted hy tlie frontal .'inus mav be .small, and the symi.toms induced by it may be m them- selves trivial, but the indications for attemptiiif; a cure of the ac( i- pinviiiL' .'thmoidal and maxillary suppuration may b<- promment, l,ut"iini)ossible of realizaticm. so lonp as the u-i)er cavity remains to iv-infect them. . .. . » In ill cLses it is well first to trv the effect of intranasal treatment. In the pn-st'iice of troublesome headaclie, fre(|uent neuralgia, recurring ■„.ute or subacute attacks of exacerbation, profust^ dscharge, or marked secondary results, the position of affairs must be explained ta the patient aiwl the external oiK-ration advised. Chronic Suppuration in the Sphenoidal Smus. Etiology. The ..ti.iloL'v of chronic sui)puration in this cavity is simil.ar to tliat ncciirnng in the sinuses already considered. The position of the .ntiiral ostium is verv unfavorable for the escape of secretion, and possihlv this is a reason whv the secretion escapiiiR from the cavity is part'icularlv pn.ne to dry into crusts. In many cases th,. smus is itTected at the same time as others situated more anteriorly, and it is said to occur ran>lv bv it.self. In the only p. .st -mortem I have s<.en of a case of sphenoidal suppuration it was, however, the only cavitv found affected. . * i ♦ Many cases formerly regarded as simply ozienic have been traced to a suppuration in this sinus. . . , , , i •,• i ,= Symptoms. The svmptoms complaine.1 of may «> classified as thev refer to ui) the head. ('-) the discharge, and (c) the eyes. (a) In manv cases no svmptoms of pain are complained of, whereius in others the' patient mav only s.'ek relief becaus(> of some form ol |».M.lache This mav be o'nlv a general diffuse headachi- or heaviness, or it mav be referred to the temples, the forehead, the occ.]. t, or d-cplv b'ehind the eves. Whh this headache whi( 1. is sometiines verv "variable, the patient is apt to complain of many of the mental sv.nptonis alreadv referred to, and I have found that afternoon som- Mnl.M.n- appears to !«• more common with rhis than with other smn.ses. (M In manv cases the patient has nuul.' the diagnosis o his case as one of -'postnasal catarrh," and there can !)<> little doubt that a numJM-r of cases whicli are ordinarily treated as originating in the pharvnx should correctly be locaied in the sphenoidal sinus. Cacos- y74 SOUE AXD Til HO AT. mia is often r<)in|)laiiio<l of, ami in advaiin-d cases the sense of smell is more or less completely lost. (r) The eye symptoiis, wliicli are often tabulated as associated with suppuration in tliis cavity, are. in my opinion, only met with in the l.if( r stapes of the disea.se, hut of course they might Ix' the first to attract attention in patients who had not sought advice or whos<' symptoms had Imm-u misconstrued. These ocular troubles may 1h' of the nature of lacrymatioii. photophobia, bli'pharospasm, transi- tory scotoma. The optic neuritis with complete- blindness, and such developments as exophthalmos, basal meningitis, hemorrhage from envsion of the cavernous sinus, etc., an- due to extension of disease to the walls of the sinus, and should pro|)erly Ix- cla.ssified as com- plications of a<lvanced disease.' Examination. Attention in the first i.istaii.-e may be directed by the patient to the larynx and when dried greeni.sh (ir yellowish scabs are found in this region (oza>na of the larj-nx or iracliea), the |M)ssi- bility of supi>uration in some of the acces.^ory cavities, and most probably the sphenoidal, should be kept in mind. Dried ^cab8 producing .atrophic pharyngitis may be found coating the posterior wall of the |)harynx and the roof of the nasopharynx. They may be found lying on the back of the soft palate ami generally in'a les« dried-up condition hanging about the choana-. It is important to carefully insiwct this n^gioii, as the escai)e of r.(|uid pus from above the middle turbinal into the postna.^al space could hardly indicate other than an origin in the sphenoid sinus or posterior ethmoidal cells. =m^ Fio. 508. Canula for wuhing out the apbenoidal iilniu. In the majority of ca.ses the How of pus is chiefly backward, but in many ca.<es it will also U- visible to anterior rhino.xcopy. It is gen- erally fomiil in the olfactory cleft, but it niav even pa.ss around the lower margin of the middle turbinal and ap|K'ar in the middle meatus, when it would have to 1m^ distinguished from pus originating in tlir frontal, ethmoidal, or maxillary caviiies. In ca.ses of doubt th(sc latter cavitii's must Iw eliminated by the methods of exclusion already <lescribed. It would be well in the first instance to carefuliv cleanse the entu-e iio.^e and postna.s-d space, and then to watch carefuliv tor the re:.pp<.arance of pus. If this is first visible in the olf;./- tory (left, and still more if it is .seen on the roof of the choana an ' above, the diagnosis of suppuration in cither the sphenoid cavitv o' posterior <'thmoidal cells is almost as.sured. If, as often occure in 'A i..,mm-.ry of 22 rcTor-M eases of fatal intra.ranlal complication, following ,Ilsc«..e of il„ sphcmmlal s,nu. will be fuuod -cconled by Zoubert in ibc A.-chlvea iic«.^n.ie8 de MMecini- DISEASES i)F THE ACOESSORY SiyUSES. 970 ilculiiijt witli tills cjivity, thr rcapiH-iiriuiPf of pus is ditfirult to dotpr- iiiiiii' aii.l there is any srspicion of its entry beinj; iniule in the iiiiiMle meatus, it is safest to make an exploratory puncture of the antrum. This will not only settle any doubt as to the presenec or .iliscnce of i>us in that eavity, but any reappearance shortly alterwanl ..f pus in the middle meatus would |>oint to the anterior ethinoi(jal c.r frontal eavities. Of eours<', the detection of pus in thes«' r:ivitirs would not invalidate itsoeeurrenee in the sphenoidal, imt it would l»e wiser to assure tlieir eompletc drainage More proceeding to deal with any n'lnaining pus which inuat then c.nie fmiu the iK)8terior Mucous i)olypi nn' rarely met with ui association with this form of sinusitis. I,' It various forms of iiidammatory hyiierplasia are often found, jKirticularly in the comp-iratively recent rases. In such cases, often with atrophy of the pharynr from the drying and irrita- Fio. S0». Melhoil iif ittlheterizing the sphenoidal tlniM. liMii of the s«>cretioii pus'ing backward, a chronic hypertrophy is -Miiietimes oncounteicd, particularly in the middle turbinal, which iiiav sfciii larjier than it really is in comparison- with the atrophy which has often set in in the inferior turbinal. The midille turbinal iiiav be so closely pressed against the septum that a sound is mily passed after careful application of cocaine and adrenalin. If inserted ill a sloping direction inward and upward diagonally acro.ss the plane ni the middle turbinal it will imjunge on the nasal surface of the lid in the neighliorhood of the ostium. (Fig. 509.) 'Uiis open- spiienoii lii^: htis Ix'en found catheU'rizable in only 40 per cent, of cases. It lies JL »7G yonK Axo ntiti) \t 'llll III ut 12 mm. abovr tlu* |">st<Titir I'lul if the niiidlc turhitiul, uml plofK' uiiiUt the n!i.s;i! I .of.' ill tlir inujority of ciiscs tin it\>i iiiii^ lies a little PXtfTiuil to th<" (lin<'ti()i» <»f the olfactory ch'ft ialH)Ut 5 iimi. from tlic iiiiddlt' liiH'), ami. it is then iinjMi.v ilili' to p i-,s a sound into llu' sinus witlioni n-nioxai of the niitldlc turlnnal. This should Iv dono as alrc.'idy dcscrilM'd. If i he anterior end ha.-* liad llie typical amputation ixrfonned then tlu' remains should l)e removed with a Cold win- snan\ the punch forceps of (IninwM I. or, under a Ronenil ana'sthetic such as nitrous oxide gas, with thesimkeshave. A<'cordinjt to Cholewa a view of the anterior wall of the si)henoida! sinus can Ik- obtained, and the midi'le turliin.tl at the same time re- tained, liy the following method: a sh-nder < !< - ator is intriKluced iN'tween the tniddle turhinal and the septum, and the former is pried outward and fraeturt'd, pmhahly alotig its base of attachment.' Kven when free access has \h'vi\ olitaine(l to the anterior sphenoidal wall the ostium is seldom distinctly visible, Immi.'; generally close<l by the folds of mucous membrane, much like the meatus urinarius. But, on carefully wiping and watching, the pus may Ik' .se«'n exuding from the region of the ostium. A catheter can, however, be pjussed into it by gentle niani|)ulation, and the cavity should be syringed out. The nose having previously Ix-en carefully cleaned the exit of any pus will show that it comes from this cavity. The distance from the anterior nares to the sjjhenoidal ostium varies iM'tween "JJ and :i\ inches. The following an> figures of difTerenl ob.servers: (Jriinwald, in males H.2 cm. (3} inches), in females ".ft cm. (li inches).' R. C. Myles, 2V to 3} inches: to i)o.sterior wall ot sinis, with i)rol)e lx>nt a little, 4J inches. .Jonathan Wright, 2J to 21 inches (5.4 em. to <>.7 cm.): in a living specimen he found the di>- tance to the anti-iior wall to Ix- ,i incht s, and to the [xisterior wall :i\ inches.' (iKiismann, 4 inches.' ('. R. flolmes, from 5 cm. to 7..") '■111. average, fi.lS cm." Uosworlh found that a prolK' impinging on til |x)sterior wall of the sjihenoidal sinus was ti} inches from the tip of tiie nose.' My own exjM'rience is that th(> secn^tion which can be washed mit in a chronic case is comparatively slight m amount and it is .-ieldom l)iirc pus. It is nuich more apt to Ije iiiuco-pus, or even thick mucus with thi-eads of pus in it, and I hav rciiiarked that it floats in tli'' lotion used nuich like islets of frog's sjiawn in a pond. hut the catheterizing of the sinus ha.s anothiT value even in tlio case of a doubtful result from its lavage. It is this, that it determim's |)ositively till' ijrescnce of a sinus and the justifiability of opt>ning it ti]!. I C. K. Holmes Anblvea of OphthalmnlnKy, 1H9A, vol. zxv. p. 461, » IJuoletl by II. I'ordes. Mont's, fur Olirtnlieilk., May. I8'J9. 3 Nuwl S'lppnratloD. l.oli<luii, l*J01. • Twemifth Century I'raclice of Me<ticinc, lsa6, mjL. vi p. 82, and Aniwln <if Otology, KibruB ■. > New York .\.'ftJemyof .Mi'dic ne. Joiir-ialof Laryngology, l)t9<i. xl. p. 13". • Archive* of Ophilnlinoloity, 1S96, xiv. p. 461. ' Trani«ctloiu of the American Laryngological Anociatlon, IXit'i, p. 94. DtSKAStCS OF THE ACCESSORY SISVHBS. U77 Tlic -phrnouliil simiws are so im>Kuliir in rDtit.mr, iiiul their vitv |,rr«riic»' soni.'tinies sn pr..l>l»-matical, that it w..iii.l Ix- rash to atu-ii>l)t !M hirak into u siiiiw without Hrnt .Irt.TiniiiiiiK that ono is pn'soiit. Xtronhv is a iiuirli "lorc fmiiwiit n-sult of proloiiip-.l spl„-noi.hil suppuration, an.l not iiifn^iunitly the nasal loKsa'ari' so wi.l.-.an-l so tillfi with fcti.l «Tusts. that thi-y pn«»ont ail thoapiM-aranc-sof „za;na. !t is in such cases tliat it is sonietimcs ih..ssii.I.' to fxplorc th«' ostium without pn'iiniinary n>niovai <»f the niidtlif turiunal. Treatment. In n.anv <as<>s wh<'n- tho ostium is not n-aihly acwss- il)lo and in whicli thcVomplaints of thepati.-nts an- not very nmrit«Ml. 1,(. will Ix' well a.ivisc'.l to n'st content with alioviativc tn-atnuMit. niiswiii consist of svmptomatic treatm.-nt to sccun- Inv 'Irainap;, an.l chu-Hv "'f regular cleansing of the nose an.l i.harynx. Ihis w iH-sf carriiMl out with the ,>ostniml syringe, or the anterior nasa svrinee. using simplv cleansing, tepi.l. alkaline lotions When all .nists an- ex|)elle(l the nmil fossa- may 1h> luhri-ate.l with som.- oi y preparation such as simple li.iui.l vas««line or l)enz.)ni.il. Ihe a.ldi- ti..n of any antiseptics is apt only to be irritating. The dryness of Flo. .MO Hl^k'i hook for opening uphenoiilal (.Iniu. the pharjTix mav be relieved by a carbolic or other lozenge. In nwiiiv ca.ses. once the natural defensive power of the iinicnus nem- l.raiie of the nose an.l cavum has Ik-cii assisted by this treat fin-nt, it is .)ften remarkable how the continuation of a sphenoidal suppuration can be tolerat*'.!. i i • j Where more active measures are indicated access must Ik' obtained t.) tlie ostimn as already imlicate.1, an.l the sinus must Ik- regularly ••leanse.1 with alkaline and antiseptic loti.ms. If a freer exit i>ji '"died tor the natural oix>ning mu.st lie enlarged by inserting into it Ilajek s sphenoidal hook and so tearing awa p:irt of the front wall. .\s soon MICROCOPY RESOLUTION TEST CHART ANSI and ISO TEST CHART No 2 1.0 I.I !-! ~ {lilt O O **• I - l_ •- i._ !" 136 132 m 2.2 [ 2.0 1.8 1.25 WWWA 1.6 ^ APPLIED IK/MGE i,''6) *82 - 0300 - P^o^t* 978 SOUE ASD Tim OAT. as tho margin is dpfinod it can ho furthor onlarRpd l)y the use of Griin- waldV iniiicli forc('i)s. Where tiii'n is ditficulty in eiilarf;inp: tlie natural ostium, and par- ticularly where there is any softening or caries of the anterior wall, it ran he ]H'netrate(l with a trocar and canula helow the level of the situation of the ostium, the opening being enlarged by curettes and sharp s|)oons. I have found the following a simple and easy method of effecting an opening into tli'> simis. The patient is placed under a general ana'sthetic and the fiireHnger, introduced through the mouth, is in- serted into the choana of the affected side, as high up on the anterior sjjhenoidal wail as possible. A pair of blunt-])ointed sinus forceps of sjK'cial form (Fig. .tIH are introduced through tli:' nostril, and the point located just above the tip of the examining forehnger. With a little careful palpation a point can generally be found where with firm ])ressuro the forceps will penetrate the anterior wall. As the in- strument is witlxlrawn the blades of the forceps are expanded so as to enlarge the o|)pning. On the following days this opening can be further enlarged under a local aniesthetic. Kio. 5U. StClair Thomson's forceps. It has lioen proposed by.Iansen, and lately recommended by Furet and Luc,' to a]ii)roach the s|)lienoi(lal sinus by traversing the maxil- lary cavity first. In that case a large o|)ening in the canine fossa should be made as already directed, and then the nasal wall of the maxillary cavity should Ix" freely removf'd in its posterior two-thirds. The anterior wall of th(> sphenoidal sinus then comes into the field of view oi)ene(l out from the canine oiM-ning, and it is claimed that it can readily b<' dealt with. The extensive destruction of ti.'^sue entailed in this, the dangers associated with the proceeding, the more or less pennanent disfigurement and discomfort of large urmatunil permanent openings, and the still uncertain results obtained for what has not yet In-en proved to be such a fre(|uently dangerous condition, prevent this operation from coming within tiie province of {)ractical treatment. The iiossibility of reaching the cavity from the naso- j)harynx is neither practical nor useful. When the sj)henoid s nus is artiHcially opened, profuse hemorrhage • SocUHO FrantKise ■1c l.arynKnl.. 1901. DISEASES OF THE ACCESSORY SINUSES. 97!t l,Ms somotimos occurml. In a case of {Jleitsinann's. the bleeding ,li,l not take i)lace until seven day? after tiie oiM«ration.' TiH' opened simia must l«" dealt with aceording to the conditions met with Xeerosed portions of bone may re(|Uire to be remove. . |>,,lvi)oid conditions of the mucous lining should be removed with loireps or curette, care being taken to respect the posterior wall. The condition of the mucous lining may be improved by j)lugging with iodoform gauze, or cleansing with iodoform emulsion In many CHOI'S tlie cure is incomplete, and Griinwald has found that oziena, traceable to suppuration in the sphenoidal sinus, is one of t!ie most inveterate forms. , , .. i Indications for Treatment. Profuse i)ostnasal purulent catarrh. -.Mvistent headache, orbital or intracranial syini)tonis, call at once tor ireitment In their absence treatment must not only deitend on the atiiount of suffering of the patient, but also on the skill of the surgeon. ( irunwald differs from manv of le,«s experience in thinkmg that the sphenoidal is one of the most satisfactory of the accessory cavities to "Mucocele. Synoiiyms: Chronic catarrhal sinusitis; serous sinusitis: cysts of the antnmi: dropsy of the antrum: hydrops antri: hydrops inthimmatarius. . , u r Symptoms. It is difficult to prove that any increased flow of muciis ,,r aiiv serous discharge from the nostril originates m one ol the •ure-^orv cavities. The source of such nasal hydrorrhoea may be MisiH.ct<"d when, as in the case of a distinguished colleague there is •1 <u.lden escai)e of abfmt a teaspoonful -f clear watery fluid from ',hc higher nostril when one ear is lowei..! over the single wooden -i.tho-^cope. When the opposite ear is used no such flow occurs other possible svnnptoms are supra-orbital neuralgia, and occasional ,n<al obstruction, without any intranasal condition to explain it. lixploratorva.^pirationof the n.ixillary sinus will sometimes with- (h'lwaclear waterv, sometimes amber-colored fluid. In hv.lroi)s antri and in disten.led mucocele of the fn.ntal sinu.s ih.M-e is a gradual. painle;<s distention of the cavity unti the walls of tiic >^inu< are so thinned that under the finger they " crackle like stronv parchment.-^' The swelling may reach the size of an ..umge. S>nie- tini.- the external wall is absorbed to such thinness that fluctuation i< readilv i.erceptible. The walls may yield so that when the maxil- l.uv .imis is affected the hard palate becomes flattened and the nostri hl.;..ked bv the bulging of the nasomaxillary wall W hen the fmntal .-.vitv is mvoived the orbit is seriously encroache<l on. When tUe ,.„ntents of the sinus are removed they are found to consist ,.l •inspissated mucus" (Ferguson), or clear or yellowish serous fluid, lrc(iuentlv containing cholesterine. 1 TransactioMOf the American I^ryngologlcal A««oclatlon. ia95, p. 91. i N.-.'::i! =upi>urati<;tL I.-amh's trandatitin. London, !««) » Sir William Fergiuon. System of Practical Surgery. 1x70. p. 597. III''! 'J8U yOUE ASD THROAT. I Pathology. The old view of tliis condition was that it was due to "catarrh" of the niucoiis iTicnihrano, and tliat wlicn the exit of tliis secretion was oi)stnict('d it accmnulatcd and distended tlie cavity. Altlioiijili ficneraily abandoned, this view has -n recently supported by Xohenitis, who reports 37 cases in whicii ' y ex])l(iratory asi)iration he found serous exudation in the antrum v.here lie thinks it was pro- duced by • hydrops inHannnatarius."' Tiie mucous membruie, as has l)een i)ointe(l out, is inihtTerently sui)plied witii f^lands, and has no vascular secretinji arrangements like the nose. The mucus secreted l)y a catarrhal .simis amounts to very little. These "mucoceles" are much more likely to i)e caused by the develoi)ment of cysts in the mucous membraiir either by the cystic dilatation of a jiland or the cystic defteneration of a polyjjus. These cysts may grow to such a size that they occupy the sinus and are mistaken for its cavity. The cyst wall may rupture and the Huid iM'como free. The walls are thin and the contents vary. .\s a rule it is a viscous !i(|uid, thick, .strinjiy, transparent an<l sometimes yellowish. In other cases it is opa(iue and even caseous. It freciuently contains cholesterine. In large cysts i' is more li(|uid, yellowish-white, sometimes transparent and syni, in consistence, or stringy like white of egg. This pathology is supported by Christopher Heath, ^ who thinks that the term " dropsy of the antmm" should be abandoned, and (iiraldes,' Virchowj' Uernher,-' Alexander," Scheppegrell,' and other- object to the designa- tion of hydrops antri as giving a false notion of tlie real pathological process, viz.: cystic dilatation. (Jriinwald says in relation to the frontal sinus, that the cases in which the secretion is [)urely mucou- are ''extraordinarily rare."" Luc describes a case of closed nuicocele (passive) of the frontal sinus, the contents of which were typically cystic." Cases in which this sinus are affected generally come under the oi)hthalmologist. Cystic dilatation of the ethmoid cells is dealt with el.-;ewh(>re. Treatment. This consists in opening and evacuating the affected cavity on the iiriiicii)les already described. There is no hesitation in recommending ojH'rative measures, for gen-rally the disfigurement of tile disea>r is worse than that left by the operation. There is not the same risk attending it, as pyogenic organisms are not present or only in insignificant ntmiber and virulence, and there is no need to make a counter-opening into the nose. Tumors of the Accessory Sinuses, (irowths in tlie acces.'jorv sinuse,- niay be either siii.ple or malignant. Among the former are" (edema- tous fibromata (so-called myxomatous jiolypi), cysts, and osteomata. ' M.iiials. f. Ohrenlicilk., April, lsa.'i. (i. JI4. = Injuries and Diwwcs of tne J«\v. Tliirti eilition, London, 1HR4. ' Ui<hirchi'> snr les Kystcs mn.iiieux (In SItuib maxillaire. Paris, isfio. < Herliii, kliii. \V(K'hen»chrin, 1W*7. .Vn. 1:1, •■ .\rchiv f. Laryngol , 1S97. Band vi., Hefl I, 8. 130. " Nasal Siii^ii'.iralid!!. i . 'J^5. '* Annalesdes mal. lU' rorville, etc.. 1M!><.>. xxv.. No. l,p .I9r>. actionsof the American Laryngologlcal AssoclHtinn, 19«1. ' Archiv f klin. riiir , Band lii. ■ Medical Reconl. August 26, Vm. See also W. E Casnelberry. Traii* DISEASES OF THE ACCESSORY SIS CSKS. 9£1 Tlic latter coniijrisf sarpoiiiiita and ciMthclioiiiata. Neoplasms are not of conniion occiirrence: they are more frecjuently met with in the maxillary than in the other accessory cavities. Masilhmj Sinus. Simple growths like polyi)i (irdematous tihro- inata) have already been referred to. Cysts of ^he antrum may lie due to (1) obstructicm and dilatation of the glands of the lining mcmhrane; (2) cystic degeneration of i)olypi: Ci) dentigerous cysts; 1 4) dental cysts. ' Tlie two latter are not true antral cysts, hut only invade it from without. Osteomata, fibromata, and true myxomata are rare (Jonathan Wright). Among the malignant growths may be mentioned epithelioma, carcinoma, and .sarcoma." Frontal Sinun Neopla.sms are rarely met with in this cavity. Cysts, ostfomata, and fibromata are the innocei't growths which have been recorded. Carcinoma and sarcoiuii are very rare. Ethmoid. The occurrence of i)olypi and cysts has already been dealt with. Osteomata are occasionally met with presenting at the inner angle of the orbit. Carcinoma and epithelioma are not uncom- mon in elderly subjects, and it is important to remember that sarcoma may occur as early as the ninth or oven the fourth year (A. A. Bliss^). Sphenoidal Sinun. Polyi)i are not conunon. Nasopharyngeal til)ron!ata, sarcomata, and carcinonmta are not infrequently met with, but generally invade the cavity from the outside. Diagnosis.' The age of the patient, the progressive character and constant pain, the occurrence of hemorrhage, the external manifesta- tions, the secondare involvement of glands and neighboring tissue?*, ;is well as the api)lication of the tests described, will help in de- termining the presence of a malignant growth. The simple ont>s, with the exception of the polyjji and cysts already descrilml. declare themselves bv their .slow growth and evolution. Treatment " This has already been considered except in the case of the malignant growths. Ivirly diagnosis of ethmoidal cancer will oiiiietimes suciced in ensuring success by intrana.>*al treatment only. Sarcomata are t.ften slow-growing, and remain limited to the bony tramework of the nose for some time after declaring themselves. W hen originating in the maxillary cavity partial or complete re- --e.tion of the ui)per jaw is generally re<iuire(i. In the other cavities operative treatment is almost hopeless. Foreign Bodies. These have been incidentally referred to in the pivc(>(ling pages. They are most freciuently met with in th" maxil- larv sinus. Considerable help is given in the diagnosis and treatment of such toivign bodicr: as metal drainage-tubes, broken ends of instruments. .iimI bullets, l)y the employment of the Roentgen rays. < liniitliaii Wriglit. New York ModicalJoumal, November 4, 18«!. ehrii!to;.her Heath. Injuries 1.1 niseasos of the Jaws. London. Hcymann. Virehow's Archlv, 1892, vol. c»xlx. Bry«n. Con- I s« iif l-hysioiHiis and Surgeons, 18U1. - TrttusutlionB of llic American Laryngologirai AsrotiaUuii, l'^*: |.. 4«. 982 SOS E AND Til HO AT. A P P K X D I X . TiiK fiillnwing scheiiiii, as suggested by UiindaM (trant, is founded on the method employed by Lermoyez of dividini; the aymptorns of sinus snp|Miration into preMiiin|i- tive, probable, anil certain.' It must not be employed as if mathematically exact, but is useful as indicating the steps of a diagnosis. T.\B1.K I. SuiNS OF A C'liKoNir Empyema is Onk ..k thk .\cce.s»oby Cavities of the Nosk. PKESl MPTIVE: (a) Unilateral discharge. (6) Headache or neuralgia, relieved by discharge. («) Subjective caconmia. (d) Polypi, especiblly ifbathe<i in pus. PROBABLE : (ii) Presence of pus in middle meatus or olfactory cleft. (6) Opacity on transillumination. CERTAIX: (a) Catheterization of sinus through natural orifice, and expulsion of pus on irrigation. (h) Exploratory puncture of sinus, and aspiration of pus. (<■) " " " 'xpulsion of pus by air. (<*) " " , " V I pulsion of pus by irrigation. TABLE II. Differential Diagnosis Accordino to the Sitk of the Pukulent I)is<'ii\kue. PUS IX MIDDLE MEATUK: ! Maxillary antrum. Frontal sinus. .\nterior ethmoidal cells. PUS IN OLFACTOKY CLEFT: Posterior cavities. \ «ph«-noldal sinus l Posterior ethmoidal cells. TABLE III Skins of Suppuration in Maxillary .Vsthum. PRESUMPTIVE: (a) Unilateral discharge. (6) Intermittence in discharge. (r) Pain— infra-orbital, supra-orbital, dental, or more distant. («') Subjective cacosuia, intermi'tent (c) Carious teeth. (/) Pus in middle meatus. (g) Polypi in middle meatus. '*) Hyt)ertrophy in middle meatus. ' Lermoyez. Ther»|ieutlqae des maladies des rones naaales. P«rl«, Octave Doin, 1896. iJl.SEASJiii OF THE ACCESSOR Y SINUSES. 983 PKOBAHI.K: , ^ ^. ^ , . (.1) Reappearance of pus on cleansing middle meatiw, and bending head for- ward (Fracnkel). It) Transillumination showing opacity (lieryngi. Ig\ " " obscurity of pupil (Davidsolin 1. Ijx " " absence of subjective sensation (if light. CKRTAIN; I'uncture and aspiration, tranaulflation, or irrigation, by— (a) Ostium maxillare. lb) Inferior meatus. (p) Alveolus. TABLK IV. Signs ok .Si-ppuration in thk Frontai, Sinus • ' I'KKSl'MPTIVE: ((i) C'ontinaou-. discharge. (i) Pain. (c) Teiidemeiw on pressure. I'KDBABLE: , ^ ^. , , (a) No reappearance of pus on cleansing middle meatus and bending head forward. (6) Reappearance of pus after irrigating maiiUarj; sinus. (f) Appearances on plugging the hiatus semilunaris. (d) Small qiiantitv of pus, which does not crust. (e) Transillumination of maxillary sinus negative, and of frontal sinus positive. CERTAIN: . Direct proof is impossible except by external operation. TABLE V. Siosa OK SiPPfRATioN OK Antkrior Ethmoidal Cells (DISEiSE or MAXILLARY ANTBHM HAVl.VO BEKN EXCLUDED). PRESUMPTIVE: (n) Continuous discharge. (6) Pain. (c) Tenderness ov« 1 icrymal bone. (d) Menial depref ;io.i. (e) Asthenopia. PROBABLE: (ii) Pus, with granulations or polypi, in middle meatus. ( h ) The use of a probe exposing pus or bare bone. CERTAIN : Exploration. . TABLE VI. Signs of Suppuration of Sphenoidal Sinus. pr::sumptive: (a) Pain. (6) Ocular disturbance. (e) Somnolence. 984 XOSE ASI> Tim rUOBABI.K: l'ri*ence of \m» (or crusts) — AiiU'riiirly, in olfactory cleft. I'oBteriorly, on Huperior and miilillelurliinals, on roof of cliimiui', anil vault of naxopharynx. I.rsions in olfactorv i^left— Bulging of wail of sinux in acute caHw. Mucous |iolv|ii CKRTAIX: la) Pus seen flowing fnnn ostium. (b) Catheterization of sinus, (r) Kzploratory puncture. TABLE Vll. SlONM OK Sl-PPIKATIOX OP t'oXTKRUlK KtHMOIDAI PRESUMPTIVE: As for sphenoidal sinus. PROBABLE: Poly|Hiiil middle liirbinal. (ERTAIX: Return of pus after irrigation of sphenoidal sinus. Bare bone felt at poHterior extremity of middle turbinal. CHAPTER XXII. DISEASES OF THE OROPHARYNX AND NASOPHARYNX. By H. S. BIRKETT, M.D. SOFT PALATE AND UVULA. Congenital Malformations of the Soft Palate and Uvula. Con- fliMiital ahsPMco of the soft palate and uvula is of rare oecurrenee. ^ceoinpanying is a photograph of sueh a condition. A second speci- men of Ihis malformation was lately founa in the dissecting-room of McGill University. Flo. ijia. Congenital nbnence of «oft patate Bnd uvuUi. (From Professor Shepherd's Anatomical Museum, McGtll L'nlrenity.) ( 98.5 ) nvui aso yosK A.\n THROAT. Aiii.tlicr coiiKctiita! coiKlilinii of tin- soft palate and uvula is a want of fusion of the cniiiryonic tnaxillarv processes. niviuK rise to !i condition known iis cirft ix/lote (complete). Tliis want of iniion may vary in extent, and .sum, ijme.s both hard and soft palate are involved in their entirety, as seen in Fi^. 'A.i. \\ other times it. Km, .'iLi. Flu. i\*. Cleft palate and uvula, (CnHF-N,) Defects In the iinlirlor pillar of the fauct may only involve the soft jjalate and uvula, and again oiilv tin uvuhi Itself may be affected, ami in this latter ca.se it gives rise to what IS known us a hiftd uvula. This division of the uvula niav be partial Dr complete. Another congenital defect is occa.sionally met with in the |)illar> of the fauces. Thi.s defect consi.sts of a fXTforation of either one oi both anterior pillars. They - ay be congenital, due tf) an incom- plete cKwuri' of the branch'" clefts, or as the result f.f ulccrati<.i. occurring in the course of an infectious fever (scarlet fever), as in one of the writer's cases, or as the result of breaking down of :: gummatous infiltration. uinEAiiica OF Tin: oropuaey\x asd XAsoPUAiiryx i)«7 DISEASES or THE UVXTLA. UvuUtis, Etiology. Tlif usual oaus(> of an acutr iuHainmatidii t)f the uvula is ••cold." It luav also l)c llic rcsuli of an .'Xtciisioii ot an acute iutlaiuniatorv process from th.' a<ljac<'iit strur.ur.> ipiiarynx ami tonsils). It may also occur trau .latically tliroupli torcipii bodies or from the aclioti of any corrosive. Symptoms. The first svmptoni usually iio''ce<! is a sii>;lilly pamlu sensation of liie throat upon every movement of the soft palat., aiul especiallv marked when swalL.winn. Later on this is followed I >%• a feelinU o'f a foreign hodv in the throat, and every eHort to dislodge it is apt to he followe.l l.v an iiitensitv of the syin|itoms. Tickling and a eoupli are also apt to he present. The symi)t(nns may l>ecome so aggravated as to actually pnriintate attacks of stiflocatiun du.- to the ei'laifted and elongated condition of the uvula irnt-vtuip the upiier part of the iaivnx. I'poii examination in the early stage of the disease, the uviia is s<-<-n to he uniformly injected from its tii; to its Ivise. and from here exteudinn slightly into the soit ' '\vhen exudation has taken i)lace into the loose tissue of the uvula it then a.ssiimes a swollen, (edematous, and semitransparent look: its original outliii.' and shai-e are c()m|)letely altered. The general disturiiaiice is usually very slight. Treatment. In the (>arly stage, before traiifudatiou has taken place, thea|ii)licationof a 5 per cent, solution of adrenalin chloride (1 : 10()0), piiiited everv hour, will frequently cut the inflammation short. It transudation has taken place, then the tension is best relieved by nuiltiple punctures. This is best done by having the patient hold his tongue down himself bv means of a <lepressnr. then grasping the uvula at its tip to steadv it, and with a long (Jraete knife make several deep punctures into the most dependent portion of the uvula. The subse<iuent treatment is the use of an alkaline and antiseptic spray -^uch as Dobell's solution. In this coniM>ction mav be mentioned adema oj the uvula occurring, ilthough rarelv. in the'course of chronic Blight's tl'«ea.s(>. and that due to the result of patients suffering from jxistna. al catarrh who attempt to draw the secretion from the na.sopharynx with such vio- lence as to produce a traumatic (I'denia. Relief to local .symiitonis will be followed bv puncturing the uvula a.s described. Elongation of the Uvula. Causes. Recurring attacks of : ute inflammation of this organ, chronic pharyngitis, nasopharyngitis, and wan' of general tone. Symptoms. Fre(iuent cl«>aring f the throat, tickling followed l.y cough, especially aggravated whe.. lying down, and in some cases the uvula ha« been so long as to reach the entrance to the Larynx and produce a spasm of the glottis, the patient awakening with feelings of impending suffocation. 'J8H .\(»SF AXh THRU. IT. H Treatment. Let one livar in mind that attention to tlic pnticntV Kt'n(i;il state of h 'altli is of |iriiMaiy iinixirtancf, anil eonihineil witli the u.se of astringent apphcalions siicli !i.« ftl.vcerin ami tannic acid (H. I*. I, or .") per cent, solution of |)rotar>;ol will serve in the majority of cases to relieve the symptoms. In the ca.se of coukIi beiriff "a trouhlesoriie symptom, h't one here he warned not to he deluded that the uvula may he the cause without first carefully investixatinfc the patient's jjeneral condition as to the po.ssihie existence of other causes. The writer has fre<|uently seen cases where a portion of tiie uvula has heen removed with the exiM'ctation of relieviiiji the coukIi, when, iipon careful examination, the patient wa.s found to 1h" sufTerinR from incipient (uherculosis. When pfftiM-rly indicated a portion of the uvula may he removed as follows: The uvula, es|M'cially its posterior surface, is first |)ainted with a U) jier cent, solution of cocaine, followed l>y an application of a solution of aflrenalin chloride (1 I'MK)). At the expiration of ti'ii mimites the uvula is sulficienlly aiuesthetic to proceed. The l)atient lu.lds his own tongue down to the floor of the mouth hy means of a depre.s.sor, and the uvula, wiiich hiis been grasped at it's extreme tip hy means of a pair of lonj: anjrular fon-eps, then with a pair of long scissors, curvetl on the flat, the excessive len>;th should he cut off in a direction from Im-Iow backward and upward, thus leaving the greatest jxirtion of the cut surface posteriorly. In cutting the uvula one must he careful to remove (tnly the elongated mucous membrane, and not to injure the azygos uvula- muscle. Complete ablation (»f the uvula is to be condetmied as wholly unnecessary. The slight bleeding which usually follows a uvulotomy re.piires no attention, as it cea.ses in a short while: but it has occilrn d that the hemorrhage has |,een considerable, and when of such a degn'e, then the application of such a solution as ailrenalin chloride (1 : l(XX)l, glycerin, and tannic acid. .,. the application of the galvanocautery may be sufhcient. If none of these measures arrest the hemorrhage, then the application of a ligature around the uvula and above the cut surfaci' will suflice. The subse(|uent treatment of a c;ise of uvulotomy is rest of the organ, and this means abstaining from speaking and Of taking nour- ishment in such ;t form as to re(|uire the least amount of sw.r.iowing consistent with the greatest amount of nourishment: therefore, such foods a.s jellied beef '.s.sence, calves' foot jelly, and oysters are the best form of nourishment. The |)ai;i fr.l'owiiig a uvulotomy is con- siderable, and will be relieved bv the !is>. of small pieces of ice being hehl in the mouth while rec!ining. Hematoma of the uvula is not infre(|uently .seen as the result of operative interference on the organ itself or as a .se()uence of ton- sillotomy, '''he writer has also seen it as the result of violent efforts of nn.sal screatus. A varicosity of the superfici;i! !>|n(»dvesse!s of th<- .soft jmlate and uvula may occivsionally be se(>n m cases of arterio- sclerosi.s. DisK.isKs OF Tin: onniif ■ nrxx asd SAaovii.mY.sx. wm Benign and Malignant Growths of the Uvula and Soft Palate. Benign Orowths. P»pUlom«. This is \\w most frcr m <.f the l,..|ii)iii iiiowtlis occiirriiin ii> this rcKiuii. I'iipilldiiuita in..y Iw .-ithiT .r^iii' nr |MMhiiiciiliit<Ml, iiii.l .listril.uliMl in jrnmps ..r siiifjiy mi any ..•lit i.r tli«' soft palat.', uvtili, !Ui<l !>illars of tli.- faiin-s. W h.-ii scssil<' 'mil sinnl.' thfv cause no >vniiiti.ms. but wiicii apiiiiiatiMl or iit.hiu- iiiiatfci they may pnxhicc symptoms of a foreign hotly. a.s tickiiiijt c.iu^th or frciiuriit clrariiin "f tiic throat. Angioma. Aii>.'iomata are rarcaml s(.mctimi's fouml tolx' assoc; ted with a simihir ooiulitioii in the othiT portions of llic respiratory act. These tumors iiiav !)<■ sinnle or consist of a .series of small on. "( .t- tere.l over the IKilatr and uvula. In one of the writers c .the tuii.ors were scatteri'.l over the soft palate and cheek of one side, hut in the larynx they were collected into a very dehnite tumor iiivolviiift the false cord on the <ame side. They seldom cau.se anv svmi)ton!s or require any interference: i.ut if"larn-c and thev lend to he a • - ce of recurriiiR hemorrhages, then they are Im-sI treated hy nwa"- of electrolysis, although there are many who advocate their remova .>y either the cold or galvano- cauterv snare. Simple adenoma of the soft palate is rare, more commonly f»ucli tumors being mixed, as tibro-adenoma or myxo-adenoma. These tumors are u.suallv sessile or |«'(lunculated and covered with normal mucous membraiH". and do not tend to inva.le the surrounding struc- ture- Their |)resence is not attended by any painful sensations, tuit usuallv those of a foreign body in the throat. Hemoval by . Means of the cold wire snare or by scis.sors an- the best wi-ys of dealing with them. . • i • »i • The following rare benign tumors may also be met witli in tins region; dmnoid rusts. U^HitmUt. )ihro-clwii<lr»viat<i. and uhtw.n ecu "'waUgnant Orowths. ^hllignant tumors originating in ei !'(r the soft palate or uvula are not of fre.iuent occurrence, but, as ■ cNten- si„ii of the disease from neighboring structures. !'re not ui."' vunon. Carcinoma. Carcinoma of the soft palate u. . i'- aj-pear. e. t he f,,n„ of epithelioma. The disease shows itself i ly i-ortion of the uvula or soft jialate, and in the early sta;:e makes itself known by a definite ..welling of the part invaded; the mucous membrane covering it is sli<rhtlv injected. To the t<.uch it is firm and the overlying vtructuiTs iiitimatelv adherent. TIktc is gradual enlargement until the surface is brokeii ami an ulcerating surface presented, th<" granu- litioMs of which are inten.selv red, bleed easily, and the edges hrm Symptoms. In the earlv stage the symj)t()ms are those of impaired movements of deglutition and sijoech. The pain may not be severe ui.til ulceration takr- place, when it is .ipt to be severe, especially during the process of deglutititm, the pain radiating toward each .'•ir should the growth be situated in the uvula alone or m the centre 1 '5 : ' ' i ■'if c U 9510 SOSi: A.\D THROAT. of tlic soft palate; but if to one side of tlio niuldlc line, tlx'ii tlic pain shoots into tlic car on the corrcspondiiift side. It is a disease usually of advanced at;e. Sarcoma. Sarcoma of these structures is rare, the most common variety Ix-iufr the fibroid: less connnon arc lymphoma and the melan- otic variety. Sarcoma may in its early existence i)resent a .swelliiifr of the invaded structures not unlike carcinoma: liut the mucous memhrane coveriiijr it is not so liyperaMuic. It.s course is slower than that of carcinoma, and the lympliatic jjlands are fre(|uentiy not in- volved. It is a disca.se found nuicli ; arlier in life than is carcinoma. Symptoms. The symptoms may in every respect resemble tin i.se of carcinoma. Treatment. JudfinuMit in operating u])on all malijinant cases in which the .soft palate and uvula are primarily involved must be treated according to individual conditions jm-sent. When the disease is well limiteil to either the uvula or soft palate com])lele removal is to be strongly advised. .\ny glandular involvement will also re(iuire removal by surgical measures. In the tn'atment of sarco- mata the use of ("oleys serum ha.s found many strong sujiixirters, and it is only one of those measures which are advocated when .surgical measures seem to be out of the (|uestion. DISEASES OF THE TONSILS. Tht> tonsil is a collection of lymjihoid tissu<' upon whose free surface are a number of depressions (crypts or lacuna'), .sejijirated from each other by follicles, and is covered by a nuicous membrane which dips into tlii'se crypts. I)e|)ending upon the situation of this collection the tonsils have received various names — faucial, |)liaryngeal, and lingual. The faucial ton>ils are two in number, one on either side, between the anterior and jxisterior pillars of the fauces. In .size and shape they may v.-uy very nnich in different individuals: ordinarily they are about the size and shape of an almond fruit. If. when inspecting the f.aucial tonsil, the anterior pillar is dntwn forward, outward, and slightly downward, a fold of mucous membrane will be seen exten<l- ing from its edge downward and backward to the tonsil. This i- known as the plh-ii Iriininiilaris iTIisi. Immediately above this is ;i lecess or fossa to which the n:\u\f yii pnilinisillfir fos.-^a has been given, .•uid this recess is found to extend backward and sometimes forward into the substance of the soft palate. Acute Catarrhal Tonsillitis. In this alVection the nmcous mem- brane covering the tonsil is the p;trt chiefly alTected, and is nearl\ alw.Mvs ;i part of ;ui acute |)haryngitis. Etiology. This disease is most common in chiMren. Sudilcii changes in the temperature and exposure to cold, gastro-intesiina! affections and manv of the acute exanthemata. Symptoms, The symjjtoms may b(> ushered in by ;i sense oi chilli- ness, and ill young children even by a convulsion. This is icCPom|)a- DIsfJASKS OF THE OROl'llARYSX AXI> yAaOPJIAlirXX. <J91 iiicd l)V liciidaclic, pcncral depression, temperature raiiftiiip from 1(1(1° to" 102°: i)ulse full and bouu.'ing. deglutition is painful, and the muscles of tlie neek ami the cervical glands may he tender. Ipon ( N.iminatioii in the early stage of the disease the surface (if the tonsil and surrounding structures present a marked degree of hypera'inia, and later on a very thin, whitish exudate may Im- seen at theoix-nings u| the crypts. The disea.se usually runs its cour.se in about four days il unattenih'd to. and may by its extension involve the middle ear 111 ;ui acute intianuuatory |)roce.ss, attenth-d either with or without -uppuralion. Treatment. Begin with a purgative, such as calomel and soda in ■■niall doses, gr. j each, freijuently repeated If the temperature be high and the jmlse full and bounding, small doses of tincture of aconite iM. 1'.), 1T|i.i "'very two hours, will be of service. ('oi<l alka- line sprays such as the following will t>i' found to give relief to the -ymptoms in the early stage of the disease: Sudii bictirboiiatts. Sodil biboretis, »ft nr. ix. 01. cinnainomi, lll'j Aciiiac. 'iv .\pplications of a solution of nitrate of silver (gr. xxx to .^j) (iiice a (lav, or guaiacol in its ])>ne state, to the surface of the tonsil .iiid into the cryjits, are stningly recommen(l(>d. Should the di.sease progress to such a (legre(> that the inflammatory process shows by its inlensitv that the lUKh'Hying structures have been invaded, then local depletion (scarification) is advisable. The .-^pray then, or gargle. -Iiould be used hot. Acute Lacunar Tonsillitis. This affection is an inflammation of the crypts or lacutue of the tonsils, and is characterized i)y the fliling-ui) nt these cryjits with inflammatory products, which appear on the -miace as ;i white or yellowi.sh-white exudate, accomjianied by an iiivolveinenl of the adjacent and deeper-lying structures in the lutlamniatory jirocess. Etiology. Among predisposing catises a lowereil state of the general <vsleiii st;inds pre-eminently first. Sudden changes in the temix-ra- iiire. unlicaltli\ <i:iidition of the tonsils themselves, and ;is exciting rauses, in the liglil ' jiresent bacteriology, certain bacteria, notably I he pvogeiiir cocci, are found to be the cause of such inflammatory .•iiiiditions. Other exciting caus(^s, as iniperf( 1 1 sanitation, close, overheated, and foul atmosphere, so fr(>(|uently met with in the out- dnor clinics of many large hospitals, give rise to this condition, and is uvnerally known as "hospital sore-throat." This disease is more roiimion in young and middle-aged individuals, and less fre(|uent ill advance(l life. It is not unconinion to find this form of ton.sillitis attacking individuals in a house where scarlet ' ver i.- jiresent. One attack is apt to predispose to future attacks. Symptoms. The disease is usually ushen^d in by headache, pain in the liack or extremities, chilliness or even rigor. The throat is painful. 992 -VavA' AXD THROAT. \ e>s|)cci;illy when swallowing, and ovoii speaking may l)o painful. Tlip pain extends upward to the ears if hotli sides are involved, and to one, on the same side as the atTeetion, if limited to one tonsil. The tem- perature varies from 1(K)° to 10;]° or 104°: the pulse is rapid (100-120). full and bounding. I'sually, the disea.se begins on one side, and within a time, varying from ;i few hours to a day. the otiier side is m vaded. The submaxillary glands are frecjuently swollen and tender. The inflammatory eMudition may extend to the parenehyma of the toii>il, when the sym|)toms beeome .somewhat more intensified (par- enehymatous tonsillitis). Tjion examination the tonsils are seen to be swollen and hypera'inio. and if the i)arenehynui if involved the hypera'mia may be of a livid hue. On the surfaee of each tonsil are to be notieed small isolated spots of exudation, their size and .shape corre.sponding very often to the opening of the crypts. This pxu- dated materi.-il varies in color; it may be white, yellow, or gray. The exudation may be limited to tht openings of the crypts or may extend and coalesce with that from the neighboring crypts, giving to it in some ca.ses a distinctly membranous appearance. The exudation may l)e so slightly organized that it may be easily wiped off by means of a cotton-wool swab, or it may be so dense as to be adherent to the mucous membrani>, and re(|uire theu.se of a |)airof forcep.s to loosen it, and when loosened it exposes an underlying, very hypera'inic, and even superficially ulcerateil area. In persons who have suffered from recurring attacks of a( ife lacunar tonsillitis the secretion is apt to have a very fetid odor. The uvula is usually hyixTa'inic and sometimes .swollen. Treatment. .\ brisk purgative of calomel and .soda should be given at the outset, alxiut gr, iv of calomel andgr. iij of soda. Small doses of tincture of aconite ( H. P.), ITlij. may be given hourly until the |)ulse and temiM-rature are lowered, provided, of course, that the |)ul.se is ;i rai)id, full and bounding one. The .salicylates in various forms have in some ca.«es proved advantageous: salol gr. v and phenacetin gr, iij, given every two hours in combination, have, in the writer's hands, proved most beneticiaL (iuaiacum, a much vaunted r(>medy, has not, in the writer^ experience, proved to be esjiecially efficacious. Henzoate of soda in 10-grain doses is waririly advocate<l by manv authors, [.ocally, the tonsils should be sprayed with a warm alkaline and antiseptic solution, such as one of the following: .\<'iili iHrlKillii, H'Klvert's No. 1) Skxiii birnrbollHtix, Afimc, Poilil blrarbiinatis, Li^^terine. A(iua>, «r.J. gr. T. Sj. gr. V. Sj. Sj Whenever possible it is advisable to ole.nr out the crypts of anv retained serretion, and this cati Im done by means of a small curetl>' or scooj). .\nother method of dislodging" these inflammatory plug y^Wi'-Lbii-A' OF THE ORnl'lIARYSX ASD SAHOPHARVyX. <)y3 wil illl|iliS: which the writer has found lu'iu 'icial is to project ajjainst the tonsil hv means of a syringe a stream of wjnn Ixric-acid solution (ffr. xx to .=,i). In carryiil't this out it is iiecessai., »o have the patient leaning a little forward, and thus facilitate the escapeof the fluid by the mouth. The aiipliciition of either sua! icol, the nniriated tincture of iron, or liiicture of iodine, by means of a cotton-wool swal), into each cryi)t ill tend to cut short the course of the di.seitse in many cases. If sible to make these applications, then these remedies may be used in the form of frargles; thus guaiacol should Ije used as a 1 per cent, solution, the tincture of iodine in the same strenjith, ami the niuriated tincture of iron mi doses of lUv combined with gr. iv cf chlorate of pota.ssium to the drachm will bo found efficacious. .\s to a clioice of any of the above-mentioned remedies as a local application there does iiot seem to be one, in the writer's e.xperienco, each drug having its own adhenuit. As tliere is in all jjrobability an inlcctious character about these acute inflammatory [)rocessps of the tonsil, such ciuses should iis a precautionary mea-sure be isolated. In iio'.ises where there is a fnvjuent occurrence of these attacks, investi- gations should be made into the conditions of the drains and sanitary surromidings; in all cases a cause should be looked for, and, if possible, he removed. Any existing diathesis, as rheumatism or gout, should he corrected by suitable remedies. The course of the disease is usually favorable, terminating in recovery in about four or five days. Com- plications of a more or less grave character are rarely met with, and when they do occur, they indicate a general infection. The occur- rence of joint affections and canliac complications ha.s led to the sup- position of a very close iussociation between rheumatism and tonsillitis. Tonsillar and Peritonsillar Abscess. Depending upon the situation of the accunmlation of the inflammatory products, so is the affection named. In the one, the suppurative process is situated in the sub- -tance of the tonsil, and in the other, in the tissue surrounding it. The former affection is comjjaratively rare and the latter (|uite frequent. Peritonsillar abscess may occur at any age, but is especially associated with adolescence and a strumous habit. Etiology. Acute lacunar ton.sillitis is apt to be a precursor of either tonsillar or ])eritonsillar abscess, chronically enlarged tonsils, retention of secretion within the ciypts, especially in the supratonsillar fossa. Symptoms. The symptoms are those of an acute lacunar tonsillitis, though they are apt to be more intense; <leglutition is more difficult and more pai"ful; the pain in the ear is apt to be more constant from the swelling of the .soft palate, extending often up to the mouth of tlie JAistachian tube. There is marked difhculty in opening the mouth, the opening being so limited in severe cases that a thin tongue- depressor is with difficulty inserted between the teeth. Thesecreticm of saliva is much increased, and with the other glandular secretions it hccoiiies verv tenacious and difficult for the patient to get rid of; ill fact, attempts at its removal are so painful that many patients allow it to dribble out. The breath usually is very fetid, and especially (>3 I i. 994 XOSE AXD THROAT. is this so when suppiiratiiiii iius occuricd. Tlic t('in|)('i'iituro at this stage is apt to he more elevated (101° to 102°) : the patient's voice he- coiiu's very tliick, speeeh is with diHicuit}- carried out, and, oe account of its ciiaracter, dithcult to understand. Tiiere is often oDstructed i)reathing tiirough tiie no^trils on tiie affected side, and the patient lias a sense of fuliu w at the haciv of tlie nostril, and freiiuently tries to clear it hy making a snorting noise. This obstruction is due to a swelling of the ui)per surface of the soft palate posteriorly. There is a marked tenderness of tlie sulmiaxillary and cervical glands, and there is often a markeil fulness behind the angle of the lower jaw. I'Yoin the inability of the patient to take nourisliment there Is loss of weight, and the facial exj^res.sion is that of acute suffering. The ex- amination in many cases is carried out with a great deal of difhculty. owing to the inability of the j)atient to open his mouth sufficiently wide to make the examination thorough. In tiiose c:uses which allow tiie examinat'on to be made it is noticed that there is a definite and distinct .-wellmg in the soft palate just above the tonsil of the affected side. (Mite WIX.) The imicous membrane covering it is of varying intensity of color, from either a rose to a iivid hue. The tonsil it.self is pushed inward and downward, atid to such an extent in severe cases that its inner surface looks directly over the epiglottis. The uvula is swollen, (vdematous, and |)ushed •■eyond the median line, and .sometimes in contiict with the tonsil of the oi)po,site side. If it is possible to ex- amine the swelling digit.ally the- is a full, ten.«e, and deep fluctuating sen.sation to i)e felt. Treatment, if the patient be seen in the intlanunatory stage. i>efore suppuration has taken place, there is nothing better, in the writer's experience, than a deep, free incision into the substance of the .«oft palate, just a ijuarter of an inch above the anterior palatine arch, and made at right angles to it. This gives relief to the tension and allows of the free e.«cape of accumulated infiannnatory products, .•uid the local depletion adds very much to the relief of tlie symijtoms. No thera- peutic measures seem to relieve tliis condition, .'^hould the stage of supl)urati<.n Im' i)resent wlien the patient is seen then the pus shoultl be allowed to escape by means of an incision Tuade as above described. In either ca.se the kind of knife and its method of u.'*e are of some con- siderable iin|)ortance. The useof a curved bistoury is not advisable, because it is iiiijxi.ssible to tell where the point of the instrument may be : preferably, a straight back, nainiw-bladed knifi' is il'e better. The knife should be held with its blade horizontal, and the cutting 'mI^c directed toward tin middle line. \\\ m;ikiiig the incision in this way its edges are more likely to be kept apart, and thus f.acilitate the escape of pus, than il made vertically, when the edges come together and close the wound. The juis wiiich e.srai>es has usually a very fetid odor. IVc-.-ure on th' region of the abscess will facilitate tlie contents being thoroughl} evacuated. The subse(|uent treatn.ent is merely the useof an anti IM.Al-f: XXIX, 1 I'lTlllMl'^ll llll All - Aulhc .rV in^.', i uii;i:Asi-:s of the oropuarysx asd XAsoj'iuiiy.sx. »jy5 s«>i»tic pirfilc nf listcriiic (1 ilraclmi to the ounce), or a weak (2 j I'lit. oarholic so ilut ion. I.cland stroiifily advocates the rcadiing of these al)sc(>-ses tliroujih a very free incision made into the substance of the tttnsii, and sul)r.'(|uentiy using tlie finger to enlarge tiie opening. In several of this chtss of ca.ses the writer has found thesupjmrativp pro- cess to have been cau.sed by ca.^eous products retained in the supra- nsillar fo.ssa, and by siin[)ly drawing the anterior pillar of the fauc 111 cs forward and downward by means of a bent |)rol)e the collection of pus has been allowed to escape, with relief to the symptomsand with- out further operative interference. It is therefore always well to in- vestitrate tlie possibility of the |)us being thus retained before |)ro- cced ..g to inci.se. fpon recovery this p:.cket can be dealt with by providing free drainage and curetting the cavity. The duration of this affection if left to it.self is usually from five to seven days. The danger, however, of allowing a coMection of this kind to go on until the pus finds an exit for itself is that it may e.sca|)e during sleep, and produce alarming symptoms, if not suffocation itself. If the pus has burrowed very extensively it may erode the a.scending |ih:iryngeal or internal carotid artery, producing alarming or even fatal hemorrhage. Septic thromboi)hlebitis is also known to occur, and is generally a fatal complication. The infiannnatory condition may extend downward and ])roduce an (vdenia of the laryn.x. I'sually only one side is involved in ton.sillar or periton.sillar ab.scess, but the process may (jccur in both sides. Acute Ulcerative Tonsillitis. This is the title of an affection of tiie tonsils given by Moure to a condition seldom int t with, and char- ■icterized by the occiUTence of ulceralioiis involving only the .super- hcial structures of the tonsil. It is benign in its nature, althoi zh the healing jjroce.ss is slow. The ulcers may iii)pear either single or mul- tiple on any portion of the t(:nsil. The affected area is covered with .1 grayi.sh-white exudate, and on removal, which is easily done without bleeding, it ex])oses an underlying superficially ulcerated surface, the edges of which are clearly defined and not indurated: the sur- rounding area of the ulcer is nnich inflamed. The symjjtonis are tho.se of a mild, acute lacunar inflanunation, ,111(1 the treatment consists of the frc(|uent (every two hours* use of an alkaline and antisejjtic spray, such as Dobell's solution. Thr- daily ,il)plicatioti of a weak .solution of silver nitrate (1 jier cent.) will stimu- late the ulcer to heal. The affection may jKi.ssibly be mistaken for malignant ulceration or primary syphilitic infectior;. Careful ex- amination, however, into the clinical hi.story of the case will lead to a definite diagnosis. Membranous Anginae (Non-diphtherial). I'nder this heading is included se\ cral forms of angina characterized by a membrane involv- ing either the tonsils, soft palate, or jwisterior wall of the |)harv!ix. separately or collectively. The condition is an infectious one. and may be due to any of the following bacteria: staphylococcus, strepto- coccus, the bacillus of Freidliindcr, pncumococcus, the bacillus .■" uoa -Yo.sA- .l.\7* TintuAT. it 1 i t and the fiisil'cirm l)acilliis tif N'iiicciit. Tlic inciiihraiK', wliicli is dc- jxisitt'il ill till' various lucatiuns just niciitinncd, is citiicr whitisii or yt'llowirli in culnr, and in liiicknos varies from a tiiin ixHicIt' to one of considcralilc di'<;rci' and toufilintss, hut never attainiii}; that tiiiek- ne.-s ami loujriiriess cliaracteristic of dipiitlieria. it is fairly adiierent to tlie underlyinj; mucous memlirane, and wlien removed leaves a lileedin;: and, in some cases, an ulc<'rated snu'face. The constitutional disturliance is usually siijrlit : hut in some cases, especially the strepto- coccal, stapiiylococcal, and pneumococcal infection, it may he luarked. tile temperature risinjt lo 1(11° or even to 101°. The pulse under .sucli conditions is rapid and full, and tlie suhmaxillary glands swollen and teiitlor: tliere is sli<;ht pain on deglutition, increa.sed salivation, and even a fetid hreath. There is usually very little general dejjression. even in tiio more severe forms, and in this respect ilifTers so markedly from dipiitheria. The course of tlie diseiuse varies. In the form due to stajihyiococci and streptococci its duration is from five to seven liays, but when due to the presence of the other mentioned bacilli, it may be from one to four vveeks before the membrane htis entirely di.sapiieared. Clinically, its appearance resembles closely dipiitheria or syphilis, but bacteriological examination will clear uj) any doubts a.s regards the former, and the personal history and anti.syphilitic treatment will correct any doubt ius regards the latt<'r. The treatment consists in the use of antiseptic sprays or gargles, such as a solution of boric acid (gr. xxv to .^ij), bichloride of mercury .solution (1: 10,000), antifelirile mixtures, when indicated, and subse- ([uently general tonic treatment. Hypertrophy of the TonsUs. This is a condition which may be found in all ages, from the younge.st infant to the oldest adult.' It is usually an evidence of a strumous diathesis, and is in many cases hereditary. Several local conditions are apt to lead to a chronic hypertrophy of the t(msil, and especially in those tonsils where there are recurring attacks of tonsif'is due to di.sea,sed conditions of the crypts (retention of secretion, chronic lacunar tonsillitis, tonsillar and jieritonsillar ab.scess). .Mouth-breathing dependent upon nasal obstruction, all inflammatory affections of the throat — whether due to local or systemic causes (infectious fevers) — will ])roduce chronic enlargement of the tonsils. In young individuals the condition is usually ;i.<sociated with the existence of enlargement of the pharyngeal tonsils (adenoids); but in older individuals this is not alwavs the ca.se, the strumous condition having apparently centred itself in the enlargement of the faucial tonsils alone. Two tyjies of enlarged tonsils are usually recognized, tlie one which is .soft and lymphoid in character, and the secon<l. which is firm or fibroid. The former is usually the one found in voung children and the latter in adult life. Symptoms. When the tonsils are considerably enlarged they pro- duce mouth-breathing, thick speech, and freijuently cough when the iust:Ash:s OF THE onoi'iiAHYsx A.\i> yAsoriiMiyw' yjjy patient is lyiiift down, thrdU^h tlic lower part of tlie tonsil heiiiR -iiliieiently eiilarjied as to irritate the ii|)|M'r part of the I'liijrlottis. In lesser (lefirees of hypertrophy there may he no sytnptoins or ineon- venienee. ( »ni' tnusl always have in mind that the ahove-nientioned svinptoms, esp.eciaily in ehildren, are apt to 1)0 iissoeiated with an inlarneinent of the pharyngeal tonsil (adenoids). In adults, tlie pres- ence of enlarged tonsils i.s apt to produce fatigue of the voice, oitlier ill speakiii); or vocidiziiin. Frei|uently, patients eomi)lain of notieinR white spots on the tonsil, and upon manipulation of the tonsil itself lliese spots are extruded in the form and shape of a small pea wiiieh, when crushed, produce a very tlisanreeahle odor. The effect on the licarinj; is indirect and largely due to the interference witli the action III' the palatal muscles, and not to direct pressure upon the opening 111' the i'lustad' .n tubes. rpon examuiation, the ton.-dl may Im- found enlarged to various degrees, fidiii just beyond the edges of the pillars of the fauces to niceting each other in the median line. The tonsil in the lymphoid varietv is usually soft, of a pale rose color, and the .surface smooth. Ill tli(' fibroid variety it is hard, paler in color than the other variety; tlie surface irregularly divided liy bands of fibrous tissue, and the crv|>ts widely oi>eii and sometimes filled with caseous [ilugs. The nilargeiiKnit (if either variety may be either in the antero-jiosterii r or vertic:il plane. Pynchon lias given the name "submerged"' Id that condition of the tonsil which is hidden liy a large hypertrophied I'uid of the anterior pillar spreading over the tonsil. Sonie'imes the .Ulterior and even posterior pillar may lie adherent to the hyper- trophied mass, and this conilition may be easily overlooked if n< t carefully investigated by means of a bent probe, whereby the ante- rior pilhir of the fauces may bo drawn forward, and thus allow of a more cireful examination. Sometimes it happens that the mouths (.1 tiie crypts being do.sed, we have then a coiKlition produced known as a ••retentioti cyst," which shows itself as a white or yellowish-white spot covered by thin f.iucous membrane. In size, they may vary I'idiii that of a jiin's he.-id to that of a large-sized pea. Treatment. Before beginning treatment for hypertrophy of the toiisii.one must ask the (|uesti(m. Does the ca.se call for treatment? .iiid. based upon this, mu.st the case be dealt with. It fre(|uently happens that patients present them.selves with enlarged tonsils, in whom they jiroduce no symptoms at all, and sitnply because' they are en'arge(l is their re;i.son for having them removed. Only, then, if there are tangible symptoms referable to the enlargement of the tonsil, is interference called for. Mach ca.se mu.st be dealt with upon its own merit and the treatment best adapted for the relief of the symptoms carried out. Local medicinal treatment is, in the majority of ca.ses, useless. When, however, the cause of recurring attacks of loiisillilis is due I" the retention of ca.-.eous plug.- within the lafUlliP, and the tonsil it if is not enlarged, it sometimes is of u.se to clear out these crypts of their contents and ajiply the following application; W8 AUSi: A so TUJIUAT. Irallnl, Pot l<«1 , Ulycerinl pur , ■r.lU. or solid nitratp of silver fused on the end of the probe. These inens- ures may l)e tised in patients who will not submit to more radirnl treatment; but what may appear to the patient to be a less formid- able measure than removal is the followinj;: Thoroughly o|M'ninK "" the erypts by means of scissors or a suitably curved knife, and of cut- ting through every band of tissue which serves to partially divide the crypts from one another, and then applying either solid nitrate of silver or the galvanic electrode to the floor of the spaces thus ojM'ned uj). A better result is often obtained by using a jtair of punch forceps (Farlows, Fig. .515), and directly removing piecemeal the offending Fiu. &13. Punch f'lroepp. portions of th" tonsil. Especially is this method of uso in those tonsils in which this condition (retained .secretion within crypts) exists and are well retracted within the fauces, and difficult to get at by other means. In such ca.ses it will re(|uire the use of a tenaculum to draw the tonsil up from its t)e<l into the fielsl of operation. This methoil of treatment (niorcellement ) will also be found useful in freeing the supratonsillar fossa of tissue which dams uj) any secretion, and thus allowing better access to treat the pocket in the fos.sa, which so fre- quently retains secretion. This pocket wlien thoroughly exposed and drained is best treated by the api)lication of solid nitrate of silver, the galvanocautery point, or the use of the curette. DJSEAHEti OF THE UHul'IURYyX ASD XAHOPUAHr.W. yya ( )ft('ii uiKiii I'xuiiiiimtioii the (.itPninRs of tlieso vTy]tU iiro not rptwlily sc<>ii anil ri'<|uir»' on*- to ciinluUy cxaiMinc the tonsil l»y mvam of ii prolic wliocc end is JM-nl at right angles. Hy means of this, hands of tihrous tissue iiiav he drawn to one side, rcvoalinR tilled erypts, and (siH'ciallv should tlie anterior pillar of the faiiees Im* drawn for- ward and the underlvinR l)ortion of the tonsil rurefully examined. In all tln'se o|)erative "procedures the part to be ojXTaltMl upon should In- swahtied over with a 15 per rent, solution of ei.caine; the aiui'S- ihetic aelion will lie present in about ten minutes after its applica- tion. The subsequent application of a solution of adrenalin cWoride (I :!(KI<»l will moderate the ble<'dinji. When the tonsils are so enlarged as to recjuire reduction in size, then there are several ineuiis at one's disposal. Tliese are: 1. (iuillotine. ■_'. Cold wire snare. ;{. Illectric wire snare or electric guillotine. 4. ilnueleation. • ■ ■ u In the selection of one of these measures one must be pudod by the condition of the tonsil. In the soft variety, occurring chiefly in cliildicii. the guillotine should be selecte*!: but in ca.ses of the fibroid or hard varietv of tonsil, then the cold wire snare or llie electric (•iiiTci't. as applied to the snare or guillotine. The reason for thus laying down very definitely such a ruh' is that in the soft variety, wiiich largelv occurs in children, bleeding is more likely to be only moderate, and ceases readily of its own accord, while in the fibroid v.iiiety the blootlvessels do not retract so readily into the remaining substance of the tonsils, and the result is that there is a greater teiidencv to not oiilv primary, but secondary hemorrhage. 1. (ii'ii.i.oTiNi:. tonsillotomy ill children up to liftwii years of agi' ^lioiil.l be done with the palieiit under a general !ina'sthetic. for, a-s :i rule, enlarged tonsils are a.ssociated with adenoids, which also iiould be removed at the same time. When sutfieieiitly under the iiithieiice of the aiuesthetic the patient is gently raise<l to the upright position the mouth-gag inserted, then, by means of a head-mirror, the tonsils are illuminated by reflected light, and the guillotine, either Mathieu's (Fig. 516) or Mackenzie's mmlification of Physick's (Fig. .'AT), is held in the left hand when removing the patient's right tonsil. .Mathieu's tonxlHotome. and in the right hand when removing the patient's left tonsil. The iii.-iruincnt is now made to engage the tonsil in the ring, .ind this is done bv encircling the gland from below upward. In this movement the ring of the guillotine must be held almost horizontally, thua mm .\OHE .1 \l> rillin.lT. iillowiiiK of til)' riioxt ilc|M<ii(li'rit |>iirtii>ti »( tii<- tiiii>il to Imtoiid' fir>i (•iina>?f<l; tlirii l>y l)riii>;iiiu llir ritij; iiitu tin- vi-rtical ixtsitiini ih,' n-iiiaiiiilrr nf tin- tnn.sil will Iw I'li^ap-il. HcI'dic aliscisiiiK tin- cnjiajfctl jH>rfinn it is wrll tn ••xatiiirif with tlic iruicx liiiRcr of Ihc iliscnjrafft-.l limid ami a.-iccrtain whether all that eaii he erinajjeii i.s well within Kiu. M*ekentl«'9 tonilllotome. the riiiji of the jtiiillotiiie. The eiijtajtenient of the tonsil may some- tiiiKs he faeili'ati'il hy pressiiij; on the jiht'iil uiideriieatl, the aiigli- of the jaw. In ca-se one is usitifj the Mackenzie instrument, the hlade is now jiushed home and the portion of the tonsil removed. In usin^ the Mathien instrument the fork is only thrust into the substance of the tonsil when it is well en>;af;ed, i'.nd the cutting hlade is then Kiu. 51>.. Instraments for freeing a(lhe!*if>nfl bctivccn the I'lllars ft the taiice" and tonsils (Maki'EN.) drawn tnwanl one. This hitter iiislriiment is uf use when the tonsil lies fairly well retractijd, for hy u.se of the fork it is drawn tiut of its '"'■d. .•itid also the atnouiit of the •jhuid to he n'Uioved is n'f;u!ateii. In many eases where the tonsil is vi'ry dependent at its lower portion, if this he not properly eiifiaged. the very oi)ject of its heinj; removed DISKAUKS Of Tilt: OHOI'UM{Y.\.\ AMt SASOl'IIAJiiyX. 1(M)1 iii:i\ Im' (Icfi'iitftl f.ir ill such casi-s tin- tmiftil w iHiuilly » wiurcc of iiiii:iti(tii tti tlir stiiictiirfs iifiir till' tip of the f|ii>{l<ilti."<, ami itw jiri's- I'lii'i' |iri)iliii-)'s :i tlLHtiii'liiiiK ami iiiuiuyiiiK coukIi lii't'iirc iloiiiK It luiisillodiiiiy Im' sure tluit there are no aillie!<i(in8 Ixlweeii the pillars of the fuiiees ami the tonsil itself. W hen present, ami it is rliieflv anions ailiilt cases that such a eonilition exists, they Mir liesi freed hy the use of sucii all iiisiriiiiient as imlicateil in l''ig. .'lis. U; 'hus freeing the tonsil it is more readiiV enjiayi'ii, ami there i« also a -iM-iieil danger of cutting the anterior jiillar. 2. Coi.n \\ iKi. SwuK. The ordinary nasal snare with a regulating «(re\v is the iiistriinieiit ii-ed. The instrument rei|uires to Im> rtrn -ii.iiiijlii made, and rather stout piano wire (.No. lOi should 1m' used. Tlic loop is made of just siitliciently large size to engage the tonsil, and when engaged it is made taut ami slowly screwed home, about iliiee to live minutes iM'ing occupied with cutting it through. ;i. Ki.KiTRK rrv .\.h Ai'IM.ikd to tiik Wihk Sn.vkk nu (irii.i.oTiNK. Tlie liest means of using the electric wire snare is that known a.** Knights electric tonsil snare (Fig. 519.) In this instrument the Kiu. ftW. KntKlil'i tonsil itmlviiii<H«iiter>' ■narv. I'latiiiuin wire looj) is made a little larger than the ring and tied at its lii.-lal end hy nieaiis of a threail. The tonsil is now engaged and the wire iliawii closely around it, and when this is fully and thoroughly accoii)- piished the current is turned on and the wire dniwn slowly hoim . •luii.ithan Wright has applied this means of removing fon.sils to the iiniiiiary Mackenzie guillotine. The atlvantagc claimed hy some in the use of these electric instruiiieiits for the icnioval of tonsils is ili.it the amount and even the possibility of hemorrhage is mod- irated or prevented: mi the otlii-r l..iiid. the disadvantage is that ill addition to the wound it.self there is a cauterized surface. \\'hen one decides to remove tonsils by means of local aiucsthesia, il-'ti i-ach one is to !)(> swabbed over with a J" 'ler cent, solution of ■Dcaine. The u.se of a mouth-gag and an assistant to steady the iicitd depends entirely -pon the |iatient's .self-control. The u.se of '•(ic.une in no sense makes the o|)erati()n a painh'ss one. It may moderate it; but in the writer's experience the operation itself, even with the lociil ana'sthesia, is an extremely painful one. Heiiiorrliage at the time of the tonsillotomy is apt to be profuse in young children and in adults wiien the guillotine is used. In the case <tf el.illrcn it soon eeasen, hut in :>du!t« it may ' troulslesome. Tills, however, in the case of adults is considerably le.s.sene(l by re- moving the tonsils by ineuiis of the cold wire sna;' electric snare, c" 1002 NOSE A\D rUROAT. i'loctric guilldtiiic. As prccmitioiiary incasurcs, it is ;i{lvi>;il)l(' that the patit'iit, sulwoqucnt to tiic i)])('rati(iii, be not allowed to lie down, but a.ssiiiii(' a scinirccinnhcnt position: tliat tiic blood ho allowed to escape from the mouth without any effort on the part of the patient; tiierefore, all cleariuf; of the throat should he avoided, and the use t)f the voice abstained from (secondary hemorrhage two chiys after the operation lias been met with in the writer's experience, due to the want of the lu.st observation). Food in as concentrated a form a.s possible, and re(iuiring but little mastication, should form the diet. The hemorrhafie, wiien moderate, is usually arrested by tiie use of iced cold drinks or small pieces of ice held in the mouth. Locally, a solutioti of adrenalin chloride (1 : KKM)), applied by means of a pledget of cotton-wool held against the bleeding surface, will in some cases act well. A mixture of g.-illic and taimic acid in the proportion of one to three, with sufficient water to make a thick i)aste, applied by means of the index linger, lias also |)rove(l of use. The use of the |)erchlonde tincture of iron nnist be a|)plied with caution, the cotton-wool swab should not be smcharged, as otherwise it will then flow into the pharynx and cause unpleasant symptoms. If. howe\<T. the hemor- rhage be very |irofuse. these measures are of little a\ail: then one must, with good illumination, carefully .search for the l)lee(|ing i)oiiit and catch it by means of a pair of long artery f()rce|)s. and if possible. a ligatvire ])la("ed around it: it' not, then the stump of the tonsil must i 1 Butt's tonsillar becmoBtat. be well drawn out and a strong ligature placed around its ba.'se. Butt's tonsillar ha'inostat (Fig. .')2()) has been found of .service in arresting hemorrhage. Wingrave has drawn atteiitiui! to the occurrence of a rash (either papular, roseolar, or erythematous in tyjie) following tonsillotomy: but, as many of the patients operated upon v.cre taking sodium salicylates and |>otassiuni bromide, the importance of its occurrence can be of little moment. The .'ifter-tre.'itmeiit of cases of ton^illotoniv is absolute rest in beil for two or three days, the use of soft food, and on the third day an alkaline and antisei)tic spray or gargle. The reaction is usually liI.'iEASES OF THE OROPIIARi'yX AXD yASOrilARYyX. 100;i slijrlit, and on the sccouil or tliinl day a thin white pellicle is seen on till' surfai'o nf the cut toiisii, wiiicli, however, soon disappears. (iiMicral tonic treatment is especially indicated in strumous children aitrr such opi-rat've procedures. 1. i;.\i (i.KATKJX. In order to carry out this method of removing the tonsil the anterior pillar is drawn to one side, and hy means of tiic index finger the tonsil is removed from its bed. This may be liirther assisted by lifting out the tonsil by means of a pair of forceps; the bleeding is u.sually free but eiusily arrested by pressure. Foreign Bodies in the Tonsils. These may be of atiy kind or nature, the most common being fish-bones, s|)icula' of bone, bristles of a tootii-brush, and husks of grain. The most conunon site is the centre of thi' tonsil: but fre(|uently they are hidden behind the ante- riiir i>illMr of the fauces. By repeated swallowing the foreign body, Mild cspcci.'illy in the ca.se of fish-bones, is apt to be driven deeply into tiie substance of the tonsil, leaving a very minute portion of it exposed. Sometimes this portion is covered with secretion, and at lirst sigiit the foreign body may be overlooked. It will, therefore. brconic necessary when there is dilliculty in finding it, to mop otT ;iii\' serrction which may be covering the tonsil. The removal of loieign bodies in this region is easil\- lu'complished by means of a pair of forceps, giving immediate relief to the symptoms produced iiv its presence. Tonsilloliths. Fre(|uently the retained cheesy secretion in the <iypts undergoes calcareous ilegeneratioii. constituting what it known ,i< a calculus or tonsillolith. They vary in consistency, chemical cimposition, and size. SymptoKS. '{'he jiresence of a cnlculus may produce no symjjtoms at all, and may be accidentally discovered: usually, however, there i- a sense of fulne.ss .alxiut the tonsil. fre(|uent attacks of subacute tonsillitis and cough may also be ])resent. The existence of such a condition is usually discovered by probing the tonsil, although the calculus it.self may .sometimes be visible within the crypt. Treatment. Single and small calculi m;iy often be dislodged by means of a curette or probe, or it may be so engaged in the tonsil that it is neces.su-y to enlarge the ojjcning freely in order to extract it. Benign Tumors of the Tonsils. Hie most common of the benign l\nnors of the tonsil are the jmpilh.-" it, filiriwia, ftbrochotidroma, nnqi- imiti. and crhitioforniK ci/sls also occur. These tumors may be either scs>ile or jK^dunculated. When sessile they cause little or no dis- turbance: but when pedunculated they may produce symi)toms re- llexly. such as cough, s])ii.s!n of the glottis, difficulty in .swallowing, attacks of dyspno-a, and even a.«i)hyxia. Their removal is easily ai-coiiiplished by either the scissors or snare. Malignant Tumors of the Tonsils. These embrace sarcomata Mvninhosarcoma and librosarcon.a) and nircinomnla. Sarcomata. Sarcoma of the tonsil may occur at any age, but is usually found in young individuals between the ages of fifteen and 1004 twciitv-tivc yotllC AM) TIJRn.lT. years. It is said to Ix' more coiiuiioii in incii. hut in the writer's cases (six) tiiey were all in females, and the ajjes were between tii'teen and thirty years. Tiiis disease only attacks one tonsil. Symptoms. The symptoms are usually those of a mild- attack of tonsillitis, for which the patient is continually treated, or it is even regarded as an enlarged tonsil, and when the tumor becomes defin- itely pronounced, it is then regarded and treated its a case of '•(juinsy." The pain in sarcoma is not a marked feature, and when jjre.sent is not a continuous one, but is of a rather dull character, in contradis- tinction to the sharj) lancinating pain of carcinoma. There is ;i feeling of fulness about the throat, and deglutition is difficult, whicii gradually increases with the .size of the tumor. The voice becomes thick, and as the case advances respiration oecomes difiicult, necessi- tating traclu'otoniy; deglutition at such a stage is usually impossible. Emaciation is not a marked synijjtom in the e.-trly stage of the dis- ea.se, but tin ■ patients usually are • v. y ana'inic. There is little tendency to ulceration, and hemorrhages are therefore rather infre- quent. The lymjjhatic glands are not usually enlarged. In ad- vanced cases there is often some febrile disturbance. Ipon examina- tion in the early stage of the disease the tonsil shows a little fulness: it is pushed toward the median line, and the soft palate in its innnc- diate neighborhood shows a slight fulness, and the bloodvessels become more mnnerous and dilated. ( Plate .\\.\., Fig. 1.) The condition gradually increases until the isthimis of the fauces is dosed. Diagnosis. In the early stage sarcoma of the tonsil often resembles a subacute |iarencliymatous tonsillitis or a hypertrophied tonsil, but the inflammator\ condition, in spite of all treatment, still continuing: should lead to suspicion. The (juestion of a ginnmatous infiltnttion is easily solved by the use of antisyphilitic treatment. Treatment. In the ea. stage the tmnor may be ermcleated bv incising the cajjsule with uie galvanocautery kni'fe: in the more aii- vanced stage of the affection a more extensive operation by means of pharyngotomy may be undertaken. Uut for ste|)s involving sucli ojH'rative procedure reference to standard surgical works is advisi^d. In this kind of malignant growth Coley's serum has been used in some cases with benefit; in two of the author's c.-i.ses this methoil of treatment proved of no avail. In hopeless cases palliative measures are called for, and tracheotomy may be needed as a relief to the ilyspncea. Carcinoma. In carcinoma of the tonsil the afTeetion usuallv s1ma\> itself as an epithelioma. .\s a primary jirowth it is rare, usually being an extension from the surroun<ling structures. It is a disease of middle and advanced ages; the tmnor rapidly enlarges, ;uid may pre- sent it.self as an .apparently enl;irged tonsil (Plate .\.\.\.. Fig, 2' : but upon a careful exainin.ititin. wlu-n-by the posterior and internal sur- faces of the tonsil , are thoroughly exposed, an ulcerated con<lition mav be observed. (I'l.-ite \.\.\., Figs. ;{ and 4.) The pain is ofi:-n markell PLAT!-: XXX. ^ l» / f 1 / (.,,,. I. .,11, 1 J. l'Miiiar\ fCpilh.iii ■ma . ■! Ton.^^il, -h'ivs MiJ llw iiHUal -ia(|.v hiM .i 1 !..■ 111. .M atiMl ."Mil la. !• Ex|M .-'■'I. Fu). 'f Sii. .\\ iiHi ih.. L;m.-ii~i. .11 . >l 111.- L.->i.>ii. ! A HI hill V .a^.'. ■Hi ■M t ^ i i>isi:a.si:s of nil-: onoi-UAUvyx and XAsoriiAKvyx. ioo.> 1,1, i l:iii(iii;iliiin ill cliaiactcr, cxtciKliiifi into tlic car mi the same rtiilc, liXtrnivali'il liy ilifjlutitioii, hut occiirrin'; iiulcpciKlciitly of it. The lU 111' r^aliva IS iiicrcascd and tlic (liscliai<;c from the ulccratfi urfii ,- u>iially fetid, (ilaiidular iiivolvcnicnt is early and tlie prufiress of lisease rapid, involviii>; tliv adjacent structures. Tiie etTects upon Ihe I he ciiiistitutioii are mar ked aiia-nua aiu I cachexia. ^vi Diagnosis. The disease may bo confounded witii primary or tertiary ijiililic maiiifi'stations, hut treatment directed toward this as a pos- cMiise will clear up tiie (luestion. .Microscojjic examination :il>N lit ion will assist m an liii^ tl lie dia};iiosis m iiianv cases. (il a por r- - r. Treatment. Dealing; with these cases by means of the snare and gal- vMiiocautery knife are not to he advocated, hut the more thorough >uijrical measures are indicated, and reference should he made to >laiidard siirpeal works for the methods of operative technique. The Lingual Tonsil. This tonsil is situated at the root of the IniifTue and just in front of the einplottis. In .structure it is similar In the f.iiicial tonsil and belongs to the ring of lymi)hatic tissue de- -rrilH'il as the " Ring of Waldeycr." In some .ses the tonsil is divided by a median line, thus giving to it an appearance of two distinct riands. This tonsil is subject to many of the same affections which attack the faucial tonsils, especially tlie acute catarrhal, lacunar, and l.hlcjrmonous infiammation, mycosis, tuberculosis, and syphilitic niani- te^tations. The api)earance of these conditions is similar to thase seen ill the faucial tonsils, and repetition of either their subjective or objec- tive symptoms and treatment is unnecessary. The commonest form i.f atrection of this tonsil is hypertrophy. The afteciion is one of adult life, and is more common in females than in inaies. It is fre(iuently met with in hysterical subjects, and is pro- iluctive of the condition known as -'glofjus hysterictis." It produces -vmiitoms of a feeling of a foreign body in the throat, irritating cough, and a weakness of the voice in many cases. The treatment is carried ,>iii on the same lines as that for hypertrophy of the faucial tonsil, and .(insists in the use of either the galvanocautery or. in ca.ses where the nilargement is considerable, of the guillotine especiall} devised for tliat purjiose. (Fig. 521.) FKi. .i21. Lingual K>iill'>tine. The lingual tonsil may also he invaded by the followirig tumors: riliroTua. ]iapill"ma, lipotna, aiigivinui. aiu' cyst-^. A p'Ttinn nf the thyroid gland may in some cases he .seen, and is then due to a previous st.ite of the thyroglossal duct. mmmmmmm ■MM um XOSE AM) TIlltOAT. I ■ I > i A "viiricosc" coiiilitidii of tlic veins ;it tin' l)!isc nf the toiijiuc is soiiictiincs met witli, and its picsciicc in some cases pniduces a t'eeiinK of a foreign Ixxly in tiie throat and often paia'stliesia. \eiv occasion- ally these veins may l>e the source of henionhap': and this has <;iven rise to the opinioi. that the i)atient has had an lia'nioptysis. The a|>plication of thegalvanocautery jioint will relieve many cases. Kiu. ba. V/'- jihowingthe imsi>|.hiirynx hihI Ihe lur>tiKr)phiir>-nx opeiirrt troiii tiehind. iMrxlified fn™ 'irtiy's Anatomy.) The niiKophiiripLr lies hetween the liase of the sknil and Ihe lower edfre of the soft palate. Into this space the foiiowinj; openinf;s are ul.xTVed till- |)o.siciioi narcs ( iwo), and the months of the i']u<lachiMn fulies (two), iVifr. r)22. The oraphirunx is that portion of the pharynx visible when tin I>lt;EASE^ OF THE OROPUARYSX AM> XASOHIAHiWX. KK)7 iiioiitl'. is i>;:vn ami the tuiinuc (loprt•^s(•^l to the lloor of tlic iiiouth. I l'i>;. iyZi.) ' Till' l(inin!i(>phitn/iis I'Xtciuls from a lin<' drawn horizontally back- wanl to ilic posterior wall of the pharynx from the root of the toujriic, and extends to the iip])er border of the cricoid cartilage. '■""•''■-''• 'Tij;. .V-'2.i Malf ormations and Deformities of the PhaiTnx. A congenital iiialforTnation rarely met with consists of the pharynx endinj; in :i cul-de-sac below tlie level of the cricoid cartilage, and the (esopha- gus terminating in the posterior surface of the trachea, congenital condition is th( niice of diverticula; they found in the lateral wall of the pharynx, and are due to .somi- modification in the closure of the lirst post mandibular visceral cleft. Tlicse diverticula may be single oi' iiuiltii>le and corres|)ond with that of Meckle in the intestine. Another occur- ire 1. .Viiterlor plUur. J. rosttrior rillar :!. Tousil. 4. I'vula. .V Tongue. 6. Piwlerlcir wall of |>harynx. 7. Sofl palate. ». Uarrt Iialate. Fi(i. 524. 1. Tenaor palati. 2. Levator jsilnti. a. I'alatoRlossus. 4 i'iiliit.ipharyngeus. 6, UHmular process 7. Toiignc. AzyRos uvule. 1008 Ao.sf; Axi> nil: OAT. Pharyngocele. This (•(iiiilitinn cniisists nf a |)(Hicli-likc fniiiiation in the lowiT |>art nf the pliarynx. said tn lie linc to a weakness of tlir coiistrietor iiiiiscles in one place. Tlie symptoms wliicli occur in these cases of (hverticnla or pharyn- pK'cle ari' piactically tlie same. Food fails to reach iheslomach. and is rejiui-fiitated in small (|uantities from lime to time. If a houf;ie is passed it is arrested in its coin-si' to the (esophagus liy entering one of the poiichi's. The existence and situation of such pouches are very materially demonstrated hy tlie use of the iioentften rays, a Ijougioor other foreign hody having first heen pa.ssed into the pouch. Stenosis of the pharynx may occur primarily as the result of disease (syphilis, tuberculosis, scarlet fever, di|(htheria, smallpox, and ery- sipelas), or tniuma'icaliy as the result of injuries incident to the swal- lowinj; of corrosive li(|uids (carbolic acid, lye, etc.), of scidding water, or inhalations of steam in considerai)le (|uantity, or secondarily, lus the result of i)ressuro from the following conditions: retropharyngeal abscess, spinal caries, glandular enlargements, and e.si)ecially when the thyroid gland intervenes between the trachea and upper part of the <i'sophagus, as the writer has .seen in .several ca.se.s of enlarged thyroid. Wounds of the .soft palate, toasils, and pharynx frecpiently occur as the result of the action of corrosive li(|ui(ls or of the entrance of a foreign body through violence applied to it. Among such foreign bodies are ))ii>e-stems, pieces of wood, or metal. Injury involving i'oinplete perforation of the soft palati> an 1 partially involving the posterior wall of the pharynx has been seen by the writer in two Ciises: in one it was due to the child falling while he had a pea-shooter in his mouth, the other occurred in a man falling while in an intoxicated condition and striking his pipe, which he held in his mouth at the time of the accident. In some ca.ses the injury may be of such a nature as to involve im|)ortant bloodvessels in the throat, and when this does occur hemorrhage may lead to a fatal result. Anomalous distribution of the ascending pharyngeal arteries is some- times to be s(>eii in the posterior wall of the i)harynx. The most oommon anomaly is to see the artery coursing upward on the posterior wall do.se to the lateral wall of the pharynx. It may occur on one or both sides; less fre(|nently it ha.; been ob.served coursing trans- versely from one side to the other. The internal carotid artery has been found to take an irregular course and apjiear just under the mucous membrane in the lateral wall of the pharynx (Kelly) Such conditions would render operative mea.sures in this region very dan- gerous. DISEASES OF THE PHABYNX. Acute Phar3aigitis. Etiology' Among the causes of an acute inflammatory condition of the pharynx may be mentioned sudden exposure to "cold," the existence of a chronic catarrhal pharyngitis, the extension of catarrhal conditions from the nose and nasopharynx. DISKASfS OF THE OROrilARrXX AND yASOl'JlAJliWX. 10()9 a K<'"ty '"■ ili<"iiii!itic (liiitlicsis, jjiislric nr intostiiial (lisonlcr!*. acute iiilVctimis fevers (measles, scarlet fever, smallpox, typhoid and uphus); sometimes the use of certain drugs may cause it, such as UHlide of jxttiissium, mercurv, antimony, arsenic, and occstsionally the salicylates; the excessive use of tohacco or alcohol, highly- M'at^oned food and confinement in close and ill-ventilated rooms. Symptoms. These are usually ushered in i)y a chillines.s and feeling of malaise; the throat is sore, especially when swallowing, the jiain extending upward to the ears; there is a feel-ng of irritation and a desire to friMjuently clear the throat. The general disturbance de- pends uixiii tlie severity of the local conditions. I'pon examination tlie color of the mucous memhrane covering the soft palate, uvula, pillars of the fauces and i)osterior wall of the pharynx is seen to he a inight pink or livid hue. Its surface in the early stage is dry, and numerous dilated vessels are visible; the uvula and edge of the soft palate may be slightly (i-dematous; later on the secretions form wliich at first are clear mucus, but later become nmcoj rulent. Treatment. In severe ciu^es, and even in mild ca> - occurring in frail individuals, confinement to bed is advisable, .vi the outset a mercurial (gr. iij calomel) followed hi six hours by a Seidlitz powder is to be given. ShouM the tem|M'rature be elevated and the pulse full, iincture of accmite (B. P.) in two-minim doses, hourly admin- istered, will greatly relieve the discomfort experienced in the early stage of the <lisease. Salol (gr. iij) combined with i)henacetin (gr. iv) or Tx'nzoate of soda, or salicylat« of soda, will l)e found beneficial where there is a rheumatic history. Locally, small pieces of ice to suck or ifc-bags to the throat will be found comfortable. The dryness s-i fre(|uently complained of may be relieved by steam hihalations (if compound tincture of benzoin (one drachm to the half-pint). The use of an oil spray such as the following will give relief to the pain: Menthol. < dmphonc. 44 gr. Ij. 01 gBUltherlffi, lllj- Altxilinu. Sj. Hi; I'sc «» a I hn«t spray hourly. When the secreticms have begun to form, then an alkaline spray is indicated, such as: .So<lii bioHrbonatis, Sotlii birborrtlls, aKiii ohloridl, Sft gr. lij. AllUlB. Sj- Later on, when the secretion has become mucopunilont, then a slightly astringent spray, used about three times daily, is indicated: Llq. liydrastli, mxv Tr. lavandulit Co., miij. \<inx. B"! ",j Chrcnic Pharyngitis. This may be defined as a chronic inflam- mation of the mucous membrane of the pharynx and adjacent .struc- <i4 . 1010 XOSK AM) riHiDAT. tiircs, attt'iiilaiit with structural cliaii^irs in the ^laiidnlar cli'incnt or (••miicctivc tissui'. It may he cniivi'iiiciitly considi-rcil undfr tiircc licai lilies: 1. Simple chrotiic pliarynjiitis. 'J. Clirdiiic >;ramilar pliaryiijtitis. '.i. Atrojiliic pliarynjiitis. Simple Ghronic Pharyngitis. Etiology. This may Im- tht> s(>(|ucnci> of .-iiihafutf or acute attacks of pliarvri>;itis as thi' result of an exten- sion of ciironic na.sal catarrh, the existence of nasal and pharyngeal conditions producing huccal n'spiration: the ahuse of tohacco and alcohol, the use of hinhly-seasoned foods, gastric and hepatic di<- turliances, aiueniia, tuherculosi-;, and syphilis all act as etiological f.'ictors; occup.'ition, wiiere a great deal of dust or irritating vapor is present in the atmosphere. Symptoms. Tliey are thctse of an acute pharyngitis considerahly modified. The most prominent .symjitom is the clearing of the throjit to such a degree that the pati<-nt may retch or even vomit in his end<'avors to clc;ir the thr()at of secretion. This retching as the result of such efforts is usually found in those indiviiluals who indulge too freely in the use of alcohol au(i tobacco; the voice may hecome liusky, and frequent efforts are made to clear it. In those who sing there is often a dilliculty ex|K'ricnced in reaching the higher notes of the register. Cough may he present, especially when associated with an elongated uvula: re|M'ate(l efforts of cougliing or clearing of the throat m:iy lead to a slight ru|)ture of niimite hloodve.s.M-ls and show itself as miinite s])ecks of blood in the expelled secretion. I'pon e\;uuina- tion. which not infrequently is made with dilliculty, on account of the extrino irritation of the iimcous membrane, one observes the mucous tnembraiie of the |)illars of the fauces, soft palate, and uvula to be very hyp(>ra'mic. The color may vary from a bright red to a livid hue. The posterior wall of the j)harynx shows muneious dilated vessels, and its surface is covered with a very tenacious mucous secretion. Treatment. The basis of treatment in in the correction of faulty habits; the u- should l)f> strictly interdicted: a gouty or reci'ive ])roi)er attention: heavy and high living individu.als should be advised as to their ])roper dietary, and any existing n;is;d or naso- pharyngeal condition likely to produce buccal respiration should be corrected. Ijocally, .after the throat has been cleared of any adherent mucus by moans of an alkaline spray, a solution of nitrate of silver (gr. X to 3J1, protargol (gr. xv to 5j), or zinc chloride (gr. xx to 3j) may be applie(l by me.ans of a cotton-wool swab. "'•xonic Orantilar Pharyngfitis. Thi.s is characterized by a chronic inflammation of the nmcous membrane with hypertrophy of the lymphoid follicles. Etiology- In enumerating cau.ses for this affection one recpiires, to a great extent, to repeat those acting as causes in chronic pharyn- ■ m.ajority of cases lies stimulants and tobacco iii'umatic diathesi-; shoulil IflSk'ASES OF Till-: itROPIIARV.W AS It .V.|.SO/'//.l« J'.V.V. 1011 til ••I I ll iriii-. aiitl fiir tlicsi' mic is rrfcrrcd to that scctidii. In addition, the iiii|iii>|KT use if tlic viticc, I'ithcr in siM'akinj; or sinjiinj;, will a<'t a.n a cMiiw. Tliis ha,-* It'd to the " "cli-rjiy man's sorc-throaf " being >^i\('ii to it. Symptomi. Then is a ftH'Iinj; of inorc or less discomfort in the ilu":il, fri'i|iicnf clearing away of a rather tenacious mucous secretion, tjie voice is often husky or weak and the use of it leads to a feeling 111' fatiftue anil an aching sensation of the muscles of th<' neck. One, however, tmisl not l)e mi.sled that in each patient in whom such symptoms an- jiresent they nec(s.sarily an- of local origin. The writer lielieves that many of the local symptoms and conditions pro- ijiici'd in singers and speakers are due to impro|)er methods of voice (nluction. rpon examination the posterior wall of the pharynx lows the glandular element to he distinctly enlarged and hypera'tnic; le I'lilargenient varies in size from that of a pin's head to that of , pea. The surrounding mucous memlirane is pale, and on ifssurfao«>, •nursing toward these so-called "granulations. " are several tinehlood- \issel> This collection of "graimlations" is oftrn very marked in \iiuiig children who ace the suhjects of jtostiia.sal growths. (Fig. '.'.'•.) I'n'i|uently hands of hyiK-rtrophied tissue are to he s(>en on rie Literal wall of the pharynx and just behind the posterior pillars. I'lie hy|)erlrophy continues into the nasopharynx with the salpingo- iharyngeal fold. This condition is called by many autliors " pharyn- .'iiis lateialis hy|)ertrophica." Treatment. This shoulil, as in the case of all local troubles, l)o ilirected toward the investigation of the g ral health for causes, niiil these corrected. .\ny aiucmic, litha'- I'lic, or gouty condition should receive proper attention, and the use of alcohol and tobacco should be prohibiteil if act- inn as an exciting catise. Naso|)haryn- i^cal iDiiditions should be c:trefully inves- !i;:ated and s\iital)Ie treatment a])plied. 1. neatly, in pronounced ca.ses, the best Idiin of treatment is the application of I 111' galvanocautery to each granule and dr-tniying the bloodvessels which supply ii. This should be very carefully done. Theapiilicatioii of chromic acid, trichlor- acetic acid, or silviT nitrate fuse 1 on a probe is also advocated: but the ajjpli- ration of any such escharotic is not so easily limited as the u.se of the galvano- c.iutery. The galvanocautery point <hiiuld. when being used, be brought only to a dull red heat. Mayer lias very successfully used a s|H'cially formed curette for removal of these gramilat'ons. and claims to have had very .satisfactory results. The curette a-, ised by him is seen in Fig. 5'J6. Cimnntar pharyngitis. (Coaklky.) : 1012 A04A' .I.V/» riUlO.tT. I'rcccdiiij; the use nf ;iiiy (Uic of (lie fonnniii); rnctlKMls. cacli 'graii- ulr '■ to Im' so trcatril .xlioiilil rfn'i\i' an applicatioti of a 10 [mt cent solution of cocainr. In the case of the latiTal liyiMTtro|)liy tin- haml-i may lie so thick as to ri'<|iiirc excision hy means of scissors ami fm- ct'ps: luit in this |iroc<'iliirc one must lie careful not to exce«'(l the reiiuirements of the cas«' hy ovenloing it. Fm. .fX. MHycr'H ciiri'llc. Atrophic Pharyngitis. This is characterized liy atrophy of the mucous menilirane and glandular structurr- containecl in it. It is li"ld l)y some writers to he a s> uience of a chronic pharyngitis, and hy others to orij;inate yur .vc. i, may tollow .severe ca.s's of di|)h- thi'ria or scarlet fever, or may occur in the coin-se of diahetes or Mri^ht's disease. It is usually an evidence of the .same process exist- inj; in tiie no.se and nasopharynx. .\ dry condiiion of the pharynx, not necessarily atrophic, may he produced hy niouth-hreatliing and excessive smokinn. Symptoms. The symptoms are those of a feelini; of dryness in the throat and a desire to fre(|uently cle.'ir it. ['p<m examination the wall of the pharynx looks dry and glazed. The |)harynx looks spa- cious in many cases, iind the mucous meinhraiie is covered with a thill layi'r of hardened secretion which, when removed, reveals often a rather conj;ested-lookin}: mucous inemhrane. Treatment. The peneral state of the [)atient's health nuist he care- fully investiftated and treatment directed to ;iny existing di.«oases which might ])ossil)ly act either asanexcitingorapredisposingcau.se. Locally, the use of alkaline s|)rays such as Dohell's solution or Seiler's tahlets will assist in some ca.ses to remove the h.ardened secretion. The suhse(|uent application of a mixture such as the following will be of henefit : Ifxiini, (ilycLTiiii, Ai|iia'. «r. T. Kr. IJ. SiiJ. Steam inhalations, such as compound tincture of henzoin, one drachm to the li;ilf-pint, or the following, will he of use in relieving the dryness: creH-sote. ill'xxi. .MuKiH-siie farUtiiis leviK. u'r. x!. Aiiiue, sj. Sis. One l'.-a?iK;ni;fui .v. hulf a pint nf boiiing water. mu\ u-c u.- „i, |j,|ja!iit;nii ni^lii khU iiio-niiii; Those inhalations give the most henefit wheti the |)harvnx has heei thoroughly cleared of any dried secretion. One must i)ear in inui.' lUSEAHES OF THE HHOl'UAHYSX AS'l) \AiiOril.lJty\.\. 1013 tli:it tlic :il)<»vf iiK'ifuri's an- only a iiicans to make tlw patient luon' riiiufortalilr, for ihc ilw'a."*' in its atlvantrd form is prat-tifally in- rlllllliii'. Acute PhlegmoaooB Pharyngitia (Ludwig's Angina). Senator d.- tiiio tiiis condition as "a difTiise purulent intlainination in the dee|K>r ti-siies of the pharyngeal niiicous rneinlirane, which thence is prttpa- )iuled to the larynx and tlie ((lands, and s<'condarily involves also other organs. Tlie di.s'a.-*e has attackeil jhtsoms jireviously in full health and without any etiological factor iK'infj demonstrable." As a primary di.sea.xe it is rare and often fatal. Symptomi. The onset is marked hy a rigor or chilliness. The first >yiiipt(im referable to the throat is dysphajfia, which suddenly sets in. This is closely followeil hy hoarseness, tlyspniea, and even lurvngeai ,-tridor. There is considerahle difficulty in Retting rid of the .xecre- lioiis of the throat, which are very tenacious in cliar;i( ter. The fever i-' lii^rh ( l(l.'{°to l().'»°), .and the pulse rapid and weak. I'pon examination either one or both tonsils and the pharynx on one side or both show evi leiices of acute intlammatioii : the color is of a very deep red or livid hue. This condition may extend downward, involving tlie epi- glottis and the aryepiglottidean folds. These parts lu'come swollen Miiil distended, accounting for the inrrea.«ed dysphagia, stridor, and tlie deeply-pitclied tone of the voice. Kxternallv, a board-lik- hard- ness of the ti.'isues isapprecial)le on palpation. Treatment. The condition is always a verj' grave one. and stinui- lating and supporting fn-atment from the out.set is indicated. Iron and (|uinino, in large doses, should be given; cold to the throat by nie.'Uis of ice-bags or I.eiter's ice-coil should fx- use<l. Fre(|uently ■^c.irification of the epiglottis and arvepiglottideati folds will reduce tin' -:\\(llinf; of these p.srfs and n-nder the (h>;)hagia and stridor Ic-^s marked. When symptoms of obstruction to respiia»ion s( t m, trache- otomy is calh'd for. Gangrenous pharyngitis is a rare disea.<*e, and is found occurring as a se(|uenco of a .severe attack of scarlet fever, measles, diphtheria. Ml- smallpox. It may not be limited to the pharynx itself, but have liad its beginning in the soft palate or tonsils, and extended to the |ih;iiynx, or vice versa, (ieneral sustained and stimulating treatment is indicated, with cleansing of the local condition by the use of anti- septics. Herpes of the Pharynx. This affection is characterized by the jircseiice (tf small vesicles on either the soft palat<', uvula, tonsils, or iiiiccal mucous membrane, .and, more ran^ly, the pharvTigeal wall, epi- jrlottis, and larynx. It occiirs as the result of exposure to cold or si|itic influence. In the writer's experience it occurred in three cases during the cour-^e of an attack of la grippe. It may attack one or Iw-th sides. Symptoms. H<'fore the a[)pearance of the vesicles there is a feeling of heat and pain in the mouth and throat, increased salivation: the febrile disturbance is market!. There is considerable pain when mas- . 1014 A'«*'£' A SI) Til Hi) AT. it !i apix'iir MS ( Fij;. r,27 1 ':^m Fin ticatinn (ir swallowiiip;. Ipoii cxaniiiiatiDii the vesicles siiuill ijlisters. varying from a pir/s head to twice that size. ( Fij;. 027 Tlie coiitciits (if the vesicles are at lirst clear, hut in a few hours he come turhid and yellow. They then hreak and leave an underlying liyperaMnie area. Treatment. Nothiiif:, either jieneral or local, has heen found to ap- parently curtail the course of such an affection. General tonic treat- ment is, of course, indicated and locally, the only remedy which the writer has found of u.se is the a|)pli- cation of orthoform to e.-ich spot. The di.sea.se is a vorj' tedious one and the course apt to be prolonged. This affection may also be seen in a chronic form, where the vesicles ap- pi'ar aufl disajipear only to reap|M'ar. The vesicles may coalesce, and the exudate may appear as a thm, yel- lowish-white membrane. Th(> con- dition is unattended by any jieneral disturbance. In one ca.se .seen by the writer it occurred in an elderly man wlio had been operat(>d upon for a larjie sarcoma of the neck, and the occurrence of the lieri)es was probably due to injury of some of the nerves. Another, j)prhap.«!, somewhat allied affection is p(>mplii^is. This shows itself in the eruption of largo bulla> on the soft palate, uvula, and posterior wall of the pharyn.x or laryn.x. Rarely ar(> the bulhe .seen, for they are generallv ruptured by the slightest contact, and their previous presene(> is shown by areas of a thm, white exuilato varying in size. In a case s(>eii by the writer it was att(>iided by a bullous eruption on both forearms. ' No treatment seems to .avail very much in these ciuses, and it should lx> based on general [)rinciples. Parasitic Diseases of the Pharynx. The most conuuon parasitic affections of the pharynx met with are: first, thrush: .s(>cond. mycosis. 1. Thrush. This .affection is u.sually met with in children who have bei-n nnproperly fed. It may also occur in adults who are in a debili- tated .stat(> of health. IIy|.eracidity of the secretion of the mouth favors its development. This condition is not limited to the pharynx, hut may be seen on the soft palate and buccal mucous membrane.' It IS due to the presence of the oidium albicans, the most common of vegetable para.siies found in (he month. Symi'tom.s. In infants and young children there is difficulty in swal- lowing and a regurgitation of food. In the cjtse of infants tliey refuse Herpes of soft jielate and uvula. (Author's caae.l i)isEAi>i:s OF Tin: onoriiARYSx and yASOPiiARrsx. ioi5 fixid, and very .soon hopomo badly nmirishod in pniisequoncp. Upon cxainination the niuptms nipnihranp of tlic mouth, soft jmlate, ami pliatyiix may soem to be dotted here and tliere witli immerous white o]ialcsppiit spots of exudation, whieh, when removed, reveal tiie uiKlerivinj: mupous membrane hypera'iu'e. The use of the mier()SC()i)e will show thepreseneeof thefilameni ■ (,i 'he -idium albicans. TiiKATMKNT. As the disease is of . | iirasitie iiafin , one's pffcirts must be direeted to the destruetion o tin i'Mfai-ifo. "; he old-fashioned remedy of borax and lumey, pain mI ,n the p;.rt still ans\vers very well. "Ajiplieations of a weak solut ". ■.:■ iiiti-up o' silver (jir. iij to oj) will also be found useful. The general liyffit ;.; of the patient nuist also be attended to as well as that of the oral pavity. 2. Mycosis. Mycosis of the jjliarynx is a eliro'iie affeetion charaeter- ized by the a])pearanee of small white sjMits on the tonsils, jxisterior or lateral walls of the pharynx, and due to the ))resenpe of the vege- table jiarasite leptothri.v. It is usually met with in adult life, and is more eommon in women than in men. All catarrhal ponditions of the pharvngeal mucous membrane favor its develoimient, as also do debili- tated conditions of the system, dental caries, and acidity of the saliva. It may occur on any or all ])ortions of the •Mym];hoid riiif;" of Wal- deyer; therefore, it is .seen on the faucial, lingual, or pharyngeal tonsil, or on the posterior and lat(>ral walls of the pharynx and pillars of the fauci's. SvMPToM.s. A'ery freiiuently there are no symptoms until the pa- tient has appidentally dispovered the ])resence of "white spots" in the throat and has bep>)me uneasy about them. Sometimes these ])atients coniplain of a feeling of a foreign body in the throat and of a di'sire to swallow repeatedly, or fre<iuently clearing the throat. Upon examination " wliite spots," varying in number, are seen varicmsly distributed on the tonsils (faucial and lingiuil), posterior and lateral walls of tlie pharynx, and in the na.sopharynx. These spots look like white bristly points standing out a very short distance from the mu- cous membrane of the invaded jiarts and to which they tenaciously ailh(>re. Any doubt as to the nature of the affection (liable as it is to be confounded with such affeetions a.s tonsillitis or diphtheria) is .set at rest by the miprospo|)ic examination. In this affection there is an entire absence of any general disturbance. Treatment. This affeetion, like .some of those occurring at the base of the tongue (moderate hypertrophy of the lingual tonsil and " varix"), is apt to occur in neurotic and run-down individuals, and ther(>fore atte 'on to the general health is the most important. WTien demanding :. ference. which is seldom, the use of the galvanocautery points to eacii s])ot, whiph is a tedious process when the .spots are numerous, and excision of the hivaded parts, where po.ssible, aie the only means to be relied upon. The use of loeal antiseptics (parasiti- cides), in the ujiinion of the writer, avails nothing. Hemorrhage from the pharynx is a condition occa,sionally met with, and may be mistaken for ha'inopty.-.is. It is usually due to a 1016 \OSi: AXD THROAT. >'lo. ,i28. small vesst'l. oithor on tlii- postc-rior wall of the pharynx or root of tlic toiifiuc, hciiij; nipdircd througli violent efforts to elear the tliroat, or of retchiiij?. In two cases the writer met with, it oeeurred always with menstruation. Cases of hemorrliufte of the tliroat must he seen at the time of occurrenee in order to he sure that it is not (hie to pulinonarj' disease. When ti>e hleediiiR |)()iiit is located the applica- tion of the galvanocautery point will usually sufhce. Foreign Bodies in the Pharynx. Foreign" bodies which are found in the pharynx may 1k» of any nature, hut are usually fish-hones, spicuhe of hone, bristles of a t()otli-l)rush, coins, nut-shells, false teeth, husks of grain, etc. They may become lodged in the sub- stance of any of the tonsils in the case of .sharp penetrating objects, behind the pillars of the fauces, in the epiglottic fos.sa', in the pyri- forin sinus, and in any part of the a'sojjhagus, hut especially at a !)oint oi)i)()site the cricoid cartilage, or, through efforts at coughing or atteini)ts at dislodgement, they may Ix! found in the nasopharynx. The symptoms present dei)end upon the nature, size, and situation of the fonngn body. Discomfort from a feeling of irritation in the throat, a constant desire to swallow, even to inability to swallow, and when, from its size, it is either situated at the entrance to the larynx, and is i;i such a way as to interfere with the ingress cr e;ress of air, or when in the opso- jihagus, and sufficiently large to press upon the posterior wall of the trachea, symj)tomsof dy.sp- n(ra may be present. In the ca.se of a foreign body being lodged in the nasopharynx, which is a very unusual ■ccurrence, there may be no syin[)toms present at all, either from its small- ness or situation, or it m!:v, wiien largo, pro- ihor'9ca-e.) tion. In the writer s case of a foreign body in the nasopharynx, it was an ordinary tailor's brass thimble. (Fig. o2<S.) This at first was in the lower part of the pharynx, and, perhaps, on reaching the entrance to the larynx, it was blown into the nasopharynx through violent efforts of coughing. It was lodged in this region for eighteen years, and had, when the writer saw the p.itient, produced a chronic nasopharyngitis a?id con- comitant symptoms affecting the hearing. One must be sure of the exact location of the foreign body before any attempt is made to extract it, because rccasionally symptoms are produced simulating the presence of a foreign body, but which are entnely due to the scratching (ir abrading of the ii'.ucous membrane by the pa.ssage of the foreign body downward into the crsophagus anil stomach. If the foreign body be situate<l in the lateral walls of the pharynx or the upper j)ortion of the oesophagus, its ex.ict locality may l)e more ch'arly deluied by ma'dng the |.atient n-tch while under oli.servation. The removal of a foreign body occurring iti any portion f>f the pharynx can readily be do!-'- by fon-eps suitably adapteil for the i)isi:.[si:s OF Tin: onoi'iiAiiYsx axd xahoi'iiakiwx. 1017 ri'jiioii ill wliicli it may I ■■ situated. This should alwiiys bo uiidcr- lakcii with tlic rejfiou ])i' utIv illuniiiiatcd. Olio must he careful in not mistaking pertain anatomieal points for foreifin hodies. One case has been met witli in the writer's expe- lieiice wiiere th<' family physician mistook the asceiidiiifccormi of tlii! Iiyoid bone, whicii was very jiromiiient heiieatl! the pharynx, for a -iipposed foreifin body, and in a* ' t the sharp point of the haiii- ular jirocess of the pterygoid plate of the sphenoid iione had bi en mistaken for a {)iii sujjposed to have been iini)acte(l in the naso- pharynx. Forceps of Buck, oi>ening aiitcnvjiosterinrly. Fio. KIO. Forceps of Fauvol. opening laterally. Tumors of the Oropharynx. Both benign and malignant tumors may involve this jiorticm of the pharynx. In the case of malignant jirowths they usually ar(> an extension into the pharynx from disease ill the neighboring structures. Primary carcinoma of the jiharynx is rare. The growths most commonly met with in this region are considered under the parts they especially invade, viz.: soft palat(\ uvula, and tonsils, to wliicii section the reader is referred. Tumors of the nasopharynx will Ik" dealt with when considering diseases of tliat region. Retropharyn^^eal Abscess. Primary retropharyngeal abscess is a suppurative process which takes place in the lymphatic nodules sit- uated b<'tween the prevertebral fascia and the tunica pharyngea externa. Etiology. The disea.s<' occurring primarily is an affection of infancy, between the ages of six months and one year. It is uncommon after 1018 AUHE ASD rHKU.IT. throo yt'iirs of ago, and tho reason of this is said to bo that after threo years of age the ciiain of lynipli nodules most marked up to that ap rapidly disappears. It may Ik' aeute, as tiie n'sult of adenitis and from tiie intimate eoimeetion between the iymi)haties of the jjharynx and those of the soft palate and tonsil, or it may be a s(!(|uence of an inflammatory condition involving these regions fron» any cause whatsoever. The di.sease may occur in tubercular and rhachitic children. Retropharyngeal abscess when occurring secondarily does so ,is a s<^(iuence of .spinal caries, and is then chronic in its nat-- In this form the disea.se is more freciuent in adults, and the p situated 'uetween the .spinal column and the |)revertel)ral mu.snes and ligaments. It may occur traumatically from the impaction of a foreign body in the posterior wall of the pharynx. Symptoms. The sym])toi:i first showing itself is tho n'fusal by the infant to continue to take nourishment, evidently frotn the paiii and ditliculty of swallowing. The child is restless and feveri.sh. As the case j)rogres.ses there is difficulty in breathing, either through the no.se, if the abscess be seated in the na.sopharynx, or through the larynx, if it be seated low down in tl ;> laryngopharynx. In the first case the mouth is widely open, and th > chi'd snores,"and in the .second case there is laryngeal stridor. The voice 'i;is a nasal character and the noise like a hen clucking accompanies respiration; the neck is rigid, and the head is held toward the affected side. Cough is fre- quently present. There is sometimes a marked swelling in the neck on the affected side between the sternocleidomastoid muscle and the angle of tho lower jaw. The abscess, when due to lymj)h nodules breaking down, forms ra])idly, but when duo to bone disease develop,- slowly. In .some ca.ses there is only a lymphadenitis, and then tho symptoms are much less jjronounced and not as urgent. When one proceeds to tho inspection of the throat this should bo done verj- gently, as rough handling may -mexpectedly rupture the abscess, with jiorhaps unpleasant if not fatal results.' It may bo noccs.sary to insert a mouth-gag in order to carry out this inspection; this too should bo gently done for the same rea.snn. When tho i)harynx is well illuminated a swelling occupying either a central or lateral posi- tion on the posterior wall of the pharynx is obser\-ed. It bulges forward, and may, if large enough, throw tho soft palate forward; tho swelling is decidedly hypera-mic, and upon examination is found soft and fluctuating. rPlafe XXXI.) Diagnosis. The disease has been mistaken for croup and quinsy: but a can'ful consideration of the general symptoms and insi)oction and palpation of the swelling will readily load to a correct diagnosis. Treatment. In ca.ses where there is only a lymphadenitis and the symptoms present very mild, the application' of hot fomentations and .tononv! tonic troatiTtojit have led to theaiisorption of the itiflam nia'ory condition. When, however, there are distinct evidences o! l»us being i)resent operative measures are at once indicated. Then are two methods of dealing with such cases: first, by an incision I'l.ATi: XXXI. K''ii.,|,iia, \n.|<-.'il Al,~. ,.■-,. , Auili..]-- ,.;,-,, i DISEASES OF TUB ORoPlIABYXX ASD NASOl'llARYW. 1019 ilirmifjli till" pharyngeal wall, or, secoiul, by an cxtcnial incision in tiic neck. I. The first method is aeeoiiiplished as follows; The child is wrapiH-d in a blanket, and by this means movements of the arms and Icjrs are restricted. The nurse holds the little one in her arms, with tilt' child's head resting on her left shoulder; the head should then be steadied by an assistant. The mouth-fiag is introduced and genily iipiMied. With the swelhuR well illuminated a vertical inci.sion is ni;i,|e into the centre of the swelling; l)y means of a straijiht-backetl knife. The exit of pus is rapid, and 'ii many eases consi(leral)!e in quantity, and as a forethoufilit to such an occurrence the child's head is immediately held well forward and downward to allow the pus to iM.ipe throufili the mouth, which otherwise mijiht find its way into ihc larynx and jjroduce .suffocation. In a day or two a re-collection may take place, necessitating reopening of the abscess. In rare cases tlii'Opening of the abscess may not give relief to the symjitonis, and ihcii one must make a careful examination for the possible exi.stonco di' another abscess lower down. This method of oijcrating has its many advocates, but there are many objections to it. The abscess cannot be properly drained, and any drainage that may take |)lace is swallowed l)y the chihl; ihe opening may close too soon and pus reaccunmlate. Proper anti- septic precautions cannot be taken, and there is always a '^ngor of suffocation from the pu.s, for, no matter how carefully Hone, one cannot tell how rapidly the pus may escajx-. 2. iU- an external incision (Hilton's method): This operation should "be carried out with all the u.sual steps of strict a.sepsi.s. The incision is made Ix-hind the sternocleidomastoid muscle, beginning one inch below the tij) of the mastoid process and extending down- ward for one inch. The skin and f'.iscia are incised until the nmscles t'ciming the floor of the posterior triangle of the neck are reached. 'I'lien carry out the rest of the operation by means of blunt instru- ments jiassing l)ehind the deep ve.s.sels and nerves of the neck. This is l)est done bv means of a grooved director and with one finger in the pharynx. "When the absces,s cavity is reached and opened a pair of forceps should be inserted, closed, and when within the cavity ojiened and withdrawn in that state: this will enlarge the opening freely. A careful examination by means of the finger will enable the <iperator to further ascertain the existence or non-existence of any further complication. A drainage-tube of good size is then inserted and the usual a.septic dre.ssings applied. Subsequent washii.g out of the cavity with boric-acid solution may be neces.sary for a few days, and at the end of a week the tube may usually l>e withdrawn and tlie wound allowed to close. Tiie writer, in his experience, Itelieves this to be a better method of operating than the former, on account of the better drainage. l)etter asepsis, and that the operation once done is completed. It is also a more surgical and more scientific method of procedure. "" This ! ii 1(120 sunt' A.\D TJIHOAT. imcIIkuI (if (ipcratiiij; is the only one wliicli slioiil.l hv .•idoptcd when (Ifiiliii;; with the flimriic luriii of rctropliaryiiftcnl :il)sccss .-issocijitcd with spinal caries. In these ease.-, such jmrt nf the caries as it is pDssilile tn remove should Im- dealt with. Suhserpient to any "iM-ra- tive measures the patient always re(iuires general tonic treatment. DISEASES OF THE NASOPHARYNX. Acute Nasopharyngitis. The afl'ection localized to the nasopharynx itself is very seldom met with, and its e.\istenee as a primary di.seaso is douhted hy many, it usually heinj; concomitant of an acute rhinitis. Etiology. Isually. it is an extension of the inflammatory atVection from the nose or pharynx. Children in whom there is an enlar<;e- ment of the lymphoid tissue ;ire especially prone to it. It may occur in the course of any of the e.yanthemata: sudden climatic changes may also act. Symptoms. The symptoms may in severe cases he ushered in hy a chill or feelinj; of m:dais(>; there is a sense of f ih ess in the heall and slight tinnitus aurium. dryness at the hack of the nose, and deglu- tition is painful. Later on, that is, in the course of twenty-four to thirty-eight hours, there is a thin mucous discharge, very tenacious and stained with lilood, which .sul)se(|uently becomes mu<'opurulent. At this st.-ige of the disease there is on the part of the patient a desire to hawk and expectorate, and the voice may heconie a little husky. In children, the onset is marked hy decidedly febrile distin'bance, rapid jMilse, and liigh temjierature ("l()_'° to 104° F.); further, many children become temjMirarily mouth-breathers because of the involve- ment of the pharyngeal lonsil in the acute inflammatory proces-s. rpon examination with the rhinoscope in adults there is iii the early stage marked swelling, redness, and dry appeanmce of the mucous nuMnbrane of the vault and po.sterior w;il! of the pharynx. When the stage of .secretion has set in the mucous membrane is bedecked with a mucous or muco])urulent secretion. In children it is often impossible to make a .satisfactory rhinoscopie examination: but when it is permitted (>ii(> ob.serves t Jie lymphoid tissue, and especially the phary <'eal tonsil, to be much swollen, hypera'mic, and glazeel, and sometimes small spots of exudation are seen. Treatment. Should the di.sease be concomitant with an acute rhin- itis, the treatment as detailed under that disease should be followed out. One shouM begin with a mild mercurial purgative, such as calomel, gr. iij, to be followed m the course of eight hours hy a Seid- litz powder; phenacetin in small doses (gr. ij) every two hours will relieve the febrile condition. When secretion has set in, an alkaline lotion, such a.s bicarbonafe of so<la igr. x to ^JK may be used. In cases where the postnasal syringe is tolerated, this is the best wav of using the solution: but in other cases one must be satisfied by spraying through the anterior nares. In the e.arly stage steam in- uisE.Lsi:^ OF TUi: oRopii.myyx axd .\aso1'Jiary.\x. 1021 li:il;iti()iis of ('(mipouiid tincture of hcnzoiii ( 5j to()ss),aii(l tlic sul)sc- ,|ii(iit :i|)plic:itioii of a weak solution (f;r. ^• to ;*)j) of nitrate of silver will moderate thi' amount of secretion. In diiidreii very little local treatment can, as a rule, he carried out with muchelTect. However, I, ' writer has found tliat a small .luaiitity of the following' ointment ii.trodut-ed into each nostril three or four times a day seem* to give relief: Hydrantiri oiidl rubri, (jr. v. I'HraBln, Kf vlij. Vuel. alb., il M. Ft. ung. Chronic Nasopharyngitis, "^hi; afection is a chronic inflanmm- tioii of the nasopharynfjeal mucous memliraiie. It is es.sentially a <li.-^ease of adult life, and the .symptoms of a chronic nasopharyiifiitis in childhood are indicated hy" the presence of adenoid vepetatioiis. Etiology. I're(iui'iit and neglected attacks of acute na.s()i)hary'if;itis, clian-res of climtite, syphilis, tuherculosis, rheumatism, gout, anaemia, j:astro-intestinal disorders, ahusive use of alcohol and tohacco, occu- pations where there are irritating pases or dust, overheated rooms, suppurative disea.ses of the ethmoidal and sphenoidal sinuses, hyper- trojihy or atrophy of the pharyngeal tonsils, nasal stenosis due to .septal deviation, .s'purs, hypertrophic rhinitis, polypi, etc. Tormvaldt has laid great stress upon" certain pathological dianges in the so-called Imisa pharvngea (i)ursitis) as a very freriuent cause of postnasal catarrh. I'i)"" this point, however, there are many opinions, ami iintalily Schwahach, who contends that the pharyngeal bursa is nothing more than the persistence of the median cleft in the phiiryngeal tonsil. .Adhesions between the edges of the cleft in the pharyngeal tonsil may lead to the n-tention of pathological products, and by a complete inclusion may produce a cyst, these conditions acting as a source of postnasal catarrh. Symptoms. The most freciuent symptom complained of by the [latieiit is the presence of a mii •"purulent secretion at the back of the iio.se, which <-itlier droi)s into .nc throat or is of neces.sity removed by hawking. This symptom is especially prominent uixm first rising, aiid often attempts "at the removal of the .secretion are so energeti- ciHy carried out as to jtroduce retching. \'ery frefiurntly these patients ])ro(liice a very di.sagrec-able noise, made by sending a sudden l.iasi of air through the ixisteriornares. as if trying to dislodge some- thing from the naso])liarynx into the nose. In many cases of long- standing aural .symptoms (varying degrees of dulness of hearing and tinnitus) may be present. Through the extension ol the catarrhal process downward, or the influence which the condition has upon structures below the seat of this affection, huskiness is frequently met with, Indir(>ctly, dull headache (frontal or occipital) is produced, and there is a tendency to repeated colds in the head. Upon exam- ination the nasopharyiix is seen by means of the rhinoscope to l>e covered, either uniformly or discre'tely, with a mucoinirulent secre- Ml 1(1-22 .\o.st-: AM) III Hum: tioii, or (Irinl into :i Imnli'iicil crust. Tliis Inttcr condition is ospc- cially to lie iiotcil in the ccntri' of the v.iult of the piwiiynx, iinil i- said l>y Tornwaldt to Ix- pathojiiioinonic of (hscasc of tiic linrMi [•harynfica. Tiic secretion or crust when ri'movecl shows the under- lying mucous ineinhraiie to he either hypera'Uiic. or in sou'e cases practically norinal. IJeinoval of crusts and a careful exaininatioii of the nasopliaryiix afterward is eswiitial, as it occasionally hap|M'ns that upon removal of the crusts there is found to Im' a specihe ulcera- tion present. Tiie pharynjieal tonsil is sometimes s<>en to he swollen or atrophied, and in many cases, throujth openm^s left hy parti;illy adherent clefts in the tonsil, ;i muco|iurulent .secretion is seen exuding. Diagnosis. The condition in;iy he mist.-iken for suppurative pro- ce.s.ses invniviiif; the sphenoidal, j)osterior ethmoidal, or (>ven the maxilhiry siiuis, ami to tlie cha|)ter on these alTections tlic reader is referred. Treatment. In all local atTection.s one must never forjjel the proh- ahility of a constitutional condition heiiifr aiiswerahle for the locil trouhle: therefore, careful investijiation into the prohahle existence of any .such condition should receive careful attention, and he treated accordiiifrly. Locally, the secretions should he removed hy alkaline s])rays— hicarhonate and the hihor.-ite of soda (gr. x to oj water). This may he used hy niejinsof an atomizer, or. hetter, hy a postnasal syrinKe, for, ;is a rule, the spray from the atomizer is not sulliciently stroll}! to dislodtre the icious secretion or the crusted formation. When the surface i.- t . from secretion or crusts, the itjiijlication. hy means of a cotton-wool swah. of a solution of nitnile of silver (jir. x-xx to o.i' or ehloride of zinc (jir. xv xxx to 7).i) may l)eai)j)lied. In makiiifr such an application the cotton-wool swali should not he surcharged with the solution to lie useil, ;is the excess inav find its way into the larynx, produciii}; what may appear to the inex|H'rience(!, .•iiarmin<; stridor. In adults, where the disease is dependent ujion an atrophied condition of the pharyngeal tonsil retainiii}! secretion ♦hroufih .adhesions, the removal of the tissue hy means of a (iottstein curette is indicated. Some .autiiors recommend the application of solid nitrate of silver or the fialvanocautery point to ohtain the same result. A cyst or suhmucous ah.scess may he dealt with hy either of the foregoing methods. Atrophic Nasophar3mgitis. This condition is always !v.s.sociateil with a similar condition of the nose. It is characterized hy a glazed and dry appearance of the mucous memhrane which, in many ca.ses. is covered with cnist.-i of a diirk-grnen or yellow color. It presents many of the .sym[)toms in conunon with the same affec- tion of the nose, and for the treatment of which the reader is rpforreil to the article under "Atrophic Rliinitis. " H3T)ertrophy of the Pharjrngeal Tonsil. Iti th(< mtsophrirynx then normally exists lymphoid tissue which, when collected together in the vault, con.stituti-s wliat is known as the |)haryngeal or third tonsil (Luschka). This tonsil may bo the subject of an acute inflani- hisi:.i.sKs OF Tin: DnoriiAursx asd .sAsfii-iiAuy.w. i(»-23 timiMTiitiin- ( 101° fii l(i;{° r.). Tliciv ij< iiiJirkcd dilliculty in lucatli- iii;; tliioiiuli the nose, and the cliildV voifo Imtiuiics tliirk. Tliciiii.sil -icii'tiniis arc lal inc now, anil mr i-iuni .-■><'"<■ m < <mih •-■ m" ". ■ ■•■ ■ •(• later on (in the course of a !'<)ii[)l<' of days) incrca^'d :ind chanficd in cliaractcr, licin^' at first tliin •■"■I "Icir l.nt snl.sc- lurnilv Ix'coinc mucopurulent, li - i' I .. -.1 I and clear, hut sulisc- 1 many eases tlie alTection may l)»' lurniiv IxTome mucopurulent. In many eases tlie affection may Ix- .illend'ed Willi an acute catariiial otitis media. The treatment coii- HMs of a inilil purgative, the syrin)rin« of the nostrils with an alkaline I MUtiseptic solution, such as Dohell's, and the ap|ilication of the llowin^r ouitmcnt within the nostrils every four h.ours; llyilnirKvri oxUli riibri. I'ttriiltiii. ViiHL'l. alb.. l!r. j»s-i>.- gr Iv-vilj. Slj. M. Kt. niiij. Adenoid Vegetations or Postnasal Growths. The affection which i- most commonly met with is where the pharynjieal tonsil l>ccoines ihronicaliy eiilarp'd, and when such is the ca.se it is commonly known a> iiiliniiid rt(iiliili(iiis, or jxistudsiil <jri>irths. Etiology, it is an atTection lar>rely met with in children, although ,„r:i-ionallv met with in adult life. In the author's collection of ca.^es ilic aires at which sU'-h a condiiioii was most frequently found were l..i\\,rn three and live years: the earliest aj;e in which it was met wiih is a sinjrl.' case at three weeks, the oldest at forty-five years. .\> to sex, there is a sliiihl |iredoniiiiaiice in favor of males. That iirivditv i'>lavs some part, the writer helieves there is no douht, as ill his ti)tal cases there weiv no h'ss than fifty-three families in which Irom two to four children were the sulijects of iiypertrophy of the |iliarvnfie;d tonsil. In" the table on pa«e 1024 are p;iven the writer's statistics, taken (iiilv from his private practice. The total iiuiiibor of ca.ses was* !(■.().-), occurrinj; amoiifi 1(),(MM) patients. This represents Ifi per cent. n|- cases in which adenoids or adenoids and enlarRed tonsils were found to exist. .\fter some of the infortiou.s fevers, ospocially mea.sles and scarlet fever, it would seem as if the alTectioii were ])recii)ita.ted. Climate, where there are extremes of heat and cold, seems to 1)p favorable to its development. lieiK-ated attacks of acute nasojiharvnigitis tend to hvpertrophv of the Ivmphoid tissue. The pharyiifteal tcsnsil is apt to underp. atrophv after puberty, and the writer has also seen this take |)lacr' following a severe attack of nasal and nasop'i.aryngeal diphtheria. . Symptoms. The existence of adenoids is very frotiuently recognized by the facial expression of the child, altliough one must be very 1024 A'o.sa; .\m> riiiiDAT. rari'fiil in ninkiiiK a iliapinsis Inmi tlii.-< alone, a,« is so often dune, iH'caiise iii'irked anii'riiir nasal steh »i-i may prnilucc' a similar exiires- /u,u (if ciiutitenancc. Cliihlrcn \\\v> sutler I'rnm ejimnic enlarnemeni of llie |)liarvii>;eal tonsil an- of two ly|M's: one is of floriij cnniitenance and well ii.".iiri-lie.| i Kij;. 5ai), ami the other isjialeaml tliin looking. I' ; ; I A.K'llol.l" Ailfli. |il«Klllt t lllflllH. 1 . innil TnUl Age. tfk« 1 Feiimlf, 1 Ti.lKl 1 MnU'. Fi'Illttle. TuUl. t M»li'. KL-male. Toliil. 3 w t 1 • Ut 1 > ftir 11 1 l« .') :i « r.i 1 ■J(' A • 1 i; N u M ij 'J II _' \ 'ttr<i 1 '. |M '.M It ir. 31 :ii ■Jrt ■'»7 w ' :tii l'.< I'.l 4ii ;i7 b:i 7ii .'•(■» 13J 4 /.' Jl "rft 1 :«; Xi Ci'J (h» .il nil -T III ti'.i III 4.' KJ (i'.l KJ i.'ii t'l >• 4.' ■;»i (Is ;ti ^H Mt 73 •'4 IIW 7 • • :il :i| t'^ Mi ■_".• ti.) III I'rf) IJ7 H ;«! l.I ■jd ■Jl' flj (■'J ,M 113 9 i: '-> .': •Jl l.-i ■M ;tt 40 "I* lU j^ 17 I'.l :!« 1". 4" Wl 11 LM i"i :!.'i l« 14 ;ij :w JII fi7 \£ 'ji I'll IT ir. I'l :il ;i7 41 7H 13 ■.'4 111 Rl 1 n 11 JJ ■x< Jl ,-.<l 14 •.'•I 1.. ;w 1(1 \u ■Jii 3:1 ■J.^ .'kK Kt t a'> '.* :<4 'J H 17 34 17 .M If! '."J l.I 3(i 1 VI i;t Jl 'J5 4'J 17 tl 1 i:t :i ;i IJ 4 1« IM 1. s I.-. ■2 3 .") a 11 JO ly o .1 .'> 1 1 J 3 4 7 21) ai -•■ ,'Hi II 10 ■Jl 41 lill 77 *iI-2.V -'> I'.l II r» H 13 80 •r- .'i7 •2^Mi 11 IJ -M 1 * 5 IJ id JS St-40 " 1 II 1 t I) 1 '2 '2 4J 1 1 ' u 1 I 1 1 3M 374 341 i 718 i ^" UX)6 In hotli till' month is o]ien most of the time, the nose thin, the nostrils nan-o'v, the depression on either side of the ahe doe|K'r than normal, the iipjier lids may droop, and the general exjiression is often dull, listless, and idiotic. I'pon (|Uestioiiinj; the parents, one m;iy elieit the faet that the child is a niouth-hreather, especially at ni<:ht, and it may he so marked that the child snores. In some cases there may be even a struggle for breath to such an extent as to alarm the parents, and the child may start uj) from its .sleep (|uite fright- •■ned (nifiht-termrs). These symptoms of disturbed breathinj; are moderated when the child is turne<l so jis to sleep on its side. \'aryin!r dejrrees of deafness may lie noted, which condition may pas.s off in warm weather. From this very fact of the deafness beinji only tem- porary, and of a sliirht defrrec in some cases, parents jire .apt to pay little attention to it. Hejieated attacks • ■ earache, foilowed by a discharfre in some c;ises. are f ■"i|Ui'ntly met with, ("olds in the head ail' of fre(|uent occurrenci i .sonii children it may be said that thi'v sTOiii to have a con.-tant culd iii tlie head. .\ cough, esj-K-ciaily ,tish:.i iji' Tin: DRoi'ii. AltYSX l.V/) .V.l.sory/.UJI'.VA 1025 vhvn llu- .iiil.l H asl.'.-i), i'' n'.t.-. Mtit I litMiifhitH i- lis., UK 1 .,,,,1 lialiilitv to altiirks „f rroui. Icri.lf.lly iliifk iiiiil t with. I'll"' v"i«T IS ( iihoiii n'sntiiiiicf; It ■'"•1111 Is ii" if 111'' •■liil'l '""' -^ '*!'^'"' >I>1 ill his hcti'l; letters rn|uinii'r ir HJisa I ..hamlHTs f..r llifir ivsoiuiiu- roiinlv I iroiiDiiiu'i'' CIV 111 thus III H'C'OIIH-; '1. a iirt- H'l-Kllll'S iikfil fiisi' there iiuiy l)e evi inlitliriilly in I'rea thiiiR Khi. Ml t Typos of the " ailf n""' ' f'"''''" when oiitinp. Ill !in ill faiit the ilitrieiilty ir l.reathiiif: niiiy serinu: •\v 111 tcrfere witli Its nnrsiii^: II a ( use lit Mil III l;ilit three W(H ks oUl, opera teil 111 hv the w iter, It was w the ihiia iiiirseil, haviuf: i' let CO its li"l'l "" itii .lie K'ea th' test ililiieiilty that e verv (jiii iitlv. Tt e talilishineiit ic resii of iia iiiaeiate lit was that it soon < sal respiration. lUii-sinir wa: '"I'l . , , 1, Imt. with the thout aiiv I htlieiilty, the r suit heiiin a |-IlllUrl^ s carrietl out wi heil I'hilil in thi- eoursc ifanioiith. Nin -throat isolteiiniet with as a coin laint. the tonsils ill many < hildreii lieinjl enlarge. 1 wit h the as-iciated aileiiiiu Is. At- tacks if (iiistaxis are occ asionally met w ith, verv ri irelv asthmatic ='^^t; mouth-hreathin. . vei. .-;;-| -yi-Z-t;;; ^^^ T^!: ..ahle length of time an^ahet^Uo m ' .^-l"^,, ,., .,„,,,. The iluceil III some ca.ses, 11k i-m I '^ „„,uth-breathmK n=:it''l:;;i^l..si i;-^ ''"•^^'" ■'" „i.l, is ,h- aM..,„i.t "I. tl«' 1»" '''/*„,„„ ,„.wn«M. In tr,,,,, ti,.. i».:k "f .!„■ ';~_t!y,".':|::;;ii:,::':,;;";i;;„„„..fii..-cwij 102« .\().si-: A.\D rniioAT. "apro^oxia' rii.'sui.iMa\illarvKlaiulsanMr(S|U(Mitly f(.un(l<Milarfr(><l. The ('xist.-nc.' nl' a.lcnoids is occasionally to l>c found answerable for many cases of [MTsisK'nt and recurring phlyctenular keratitis and conjunctivitis. . i r .1 Diagnosis. The recofinition of the existence ol hyixTtrophy ol the pharvnfieal tonsil niav Ix' carried out hy one or two ineth<ids. The first "tnethnd is hv i)osterior and anterior rhin(.scoi)y. Posterior rhinosco|)v is not "often carried out successfully in many ciiildren: but when allowed. th> mass is recofmized as a rose-colored jtrowth. situated either on the vault of the pharynx, on its jM.sterior wall, Flu. i*!. \mcro-|H>i!t.T.ur suitloii of the hoa.i ..1 hii adult, showing the .it.miu.ii hii.I gr..--, sinKtim. of hyi«Tirripl>y nf tlio lyini.h»i.l t;s.«ue of tlic iwi..i|ilmrynx. : Zitkkkk.»m.i.. i or on both. It (.l)scures from above downw.-ird to a jrreater or lesser de.rree the posterior jiarts of the .-.plum ami middle turbinated bodies. " III some cases even the itosterior parts of the infe- ,..„, ,,, rior imbinated bodies are totally hidden, \\lieii ^^gHM^^ occiiiiviiis; the vault the surfac f the collection ^fl^HfiBL^-^ is eitlier stal.actite ( Fijr. .'»;{.'>> or smooth in ;ippear- ! .^^^BHr* ! ance. it may be noticed in cases that the ***>^5HlWi^-^ Ivmphoid hv|M-r1rophv stretches across the vault — ^ and occupies Rosenmiiller's fossM'. This examina- „v„.„r.,,.H>'^.i- I'l".- tinn. if not carried out satisfactorily, may 1- as- rynwiiitoiL>ii. e..iiKN i sisted ill some case* by anterior rhinoscopy. Ilie nostrils h.'iviuix been carefully spraved with a I per cent, solution "f c<icaine. any existiiij: teniporai-y liy|M'rtro|)hy of the n,i-al mucous membrane iieinj; thus reduced, will enable the DISEASES OF Tin: OROPILUIYSX AM, yASOVlUHYSX. 1027 cxaiiiiiic :iii( to st'i- llif lUiiss, ill soiiu- <'ascs l)l()ckiiin the jM.stcrior nan 1 wlicn iiiarkctl tlic inovniu nt of the soft palate uiion ci thor swal- iwinn or iilionatiiifi ■h" is not soon to rise in the normal manner. lould these nu thods fail to determine their exi I'xamination inn child" ,t he carriei 1 out. This is I loll .Ids t left arm, aiu! Iiiotectetl hy annssh-mld l,e held l.v aiu.ther pers.-n an he ehilds head between the lelt side ol his < the thumb < thick t(nv( ■iteiice, then digital follows: The (I the examiner n body and his iouslv „f the left hand, haviiif: been jm'V 1 around it. is phurd well back between he child's upiH'r and h.wer mo ,lars of 'the h-ft side. The first finger f thi' rifiht hand is then gently l will immediately imi)iiige uj tlv passed up behind the soft pahite.and )Oll ;i soft mass 1 iito which it is easily ibedded. Hy mean )f this examination the extent of the mass mav 1h- iearneii by its n-kition to the se|.tum ai d orifice of the Kusta- •hiim tubes. Ipoii withdraw tingetl with blood, and sometime: nostrils. In ehiidreii where the ton ,arrv out pos ral of the finper it is usually found little blood may escape from the are en iilarged it may be imposi ;,<ibie to terior rhuiospopy on .Mccount o f their size: then digital exam liiiation will be necessary shows in many cases inai „.,, The i.osteiior wall of the pharynx ked "hypertrophy of the lymphoid tissue m the region o lilar condition exi ifthe oropharynx, aiu 1 is of" itself very suggestive o if a <im pharynx, llxamm will show them tt in a VI ;tiiig in greater ((uantity m the vault of the itioii of the tympanic membraiK in iiianv cas<'s Im> retracted, dull, am the handle of the malleus IV horizontal position :»>r, sl.( luld a purulent otitis metlia i)e present, a pt rforation of varying size !)(■ iKited. I'rominenoc of the second cervica ,1 vertebra has Iwen mi -taken for adi-noids when tl le examma tioii has been ma( le bv the rhinosci>pic mirror: but digital exam illation will clear up any ( loubt. Prognosis Before giving a progi" to the outcome of any KM •ative procedure to be im< "1 tlie various colli lertakeii for the removal of adenoids litions ditioiis mils ill' iiiqiiirei t ))(- first thiiroiighly Ithough this i: -ult would pri oe iiiiiK ' <""' -.11 1 „f the patient and other associated local coii- .• eonsidered. First and foremost to ,f anv ha'niophilic tendency: vet should it be overlooked the I into is the pos-ible existence o are occurrence n Ulioll t h,. symptoms for which the child IS to r. tieiit. Again, depending lull ,t 1,,. based upon certain pi ibl (■ associ h-breathh.gbe the most prominent symi.tom i ilteratioii ill t Thus, if iiiuut be careful that no .a !,(' ], resent, that no iiivtei marked deviation or large spur reive relief . one's opinion iiteil local condilions. iiie must ) na he shajieof the upper jaw (\ -shape narrowing of the nasal passages, no ,f septum, be present: other\vise. the tural narrowin ipiMiintmeiit to the j areiits a ^ as to the result will be ma iked. If deafiie; mem be the chief symjit m, t hen the condition of the tympanii ibian rxi^tence I am 1 the tym!>ani must ,f a sclerosing oti -dia, militating against very be noted carefullv, the ])ossible it it in f a tis media, or a chronic supp iratiye • brilliant results. Tiie question o '^^^'^^f^ites 1^ 1028 NOUE AND rilBOAT. l)<.ssil)le recurrence has also to be answered, and while, even after a verv tlioroujtli and ct)inj)let<> removal, recurrence may possibly take place, this must receive consideration, (liven, however, an imconi- plicatVd case, the ijni^nosis is most favorable. Treatment. One must In-ar in mind that not every case of adenoid.^ nuist be subjected to operative interferenc»>. The writer has rej)eat- cdlv «een eases in wliich the amount was so small that attention to geiiiTal tonic and hvgienic treatment, the local condition has 1mh-ii followed i)y such improvement as to reciuire no surgical interference. Thi« is especially the case v S(>re the pharyngeal tonsil is found acutely enlarged from some infective cause. Presuming the ease is one which demands interference, the following are the steps of procedure, as ado] )ted h->- the writer: It is advisable to administer a mild cathartic the day i)revious to the oi)eration. and the nasal passages should be cleansed by tlie use „f an alkaline and antiseptic lotion, especially if there be increased secretion. Shall the oi)eration be done with or without an antes- thetic"' The writer gives it as his oi)inion that the operation for removal of adenoids, with or without tonsillotomy, should always be un.lertaken with the i)atient under an ana-stlietic. for the reason that as the oi)eration is done largely on young children the shock of such an operation and the fright attendant upon the sight of blood are sufficient of themselves for avoiding such results. Further, tl.e operation cannot, in the majority of eases, be thoroughly done without an aiue.sthetic. ^\hlli ,.!ia"sthetic should be used? Of the various aiuestheties used, eacii has its own advocate. Chlonform, A. V. K. mixture, nitrous oxide gas alone, or the use of the gas fol- lowed by ether, bromide of ethyl and ether alone, have all be<'ii used with good, and, unfortunately, in some eases fatal results, the unfor- tunate results having followed where chloroform or .\. ('. Iv has been used. The writer has op'^rated on cases in which the various aiues- theties mentioned liave been administereil, but invari!d)ly prefers ether. .Manning ctTects were produced in several ea.ses in which chloroform or .\. V. K. had been used, but with no fatal result. With ether. h(iw(-ver, the writ-r has never seen an unpleasant result either accoinpaiiving or following its use. ,\ great (leal has been said against ether as an aiuesth(>tic m this operation: that by inciting increased s<'cretion in the throat, danger is added, but, if carefully and rnpiiilii administered and not pushed to profound aiui'sthesia.the writer has not yet seen the mucus in- creased to such an extent as to increase the danger of its iM-ing in- spired to such a dcg'"<"'' i'^ to iiriMluce subse(iui'nt bad results. The next point to Im- consiilere<l is the position of the patient at the time of the oj)eratioii. One has the choice of three methoils: thi' upright, the lateral, and the Hose. In the upright positicm the p.,li,.„t is first auM'sthetized m thf reeumbent posture, and then slowly elevated. To facilitate this method French has devised a chair well suiteil for this purjiose. As a substitute the patient may DISEASES OF THE OROPUARY^X AND NASOPUARYXX. 1029 , i„.l.l on the kiieos of an a.ssistiint, the hoa.l resting on the assistant's ''"■■V. I rCe ,,.* » So. a t..,»ill»t,m..v lm» to bo ,lo„o "7;;LrL'r;o'^i"r™Kts';;r^auv,xo ,t o„.. Tho .n rr:' h^n": as i r l" "^^^^^^^ The 'proH.ninary preparations afon>- h,s hands as stmie as , ^^.^^^^ j^^^^ ^^^^j^j. ^,^ and crosHt-u »>>» • " ,. i^rdiier v secured. In tnih "; on the vault and ,.osterior wall of the pharynx, then ens and the curette will he needed. „ h. to wils require ren.oval, the writer prefers ...H^r- "^hem previous to ren.ovinp the adenoi.ls, for the n-ason o I eritim is unohscun-.l hy hlood, and when this alone wit! vault • " hot' ,• I at ill ' j^.jy SOSE AXD TUHOAT. localizcl. aiul tlu> f..rcci.s ( Tifi. o.So), lu-l.l in lli<> .liscnRaficd l.an.l pasMMl up into tlic vault of thi' ].liaryiix, and fiuidc.l to tlic adenoid 1)V Mi.-ans of till' alrcadv intPxUurd tinni-r. Tlic mass is new ciifiaKcd aiid the foiTcps cioscd, caiv hciiifi taken that duriiij; tins procedure they arc maintained strictly in the middle line and that the blades Fia. r>;i6. Branilfgee'8 fi)rcev«. are not thrown too far forwanl l)y dcprcssiiif,' the haiullcs too much: otlicrwiso the iH.sferior i)art of the sei)tum may i>ccome enRaRcd and a pice- hroken off. If the forceps he rotated to(>ithcr side it is possihle to enpase a portion '.f either of the Kustachian tul.cs Hy means of the introduced fin>r<' ■ the s(.ft palate and uvuia are hei.l ■i\viv s.) as to i.revent either of tlxMii hciiif: en<;as;od in the lila.les '„f the forceps when dosin- them. The writer Rives a pivierence to slnr cutt;..^ forccj.s rather than to dull ones, because should the growth Ix' somewhat til.rci.l it is thoroufiiily cut through, and there is no danger of tearing the mucous memlirane when the forceps are withdrawn, which is very apt to occur in the use ot dull cutting forci'ps Thi' forceos are reintroduced as often as is necessary to remove anv remaining portions. That ])art of the adenoi.l winch is not read'ilv removed l.v th.> f(.rceps, and especially when situated (.n the i.osteri(.r wall of "the pharyn.x, is l.est removed l.y the (iott- stein curette (Fig. o.%), which, when introduced, is passed well up Fiii. r.sB 4;olts[ein curetic to the H ptum 1)V depressing the handle. Finn pressun- is now made. .,11(1 hy elevating the hanille the cutting portion of the instrument is thus made to sweep from above downward, removing any hyper- trophied lymphoid tissu.' which may remain in the vault or on the posterior wall of the i)harynx. The patient is now i|uicklv turned face downward to allow the blood and clots to escape into a basin jireviously placed below the naticnfs head for that purj.ose. While the patient is in this position, •m.l after the flow of blood has moderated, the index finger of the VI^EA^ES OF THE oUOPIUUrSX a: O SASOI'IIAHYSX. 1031 l.y „u.ans ..f tl... tinp-r. t . < "'^ ^ . ^,.,„„,.,.,,_ xh." patient, xvlu.lo mass ..t a.l.'nuuls la. '"■•' \ *'[ f, !;,., ,„,,. ,,.st tl.eiv. l.inR ,. t.. hrin, ahou: '-;■'";!;,; ;;;;,;^V^ot a.lvisable to intnuluc When up.Tat.n>r up-n " »^ ;''';, ^. .,,„,, „,ijji,t ,1.. soricus .lan.ap.- l,.,th linger an.l n.strunu-nt ^^J' j' \\,, ^^ •„,, tlu> instrument ,,y stn-tehing an.t t.'ar.njr " £ , ^ io. Tlu hemorrhage att.-n.l- i"t" tl"- vault ">;:^r "'• •'^,^'^; "irii adenoids, ,.s,H..Mally when ='"* ^'1"''\''''\''' t ni omV is apt to lu. eonsiderahle and even •■'""•>"""' r'' ' ; n h^io is a„.l nee.ls no interference, alarmmg. Imt, as a lule. it ^""^ ^' ,..,„.f,,llv insDect for the source Should it iH" alaruung then om- "»; • ^^^^'] ,!„ ,,,, „„.thods for arrestmg it as .....l <Io\m» in "" the hemorrhage s Ix'st arrested tried. If it be from ];";•;;-:•; Xdi^Hi'liodofo^ gauze. After l,v plugging this space xMth ^^•""=''' , ' " , ,, ;„ i„.,i and allowed '''-'l•''••'^^'''•'^'^'"^''■'^'^'ndSSo wae"^ Alter that, if th. nothing for thre.. hc>urs un es. a nkf.^^^ the parents with the vomiting has •••'"^[^'^-'^ \ ''':;,,,, ..Jt of blood will take place- ,a,.t that th.' vomitmg ot a '''l^;^^t''^ ^^ ,„ilk, b.rf-tea. chicken „,,,a nourishnuM,t may be ;--|;, -jj' f;,,,,, ,;,, acceptable to :;::^-.^t;:e n^U ^^nts .... . ;..^^^ ^,,^.^ .,,^,, ,„., A»,solute rest in bed is ve ' J^' , /, '^;, . „,•,,,, .,ay, when the „., .liet is gradually •">':;; ,^ ,""![,;!" It lent must be .-autioned ,ti.-nfs usual diet .> •';;'.;,,,, ,tv-f...ir h..urs, as any undue ,prinstbl..wingthen..s.-fortl.ehn^ '« "> __^j^,^,,,. ^.^^ ,flort in this way may force '' ;\ ,,7'"if ^i.e nostrils l>ecome „„, nn.bably set up an '«'"'' 'V ".'nti-.i this i-^ b.-st dislo.lge.J • ,,s,nict,.d by the presence o ''J- < ^ Vl v Iwi g the open one into l,v,.l..singeachn..str.lseparatel .a-g^^^^^^^ al,ovvl. In the majori y o '"'»'*•";; ""."^^,^.i „f tlu- nasal secn-tion is ttecessary. but ^ -"''J '^j^^,,^:,'', "as 1 obeli s. should b,. use.! an alkaline and antiseptic ^'' ".;;.,,,,, t is occasionally neces- „ifjht and nu.rmng. (.eneral '"^^ ' ,; •' ' ,,,,ti, is „ot promptly sarv wh..n the impn.vement of '^ ' " ^,,,,,,,1,. slidd. but h,,.etite.l by the o,K'ration. " ;\\ " ;)o ,,-., .r.'as the wnter ......asionally.the tem,H.ra,ure nu^> .i>. to UK. ^ ^^ ,^^ ^^^^^^^^ ^^^.^^_^ has seen it m tw.. cases. *" J'"- . "^ ' ^^^,,.,, The following day ,„„.ation. The <^;^;;;£ J;,^, "'n:,asi.many theiv nmv W a these symptoms ha\e '"^''I'l' ;"" , .^ „f ^^,^ .n-ck coniulauied of, slight stifl'ness of the muscles of the i. ■ K 10:l2 \()SK AM) rilROAT. and even a torticollis lias !)een met witii in- tlie writer- Im, tlies' soon ilisa|i|N'ar. The cliilils voiee is sometimes a little nasal in eliarartei, i iie 1.) a temjMirary paresis of the palatal mnseles, hroujiht ahout liv t!;, ir hein}! stretehcil at thi' time of the operation. This, however, sf.on (lisap|«'ars and the voiee liecomes natural. Xa.sal respiration is usually soon estaliiished alter the removal of adenoids, provided no other nasal obstruction coexists. Hut if na.sal respiration is not estahlished it may Im- assisted by iyin<; "■'" ^"^ the child's chin nji. as shown in the accom- ])anyinK illustration I i-"i)i. o.iTi. Adenoids occurriuf; in younj; adults may Im' removed under local ana-stlu'sia i)y forceps or nasopharyngeal snare. In \T^/ /'i, '',^''.-i -"i^'h fii.ses the operator re(|uires the co- -^-'/ (<''Y' - *'?<ii ojieration of the ))atient, and, therefore, it can only Im' undeitaken in very tract- able individuals. The oropharynx and na,sopluirynx ai-e to be swablx'd with a 10 jjer cent, solution of cocaine applied by means of a cotton-wool swab suitably curved. This re(|uires to be done twice within an interval of about ten mituites The patient is instructed to hold his " the mouth by means of a depressor, f the operator's w;ty; then, by means Mt'ihod of lying up the chin to favor nasal respiraiioii. l)et\veen each application, toriftue well down to the floor o the handle of which is well out ( of the rhinosco|)ic mirror, ilie forceps, which should be .sharp-cuttinff or the snare, is >;uided into the naso{)harynx and the p,oi-tion of the adenoid removed. Tliis is repeated as often a.- necessary until the ma.ss is thoroufrhly removed. The jfreal lirawback to such an inider- takinj: is the heinorrhagi', which is often considerable and <ibscures the tield of ojM'ration. thus !imitin<; the anioinit ti; be removed at each sittinj: and nece.ssitatinjr n-peated operations, Tiie operation i> not by any me.-ms a painless one, even if the cocainiz.-ition li;is In-en thoroiijrliiy and carefully carried out. Tumors of the Nasopharjmx. 1. Benign Growths liKler this headiiifi may be included /ihroiiiiitn. jU.rminicnits /iDh/pi. ciisls. jHiiiilla- malit. and liie more rare .-ifTections. cnrliiiitilrniniitd. c.ro.v/o.vc.v, linniiuita and <in(iii)iiiiilii. Of these, th i.se occurrnif; in the nasopharynx most fre(iuently— althoufrh by no means common — are the tibniniata and (ibronuicous polypi. Fibromata. This class of jrrowtii. fhoujrii liisiol,)jticMlly non-maliii- nant, yet cliiiically has such features ;is to be almost reiranled as malifrnatit. Isiiaily the j;i-owth spriiifrs from the reirion of the basilar process of the sphenoid and occi|(ital bones and from the u!)])er cer- vical vertebra-. It (ends by its r.-ijiid exfensien to invade the neigh- borinjt structures, and its prolongations may 1m> found in the nose, fuiKTior maxilla, and orbit. It is a tumor found almost exclusively DISEASES nF THE OROrHAHYSX ASD SASOPUiRrSX. l..:W \ few cases ■„, ,„.ilcs l.<-t%v.-.>i. tlu> apes ..f ton aiul tw<"nty-Hv<> yean •"■::;™.;;^ ''^:^:X>:::'^^^^ this ,u..u ..... .;''";:,; nasi; ..hstruHio.0.y,K.rs...n.i,m,n...ll..-...^^^^^^ 1 itself •; her h u^l n-H invasi.... -f tl.e orhit or by .ts •"volv.nR t he V e nakl). l).-af..ess is also p fre.iuent syn.ptm... Death nsual y .MadU.nii cerebral i..v..lv(>n.ei.t. or he...orrha{:e. I pou • ; it« nw.Mlitv •>...' ilensitv of charaet(>r ...ay be ...ore carefnllv :;:;:rtal:e;; t^a^^.-! ^-ases its prese..co is k..ow,. by .ts appear- ='"Sa!;<iS;' mti:a"::;!i!:mv;Lt the gn,wth ...ay be n.istaken for Se oi.ls 1 ut can'f..l exa..V.,.atio.. l>y ...oa..s of the rh.n..soo,K.. for ad. .lo.'ls, ' u'^ " J , , ai.u.unt of heniorrhage '; V 1 i 1^ bee fou?..l that n^trocession has t,.ke.. pla-- - t - frr V ns be.-., .lestrov..! th.-o..ph sloush...?. I« -'•<■" <'="••> " "; f,;:;:.l.;„i.. a,ul eo...,.lete .-.-...oval u...l.Ttake,.. tl.e pn.p.os.s .> ''T«t. This .....st IH- of an enthvly surgical nature, a..d th- methods at one's disposal are as follows: I'.xtractio.. through the natural 1. The galvai.ocautery snare ^ •_>. ("old wi.-e snare ;• i:i:.ctro!ysis 4. Mvulsio.i by forceits o. External operation. I I'.xtrac f pass: passages. -<r3«s»' "TT.aoi,i'- nnBT'dT' io;54 yoni: A.\D riiiioAT. 1. '/'/(.• (iiilniiiiH-iiiiln-ii Snare. In tlic .'iiiplicalion ut' the 1<hi|i altoiit till' luiiHir cuiisiilcral)!!' ilitliculty may Im^ cxixTiciiccd in scciirinfi it almiit the Kasc. This is csprcially so wlicn llic tiiinnr i~ sc- ilc. ami less su when in'ilunciilatcil. It may Ix' iiilniduccil ciiIhi- lliniii<;li tli^' antcridi- tiarcs ur tliniii;;li the (irnpliaiv ii\ witli tlic soli palate wfll rrtractcii. ami. I)y the aiil of the lirst fin^rcr in tlic plian- i\. mailc to cni'irclc tiic };i""\vtli. When well in position tlic wire is tiftlitcncd, tlic cun-ciit tiitncil on, and tlic wiic drawn slowly home. The dilli- ciiltv in pcil'onnin;; this method of operatiiif; is, Ix'sidcs that ahovc mentioned, that of seciirinji the loop around the hase. and that the wire mavhreak. In lieatinirthc wire to .1 dull-red heat (•onsiderahie dithcultv may he cxiM-rienced in cuttiiifi tlirou>;ii the frrowth. while with a white heat it is cut tlirou>;h so (piickly that the attcii(hiiit hemorrhacc is tlicn consideralilc. 2. Colli W'iir Smii-t'. This is api)lieil in either of the ways men- tioned in usinji the jialvaiiocauti'ry snare, and the .same ditiiculty is also c.\|)ericnccd in the ap])lication of the looj). When used tli<' snare must he a most powerful oni'. such as Farlow's, and the wire .slioulil Ik- No. S or 1(1. When in position the wire is screwed lionic very slowlv, occupying a couple of hours, and its use is always attended witii a jrreat deal of pain, ami the amount of liemorrhafp' is u.sually considerable. The advantasic of the steel wire is that, throujih its rijridity, the growth is more easily included and retained than the galvaiiocaiitcry loo]). .\ method of includiii}; the <trowtii, as suggested and adopteil by (Jreville-Macdoiiaid, is as follows: "With a li<'loc(|'s caiuila or soft Kustachian catheter a piece of thread is carried into the pharynx through till' nose, and to the buccal end of this two terminations of ■a jiiece of \o. (i piano wire, measuring IN or 20 inches, are attached in such a manner tliat on being drawn upward through the nose they will not abrade the surface. Hy me i"s of the thread the ends of the wire are then drawn into the na.sop! arynx and nose. As soon as they project from the anterior nares ■ le bent ends arc detached with a pair of wire nijipers, .so that thr wire can i)e threaded into the barrel of tlic snare to be employed, which is thrust well into the nose before the wire is made fast to the instrument. In this manner a large noose is left in the pharynx whicii. with the help of the fore- finger, can be insinuated behind the tumor. Once this is cfTected. there will lie no difficulty in working the snare on to the highest portion of the tumor and tightening it as it is advanced u])ward. The growth can then be cut through by gradually shortening the wire." The advantage claimed for this method of encircling the growth is that it prevents the doubling up of the loop when introduced through the anterior narcs and the necessary weakening of the wire by its thus being doubled. 3. Elirtrolifxis. This method may be applied in two ways. ('() uni- polar, and (/>) bipolar. In the first way both iiuedlos are inserted into uisEA^^J^s n, til: onoruAuysx aso sA^oriiAHYSX. 1<«> !• . .1... iw.int wticrc it is t'iiil><'<l<l»''l '" ^'"' ,„,.wtl.. IS well iiisal:it.M . liith' ^ [\ , i,,,,,-,,",,,.). a sp.mnr. is UvH is ins..r,M int.. th<. n J.. u 'I - ^^^^^^ "''-""' -i.l...n. sl.u..k tu ,1... ;;V7 r'l , \,, ,„ss tor lonp.r .nilliauMH-vs. Tl.- .•urn-nt f- ',,;,! ',,,,, ,l„.'si„in.'s sl.oul.l "'-' "•" '" ';"•■": ';"::' ::k-u^a' "allow tlu.sl..u,l. to sn.arat... |„.froni tcn.laystot\v..w<"Kr..nu _^^^^^j ,^.^^,,. 1 /,>»/./../,, Tl.is iM..tl.o.l is rarruMl . < i < r '^ ,,^. !/„ rapines, as ..sp-Mally ^"'='1 ' ^ ^ J'^^^ ., ..ivoVat.-s, l.ut unless carruM out can'luiiN an . «"■• f,ai,.,v('.l hv s<'r ous coniplica- ::'!j:;;;;;vSa;;r • norl .'d^ -y t.. aforon„.ntion...i •''•ft;.n.,/r>,....;:.,Hythisn.th.ltlK..^ tl.o oropharynx hy a.v..Un, tl... > ;^' ^^^ \ ,. ^„„,-„. is .xtir- palat.., ana hy .n-a,^ ol -"*->: ^J^^J'Jt ...vltninary tra.-h.- , .,t..a. The h.-niorrhajt- is so ^" '>'";,'*'' ,^\. ,,,,,,, ,s. .fa sp-mp' !,,..Hyanaplu,,i..«.;t ''-7^™;; ; ;*^1^:.;;; Vas intro<hi-a a ^^,, „,,,,s..ary. Inst-aa 'f ;. ; '^' ;'" ,',tranVo of l.loo.l into th- ,„,,ap,. apparatus ^vl'';:'\, '' V^'/'^,,. ?,,! ' neth...l aaoptc.! is to 1h> larynx. Hnnorrha,.. '''>^ "f^. ;'';.;;, J.^ts an- loft aft'.-r any oiHTa- ,..,„„,,„,a hy P.VSSU.V ^\'; ;f ;"'ia,.s of tlu. galvanocaut.-ry five procP<lur(' arc tu he tnaicu o^ '"''"*• P„i«.i Tlu's<> growths, acconlinfl to Jonathan Wrij;ht TibromucouB Polypi- H":^ M^ ^j • , ^ ,„,co,n.- a>a..matous. an>"til.ro.nata ot a slui^m-^h K • ' J, [.;;,,^ ,„,^,. tlu' nasal fossa., Thoir orifiin is R..n..rally m h .•;-I'^:>^ ^,^,,,^. ,.,iu„eulat..a ai.a i„t., which they may ;:>^ -'"'^ ; > ''tuc "n''«'»M>r...lua-.l may ,,., „„t invaac ^•."••••""" ".^\ , ;" ,^t arc th.; .. of nasal ohstn.ction vary with the si^c of 1 t v,r, m^ ^^ ^^„„. ,vi,h its ''"'""' ="'\r,f;,r i l^^n ocoupving the nasopharynx, translucent, pcaunculat.'-l ♦"'"['„.,„„„.,<•„,•, into that region may i:Uc:"'its ";n;:"r;s':::s;".?;;;mS-^ ••>• --- -^ ^'«' -'*' ^^fiaignantOrowths. < >f ';;f iSl! IT^^t ''''S^Su ,,,rro.K, an.l rnrci,,>,>w occur >;^,^'*,i ';,,:. ,,„,,,„,,,, pn.aucc.l arc is usually the vault of the P^^^jy^-'^J^^ , iJi,, ,,Jak a..wn a..! similar to thos.. of hhron.ata. T^'' ;' ^[;^, /^^^ ^, ,, suhmaxillary glan.ls i-aacsurroun. ...strucnm.^ -•;»--, ^ ,,ses, unfortunately arc early myolvca. As re^-ini /r^ ^^^^^ oix>rative mtcrfercncc. there is httl.' to 1k> aone. Jj; J^. ^^bv the snare or forceps or the ;^t;!;S^ni=:olS:n:are\,f the satne sad nature. CHAPTER XXIII. NEUROSES OF THE NOSE AND TIIUOAT. By KMIL MAYER, M.D. NEUROSES OF THE NOSE. Tn.vT the olfactory .sonso wa.s capable of a high dogroo of cultivation was i<iio\vn to the ancients. The Romans p(i.ssess«'{| slaves, iM-autiful in form and fipiire. who prepared their baths with perfumed waters, .anointed themselves and their masters, and kept incense burning .so that every pleasure that sweet smells might induce was theirs. That these added to their sexual enjoyment they were amply convinced. In recent times. .1. \. .Mackenzie has called attention to the direct relation of certain areas of erectile mucosa in the no.se to the sexual apparatus. Hobbs' claims to have cured two ca.ses of chronic pri- apism by the insufflation of cocaine in tiie no.se. Wright- has .shown the great amount of erectile tis.sue in the na.sal mucosa of the bull as compareil to that of the steer. Perhaps no one thing in medicine is .so remarkable as the strange and jwculiarly intimate relations existing between the nose .and tiic genital organs. These are emlnxlied in the investigations of .^chifT, in coiilirmation of Fliess' statement regardingthe.se relations. Mis ri'searches go to i)rove that there is an intiniiite relation, prob- ably through the sympatlietic nervous system, between cert.ain so- called iias.al genital spots on the anterior part of the lower turbinate bones, and on the tubercula sepfi. and the genital tract. Scliiff made practic.'d use of this fact by cocainizing the.se genital sjiots of the nose .IS a palliative treatment for dysinenorrh(ca. ( hit of 47 cases treated the pains were relieved in 72.4 p<'r cent. .\ perm.anent ( tn-e is effected liy cauterization of the s|)(>ts with trichloracetic acid or the galvano- cautery. .Mental suggestion w;is careftilly avoided, and general ana's- lliesia coii-^idered to be out of the (juestion. .Ml forms of dysmenor- rluea were treated, and only tho.se in whii-h .some abnormal condition of the genital spots was pn-seiit were amenable to the nasal treatment. The nervous or hystcric-d form and dysmenorrhn'a due to mechanical causes were not influenced. Some ca.ses in which there was a patho- logical condition of the reproductive organs, in aildition to the n.a.sal le.-iun. were impruvcii or t-und by trealmcnt of the nose. It wa.-. al.-o shown, exjwrimentally, that during menstruation or in the presence of LatyngoBcope, March, 1897. ( 1036 ) ' New York Medk'al Journal, November 19, 1898. yEL-HOSES Of THE XOSE AXO TIllinAT. iu;{7 I t.. lM-li.-v.. that "»ys.unH.rr^.-: K <•-,,>„„„ ..f „.,.,,„.«- „,s,il spots wh.<-h s<-.Mn to ^^' « -^^ " ' . ;',^,„..l l,v tivat.n.nt ap- ,i„„. an.l tliat this form ot the .hs. -^^ ' > >* ^, tr.-atnu-nt must I..- ,.arn.-(l out with an . i u ^^.^ ^.,,,,, solution ,h.. s,H.,.ulun^ an. '-';;;''; ,J, Sl'iiific... if tlUp<.ts hav pr.- „.,. ,n..nstrual p.-rio.l, with <";;'''"'-';;'';^X ' /v ■'" tl"' The Sense of SmeU or Olfaction. f„.l». i,.l.l» t.. l.i» "'''■'"',';>;• 'X c-nw "t the «■,.»■ ..t smell ;:;;;,r::,ir;;T:;i;;in;t':«f;i"-""»r '"- ptunouK la, .1. ....... ,,2,. „i,„.i,los with thoso views. porcciv.Mi as odors. A>rton <<••■"'" , , „ ^.,i,:pets have the "•''■^■'''*- .. . 1 r • . ,♦ tJio nlfaetorv sense inrreasps Toulous<> an.l Va-schale' f.ni. ^ U^ Ifaet.) ^^^ up t.. the sixth year ..t "f« ■,;;-;.:.;;! '"'Sv dso nohul.. that the distinguish ...lors mereases « th >''-^'^: '"^'^J.;^ ,^,^ in all pn.hal.ility ;;:;;;^;';li;;r ^;:;t ^-^^^ ilSiUS^o t a.. .- , : WiiMier Med BUlter, No. ••i-l'- "**'• i 1038 A-o. K tA7) rilHOAT. (luriiif; fxpinifioii. It wis !ll^ i notcil ttiat ciiilcpt'Ks \\n\i' ;i« gn-ni oll'acturv jiuwrr a- tlio^,. ii,.t iHictcd: their iMTcfptivc |M)\v('r. Iiow- cvcr. is (liiiiiiiishcil. That th<- s<'iisati(iii of tur. plavs an iiii;r(irlaiit part in ohaction is shown liy Zwaardcinakcr,' Wu >i iti-s that th<' tactile irritatiiui is hni- itcd to the anterior half uf the na-al cavity and the |Missiliility nf thi' sense (if taste niii.-t Ik- addii! llieret-i. J. \V. I'al rici<-'adds that smell, Kislif. sensati'in, and tcin}x'ratiire n ust all Im' in uiiini. with the sense of taste in iirder tn secun- ' '.iirhc ' levelupiiicnt uf the latter. I)eviali(ins frniii ndriii il , iiii hms of a M-nsory nature are nu-n- tioned inider the hemiing "f - DiHturbances i Sen^atiiQ or of Olfaction. These are either of th • i •', , \\tv nv< the\ arc exangoratcil or en tiri'ly lust. Those unuMi:'i c'i.m,!-!: u< i.i teni -rarx- loss of the sen.-*' of smell or teiiiporarv ■ x.ejiaera! "i U'liiiji {•< the ;iii<>malies ami merely lecpiire mention. Hsrperosmia ' ' h3rperosptu'e8ia, .- ■ < <u$;ei <iioii <>i tiie sen.sc (.: smell, rarely oc<'.i>ions much distnrh.iiu , ami s .ipt to l>e diie tu idiosyncrasy. Thus the writer has seen \ioleiit in-adache, nause;,. anil |)al|iitation of the hear; n>siilt from the odiv of a I'urninn cif,': rctte and the ^.mie condition I'llow upon the im! ,,( nitr; >■ of ain-l, fu-.^ i oil. chloroluiin. etc. l'retrn;Ult women are |.-.|iiently \-el -r reptilile to odor-- of ,ill kin<ls. and [x-cnliar ndor^ arr ilescrilied as > \i-;tiny; in ejiileptic aura. Werner' mentions fainting; and asihnia as syinploms followinji this condition. The prognosis is jiood. The treatment lies in constitutional measu ^. particnl ul\ \< lien due to neura>'lieiiia, aiucinia, etc Anosmia or Anosptaresia. Tin- loss , if the sen-.' of .<m<'il may he partial or compli le. dne-sided or lii!;iteral. The iejtree ' >\hicli ii exists may lie (juiie accurately determined hy ' he us<' of an ..iiactome- tei- Such instrnnients ha\<' Im-cii devi.-;ei| and descrihed liy Zwaardi'- niaker. I{eiiter. \ Stein, and .\llierto I'ini ]■]. Toiilou-e' |)roposes the use iif flasks contaiiiing solmion- of ( ii| ' u.itrr in v.'iii"Us stren;;t w hile v. (irazzi' siijr^rcsts the use of ah ili huiic sohitior of lienzoic acid as tests for the sense of smell. .\nosmia may he di\ iiled into two t;roups accordin;; lo ( )nodi." ( iim j:i<ui|i in which patholo<;ical chanjres occur in the oltactorv region, or els<' where some injury has occurreil In second irroiip where the lo» uf the s.'nse of smell is raiher to lie ;rferred in in.chanic.-d inter- ference with nasal respiration or to fum'iional disiurii.Ltrco I'h- se I Me<l. Tvischr. v. tk'iii'csi'k. So. 4, C*:* -' iMston Mu<1. aii'i Surg, s Ilfymsr.a llsn-'.!-- i !flr ^■..- •.s'l^i s ^•_. .•._ j,i,,i„.;...- p_t;- ■' (in/ctta (leKli '>^tN'<tHli, MiIhii. Niivt'iiiN'r tmc) {nn'eniix-r IHW. « ReiMirt cif thi' Thirtwtith IiitertiRtioiml Me'lioH! CoiiKre--*, Journal of I.< -VovfiuKT. law. nwl Jim,- JO. IM!I9 -rriT--.-rr ■*•. i «>il. Khin. aua Otiil.. AT. itht-r rent nil, SEi-noiit:s ot TUi. . o&£ Ayi> tun ,P,. „.n I .<H(>i full ..r tnir aiiOHT .ia. whi*'!. nuiy ||„. ,„..>t fp ...lt..u.^H ..^^^ ^i„|B,.,H,. in alc.hul. t.'lmr. l>tli -tfti i.jurvtnth.tifthiimT „.,-... ,..i Tn-sili»n n-jM.rts ii c•ll^«' "■ \ ,iiim ^^"iiiiin. l\Tnty--«(. >■-■•••'-•'' iiKin-. riu" pU-, HP' >ll To fhosf t>v>UTi inu ., lit <-:tuw M.Tur II. lalx- irnui th< ' iiiorpliiiif. foil' Aiiiilt*"' '"■ Ciic.iiiK uiiosiiiia iiiis I ' 'ii ..imsinia followiin: :i full n » f,.r , v.-ir ,„.. in wl.-.M tl ns<< or s„h.11 wa~ .1... i.t for a >(ar ;,:„■„, p,,w.-rful:Mtis,.,.f..-.th.- ?>"■■"'■ "i-'Zi'-naoi ,i„loKicu; ! 'l« !- i'« (K-cttJ'.-ifUijai *ini ..(lllf'il. Tf •«'!<«'<'( HI l.y :itresiii 'I'viati iinMii^'rariP, p< Ivj". Br ptoBM. Th« ' <,ii<<- -.1 the >«'5,-^' . (ulor, Ii- ' iacli. -. von Prognosis. Tli' |ii aiiratio: '>f t!" o-i .•iiral)lt' !t it li ;i case of ''■'' :• Treatn In'' 11,, hyst. 11 il Stii IV ■u incur,, ■!' S' !sU ii:i- ' mucosa, at a] ii.ai Parosmia anon ; v. "'■ uTI'i'.ilii' oil' ,.;ii 'I i' CI the -inuniR r ol)!<t lis of ' ■ ■if ' !iiptorii> , smell, uip. etc. •lO.-lS licp' Mr t ■nosm •struct ka-n lie IVC fi ■ptll" am-: ■'1! I Wl ;yi ■ rtri MMII! v lMMM-ca.'<ioii<'(l t the mucous or partial ai>- .1 a .iisMKreeahle mil the 1 W m- re{K>rts , , '■ ca\ cSv ""' •irs. !'<■«• i.\i- :iiii_\ years. fi ■ shiniKl Ix' reino il. I*'"!" , ises Mu^'<'stioii. The t a 1.1 'tic cases trvchnine haw Im'cii appl.*'il to the .1" the jialvaiiic current have Ix-en rversjoii occa-iona fferinjr ,u i>ri if bin 1 sul)tect Miiells o<lo! lOll-litMHlS, tlie |HM '■ ithers ! il th'' 'X*" i^TKsnua il 'he totli^i ..ll: s w , i-Oll cry I' s iiotii ipiiiiilaii auell the substitution "I' one odor for |,eo.iorsui)stitut<Ml iH'it - usually a (lis;' to jH-rverted condition^ in the ey tt\ folors .substituted for sombre ones nies tinnitus, while the iiarosnnc ,., heaven," and, as in th<' fi.nnrr I ,mlv bv the individual sutliTcr— ,„„.„„„ |„f it would not be parosmia. <.:usioned bv .l.-cay.-d teeth, decay.d matter .lisease of the accessory sinuses, atlections ol n;:or le of these may be present. Noquet reconls ,; ,„ ,„l.,r .,f decayed animal matter followed an at a k X,„ ... the insane and in epileptics, p- -ma ,s o tre.,u..nt , ; \. ,... t-reatest sufferers are um -e wh.. have hys- ,, li.^;,,,,;, h' ■' ase of this latfr varL'ty under the writer s He. KH„ W,.l,e,. ...««. =Kev.h.b.,om.deLur>'n«o..,Dec.»ber9.,H99. Zl.., urxn . Mu -I., 1-eccmber, 1««. . B.x,k.ert Ann. de 1« *k.. .1. 1. Med .le 0»nd. 3 h^«-., im Soc (Vntrali-.le M.^lechic du Nord.. Dcc-mberi). l".*. ::,V b cryp' 1040 SOSE AyD THROAT. !! care, a yotuig man insisted on the jjresence of a vile odor whieh ema- nated fioni his nose. Although the writer could never iletect it, tlie patient insisted tiiat liis employer did, not from .•mything the latter ever said, i)Ut "the way he looked at him.' The constant fear of beiriK diseharfied because his presence had become unlwarable, and the dread of beinj; shunned by his a.s.sociates, made him constantly miserabh' and a most unhappy individual. \Vhei\ parosmia accomjjanies or follows anosmia, as occasionally hai)pens, after inHuenza, Myers' having recently reported such a ca,«<e, the i)rognosis is apt to i)e good. Treatment consists in diligent search for and removal of the cause. Anssl!iesia is »'omi)aratively rare, usually one-sided and a.ssociated with hysteria. In partial central or peripheral paralysis of the tri- geminus it is of more freiiuent occurrence. If the trigeminal paralysis is complete there is. in addition, a loss of sensation in the external portion of the nose. Ana-sthesia is indicated by the aiisence of sen.«a- tion either to vapors or touch; sneezing is not occiUiioned by irritants, nor is there any overHow of lacrymation. Hyperaesthesia is conunon, variable in individuals, some suffering with the slightest touch, .{emedies that soothe mo.st individuals aggravate these. Thus the application of the suprarenal extract, of menthol, and of cocaine, that ordinarily give great relief, is followed by pain, sneezing, hypersecntion, excessive lacrymation, headache, aiid insomnia. Tlu>re are no means of being forewarned as to these idiosyner.'isies. Hypera'sthesia is common during pregnancy. Korn' has recently reported a case of unusually severe symjitoms. With- out any recognized cau.«e, a woman in the last month of her third jiregnancy was affected with .severe and almost incessant convulsive sneezing, which lasted for four days in spite of the use of morphine, chloroform, amy! nitrite, bromine, and trional. Ihiring the en.suing five days there was but trifling abatement : but then labor pains set in and spontaneous delivery occurred. The (jiiantity of li(|uor anmii was verv larg(>. .After parturition the woman snee;ed no more. Ball' in a study of 112 ca.<es found one-half of thi-m due to asthma, evenly distributed between males and females between the .nges of twentv and forty years. Hypera-sthesia shows itself principally in jjaroxysmal sneezing, and inav become excessively annoying by its contimiance. In its mildest form •• is occasioned by exposure to bright sunlight or particles of dust and the pollen of plants. Certain drugs jiroduce it in susceptible individuals. When n urcurs at certain se!i.<ons of the vcar it is known as "rose cold." The mucous membrane is apt to be engorged or o'di-matous during the attack, :iiid sometimes exfoliation takes place. In addition to the general symptoms of obstruction, as occurs in acute rhinitis, there is much depression, without, however, any aoconipanying ri.se in imiperature. I I^rytiKiwnii*. M»y. 191(1. ' FmueDaril, No. 12, 1900. • London Lancet. February li, 18», SEl-UOSES OF THE SOUK ASD TUIWAT. 1041 Tho internal adn.inistratiun ^\:^f^J^:;j:^;:S::::' ^ ,.,,:.a.n,a.anaU..:i.;^^aa,>p.^-^^^^^^ l.„v...l l.v menthol in a -> J J 4,,,,,i ,,,.,,,,.,, ti..n.-.l in ..r.Irr t..l.e ^-^^y^^l^^^'';^^'lfZ^l:^... .,f th.. ,ati..nt in pvnis (ondciniKMl. It lint aiKi. f„rincr (•(.nditums of nli"f f- =' f''^^„'"'''"'"^;;,;:;;,l :n'V';:i.«- 1-bit „.ayn.aaily '"' '"'""■'' '• i, nVa thuroud.tv efficient snl.st.tute without ,.xtraet an.l its jn-epa ations a ' "f; • , ,.,.,..^., „f ,u,, supiarenals i,s aanjiers. It was u. euni.eet.o ^^ " 1 ' . ;,- ,,„. ,,,^,,,1, „f this i„ these nialaaie^ that the wn .- ;•';„,;! ,,,' i, ^ relief following „„,a..t n..ver seivea anotl... P- ■" ^ ; ,^^ 4u,a,le aaai.ion i„ ,.se in these '-"'b'!:'"- '^;;;, ;;!:';* .^H.-atioi. of the ,ah a,,..- ;:;ri'i:;,;;:':;;s;;iveaJ":::rt;; nasal i.iii..n^^^^ liv ,.un. of the hypenesthetie '•';;;; ''; j' ;;. ^„„„. ,.,,„„(„ ,„naition. such ■ Paresthesia is usually asM..-iat ' ^ ' ■; .,, ,,i,„^,,, ,tc. -;;-;:;:;:t;:;r;;rs'j:ri";:;ltch!;:r'^^ ,,.,„.,. except 1" eoiiiiectimi witli la< '•'"'',*'. , | f ^vini.toin beinc the alletfeo iiui>""'.' _ , , ,„ove/' has recently_rec.n-.l.-u si.ch_a c:iM^. i>vc/, iiii.-.n< .■ - . ..,.^„ii, wanci'ited with other forms Paralysis of the le.aWr a^.s leivdl ; ^-'^.„,i„^, ,, the of facial paralysis. It o(( us .ui > •<- ^^,. „,,, ,,.^..jt„r ,„„scles an.l laxness of th." oth. "^^^ ' ' . ,, jj,.,„.rallv in the „f „,e highly ...Hirotic, ='•'=••'•' ';;,^'>',,^ ";.onhnarv purposes, ma!.-. There is to a 1 •MM-a' ; ''1 '..^ ''^.f j, requirea, that no '-' the iiulivuhKil '-';;;; V;^;:^';U le can h.il some synipa- ,„„- snITers as he .loev. and is '' 1 '^ • f ^^,„. jje soon b.-comes £;;v;;sr;;:;:t,™i,.«;;S-.'-.M-i ,* ui,.„... ..c of ih.' ihinologisi unhappy. ^trvchn•ne and bromides uiv the indications for treatment. Disturbances of Secretion. 1 Fn^e M.Hllcale, January ii, 1S»9. . Auu. d« M»l. ae lor., etc P"!.. July, 1S»9. (i6 1042 Snsi: AM) Til HO AT. tlic titlicr pliciioiiiciia, diarrlid'a, iiii)ir:iiii<'. I'tc. \itkiii' rofjanls most cases (if liydnirrlid'a to In- due to i)ar('sis of the vasomotor nerves of tlic nasal iimcosa. often reflex, as from adenoids. Anioiij; tlie eaiises cold, winter weather, excessive lacryniation, and emotional ex- ari citeinent. errors in diet, uric acida-mia, and dialu'tes. Kyle lias cm- lected 11 cases, to wliicii Abate" has added another. .M'ter the atfeetion has histed for .-cnie time the mucous menihrane appears sonjiy: in the early part of the afTection there is no visihle The clianpe. 1 lie discharge may 1m' one-.-'ided, hut is usually bilateral. It may ajipear with rejiularity at c(>rtain hours, usually in the inorninfi, and not occur for the remainder of the day. The condition is to he <lit1'erentiated from cerehro-spinal rhiiiorrhiea, and will be considered under the headin<: of the latter atTeclion. The prognosis is flood, deiiemlinft entirely on the cause. Treatment. Treatment consists in the internal administration of atropine for the hypersecretion, and strychnine for the vasodilators; massaf;e of the nasal mucosa, the application of solutions of protarf;ol. Insulllation of dryinj: |)owders, .-is zinc jireparations, to which tnenthol or boric acid has been ailded, have their value in appropriate cases where no discernible cause exists. The mal.ari.al, rh<'umatic, and litluemic causes neeil proper treatment, and the errors of diet cor- rected. Cerebro-spinal Rhinorrhoea, I lie siiontaneousdiscliar-ie of cerebro- spinal tluid from the nose is of infre<iuent occurrence. St. Clair Thomson' has collected a number of c;uses in a recent monojtra|)h, and T. Fisher,' Schep|M'jirell,' Ilektoen," and I'reudenthar have each re- ported a case. That of Fisher occurred in a boy of four years of ajr<'. Hektoeirs case is interestinji in that what apjieared to be a polyp was removed from the nose, but proved to ho a portion of a meninpi- c ' ■. Cerebral fluid escaped from th^ opening. This condition is due to an oversecretion of arachnoid fluitl finding its way down throufth the jierineural sheaths of the olfactory nerves. Increased cerebral pressure is always present: retinal changes occur with fre(|uency. The :iin('!'it of fluid which escapes varies. It has been known to nacli ;J(M)(» c.c. in twenty-four hours. It ll.^s an alkaline reaction, an averape sjiecific gravity of KKKi, contains cll-irides, albumin, and at times phosphates and sulphur .salts identical with cerebro-spinal fluiil. .Mental depression and headaches usually jirc-exist; dizziness and one-sided anosmia arc apt to occur, the heail symptoms cciusiiig when the flow begins. The latter is constant and one-sided. An early 1 Jnurn»l Uryn., Rhiii., Biid Olol., July, )«99. t Bolletinn dflle Malntl del Orecchio, November, IDOO. • I^rynr^K-ope. Niivomher. 1R9H. < Britiih Medical Journal. November 1«, 1889. » Journal .\merican Medical AiwKisllon, Febniary Jfi, 188H. ■ Indiana MiHllcal Jnurnal, Febniary, ItWIi ' New York Medical Journal, March 31, IWW. SEl-ROSES (IF THE SOSE A.\D THROAT. 1U43 .liHjit.usis is ..sscilial in ov.I.t tl.at w may prevent nH-nmReal aff. c- t tl.rouKh tlu- n..s.>. Tl... .•l..Mni<-ai -xan.n.at...n of tl..; flvn.l. .is !.;,;" t!'n''yan.l .m.-si.lo.l flow will help f. .litT.-r..nt.ate ,t lrun> nasal liyiinin-iiu'a. Treatment is of no avail. ^ i- i i . ,i,,. Reflex nasal cough ...•<-iirs in a largo porn'ntagr of m.livi.hials on tli. introduction of applications f. the nmeosa wi.ere .Ms oecas.,.n...l l.v patlu.lofrieal cl.anK.'s. Tlu'se latter shoul.l 1«' "1'"' ■''■'' •^,..,,. • Sternutation, llxeessive snee7,Hm nuiy .<• aequ.re, or "•>'«• ".■'^ It mav !..■ oeeasione.1 l.v .lisease ..f the hrau. or nu-.luiia. of syphilitic ..ligiiM.r not. and in c<Ttain conditions of the insane. NEUROSES OF THE PHARYNX. The posterior nares is the most sensitive portion of the pharynx. ■n„. uvula is not at all .^ensitiv.- to warmth, ass.-en m iarynposcim- ""it'Si^llio;; of the pharynx may l.<. totally or partially -liminished. ind tliis is tei'ined — . i r^ i- i Anesthesia of the Pharynx. It occurs most frequently after d.ph- ,l„.,ia an.l severe infiaininatory disturbance m the pharynx: it max ,l.u he issociated with cpiln'-^y, gummatous tumors miiltiph- sclen.sis, ■ nd pseudol.ull.ar paraly.sis. It may occur at the nu-nopause in ! .l,.,i dvsenterv. md .liahetes, an.l f..llowing tlu- use of nu.rph.ne. ;.;;;.ai!;; Inenthol.ethyl chh.ri.le. c'tc. It may l..' one-,<.ded or bilateral. "''i;t;: the'hllmix ..my is involved and the cause a min..r one. the prognosis is US. Where the larynx is invo ve.l there is im.n.non anger to life from choking, or tl,.' ....tranc' of sukiI particles of food ilito the bronchi may result in cat.arrhal bronchitis ..r pneumonia, ■md here 'Vc I.rognosis is bad. ... i • * There is .. t.ibe numbiu'ss in the pharynx, the principal complaint |„.i„g a cough .luring every act ..f .leglutiti..n. Hu.ds are swalL.we.l s l.!!vi\-. aii.l ofttinu-s the subject has learn.-.l t.. swall.-w in the i.rone '"h1r.lni.(M,tnH.stiinp.>rtancethatf..o<lsshoul.niecarefullyselecte.l, ..s... iallv where the larynx is involve.l. The •"<•"♦'';'-"'''?;;;''"- ..ughlv cl.>ane.l an.l all i.articl.-s ,.f f..(.d rem..ve<l after f.- .lug f th .es..phageal b..ugie is us.d, talking shouhl be enc..urag.Ml an.l the spirati..,, ?h..ul.l IH. watche.1 when the tube -^-^'^-'^f;^;:'^^;;^ \. n.,ur.-.l in. The writer saw a case of ana-sthesia of the i.harynx an.'l .'piglottis in which raw oysten* weiv partaken. An oyster entered ,h,. larx^x. .-i".! although but a few minutes elapscUH-foro ^^^-'^^^^ p.,^,. life - ^ -tinct: all efforts t. resuscitate fai e.l. In .simple c'.Lse^ the f '.'..i. • urront and strychnine given internally will beneht. Hyper** -^« . of the Pharynx. Excessive sensibility of the nharv^ix maN e due to the inhibit!..!. ..f . xcessively not f.-ods. chew- ing ,,f t..baeco, excessive use of alcohol, nasal obstruction causing 1044 Sd.Si: AM) Til no AT. iiinutli-lm-iitliinj.'. coiigcstioii, the result uf venous stasis. It ()rpurs ill valvular I'lirt disease, in hysteria, ami in nieiiinfiitis. It is asso- ciated witli Main radiatiiij: to both ears, nausea, and vomitinfj. Tl le ]i.:ili 1> - Uaritv ipK'tnnes verv severe uiteriMittent, and inav assume a MHO tidiaii or tertian. Kxcept when due to loeai the regular! irritants, '''.eri' is no <'onjiestion present. It is very iniportant that the cause should he carefully soujiht, and it should he (litTereiitiated from rheumatism and syphilis. A rheu- matic history will aid materially for the former condition: hut a specific hist(>ry is not so readily obtained, not so much because of untruthfulness on the part of ih<' patient, but because pharynjreal inliltrations are aTuoiif; the very late evidences of the disease, and often the |)atient is entirely un;iware of the i)resence of sy|)liilis. This is ('specially the case in late hereditary syi)hiiis, seen now and th-n. The author was recently called upon to treat a laily who had been under the care of a collea^jue for nervous sore-throat, and all the anodynes <:iven had no elTect. .V very careful pharynfjeal exani- i'lation siiowed two bands on either side of the jjosterior pharyngeal wall, well hidden by the anteri< r pillars. These bamls were putty and of a dark-red color— there v is no destruction of tissue — they ^ieemed to present the picture of fruminatous inliltrations and large doses of iodide and mercurial inunctions cured her in a week. It was subsequently ascertaine.i that a sister and a brother of the patient had evidences of here<litary sy])hilis. Where hypera-sthesia is intermittent (luinine administered internally is of value. The cause asci'rtained, recovery follows its removal. It is especially (wential that cocaine .should not be use.l here. Its cfTect is too eva""scent, and it is withal too dangerous a drug to use. Paresthesia ot the Pharynx. .\ perverted sensation of the jiharynx is rare, per sr. It occurs in the climacteric jieriod. in hysteria, and liyiMichoiidria, following the use of cocaine, menthol, and chloral, and subsequent to the swallowing of fori'ign bodies. There is com- lilaint of tlie jiresence of a thread, a hair, or foreign body, or a sen- sation of sticking and burning. These affections occurring largely in the neurotic, their fears become greatly magnified and their imagina- tions lead them to expect th<' worst, .\lnio-t the hrst (|uestion is whether they have cancer or tuberculosis. Sometimes the affe<'tion appears very suddenly, jierhaps even during deghititi.m. and th('n a foreign bodv is at once si,,'poseil by them to have lodged. I'atient .vearcii fails to reveal any foreign l»idy. A rheumatic history is negati%ed. The prognosis is good, except, perhaps, in the ])urely hysterical. In these suggestion hiis l)een of value. A case occurred in one of our clinics- the iiatient insisted that an orange-pit had lodged a f.>rtnight previous to his visit He stated that he had seen several ])hysicians who could not find it, and he knew it was there, because he felt it. A most exhaustive examination under cocaine aiuesthesia failed to find it, and he was asked to come the next day for a further yEUROSES OF THE SoSE ASD THIIOAT. 1045 ;:;:;:;;;j;:,i"'"'n::a Ji>;''::."i^» , .-.-"i. "™" <•• "■"■"■■ Motor Disturbances. i.inLr!,, >■ i.. "k. or l.l„wmc .,..1 a lisht I.T„n,.-« n.,|«.»-il.l.-. ,,„„„„„„,, liko 0,,™,... U-.;, . ■"':,;; ,'^„. ';„.■ ri„. to i,.l-n.r i„ il„,„. wh<i tear l'>'lf"l''"\'VV\";fl' ;f«aloroauso»viol...it rir^,"a,"3^'«--""'^**-"-'' -'■'- Clonic spasm occurs occasionally. *^™ .', 'Ti'^v^x in a woman, ;;;!;;;!„r,rotrflr',;f';i:':..rl.'ne »»>, ,ha, ..o,„a,i„„ ., . jo„m.lof Lan-ngul • "bU.ul., .ndOU.1., M»rch,1901. « ijirjrngoKCDpe. June 1898. ■«■ ■STSBIff 1046 NOSE A.\D THROAT. to tlif cause is idle. Lamhcrt I.jk k rcpuitiMl tlic case <if a fciiialf, aped nineteen years, who complained of i)lile}tin in liei- liiroat. llxani- inatioii sliowed a rajiid Iwilcliiiifi of the posterior pharynjieal wall, whicli seemed to i)e rapidly jeiked to tjie left side and tiieii relaxed. The niovemi-nts were rapid and unceasitifr, l'><( to the minute, and not (juite regular in extent or time. They resemhied nystajimus, and were (juite ditfereiit from choreic movements. The superior anil middle constrictors .seei> d to he alTecteil, hut not the i)alatal mus- cles. The affection remained constant for two months. He w;us able to find ei<;lit cases in the literalure. lie helieves the afl'ection to 1)1' due to fjross lesions of the central nervous system, cerehellar tumors, etc., or reflex, and apparently due to postnasal catarrh. In his own case treatment to le posterior nares was followed hy cessation of the movements. .Mcohol, mercury, and lead are j»iven as etiohjfjical factors. The enumer:ition of neuroses of the throat is not complete without mention of — Hysterical Dysphagia. This affection occurs more fre(|uently in women than in men, and may ajipear in children. It is l)est desttrihed a.s a |)artial or complete inai)ility to swallow, without known ])atho- lojlical causes, or, by reflex, from so trivial a cause that it iiiust be considered hyst.'rical iti origin. There is no pain in swallowinp, a sound passes readily, and the attack is usually sudden in on.set and not contimious. Solids are often swallowed better than li(juids. The prognosis is jjood iu* a rule. The treatment consists in rest of the parts, rectal alimentation, if necessary, antispasmodics, and removal of any exciting cause. NEUKOSES OF THE LARYNX. Sensory Neuroses. Hyperesthesia, excessive sensibility of the larynx, occurs in bron- chial asthma, hysteria, neurasthenia, from excessive smoking, in alcohol habitues, during menstruation, pregnancy, at the climacteric, and sometimes is an early symptom of tuberculosis. it is evidenced by paiti. visually unilateral and intermittent in character, sometimes very intense. It is very ])ersistent, and the tendency is toward recurrence. It occurs in both .se.xes in early and middle life. (Jottstein ref)orts a c;ise in which the pain on talking w;us so intense that i)honophobia existed. Treatment. Treatment should be constitutional and local. Cocaine should not !)(■ administered. The bromides, (|uinine, hot or cold applications as tiiey are best borne by the patient, sprays of the suprarenal extract, and menthol in li(iuid Vivseline, etc. Ansesthesia. Partial or complete loss of .sensibility of the larynx has the same etiological factors as tiiat of the i)harynx; both coexist, SEUHOSES OF THE MJilE AXD TURO.iT. 1047 occurs at till' inciioiiaiisc. S;a^:rT^. r:;;i ..0.% ...1. a...i ^,...0.. .^^^ ..n-^^y u~ ^'"N^iiSa of the larynx Iw.s l,<vn rccnlcl. It is rare. a.ul tl.c i.KlicS arc for auti-rhcu.uatic an.l aut.-ncuralpu. trcat.ucnt. Motor Neuroses. SDasm n.iv occur in the a.lult , as it .l.u's in chil.lron. It may attoct ,„v oM Tarvn^."ai nu.sdcs, an.l wl.on the al.luctors alone an : cc .1 tore i^ generally a paralysis ..f the mhluetors pn-sent. Ml 1 •'"'""! ,. i,„.,..i i,v the entrance of foo( into the larynx, nihala- •! 1 IrC hav> an esp,.cial tendency to attack, which pen.Talh :ur . ee te second uul s..enth years of life. It may also occin^ , 1, . ew V . n \-ariot an.l H.ulour' m.-ntion stru lor m newl,...n \ t. St-i n" roc..rds two cius<'s of congenital stnd..r. Strshel- ,L•^nrel;" three cases. \ ariot wa.s enahle.l to perf..rm an hitzk. pres. nth y"T<^ J^'*' , , j ^..^stant stri.lulous breathing. ;.v;ii!Sy t- ;.. ,;,;• .x-nic »,»..... ,1,,. ewi<.t.i» -h,* >,» .„.. t.'tanus. d<>ntition, larp <nui i.u digestive d sturbance.*, in the mucous membrane of the air passages, uip.. um f,,rtt,,>r . 1. pvcessive crying lymphoi.l hvpertrophi.'s, etc., are furth r '■ nf this VfTec^l n Cer ain ehildren have predisposition t.j S;;:;:L tt;.HSSten.lencies. while age sex. g^^^^ unsanitary surroun.lings n.ay be causal factors^ ^^^'^ ^^I'f ^^^ ,, cas.- of a chil.l in whom the spa-sm wivs due to a thromoosu l,.n(litu<linal sinus. ^ ,. ^ts a I Presse Miillcale, Novenitwr 7, 1900. > Mwl. .>bvs., Augunl, VMM. » Canada lAUCet. July, 1901. s Klinlorh., No. is. OM- * Hcyinanirs Hamlbuch der Laryn., I, 7, lit97. ... ..:.:-Lk.JJi. . I ll-ili 1048 NOSK ASD THROW. t" a child witli i)!ii)illoin!if!i. (i;iii};ti<)fiu'r' fdiiiid til ca^cs of inaikcil tftaiiy recorded in 10") <'ases, and lie cniirlndes that tlie association of siKu^m and tetany is tlie rule. liaRiii-ki- mentions enlargement of tile tliymus as an etiological factor. Ill mild cases tiiere is, without pre-existeiice of laryngeal symptoms, a sudden attack of loiignlrawn ins])iration distinctly heard in the room: after a few such inspir.ations there is complete subsidence. In severer c;i.ses tin' attacks always ap|M'ar suddenly; respirations liecomc more and more severe; there is a g.aspiiig for breath: an anxious expression, and even cyanosis, with evident sutTering. Tlie head is ba'hed in perspiration, eyeballs turned up, and ahe nasi widely distended. In -itill -ieverer c;i.ses there is tonic spasm of the extremi- ties, loss of consciousness, and cardiac weakness, death following either from such weakness or from sutTocation. The attack usually exhausts itself; there is a loiig-ilrawn inspira- tion with a crowing sound, .a longer jieriod of rest, followed by less noisy and olistructive inspirations, the color returns, the piils(' be- comes stronger, .•nid the attack is over for the time being. In some instances there is no recurrence, but usually there are recurrences. The suddenness of onset, absence of temperature, aii<l the result of i)acteriol;)gical examination make the <litTereiitial diagnosis fro n dijihtheria not so dillicult. From a catarrhal laryngitis or a foreign body in the larynx the diagnosis is not so ea.sy. In one case the writei'' records that of a child in whom tracheotomy reveale(l a foreign body on a lino with the true vocal cords, which w;i,s only suspecte(l before operation. I'nless the attack is due to direct cerebral irritation, the prognosis is generally good. .M. .MacKenzie claims that the greater the interval betwe(>n attacks, the better the prognosis. Death occurs either from asphyxia, from sufTocation, cardiac <'xliaustion, or cerebral compres- sion may occur from transudation between the cerebral membranes and in the ventricles. Treatment. Piioi'UVi.Acric. Rest, bromide of |)otassiuni internally, regulating the diet, small <|uantities of food at a time. The roouis should be well ventilated, the child ke])t out-of-doors in clear weather, and adenoids or tonsils, if present, should be removed. For the attack Holt advises the following: chlDral hyiln. ■i.O Kalli lirom . 3.0 Ammon. lirom., 2.0 \i\. I'iniiHiiiiim., fiJ.o-M. Sip. Tt'a'jpoonful every tweiity minnte* If not relieved. This dose for a child of seven years. F'rerichs gives: sig- Ert. hellHd., 0.27 I.I': .tmmon. ftnlut., 'l:ift \'\. ilist., l;i.o- Ten to twenty drops every three lumrs for the ftttnelc. ' Miini henermiHt. WiK'lieii-rh.. .Vo. 11. IMKi. ' New V.irit l=:yeHii<l Knr Itiliniiiiry Re|«Prt», 1-W. » Internat. CliniM, April, 1899. XEUIioSLS OF THE SUSK A SO THROAT. Iiilialatioiis of steal ,.|iil>l>'yftl iliiriiifi till' attiU tinii tkiiift liii ciiictu's, siiiapisnis an 1<»4!> all k. liotli Scvcstrf' anil Hi<'hanlifrc- iin'ii larviiKcal spiisins rciuiriiiK traclic-toiuv i>ri iitiibatioii. Hanitiski' tfiiiallv with lininiidcs ur iiius \'\n\v hv no lilt i)f rare occiir- "ivcs piiosplionis ill- ;.,^r:;Tiirri^:^^-ti-"i" i:^;;.;^..: ...yn... ..... V i. n-...rai in ori,in.\.. iu hysU-ria, chorea, an. 'j;'';^^^^. : for.ii there is some irritation ot the l.ranehes ol the red.rn.it V Sh an exeess of irritation to the -Mu-tor ,n^<^. Tetanus, hv.lrophol.ia, an.l tal.es are etmlopeal lact. is. It n.a> .,,, „!T^;, Sex t •<.... various orpuis, the intestinal traet, .ntra.ia> 1 i . J' -u. I the s.-xual apparatus. Brose' reports two eas.-s, one ; tt-'ealvlnoiia of the .ler en.l of 'l^" .-^pl^^-; -U-M ... ^Uiieh sul.se.iu.-ntlv .l.Avl..i.e.l tul.er.-..losis The ''''^'\^\''\ {' ; „„ „„„ ,f tui..'reular family hist.,., wl... poss..ss.-. a 1..^ .!> :,i,. temp.Tai.ient an.l wl... ha.l .•.■p.-at..,! .la.ly an.l n.flhtly a a ek. hrvnseal spasn. of sh.,rt .lurati.-n. Th.Te wen- no '"''•"^'■>=' I mih. th.' pharynx, larvnx. ..r pulmo..ary ajj.n.tus N.n • 'j-rn..;ir'i:t;:T;;ii;i;^ '; . .f a female' wh..s.. g!..tti.- spas,., seen.... to he ^^^^' ^^J^^ 1 ♦ :.i:.; • Mpr.mlie" reeor.ls a case ..I larvnceal spasm tiuiing r: inhS^ io..'I; eS.e" .;;;• t.. a co.i.pensaU.ry -nit-l stci-.i. Vn 1 n,av be plmnatory. .U'uh.titory. -r respiratory J he ,,;. .'k su Men in o is.'t an.l sh.iilar to th..se .KTurruiR .n ch.Ulr n, 1 , . 1 . .' . .lo not iK.w.'ver accompany the attack in a.lults. ^' Ti;:-li;;;;:it';: 'hiv m:;nmi 'tHe .ar>W.;sc..pe. The prognosis, ''^i:^^''^z:':^^:::^'^^ to have ..e ,^T^ his i.r..ath. a...l t.. hreatlu- rapi.lly -t i^ ^ :-;^,;;- ^ Mnrit- Schn.i.lt a.lvis.s pr.-ssure ..n the tip of the noM wl.il. tiio 'nS; i;.v!!!h'-s i'ci.lv. Chl..n.f..rn. inhalati...is or tracheotomy or ''oi;:;;:o£';ie'La;^:'''™s-mav occur in.lepon.le..tly. hut it is ..STL-Jde.! .^•h..n.a elsevv^here O.uuli' I-f- J - <;-' 1 if,,rm movments, h.-infl ..ppos.'-l to that of chorea of the larynx. ,1 ;;;uarmanif..sts it.elf by a constant barking noise, harassing to ti.c ir.tie'iit an.l to those about him. T i m nt: Tlu> treatm.mt is tl... san-^ :>.s applies to chorea e.se- vvlH-re: rest, arsenic, etc. The progn....s h geiL-rally P"«;l- Phonatory Spasm. An i,.co-or.li..ati..n .>f the n.uscles of the la > nx ,.l.;SSling. due to a .nore or less complete closure of the glottis, ,^,M,.„.,le.H.p.uu,,Mar.H,>.^. = „.j^. M«.. Fc...ar., ,^. • I— . J,„ir.ml American Medio*. AMocmtlon. June J2, 190.. s Jouma. iJiryn., Khin., an.l Oto... April, 1901. > New York Me.llcal Record. February S. 1900. ' Arch. f. Lar.. 1900, Bd, x. p. 82- 1050 KOSK ASD TUROAT. J'xista cither alono ()r with fuiictii)ii:il iii.-tpinitDry spasm (if the glottis. HcHex caiisfs must Ih- smigiit for ami rcmcilicd. Stammering. Few maladifH to wiiicii ticsh is hfir cause (|uitc a> much uiil\apiiiu:'s.s jis docs the stamiucrcr's iiiaiiihty to express jii.- thought. Froiu time immemorial noted men iiavc Ix'cii thus alfiictcil whose "iiervKU^ dread and sensitive sliame freeze the curn-nt of llieii speech; they stand impotent of words, travailing with unhorii thoughts." For some unknown rciuson their treatment has hitherto lieen prin- cipally left to the charlatan, who, hy some secri't method, tries to cure every case on a similar plan, and ignominiously fails. 'I"he treat- ment is logically that which the laryngologist only can indicate. Some writers have Ijiid stress on the great ditTerence existing hc- tw( Ml stuttering and stammering. It seems simplest to view stut- tering its the prodrome of stammering, ;is indicated by Makuen.' Among recent writers, Pluschowski' says that most defects of speech, and especially stianniering, belong to the curable neuroses. Ilolger Mygind' says that stammering nuist appear as thi' exjiressioii of a neurosis which is etiologically n-lated to the .so-called neuropathies of degeneration, to which diseases like epilep.sy, hysteria, neuras- thenia, chorea, and insanity belong. This relation is the stronger, as many of the latter di.seases are found in the family history of stammerers. The latter, too, have .some of the stigmata of tlie former, Staiiunering occurs at certain ages, in males from two to four years of :ige, and has this in common with hereditary neuropathies, that the occasional cau.ses are far behind the remote. This is not true in every case, for many stannnerers have no hereditary |)redis|H)sition. Stanmiering is tlie inco-ordination of the three mechanism.s of speech: the respiratory, the vocal, and the oral. In the medulla oblongata is located the centre which presides over the co-ordination of the movement concerned— the basal phonic centre — and the faulty mechatiism of one results in a faulty action of all. This co-ordination in the normal voice producti-in h;us been likened by Wyllie* to the pleasing tones produced on the violin with the bow-hand acting in pn ])er unison with the fingers of the other hand along the strings. K'lTidworth^ used the accordion tis his simile. In a report ( ii stannnering from the standpoint of military duty, Chervin ,>tM»'s that about KKM) :ire yearly declared unfit fcr duty in France Ix'cause of this alTection. Makuen' in a study of 200 ciuses found 17 p<'r cent, due to in- voluntary i!!iitation of others, 1.5 per cent, due to fright, 8 per cent, due to an injury, and |M'r cent, to having l)een ill-used at home. Fully 95 per cent, are males. It has never l)oen explained why I i'lilladeli lim Mediral Journnl. Miirch TO llOl. ' Rum. Arch. Patol., vol. vl., 1S98. » (-.•h.f, Ijir and llhliiiil, U.I. v,;i , 1-ojtt. « The Ifisonlers cif Speech, 1X94. ' .si ittcrinK: linw to Cure n. « Bulletin Mill , September ■.», 1H98. ' Th.'rapeutu ' iiiz' tie. .Seplemher . . - C IMiilaileiphia Molical Jourual, February i, 1901. .\EUi.u.ii:s OF THE vosf .i.vy> iiiHo.ir. 1051 I ; ^, : T n' nhliu^ urchin. k.-,.t in a .tat.- ..f terror, slum.. .' .V '.■ anxiHv fro.M tlu- very .un.tal -xiMTtan-y a...l t.ar s... i:;l.;;;s aconfirnuHl .ta.u.u.-n.r. wh.-n p-ntl- -n-asun. woui-l l.ax. "";;Iv'oi;!;tru..ti.,n to n-spiration m th- ,...«■ or i„ tlu- pharynx sl.oul. I ..n! : ;.;[ .on,u..-ti.- 'ut, an,l nu..-i..s -'.."rn^ surp.-a! .. tn.. -houM i..- can-a for. Th.- factor <T..at.nK thj; "-< '^ >•«•*"" -;':tl,!:;!;:;:"i" ;is;:':; >«"■ ™i"'": ■ ;-^ 'v !!:;.a w'th p.n,l,. n>ca.sun.s. following the*- U.ve., cures niay 1h' ''•'iiiSiii'VSoi'l^'k;;^' - -t- laryngoa ana laryngeal ..pU.T*rs of Stal oc-curronc. l.ut 1>>- no n. cans a nm; .-.js. . ;i.;;.,.l mla CoHet^ r,.c..ra ■->:i cases, while Chazalon.' 1-ayolle, ana th. '••^:l,l;S;;;];;:^:;;^i:^rge" ..una is auo to asthma. Tmy; .mil M 3 oun.l oxces.sive snioking rcs,M.asil)lo ana I'.TCop.ea \l'l^ o f lue to excessive smoking, the others to smoking ';;;,'1m> ro^.v"> th. a,usal n.ucosa. .\aier- re.H.rte.l a ca.se .lue t." l.l!;nga;..a \m.la. Hypertrophy ..f the lingual toml .nay act as =' ^;:r:.S r;^ia";:r:^--l in .nales between the '^ The ■vttacrb..gins with a tickling ir. he throat, causing cough, the fac bi..m.>s c.fngest...l, an.l the pat..-nt fa Is -TT^'Z^Z .. . _ J .1.. fr\m iau4 « Ann. «l<i« M»la<l. de fOr.. IfM. • I.yiin MM., 1S9«. 1 Spe«-ch and Its l)f fwts, 18«. " ThMe de I.yon. 1>W«. i I^nv«n«i MiVlieale. Augml 18, 1«». o i, iqnn . Anna,. d» Malad. de rorea^ e. '^-^'■■^;' "'^""^M^.auchr. f. Ohr«.h.. No. 9. .«9. 1 Journal Larj-n.. Rhln.. and Otol., April, ijui • Normandle Medical. February 1, 1K99. <" New York Medical Journal, February 12, V^V- ln.-)2 AVWA' AM' llHilt.lT. ri'iiu-iiilM'riiijr tin <"Ujjh ■■iily, but imi 'hi- lossof consridiisncHH. Wliilo the attack siiniilan- an f|iiii'|(tic .li.i'k, tlii-n' arc few, if any, iiui!«- ciilar spacms, tlic tongue i.s rmt hit ten, tlicrc is no snlisc<|ucnt naiisi*:}, no involuntary uiin:;tioii, imr .I'fccMtioii, ami no licadachc. Laryiiffcjil vcrtifjo (M'cuiv^ in advanccil y. .r- arnl is a'«MV' of short (lunition. riic prognosU is froiMJ. i'lu lr««tmAnt. ' •■• ixMJictl in tlu> t*(>ii:'«'h for aiiil removal 'f tlii' caii-e Larvitgeai Paralysis, Hypokinesis. Any injuiy to a part .>f the inoti i I tact of the larynx occasions |i;iralysis. Tliis may Iw functional or organii', o'l-sidei! or hiiatem' complete or incoin|ilet(', afl'cctinfi either phonator\' or respiratory liuctions, or both. To properly .-lopreciate the conditions here existing, it will 1h' Ixirne in mind that the external or small hr.-mch of the superior laryngeal ner\e .alone contains motor filaments, and these supply the crico- thyroid nniscle only, the other hranehes of the sii|M'rior laryngeal ni'rvi' iM'Uig exclusively eoniposed of sensory lilaments which supply the mucous membrane. The crico-tliyroid receives motor impulses also from *he (iharyngeal branch of the pneuniogastric. TIjc other internal laryngeal adductors, abductors, un<| teiisor-s ;ire supplied by the inferior or recurrent laryngeal nerye. The vagus, niiuiing from the jugular fonimen with the bloodvessels, dips into the thoracic cavity and gives o'V tiiC recurrent laryngeal, which winds around the arch of the aorta on the left, and tlu Mibcl.ayian artery on the right and returns to the larynx. ^I'late X.\ vll.) Regarding the ?uanner in which [laiaiysis actually opcurs, Semoii presented, in ISSl, the theory that in all progressive paralyses in organic disorders the abductors ire the first afTected. In all func- tional disorders the adductors iie ;iifecte(l practically alone. This occurred with such regularity that it miounted to a law, This view \v;is combated by many, notably by Kraii.se, and more recently by Clrossman. Mjuiy have since recanted from their oppcxsition. As each opponent presented his own views contrary to those of S<'rn()n, he promptly chall<'nged each and every one, stuniily defending his own views. The general consensus of opinio!) trwlay is in support of Semoii. DK-SiumiON (iK PLATE XXXII. ILLUSTRATIONS FOR LARYNGEAL PARALYSIS. (iCHNirjull.) Fio. I.— Pttralywi--* of twth t:»ynvar>*t«?noffJ nrnsclen Utttemi) Flo. *-'.— Pitmlywis of the ar>-tenoi'l mu.si:)e (tranj^vewiw). Flu. :t.— l'«™i>Msi)l hi)ih iliyro-iiiyteniihk-i Intenil ami iif ll.e trRnKTrnie. Fiii. 4.- I..ei>iii|ilf e repiim'iii [MmlyKis instil >|ik->li. n'niirHt.iiy position. (Paralysis of thecrlMv aryteiuililiin i-wlliin «n.l of the thym-arytsnoideiB Internum on tlie riKht side.) Fl'i. ■'>— Thi'Niiiie ill (ihoimtloii. Flo. ''.- INiralysis of ail aildiictora of hynterical ortKln. "■■-. " — T..!»! i...rn'y-':-..f !!ir :■- ■■•fvMi. riKhi sHni. T"::- ris-" "-ral r.-ni is !ixc<i .n ir.e \.*MhM ralli-' "cailaverif." In this lijfiiiv tho left normal v.kkI lord 1« ^vn I'xtenillng over Ihi median line to'vani the panilyail rij-ht cotd an.l the whole in the fiosltion <■' iihoiiaiioii Fio. S.-.-Iueoiin.lete tveiirreiit i«raly«li of hcHh «id<». (Pamiyils of both the ericoHirytenoldel poatlci ; puaiUci of reniiiratlou.) HLATK XXX I i i^ -i^...--:. U.JJ' W i .\Kntosi:s OF TJiE yosh: .i.v/> throat. 1053 Till- term " cadiivcrii' " jxisilh.ii used todcsiftiiatc the tixctl cord, i- really a iiiLsiioiiuT, Fein' having found ten different positions in the caiiaver. , , • ( )ne of the most fre<iuent of tlit eentnil Ciivuses of laryngeal paralysis is tabes dorsalis. Touelie= in a stmly of 40 tahetie patients found 12 witii laryngeal erises. Other causes are syringoniyelia, multiple xlerosis, cerehellar and bulbar lesions, and syphilis. Cases have |.,rn recorded in recent years due to foreign body in the larvnx, l)icnehocele, cancer of the (esoi)hagus, after measles, mediastinal liimors, influenza, aneurism of the aorta, typhoid fever, li'ad poison, pressure of enlarp'd glands, mental shock, primary laryngeal tuber- culosis, and overuse of the voice and of the telephone. Ofttinies the l.iryngeal lesion is the first evidence of an aneurism or beginninn tabes, and fre(|uently the cause is unknown. < )f the infectious diseases diph- Ihcria isthe niost frequent cause. Lead, copiMT.antimony, phosphorus, • iisenic, atropine, cocaine, or morphine may be factois in the causation. Recurrent Laryngeal i'aralysis. Hoth nerves may be affected, .lithough it is verv uncommon. The vocal cord a.ssumes the rigid position for v.liich"the term "cadaveric" has been api.lied In uni- lateral |)aralvsis aj)h(jnia is first present, but the normal cord .soon makes ji large excursion to its maimed fellow, and plionat ion becomes possible. Dvspncra is not pre.-ent, except when bilateral abductor jiaralysis exists. No amount of forced inspiration will mike the l)aiarvzed part move, and it is this fixation that is depended ui)()n for diagnosis. The narrow chink that is left in this form of affection is always the same, while in hysteria the opening is larger. Unilateral abductor paralysis occurs fre(iuently without dyspn-ra or dysphonia. Its presence is an indication fo** a careful search for the cause. In bilateral abductor paralysis the voice is jircsent, but the grave symptom is (Ivspiuea. Paralysis of both i)osterior crico-aryten(>id niuscles, if complete, j)laces the patient in innnediate diJiiger of d' ath by suffocation. Wright'' believes that the sudden deaths in cc.-ebral aJM.plexv might be exi)lained by the existence of this form of paralpis. Laryr.goscopic examination shows the cords to bo almost entirely approximated, a small slit fully existing between them. Tracheotomv is fre<|uently necessary, and some laryngologists con- .sider this the onlv Drocedure. Semon would leave it to the i)atient to decide to risk tlie danger of suffocation, or to wear a tracheotomy tube. N. L. Wilson' suggests intubation. Joachim." after trache- otomy. iMTformed a thvrotomv and removed both vocal C( rds. with restoration of function. J. S'olis (\)lien" says that if tracheotomy be refused by the patient he should be urged to always carry a tra- cheotomv tiibe with him to show his pliv>:"ian if the emergency arises; by this means lift- has bec-n saved in two or three instances. 1 Witn. Kiln. Wchn , V .«>, So 24. « f"""' Me.1.. August, l-<99, No. W. ' Amerii«n Text-book of Diseases of the Eye, E»r. Noee. ami Throat. < Lsryngoscope, September, 1900. '' ■''K'- ' ™'' 1().J4 XOSi: ASD THROAT. H Injections of hiclilorido of incrcurv liavc ln>fii Viiliiahlc wlion due to syphilis, (i. dcroiizi' Ixlicvcs tliat if tlif rcciincnt laryiiKral nerve coiiM he resected, if there is no Ik.jm. of restoration of'tlie function of tiie posterior crico-aryteiioid muscle, that the danger of sutTocation aould be avert( d. Paralysis of the Adductors of the Vocal Cords (Orico-arsrtennidei laterales). Milateral paralysis has its its chief etiolojjical factor liVstrMia. It is sudden in its onset, without symptoms of constitu- tional disturbances, save those of hysteria, its main symptom beinji aphonia, more or less complete. l.arynKo.M'o])ic examination .shows til.' cords far apart a.s in force<i inspiration and apparently iuuno- \ able. ( )ccasion;dIy luit one side is atTected. and a few such ca.ses are recorded. While hysteria is the main element, reflex cau.M's may exist. The ajihonia comes without warping and remains persistent at times. Semoi! believes that the large 't percentage of ca.ses of hvstericil aphonia may be cured at one Mliing, one of the electrodes being |)laced on the interarytenoid foMs. usin^ die faradic current. The application should be energetic and lasting ;ind the sitting contimied until till- voice has returned. Sugg"stion iias been f( Mowed by good results. The writer saw a cure result from an application of a cotton swab in a ca.se of over six months' duration. In another instance a young girl Wiis brought to me with the history of sudden lo.-<s of voice following an accidental fall. She travelled .several miles to come to my odice. :uid w;is well in every other way. Tiiere wjis so much pha.yngeid irritation that it wa.s deemed best to spray her pharynx with cocaiiw. .\s she saw the sjTay apparatus approach and |)oiiit !;t her. she gave a startled look 'iiid said in a loud voice, "Oh! my ( iod. What's that?" She was cured Wh. ti faradization is employed, it sliMuld not lie u.-ed too strmg, nor should we toy with it. Paralygig of the central abductor, the arytenoideus nniscle, occurs alone at times. Kxccpt for a triangular space po.steriorlv, the cords are in appo.sition in their entire length The ciiief symptom is aphonia and the cause hyste-ia. Paralysis of the superior laryngeal nerve, causing panilvsis of the extern.il tensor, tlie crico-thyroideus, and the internal teii.sor, the thyro-arytenoideus iiiternus. is of ran' occurrence. It mav be cau.^ed by traumatism or diphtheria, a. id n.iy be a.ssociated with pari'.ly.<is of the n'turrent branch, when it becomes a very dangero-is affection. Total ana-stl-.esia of the larynx mav be occa.sioned, and then there is need for great care as to the food administered. Paralysis of the thyro-arytenoidei muscles is of frequent oocur- reri< <■, .\ny infliuiiinatory process or overu.si" of the voice may occa- sifi!. it. Hoarseness ami aphoni.a to a mild degree e.xist. The laryn- gnscojiic examination shows an elliptical opening. The prognosis i-; good. Hest. iron to the laryn.x, and soothing applications result in complete recovery. I Kirorma MertlOJi, Palermo, .July 6, 1899. m CHAPTER XXIV. KXTKRNAL DKFOHMITIES OF THE NOSE; CLEFT PALATE. Bv F. K. HOPKINS, M.I). In- trcatiiiR tho suhjcct oi (Icfoniiily of the ix-so a i)r(>fap(> nii^lil well he written \'\»m 'i„rrnilio,i. s(^ larp- a pcrcciitap" of .l.-forimtirs i< (••iii-*c.l l)V (!isi)lac(Mn(>iit or fractuiv winch failed to reeeive proper ..ttentioi. at the time of the a.-eidetit. This ne<jiiKeiiee may l)e (Itie t,, lack of ;.!> .reciation of tlie daiiiafie done. Tiie swollen eotuhtion „r th<- nose sometimes renders it ditlieult to .ietermine the amount of disnlaeement or the iiltimat." interfen-nce with re.si.iratu.n: inore- ,,v.r the faet that an injurv to the nose does not usually imperil lit,. „or seriously impair the individual's .•armiiR capaeity alnmst unconsciously Ics'sens the importance attached to its treatnu'nt. The Mccident, howeyer, for seyeral reasons .lemaiu is most careful atten- tion and that early. Circulation in the nose is most actiye, and alter dispiacement from fracture tlu' fragments quickly and tirmly umte ill their yicious position, h-aviiif; i)ermanent deformity. The nos<. is .o prominent a feature, and its symmetry so laijte a factor m a p 'asiiig ^cial expn>ssion, that in ca.se of deforn.ity the patient is subject to ." decree of constant : tification which, apart from its suhjectiye side, amounts ... a taiiRihle handicap in the struggle for exi.st.Mice. This mental suffering is more acute, perhaps, iii women and children, •ind often is not amenal.le to any relief from philosophy, as the yictim .'ivitly exaggerates the effect of e\-en slight yariations from symmetry. N.,t onlv is it important to correct the external injury for \vhat may l„. called co.sinotic effect, but tho interior of the no.-e must r.Teiye ..ttention at the same time The .lisplacement of the septum causes ■ui occlusion of one or both fossa-, with c(.nse<(uent interference with nasal respiration. The proper reposition of the septum aids in ,se- .uring symmetry and stability for the injured organ, as w 1 as restores „„rmal respiration. !• ther aiuesthesia hould be resorted to if there i-; the least doubt as to whether the parts are properly replace.l, and, if the case is at all .serious, the use of an aiuvsthetic might well be recommended a.s a routine practice. Deformrties of th.' nose are ■ini.'naiile to satisfactory correction if seen early. Iracture (.1 the nasal bon.'s is often but a displacement along the lines ot articulation with each other an.l with the nasal process of the superior maxillary bone The ca.se of a friend, Dr. B., who sustained a "fracture ls here in point, furnishiiiR a typical case of displacement, and showing 1056 aoaa' a.w throat. with wliat case it iiiav hv corrccti'd. Tin- doctor is an enthusiastic h;i-si<fi-l)ali plavcr. aiid wiiiic iilayiri-; nrcivcd a iiravy blow upon tiic dorsinn of "the nose, displacinj; it bodily to tiit' rijiht. The acci- dent was attended by severe jiain and pidfuse l)iee.liMj;. In aiioiil an iiour rejiosition was ctVected by a confrere, tlie parts returninn to position with an andii>le click. Two hours after the accident he came to me to be assured that the deformity w:is reduced tir to have it corrected. Huth externally and intranasally tiie partN were in |)erfect position. No retention apparatus was rc(|uired. and tlie results are entirely satisfactory. The eise of maintainiiifi the parts in position was inferentially l)roup:lit out, in the discussion o>i fraclines of the r. se, by the .\nierican Laryn^'olofiica! .\ssociation at its nieetiu}; held in vVashiufiton in HMK). the paper w.is read l)y Dr. Di" Hlois,' and in di.^cussion it ap|)eared th:it nearly every speaker had a method of retention dilt'erin-; from all otiiers, yet all secured jjood results. This is one side of the sui),jei't, ami is encourafriufr, especially >ince the majority of cases of deformity of the nose are due to displacement or iraciure. If the general pr.-ictitiouer were imi>ressed with the importance of irivinjr e.iriy and sulficient attention to ca.ses of injury to the nose, ami undeist<ind th.ai j^ooil results may be obtained by the excrci.se of a little intiviiuitv and i)alience, there would U' fewer unsij;htlv noses. Treatment of Recent Fractures. Dr. Wrijrht' has recently ftiveii ;i hifrliiy interestinji revi<'w of ancient medicine, from which we learn that Hi])pocrates' knowledge of the treatment of fractures of the nose is well worth reviewins: by the modern rhinolop.st. He insists tijion the importance of thomufih replacement of the fragments .-ioon after thi' injury, and complains that me.ny |)atients are unwillinj; to endure the pain necessary to a correct reposition. We have the advantaj;<' of general aiiastliesia. and its use is to be recdnunended. I liave been more inclined to advise this since a recent experience with a medical man who sustained a coinjiound fracture of th<' nose. He demanded that ether Im' jriveii, and the greater control of tlie siluation which was thus secureil w;is highly satisfactory, and no <l(iubt contriliuted largely to the good result attained. The parts are resloreil to position liy combined internal and external mani|iu- lation. The finger, a h'.rge probe, tlie handle of a cotton-carrier serves well, or a pair of .Vdams fnrceps with hmg blades mav Ik used within the nose, .aided by the fingers externally. When the frag- ments .'ire rejilaced the jiarts are easily retaineil in position iiy means of an external appliance, nr intranasal splints, or a combination of both. Sometimes after perfect ri'jiositinn no retentive ajiparatus whatever i-^ necess.ary. Iiwleed, Swain.' Clark.* and othif< treat most cases witlKiut any form of splints. This ea.«e of retention is 1 'rransaotinns of tho AmiTii-nn l.ar.viiRcr!iigtc»l A«!«Ki»Uoii. IWX), y. 12, 2 |jiryiij5.i!i('.,pe. IWI. v.il. xi. y. HH. > Triiisaclliiiw ')r Ihf Aiiu-rii'an LaryiigolDuicul A«*>oiiili.iii. I'.KN), p VI. < Ibid. EXTEIISAL DEFORMITIES oE THE SOSE. 1057 .!,„. to tho fact that th<< iH.iu-s an- n..t .lisphu-.-.l by nmscula actio . -n,. .nusclcs atta.-lu-a to tl.o nasal bom's a.v t..o f.-ble tr aff.'ct 1 !ir I,.lac,..ncnt. a .nark.-.l contrast to con.l.t.ons pr-'vailinR n .„.,ur.>s ..f the oxtrenutics. Son,., n.o.hhrat.on of tl.c Asch l.ol bw vulcanite tube, ius Meyers or Me Kernons answers well, or Kyo s . ! a spli..t n,av iK.-use.l. Tlu- ri.ler splint .lev.se.l by Lo an. .« „ ingenious ami us..ful appliance. The a.-companynrg cut (1-ir : ".^ n.pr.-s..nts an a.laptation of this i.lea. A tnangular-shape.l piece of vulcanit.., with the un.ler surfa.'.' groov.'fl, an.l havinji an eve in the unt.'ri.-f .'xtreinity, tin-oufih which is passe.l a silk thr.-a.l, is i)lac.'.l in the upix'r part „f the nasal fossa-, an.l McKer- ii,,n's nuulitication .)f the Asch tube is inserte.1 beneath it. The riil.T splint is then drawn for- ward bv means of th.' silk thr.'ad. As it is .Iniwn forward the dor- sum of the nose is el.'vated, and when this is brought into the light line the thread is ti.'d i.cross the front of the tube, m Rider »pUiit above, vulouiile tube splint below. whi;^; g;K;;;rhave b.-en cut to receive it. Tins mak..s a firm !u rt ^l..ws of p.o.1 .Irainage, and p.-nnits n^u^al resp.ratum t :' ; V splhit is prop.>rly ma.l.>, t'-MM-Uan.-.- .s vv..rn wi h httle dis.-omfort an.l can rea.lilv be rcM ,ov.-.l for d.-ans ng. h an external ; is uil (Vs<'lb,.rr;- n'con.'n.'n.ls that it b.- maoe of phuster- . uiit is »••" l'^ , ,,^\.....\.^ .1,1. f„ssa' witli anti.s.-i)tic gauze, using ; i ^", ; i ;; n I's L; ' t. .-x eLl spun, Shurley= a.lvises gutta- ;;,.'" u^^s n.etal. tin. cop,.r. or aluminum for the same ;",;.. He shows a n.-atly moul.led splint .,f s.uall sue, h.-ld in ph. , ..Ih.'siv.- plas,..r arouiul th Iges only. In had cas.-s it will b. L' rv forVl .■ pati.M,l to w..ars..m,- part of the retentive appliance, 1,; i^ te a .. .•x..-rnal, for a ,..-rio.l .-f fro", tw., to hve .,r six i. The intranasal splint should not b.- re.nov.l nn.l.-r for^>- :;^\.Z. aft..r which i is taken .u.t at '■"■ -f ' ^T;^,;;; ;. needs uf each ca.se. for st.-rilizing and t.. penmt of cbaiiMn^ tlu lusal '"SE brief consi.l.Ta,ion of fractures of the nose is P<'"nane t.. 'he sul.iec, of ,n.at.i..-nt ot deluinnty of th.. n..s.>. sm.-.. •-"^<; "f/ '"^ ^^ riples of treatment are similar, but .■hi.'fly. p..rhaps, as a i.l.-a for , T™n««oU.„,, ,.. "•;;^- :,::>^^r "" 'TI:";;™:™:.!: .i^«r,er.y, >««, vol. .. p. «. • iJiseasesof Nose aim inroat, IW"'. P- <'-^ 1058 XOSK AXn THROAT. greater care in cases of recent fracture — a jirophylaxis against de- fortnity. Prevention is i)etter tlian cure. Deformities of the nose requiring |)la.st<c surgery for their correction belong ratiier to the general surgeon. Uhinologists are, however, treating every other ileforniity of this organ, and jjroperly, as intran;usal conditions as well as the external form require attention. Of cla.s.sifications of these deformities, that of Roe is the best. This author has written extensively upon the subject, and hius made all other workers his debtors, not only by his surgical achievements, but by his pertinent suggestions. His classification is as follows: "From a surgical |M)int of view, nasal deformities may pn)|H?rly be divided into the deform- ities which affect the bony portion of the no.se, and the deformities whicli affect the cartilaginous jxirtion. Deformities of the bony por- tion may be subdivideil into vertical, that is, those which distort the dorsal profile, in which the dorsal line is too convex or too concave; and lateral, that is, those which, when viewed from the front, present unusual deviation from the normal contour, whereby the bony portion may be either spatulated or <lcflected. Deformities of the cartilag- inous ixirtion may be subdivided into those which affect the tip of the no.se, whether excessive or defective in the amount of tissue, or distorted from its normal direction, and tho.se which affect the wings of the nose, which may be either collapsed or abnormally expanded." Convex vertical deformity or exaggerated Roman nose is, with rare exceptions, congenital. Concave vertical deformity is a lowering or depression of the bridge of the nose. This is usually the result of violence from b..iws or falls, the deformity remaining as an evidence of imijrojjcr or no treatment of a dislocation or fracture. It may be due to a lack of development of this part of the nose. It may also be due to loss of the supporting framework of the no.se by diseiLse. Syphilitic destruction is the most common cause of this lo.ss of ti.<sue. A de|)ression of the cartilaginous portion .sometimes follows abscess of the .septum. The concave deformity may be exaggerated by excessive development of the end of the nose, or there may be jippar- ent depression when the nasal bones and triangular cartilage are normal, in which case concavity is entirely due to abnormal develop- ment of the end of the nose. The broadened nose is usually a.^.so- ciated with the concave deformity, the na.«al bones bulging outward. This and the lateral deformity conunonly result from neglected frac- ture. Collapse of the ahe of the no.se may be due to failure in devel- opment. The ahe are sometimes especially narrow in subjects who have been mouth-breathers from infancy. They may also be held down by cicatricial contraction following injin'ies or specific ulcera- tion. Kx])ansion or sjin-ading of the ahe is usually of congenital origin. A wide dilatation is sometimes caused by intrana.sal growths, as myxomata. I have seen one ea.^e where a considerable degree of this expansion .seemed to be due to mu.*cular effort. The na.sal foss;e were narrowed by thickening and deformity following abscess of the sej)tum. In the conscious or unconscious effort to secure more air EXTEHSAL DEEORMITIEU OF THE SOSE. 1U5» 11... (lilatorrs nsisi iK-oino markedly .loveloiH^d, expanding the al:^ Tl,.' resultant inerea.se in the width of the nose exaggerated the de- fonnitv due to the iibseess. . should not be in.pUcd from the acceptance of this eliis«'f>cat on ,1, every ca.e of deformity falls clearly m one or another of the va eti.>s named, or that a single operation mil correct ne ent re iJfor nity. Individual ca.ses present all sorts of combmatmns, and I u'h must 1« studied by it.self . Sonie due to mjury simply n>.,u.re a r turn to former fM.sition an.l contour, others rc.iuire a reduc-tu.n, iis e "agg.>rate,l Roman nose; ..thers still, as the sa.l.lle-baek, nmst he tilled in. Taking up, in order, the principal classes of .l.'form.ty, convex vertical deformity ha.s been treated by Roe with resu s tlmt h"iv,> nothing to be .lesired. H.> operates subcutane.nis y but us de- ^^Itlon of t^e teehniMue is not suftieiently clear ^ «- f ! -; 'j;;'^:; and carried out the following iugemoas metho.l, we 1 dcM-nbed in lus ^oJt of a ca.se: "The patient was etheriml and placed in the Rose o Uion A irnir of short curved sci.ssors, with the convexity upper- ot was introduce.1 into the left na.sal vestibule. One blade was aU^t? penetrate the triangular cartilage at its anterior ex- tmnitv immediately iK-neath the integument, and a cut wa-s made ■il.,ng the su|.erior margin of both cartilaginous and bony sep i, ter- ming at the junction of the perpendicular plae of the ethm.nd ' lu cribriform plate. The superior margin of the septum ^^^s us eparated from the integun.ent and from the "'^>;.;'l 1-";;%'^ ^, incision, the outline of which wa.s essentially paralle with the L^^^^^ of the bridge of the nos,-. The extrem.t.es of this : fXr inc on were next connected by a straight cut made through treptun. with straight scissors, an.l the portion of the septum lu 1 Hi betw,.en the tw,. incisions was removed with f'"cops. A sep m wth a straight superior outline was thus produced. The •xt tep consisted in depressing the bony bridge of the nose so tJiat Sould rest upon the now straight septum A small nasal saw ^.^ „ ee<l ^vith the teeth uppermost int.. th.- l.'ft nasal passage and tt cula i..n of the nasal ind maxillary bones sawn through from ow m ward. A similar saw-cut was ma.le tlm.ugh the correspom - ; ar i -ulation on the right si.le The nasal bones were thus eft arti.-ulating onlv with the frontal bone ami with each .n ut. A few ,, . ritivc'lv g.'ntle taps up.)ii the nasal bones sufhc.-.l to br<>ak the X i^^^^^ and' .lepress them, still firmly u".tc.l with each tl.er until thev came into contact with the upper margin of he se urn Wit the ,lepr.-ssi.,n of the nasal bones the brulge of the isumed a straight line from tip to f..rehea.l. but a rulge at : s= m."ime appear^:! on either si.le, forme. ll>y the --'"^-y '-!- .,l.„..r the line ..f the nasal articulat..)n. As determ.ne.l l.> n. pre- V tlv in experiments .>n the cadaver, two or three li^ht blows wllh a p^otectlnl mallet upon this ri.lge fracture.l the maxillary bone, I BMloa Me(llc»l ami Surgical Journal, February i, 18S». lr.dlM KHJO XOSK AM) TlHiUAT. wliirli is luTc vory tliin, alim); a line situated about 1 cm. outsido tiic lutsai articulation and parallel t<> it, with the result of depressing the ridjie and produeing a pct'eetly smooth an<l even eutaneous sur- face. The op<'ration occupied alwiut forty minutes and was attended hy comparatively .slight hemorrhage. An external .splint Wif applied to hold the nasal hones and the fragments of maxillary hone in projxT position. The recovery from the <)}KTati()n Wius uneventful, being without headache or elevation of temperature. There wa.s a slight nasal discharge for about ten days, which then ccjused. The bones were firmly established in their new |)osition in five weeks. Inspec- tion four months after the operation showed a slight superior outline of the nose, smooth lateral walls, and a perfectly normal skin. The ti)) of the nose was not deciirved. but the ui)per li|) covered the in- cisors better than before the operation. Kxaminaiion of the interior of the nose showed a straight septum, while the turbinate •■ presented no discoverable change from their appearance previou.s to the o|K"ra- tion. N.-i.sal respiration and olfaction were normal. No abnormal subjective na.sal .sym|)toms were present. "In recapitulation, the essential features of the preceding operation may be said to consist in the excision of the redundant portion of the se|>tum, the separation of the nasal bones from their maxillary articulation, depression of the bony ridge to approximate the newly foriTied superior .sept.al margin, and, finally, fractuie and depression of the lateral maxillary ridges, the whole operation being ])erformed intranasally and without woumliiig the skin." Concave Vertical Deformity. Some cases of concave vertical de- formity can be corrected to a presentable d(>gree by nfracturing the nasal bones, the cartilaginous and bony septum, and when the |)arts are sulliciently pliable, moulding them into |)osition and holding them by retentive appar.-itus, as in a case reporteil by Harris.' De- scription of this method will follow. This s;iildle-back deformity has been corrected also by (illiiig in the depressed portion with tissue taken from the sei)tum, the patient .sometimes conveniently carrying upon the septum a large spur which can be transplanted to the de- pressed dorsum. Roe and (ioodale- have reported such cases with photographs showing excellent results. I'mler ether the spur is sawed from Ix'low U|)ward: but the nuicous membr;ui<' ujion the upper side is left intact. With a knife introduced into the nostril, the skii is separated from the nasal bones and cartilages, thus forming a cavity to icceive the sjtur, which is idlled upward, still adherent to the mucous membrane. The l.-itter must be dissected u]) along the .sep- tmn to allow of the excm-sion of the spur to its new jiosition, but not separated from the septum, that the nutrition of the |iart may be maintained. Thi' trans])lante(l cartilage and bone may be retained in |)lace by an external s]ilint. Where it can be done, this would 1 I.«rvni;ii«ri)jn\ Mnri-h, IS'f.t. vol vl. p, Jl't. » Anii«lsi)f OMlnify, Ijtr>'iiK'>l<<i;y. mill laiiMiiliiKy, NoviMiiliiT. IWH). i:xrt:H.\.ii. htcFoHMiriJai or niJi mohe. lOtil sccin ii wiwT iiri>cc( >|iliiit, iis lias Im'cii ( lurr thiiii tlic intnxlucti.m of ii iiicti-l or r.-lluloitl liiiic hv ^Vcir, Musiks,' and oti.iis. The traiis- |i|;illtf(l tissiK is saiil til iM'Cdini' iiuiti firiiilv lix'tl i'> ''■-' IMwiti*"!- It certainly is far l.-s> likely to Ix-ci.nie disi lisplaced than a metal suiiport, 1,1 it would be nuu'li ni«>ie eoi ifortal'lv tolerated l»y the putienl Ihis marks a distinct advance over the introduction of a foreign liodv. liepression of the nose over ntraction followiiif; septal al the triangular cartilage and due to hut when no perforation has occurri'i 1, 1 las The dorsum o 'been .rvercoi'ne l.y d.-vating a sr. turn of th.- caitilag. hus raised at thee\penseof h pertoiat.nn if the nose is t \ the septum, (loodale d.-scrii.es the operation m a re] •ted case as lows: "Th operation <'oiisi ted essentiailv in cutting out a <\v.i\d- niiigiilar piece of septal cartilage an until thi' external depression wa? si'prarcn 111 extract an incision was iiiaili I lifting it upward sulicutaM-ouslv filled out. liider cocaine aiui hnir"!i the triangular car- tilage about 1 cm. in front of its articulation with the perpendicii ar plate oi the ethmoid and paralh I to it, e.xtending from the skin al'ovo to tl le vol iier heh)W. A second incision l>ar illel to the first was then mai le through the cartilage, about 1 cm. behind the tip of the nose The inferior extremities ( f the incisions were ik xt connected by a third running parallel to the upper bon ler of the vomer. A flaj) of cartilage war^ thus produced adherent oiilx Iv above to the mucous mem- l.r me and fiiscia corresponding sliding the fla|) U] iward and forwan (lei)r''sse( 1 area was lifted uji. ai foi-ation of the sei>t;im w The antericr am ling to the external depression. On ml in its own plane the skin of the „1 simultaneously a rectangular per- tcd at the lower border of the Hal I posterior ends of the flap were s [ill Ul CO ntact with tl)( lorme sei)tum, .•ilthough at a loiiit higher u]) than that which they Iv touched. After be iii.r elevated to produce a nearly straight superior outline of ♦ iie'nose. tlu' transi)orti'd llap was h.-l<l in posit l.\ gold-plaied pins ttin .t through it and the adjacent septum ion on ■M'il Sllll all- in an iiitero-pi stevior direction. ifter three weeks the par's wer slight, iHicieiitlv firm to i>ermit remova The reaction was ,(■ the pins. The bridge wa from the iterforatioii." : tirm and the jiatient had no discomfort tl N i Ctid F iSe. I. ease of deformity due t,. neglected frac- .n fher is usuallv n. loss of substance, and the object m view is „ : ,: iini of the pans to aormal position, and their -ten u... unnl „„i,„ ,,as taken pla.v. The md.cations are ^""I> «' '» ' f. .^ .M.o.rentlv formidable problem sometime;- i.resented by a ba.l <li i ; V -T • -• is relnarkably tolerant of manipulation, and umon .'efra. ture will take plac^ as reu.lih as alter the ong.na ^i-)- • n f a tTseptic prec u.tions be ..bserved no s.-vere reaction is = U,„l.>u M..li<al ami Surgical J.mriml, im. vol. cixx.i. p. 562. , HBl lU»i2 MtSt: AM> TllKoii: V .1 l«l ' ! li ! ^ b<', ami -If nM>al Ih'Iii-!* iirc »<» hi 'cfracHircil, and to siich a dcpnc tliat tlif iHisf i;< iiiatlr pliaiili'. it is tl:cii ti) In- iiioiililt-d into i-nrrccl position, and iiy inlraiiasal splii ts or a ponil>inatioii of intranxsal and external splints so n tainerl until firmly united in its new pitsition. The Adams foreepH wilii lon^ lilades is a suital>le instrument for refracturinji llie 'septum. The same instrument witii mie Made covered willi ruliher tuhinjj to pruteet tlie -kin is u-' d to grasp the nasal hones and refraetwre them, or, if necr^sai*, .; piece of steel covered with ruhher luhinff can Ih- placed against the n!u*al l>oiie or nasal process of the suiM-rior maxilijiry l>one and struck a sharp l)lo\v to effect its fracture. As internal .-upport Mie rider splint, already referred to, will do good .service, elevating ihe depres.sed dorsum of the nose to its proper height, or the .-uperior and middle meatus may Im- packed with antiseptic jrnize mid an Asch s|>lint slipi)ed in underneath to allow of nasal respiration. If this chiss of deformity is acounpanied hy depression over the triangular cartilage it will he necessary to make incisions through the cartilage, as (h-scrilied it) (loodale's < ise, in order to secure ixrmanent elevation of this section of the dorsum of the nose. If this is not done the .se<'tioii over the cartilage will return to its former level on removal of the internal s|ilints. For the deformity of collapsed or widely-dilated ahe the cartilages are to he incised .suhcutaneously with a narrow knife sufficiently to render them pliahh". In the after-treatment of collapse of ahe a tube is to he worn to give pro|M'r shape to the nostrils. This mav well be of vulc.'inite. After widely-dil.ated rhe are rendered pliable an external furm, as a plaster-of-1'aris cast, is to be worn, supplemented, if need i)e, by an intranasal vulcanite tube, as recommended by Roe in such procedures. Artiflcial Support. When the supporting framework of the nose ha- l>frn distroyd, as in ca.ses of syphilis, and the sinking in and cdiili.ii liin of the .-oil parts have "riven an u>r!v deformity, attempt has been ma<le to sni)ply the defect |,y introduciiit; a metallic frame- work for supjiort If the loss of substance has not been great and the reviilii'i<r deformity correspondingly !e<s. a simple plate of metal slightly moulded ,.r a suitably formed piece ol celluloiil has been made to sustain the skin along the dorsum of tlie no.se, thus main- taining its contour. This metalli<- or celluloid form is best intro- duced snliciiianeiiiisiy or from within the no.se, ;dthough instances are i:tt wauling in whicli exti'rnal Icnigitudinal incision has been made,' the skin dissected up on either side, the plate pl.iced in the cavity, and the wound in the skin dosed .above it. (I.iod results are claime(l for the Last method, ailhough my own observation would lead me to believe th:.t these f.avorable reports must have Iwen made soon after operation. If such support is to lie used it is (piite unnice.-:^ary t;) add an um-ightly -ear to ,i p.re.sent d'^formity. The su|)poriing nm- ' I'rlrc Brcmn, Iiisiiists of the Nose ninl Thmal, liKK), p. 4,'iO. h:XTKR\M. DKhtHtMITIKS OF THK SOSK. lutia ,..rinl shoul.1 iH. plucMl s,.»H-„tnneou.ly ..r by .n.-ans of inn.ioi,.s wifhin \.n..nK ..|..>rat..rs who l.uv.- us.-.l iIu.h in.-tl....l n-lluloK .vcr any "Hkt muKTial l.(Tau>*i' it is well t<.l«'rut»>«l first to ciiiploy pflluloid f'>r this thi' IK'SC lia> |in'fiT('iicf < li\ tilt lissiu |iuriHis( I- t'asi •s. H 1'. Weir was I'lalimiiii lias l><i'i> "f" (I in a null ili«T of Misi's; liiit it Iv .hsphuTil. ami must th.'i. !.<• removal: or it cuts its way through tlic cu.l of th.' nose- l)y mere force . ,i!,. of tlic fact lliat miincrous |KTforatioii if ;;ravity. and this in luivc Im'cii ina<U' in th«' the union of tissue throufjli lli(>so >l:i It is a fact, however, tlmt FlU. KKl. |)hiti', witli tlie 1 xpectation tluit ..oeninKs would litlp to retain it in | - , , , , ..len svhen this supporting substance has t u.s ehuled the ..p«Ta or, ,|„. „„se has be.-n left in b.>tt.T form than iMfore operation. Kniglit Weir and Monies sp.-ak of this. The l.resence of the foreign body provokes inflaniniat..rv infiltration, aiul this uicrea.«e of t.ss.ie renmirw u hell, till ill the f-nni-r depression. Where the amount of depression is n..t ereat (u.odwillie has succei'ded in securing a ronsiderabie ele- vation bv drawing heavy animal ligature under the skiii and allowing i, ,o remain. Doiu- a.septically. littl.- reaction ..Hows. This he de- <,.rilM'.l in a paper which i think has not yet been published, read recentlv before the New York Academy of Medicine. The use of a metallic framework to sup|...rt the nose after <'Xtensive l„ss of bone and cartilage was first sug^'esfd by M. Letievant Tlie .^,;,i,i,iai l.ridg.' wa.s ma<le ..f aluminum and his case report e.l in S7S On his a.lvice M. Claude Martin, who had don.- much in the w,v of ...rrecting .l.'foriniti.'s about the fac, made a bridge of p at- i.niin This on.' in f..rin and material pr.imis.'d hriner support than the ."arlier effort. Dr. H. F. Weir introduced til.' meth.xl into this country in IS'.Ci, an.l in bmuarv, ISOti. ha.l oporat.'d up<m 10 ca.ses. l)r Knight, Nich(.ls, and others have rep<.rted (■•ises correete.1 bv this form of su))i.ort or some n,odilicati<.n <.f it. I have ha.l a limit.'d experi- ence with this cla.ss of cases. Th.' first patient, a woman, thirtv vears <.f age, came un.ler my ,"ire early in 1S<»i. The .l.'f..rniity of her nose was ilue't.. exteii.sive destruction of the cartil- •i.Miious and b..nv septum. There was n..t only sad.ll.'-back .l.'f..rmitv, but th.' ti). ..f the nose was .'levated an.l the ala> much r.-tract.'d. She wis eag.'r f.tr anv operati.m which pr.)mised to imi.rove h.T .•ipi.earaiice. The Martin bndg.' is .'M.eiisive and its arms too narrow to sustam . ,,,,,. ,;.„..l ;,1:.- I th.'i-efore .levis.'d the bridge shown in !■ .i:. .)•«»• It i< cut from a single .sh.'.'t ..f platinum. on.'-Hftieth ..f an in.' i thick, and 111.',. m..ul.le.l t,. fit th.' iiulivi.lual cas... The gr.'at.'r breadth . Tmi.wrtionsnf ihi- Amerlran l..,ryi,Kol.H:lcal Al-wctatlon, 1R96, p. 150. t La Pnilhi^se tmme<li»te, Part*, Iw/J, p. -'«' riatinui;! XtMff' MICROCOPY RESOIUTION TEST CHART lANSI and ISO TEST CHART No 2i 1.0 I.I JflllM ilM I-- 1^ 112.2 ^ li£ 12.0 1.8 1.6 _S APPLIED IfVl^GE Inc :'-•: t..:tst M-i- Mr«t ■'6) *82 - 0300 - Phone 1U64 yoSK AM) r II HO AT. of the l)0(ly allows of it hciiif; iiiouhlctl over the nasal iMtiics, which prevents lateral displaceinent. The shape lessens the pn>l)ui)ility of )f the thin skin ( 'er the ilorsiini of the • Ithel) erosion ol the tinn sKni ( 'er tiie dorsum oi ine nose, and ine t)roa(ler arms support the ahe with less danjier of destructive erosion. Per- forations reduce weiijht somewhat and permit the union of tissue throufih the openin<rs. Thi' arms are li'ft lonj;er than will he reiiuired, and at the time of the operation are to he cut of suitalile leiiftth. The ends of the arms are pointed and placed in holes drilh-d in the superior maxilla, 'i'lie hridj;e is thus tirmly fixed in position. It should l)e said that the supjiortiiiR arms oujiht to stand more nearly at rijiht angles to the hody than is indicated iii tlie cut, that the lower edfres at tlie ends mav not come so near the ji'"Jli^'"-l"'*'!'l f"l'l- I" the case referred to, HoUfri''s operation was jn'rhirmed and the bridge placed in posilioii. In this operation the soft parts, inchKling the external nose, are detached hy an incision along the gingivo-h.hial fold and a dissection upward close to the hone, exposing the nares and separating the skin from the nas:il hones. Tlie bridge is then ailjusted and the parts replaced. The proper moulding ;ind adjustment of the metal support and the division of cicatrici.-il tissue gives a com- plete restor.ation of external form. The deformity and vnrbi results are well shown in I'igs. 540 and 541. If a metal s'lpport is to lie Flu. WO. Flo. i>U. Kici. .'vlii.— ('iii)cnve viTllcHi 'efonnit.v. ('iillii|>8e, iiii'l I'.iiiimciioii i>f Hlftr ciirtllage!i, irom speclttc di.«)fHi*e. Khi. .'(11. — CorrtH'tt'd hy iisiMtf iinMiiii(.Ml Murlin hri'lKe. employed Dr. Knight's dictum should he carefully ohserved : "(1) In syphihtic cases the patient must have had a thorough course of treatment, ;ind a sullicient period must have elapsed since the disappearance of active symptoi'is— not less than three years; (2) the rLEFT PALATE. im'o ,li<>ii'rti(.ii of the sof' juirts must be so cxtcnsivo as to ohviiitc tlio p„-sil)ilitv of tension at anv point, and csiu'cially over tlic l)n(lf;c of tlic nose" wh.Tc til.' upper end of tiie l)iate is to r(>st. Tlie metal hri.lp- must be so moulded and smoothed down at Us odj;es as to preclude the ilanjjer of frietiou an.l pressure upon the solt i)arts, iiid the ends of the sup|)ortinf; arms must be deeply buried m the maxilla, as otherwise thev are liable to be drapRed out of i)osUion." \ word as to this method of treatment may well be m order. Ihe ultimate results of the u.se of the .Martin bridge are often disapiiomt- iii<' notwithstanding the gratification at first (>xi)erienc<'d bv l)oth pUient and surgeon. The operation neces.sary for placmg th(> bridge is easily performed, and recovery is ])romi)t. The objections are those arising from jilacing an unyielding foreign body withm living li-;sues subjected to some degree of motion. In si)ite of all precau- tions some i)art of the form, either one of the supporting arms or tlie body ov.M- the nasal bones, will sooiu-r or later cause erosion cjf tiie overlving skin. The .structure itself has become bodily disi)laced. Th(> interior niav iill witli granulation tissue, so that nasal respiration is cut off (Cicatricial tissue mav cause une.iual contraction, so that the soft parts are imlled to one side, sliding over the Iramework. Indeed the final outcom(> of the bridged nose is such as to dampen the (>ntlnisiasm which arisc-s over the immediate results of the opera- t i„ii The wearing of an artificial nos.> of celluloid is to be commomled, lather than the metal support with all its uncertainties. CLEFT PALATE. Cleft palate as here considered is due to a failure of develop- ment in earlv f(etal hfe. The perforations ..f the hard or sott p;,h,te which occur as a result of si)ecitic dis(>ase may sometimes be ivpaiivd bv plastic oi)erations: but this i)liase of tlie subject is not to be touched ui)on. Various theories are a<lvance( to account f,„- nature's failure to complete th'> work which she liad begun. 1 he interposivion of the tongue of the embryo between the two approacn- in-' halves ..f the j.alate is one of the offered explanations. Dr. Hn.ntlr in his inten'sting pai.er r<>fers to the results of observations on lions in the zoological gard<-ns of London. They were te.l f.u; a time upon flesh containing bones too laig<- for mastication. Die voung born while this m.-tho<l of feeding was inirsued had clett pal- ates The lions wee then fed uix.n smaller animals whose bones they ,.,,uid break easilv. and the young born afterward had jierfectly f,„.„„.,l palates. This observation has been rei.eate<l at the ' zoo in I)ui)hn and in Philadelphia. Some authorities claim that the want of a meat diet and a .leficiency of the phosphates of lime in 1 N'cw York Mi.-.!!.'*' '••nrr.al lOiil, -ri!. !%xlv. p. 241. • Ab8. LaryiiguKope, 1899, vol. »l. p. 308. I If; I'' 10G6 A'OSE AXD TlinOAT. tho fiMxl of the mothor act a.s a causo. The published statistics show tliat tilt' English surgcdiis have pcrformccl many more operations for cleft palate than have Americans. May the factor of a more generous diet among the poorer jM-ople here partly aeco for this? Heredity has been assigned as a cause by some authors 'Ihe cause, whatever it be, is a matter of small moinent to the jiraciical surgeon! "It is a condition, noi a theory," which confronts him. The cleft between the two halves of the palate varies from the slightest degree iis the bifid uvula, to a complete cleft of the soft palate, and even of the hard palate forward to and through the alveolar process. This cleft is in the median line until the incisive or intermaxillary bone is reached. This small porti' n containing the incisor teeth is, in young bones, marked off from the maxilla on each sid(> by distinct suture lines. If the deformity under consideration extends through the alveolar i)roc(-.ss the cl<"ft deviates from the meihan line on reaching th(> maxillary bone; and if the cleft be double, jis it sometimes is anteriorly, this bone is entirely .separated from the maxilla ami hangs froin the end of the septum. The o|)eration for closure of cleft palate has been (lone for ■' century, and, as might be expected in a liroblein of such difhcult\ las engaged the attention of the ablest surgeons 1 lie accumulated rxperience during this long period of numbers of workers has resulted in an improvement in techni(iue which gives the operator of to-day a great advantage, and yet unsucc(-sful efforts are not infretjuent, so trying are the conditions presented by this deformity. ^ Thechanges contributing most notably to a successful issue were hrst, 1-ergus.son s division of the palatal muscles to reduce the tension upon the sutures, and, second, the introduction of general anaesthesia One IS possessed with profound admiration for the skill and patience of tli(> surgeon of early days who, without ana-sthesia, either local or genera , and without the aid of sterilization or antiseptics, yet under- took this difhcult op.>rati..n and carried it through to a successful li!! ;. ri\v"" '"';;„ ''-^''f T'^^'"' *•"••'' i'"P>-<.vement in point of time, and Warrens h ling of the fissure in the hard ,,alat- by means of The niucoperiost..a flap the fourth of the major improvements In spite of every aid gained from the accumulated experience the operation is often a partial or total failure, either from undue t(>nsion direct upon the sutures, or in.m functional activity; or failure is orihe mtil.nt '"''''''"" "' '""'' °^ '■«'="P<''-'»tive powers on the part The history of staphylorrhaphy is interesting for several reasons and 111 none more than in the change which has taken place in the oi.inion legarding the ,,roper ag.- at which the operation shoul.l be performed, rii.. older wnters. lacking the advantage of ana'.sd.esia and ooking rather to goo, surgical results than j.erfect function,' adMM.,! a late operation It was necessary at that period to rel^ u. .OUT instances u|.u„ |h,. assistance which tl... patient could volun- tarily render, even if it were not other than the j.assive aid of not CLEFT PALATE. 1067 (iffcring rosistance. Ono oarly autlior' states: "As the success of the opiTation (U'IK'ikLs in a great measure upon the patient remaining pcrfeetlv trantjuil and steady during the necessary procedures, winch are of a tedious and protract«'(l character, upon his jissistmg the surgeon by opening his moutli and not struggling on the introd'-.ction (if tlie instruments^ and after the ojjeration upon his making as little movement as possible in speech or deglutition for some days, it is usually considered expedient not to interfere with this malformation until "the patient has attained the age to understand the necessity of remaining quiet and to be able to control his movements." The operation is a difficult one, and when one thinks of the jmblem presented of freshening the edges of the cleft and inserting sutures ill the small mouth of a struggling child, at an age in which *.he tissues are easily lacerateil, he is ready to approve for the earlier surgeons of the plan of operating when it can be done at the patient's reipiest and with his assistr.nce. Tlie use of amesthesia has changed this, and the reasons for operating early are unquestionable, first, because of the more perfect establishment of the function of the palate. At an early age this assures the nutrition of the child. In coinplete cleft of hard and soft palate swallowing is a matter of such difficulty tliat the child requires the almost constant attention of a nurse. Consideration of the parent, too, should have some weight. To many a woman the deformity of the child can but arouse a feeling of horror. Next to the functional aid in nutrition is that of phona- tion. All authorities are agreed tliat in voice production the early oi)eration offers vastly better prospects of good results. Makuen says both the ttmgue and the palate are important in the function of speech, but the palate is the more so. The i)urely vocal elements of speech, such as the vowel sounds, may be articulated when the palate is defective, but their resonance is so impaired that they are seari "Iv recognizable. Of the consonant sounds, only two, m and n, can be' articulated intelligii)ly when the palate is not intact, because in the jiionunciation of the other consonants the palate is necess;iry to prevent the pa.ssage of air upward. Perforation of the palate affects speech to a greater or less degree, depending upon its position. Surgi<'al measures for the relief of cleft palate should be undei taken as rarly as possible in the formative speech period, and these should he suiiplemented by instruction and practice in the normal produc- tion of sp(>ech. • • iu Hy no m(>ans least among the reasons for early operation is the influence upon regional development. Formerly it was considered debatable whether the fissure in the hard and soft palate, when both existed, should be closed at the same oi)eration, and it has been •is^erti-d that if the cleft in the .soft palate were closed early in infancy the fissure in the hard palate would gradually become narrower ' Krii'liwn. Scli'ii.i' iMul An ot Surirerv, \h-.:\ val. il. p. 4.'i9. t New Yiirk Miilual lUriiril, VM, vol. U. I'. '*■ 1068 NOSE AND THROAT. until, in sonic instnnccs, this would not require operation. If this were true, even to ii slifjht degree, how niueh more nearly normal would development be when the entire eleft were elosed at an early period. Development within the nose and uasoj)harvnx would also be more nearly normal. In cleft i)a!ate of the adiilt the inferior turbinated bones are sometimes so greatly hyix'rtrophied a.s to extend into the eleft, and removal is necessary "bef or (> operation for closure of the cleft can be undertaken. Adenoids are also (juite likely to develop, and the mucous membrane of the nose and nasop'iarynx to be in a highly inflamed condition. The Eustachian tm "and middle ear become involved, with the con.sequent unhappy train of disturbances ()f the functions of the ear. All these reasons call for early operation. R. W. .Murray' say.s from his experience in UK) operations for harelip and cleft i)alate, he is convinced that the oi)eration for harelij) should be performed about the fourth week, and that for cleft palate about the twelfth month, that is, before the child has begun to talk. C;oodwillie= has operated as early as the twelfth hour after birth. Abb(( says the earlier one operates the l)etter, and he has secured good results in one case two days after birth. The soft parts once in prooer relation tend to mould the hard parts, and, as in case of harelip, the ojieration ought to be done early. B. F. Curtis also advises operation in infancy. Dr. Brocr'" does not hesitate to operate upon a child from three to six months old, pro.ided it can have projier care. Since the operation is not one of immediate urgency, sufficient time may be taken to secure the best possible degree of g(>neral health, and this is especially important if the jialient is a voung child. At a later ])erio(l a number of local points will re(iuire attention in an effort to reduce to a minimum the obstacles to success. (Y.rious teeth should be tilled or ilrawn, and an antiseptic niouth-wa.«h ii.^ed carefully for a period before ojjeration. .\deiioids should be removed, as also .sjiould the f:uicial tonsils, and at a date earlv enough to allow of iierfeel healing, before the oj)eration upon the palate is undertaken. The reai-ons for this are too obvious to re(|uire stating. In some cases the inferior turbinated bones are hvj)ertrophied to such a degree that they projee, into the cK-ft. Theie should be removed under the rule's just iiame<l. I-lvery "ffort should thus be made to bring the patient up to a good state of health, and locally to reduce so far as possible the dangers of infection, and to remove sources of pressure, of irritation, and of interferenc(> with respiration. Ih- teclini(|ue of th(> operation for closing the cleft is (niite well agreed upon, and this will be given before mentioning anv modification. If the case be one involving the hard pal.-ite. or if the patient is a child, or not eju«ily managed, general amesthesia should be employed. > British Meiiirfil .I<;firrial. ()<Mn'H'r ].'». I<ns, « New York Medii«l Kecoril, IsiKi, viil. xlm. p. im. ' Ibiil., vol. 1. I.. 68. CLEFT PALATE. 1069 riic Rose position— the head hanging over the end of the table— is the i)rcferiil)l<' position. This is (•ornniondi'il for the reason that tlie l.lood and mucus arc tiius h'ss Hkely to enter the hirynx. The usual sterilization of hands, instruments, and field of operation is of course to be observed. The Smith mouth-gag is introduced, which is self- ictaining, opens the patient's mouth to the widest extent, and at tlie same time de|)resses the tongue. The mouth, teeth, buccal cavity, the nose, nasopharynx, and pharynx are to be carefully sterilized. The edges of the cleft are to be freshened from the tip (,!' the rudimentary uvula to the apex of the cleft, from behind forward. The tij) of the rudimentary uvula is seized with a long pair of volsella f(ircei)s, and the edge freshened with a knife or sci.«sors curved on the flat. Recent writers prefer the latter, stating that a broader sur- face Is secured, since the cut may be a bevelled one. Care should be taken to preserve a.s much as possible of the rudimentary uvula, since it will contribute to the more perfect function of the palate, lileeiling may be controlled by pressure or by gauzt s[)onges wrung from a hot normal salt solution. It is fiu'te possible that the use of adrenalin wcmld control hemorrhage to some degree, and nught well be tried. If the cleft is in the soft palate alone the sutures are now to be placed. If the hard palate be involved the next step will he the elevation of nuicoi)eriosteal flajis. Incision upon each side is made jjarallel with and near the alveolar border, and of a length (Mjual to that of the cleft in the hard i)alate. This incision extends through to the bone. With periosteal elevator this nuicoperiosteal flap is raised, care being taken not to wound the palatine arteries in the i)rocess of separation from the underlying bone. As thus sei)arated, this flap is attached only anteriorly and posterioriy and slides jxTfectly freely over the bone from which it was detached. The free blee<ling is to be controlled by [)ressure or the use of sponges wrung from a hot solution. Many (l(>vices have been proposed for introducing the sutures, which is the most difficult part of the o])era- tion. The needle in a Img handle, with a half-round ciu've at right angles to the shaft of the instnnnent jives good satisfaction. Some <il)erators use an ordinary small ha'f-.ound curved needle. It is interesting to observe how similar conditions lead different workers entirely in(lei)endent of each other to adopt like methods. \ f,-i,,,„l— a general surgeon of wide experience— mentioned to me ill discussion f)f this subject that he found it convenient to pass the sutures with a small half-rovu)d curved needle, inserting it from behind forward. For example, the suture would be inserted from behind forward ui)on the left side, and the nei-dle drawn through. The end of the suture wuild now be threaded into another needle and passed from behind forward upon the right side. Aided by forcei)S and a small nee<lle holder, this was said to be quite easily done. This seemed an ingenious manceuvre, and was original with this surgeon, yet I found the ^ame ?uggrstioii in a ropy of an old work on surgery which was consulted for hist<jrical points. The 1070 yoSE AXD THROAT. nutliod which pprmits of passiiij; the sutures from before !)aek\var(l has ill its favor the possiljility of placing them with better symmetry and exactness, since the point of tiie needle enters the mucous mem- brane" of tiie roof of the mouth wliere it can be phiiniy seen. This phin may tx* carried out iis follows: a suture is passed through one side from l)efore backward. A needle with an eye near the point, the one in the handle, already spoken of, is passed through the oppo- site side. The loop which it carries is held by forceps while the needle is withdrawn, and the suture first placed is pa.ssed through the loop which, on being withdrawn, carries the suture with it. Be- ginning in front, the sutures are placed about one-third of an inch apart. The Miture material may be of silk, silkworm-gut, or sil-er wire. Silk cannot be allowed to remain as long its the othei,y if union lia-s not taken ()lace within six or seven days, it is not to occur. To relieve the tension on the sutures incision is nov ,ie through the soft palate, as first recommended by Fergusson, miernal to the haimiiar process upon either side. Thii-' tlivides wholly or in |)art the fibres of the levator palati, ten.sor palati, and palat(v pharyngeus. Tension may still further be relieved by snijjping the anterior and posterior pillars with scis.sors. After operation effort is made to keep the i)arts cleansed with an antiseptic mouth-wash or spray, boric acid serving well. Semisolid food, as beef jelly, custards, etc., are advisable rather than fluids, since these are more easily swallowed. So far as possible, the patient should avoid func- tional u.se of the palate, since any movement is prejudicial to union. Accidents will occ ur in sjjite of all j)recautions. Violent sneezing has been known to sej)arate jiarts which up to that event promised well in the way of firm union. Staphylococcic infection niav occur, with a consequent failure of union in at least a part of the wound. Should this happen, <)weii' advises that a "condnry operation should be jier- foriiied within a short time, and nuntions a case in which, after two weeks, the granulating edges were freshened an<l brought together by sutures ph'.ced wide of the cleft. As good results were secured as could have followed e(»m|)lete ])rimary union. Owen urges this prompt effort to overcoiii(> the effects of se"ptic infection, on the theory that the patient has accpiired an immunity by his attack, conse- quently there is the better pro.spoct of securing imnuMhate union. The suturi's should be allowed to remain eight or ten davs, anil then not removed all at one time, but here and there, as seems best. McF\ernon= has projiosed as a ])reliminary to the ,)peration of cl()siii,<r cleft palate that tracheotomy be performed, the aiuesthetic being administered through the tube; and after the operation that the wound be packed, as in any other operation, the patient being nourished by the rectum. The f^ollowing is a descrijjtion of the opera- tion as i)erformed by hiin in so far as it varies from the usual techniiiue: I Junrniil I.nrvii,. Htiin., mid Otnl., isflf, p, 462. s Nuw York Miiiiriil Juiiriml, June 10. 1900. CLEFT PALATE. 1071 A liirg«'. flat, thick piece of plain sterilized gauze, with a string at- tached, is placed in the lower part of the pharynx, covering ihc (.titnmce of the larynx and (rsophugus, thus shutting off all possibility of foi-'-ign substances, such as blood, solutions, etc., from being carried i..,(i mo larynx or the (esophagus. The string passed through this piece of gauze is allowed to hang out of the mouth, with a clamp attached to it, so that, if necessary, it can be (}uickly removed. There should be several of these pieces of gauze on hand in case the one in jHisition .should nee<l to be removed, as .sometimes occurs when it becomes saturated with blood. The oi)eration is then done in the usual way, and, after the oral cavity has been cleansed attain by the normal salt solution and the pad removed and replaced by a fresh one, a thin strip of sterilized gauze, about an inch and a half wide, is passed between the under surface of the repaired palate and posUrior phar- yngeal wall. Plain sterilized gauze is then used to pack the lateral incisions, and here the i)acking should be quite firm. Sterilized gauze is also used over the whole of the operative field, the cavity of the mouth is filled completely to the front teeth, and the gauze is then pressed rather iirmly against the under surface of the new palate. Should vomiting occur and soil the dressings while the patient is recovering from the amesthetic, then we nmst redress. This happened twice in one of his reported ca.scs, and not at all in the others. If no vomiting has taken place the packing should be removed at the end of forty-eight hours, and the parts gently sponged with either a hot saline solution or a weak solution of formalin, ancl the wound gently repacked. Owing to the salivary secretions, which are now increa.sed by the mechanical irritation of the dressing, the ])acking should be removed each day and the parts cleansed as before. The tracheotomy tube is left i- for about twelve days, during which time tlie i)atient is nourished t)y the rectum. Dr. McKernon very k? • llv r*ated to me that he has now employed this method in 14 c- <- ^ nmary union in every case but one, and ill this the faihv '■ was for only a small portion of the wound, which was reui ' ■ ..eshened, and the ultimate results were perfect. Thit doctor de: i ves great credit for the originality and boldness with which h" has carried out a plan which .seems from the imrcly surgical side much more certain and correct in its technique. The method would hardly be recommended in very young children, for example, at the age suggested for operation by Goodwillie, Abbe, Curtis, and others. In selected ca.ses among older children and adults, however, a method which tends to assure primary union by keeping the parts more nearly sterile and at rest has much to commend it. ullU I FLATL-; XXXIII. M.M ;i.i .i:.ii T\ 1 1 i I Mill ii^ St (-mi T!ii (iUc|Ii a S|>i-> u hi in THE EAR. CHAPTER XXV. tWMlNATION OF THE KAIl; DISEASES OF THK EVrERNAL EAR; DISEASES OF THE EXlhR- NAL Al DITORV MEAl'US; ()T()MY(JOh &; FOREIGN BODIES; WOl'NDS OF I HE MEM15RANA TYMPANl. Hy F. K. HOPKINS. MD. EXAMINATION OF THE EAR. Thk luwssarv iiistnmunits for makiiifi an oxiuninatioii of tho <'ar aiv a linir, . a coucave mirror, and a speculum. To secure satistactory Kiu. Mi ,.-,..-.,7*^01., A, Helix H.An.ihdix e. Tra«n.. D. Antitrngus Hl...>.ule. F. roncha. K„. .-..:! -TIK. .mrlole and .he oartilugi..™,, part of the external ""'"''^ ;''„„,, ^^'J <,,^,* ., , „r,il„Ki„o™ meatus. K Inner ,«.lnte,1 en.i whieh n„i,«. with .H.s...n, ,«rt of the «n,mor> onnal. r KisMiresof 8ant<>rlnl. (Pol.IT7.EK.> result, with these imi.lemenls, however. so.u<> familiarity m\h their us.' is o^lnltial, togetller with a knowle.ige of the anuto.ny^of Uie ear. 1(»7() Tin: i:ar. Tlic liglit and its fixturos may bo simple or (■lal)(>rate, as the taste or tiie pui'^e of the owner may dictate; direet simligiit may he uscil when available, or one may make use of a eandle. In an office \\\i li^lit is (juite likely to l)e an Arjjand s:is-burner, and if one |)laii~ to do nose and throat work, he will i)e provided with a Mackenzie condenser (Fip. .J4")), which he will also use in ear work, althoufili good authorities assert that no condensing lens is necessary for exainining the I'ar. In a i)rivate house satisfactory illumination may be had from a kerosene lani]). In case the external meatus is abnormally wide and straight, it is sometimes possibh' to examine the ear by direct sunlight. The direct light of an electric lani]) suit- ably mounted for wearing upon the forehead may be .substituted for the reflected light of the forehead mirror. The electric light serves a Fl(i. .>I4. ■'Sfrni-rimilar CannI*. IMilnde. A front view nt' tbt- orgHii of liuariiig (right sidcj. (Gu useful purjKise in ether operations, since the risk of igniting the ether is thus avoided. For general work sunlight cannot be depended upon, and batteries are unei-rtain. The foreliea<l mirror has ([uite super- seded the hand mirror for reflecting light into the ear, for the very good reason that illumination is thus quite .as good, and both hands are left free for manipulation of instruments. (Jood head mirrors are now so re.adily purchasable that no further descrijition is neces- sary than that thi' h"ad-band should be of iiu^lastic ribbon, that the focal distance should be about seven or eight inches, and that the mirror be worn over the eye. enabling one to look through the per- forati"!! in tlir ci'iitvc, thii^ allowing iiwpertinn in the focal line and giving the maximimi degree of illumination. When the mirror is worn in this manner the eye is i)rotected from the direct rays of the E^ssesn EXAMiyATwy OF Tin: ear. 107: lifllii. For continuous work before a condensing lens this protection i<^a matter of considerable inii)ortance. There is a large variety of ear specula from whii : to tuake choice. \l(diride facetiously rein'arks that many aurists have uevoted their Irisure to inventing si)ecula that they might attach their names to liiem. Satisfactory work can be done with any one of them it ni the liands of its m:ust('r. It is i>nly necessary to speak of the essential Fig. :a:> Fio. 546. Mackenzie's biill'seye lens aiitl rtflector. iDilirect ilhimiimtiun of the ear. (•oiiditi<ms to which all shouUl conform. A si)eculum sliouid not be too long, as this interferes with th(> manipulation of instnmieiits tlirough it. The length should not exceed one and three-eighths inches. One .should have at least three difTerenl sizes. The smallest (lid of the smallest size shoultl not be less than one-eightli (if an inch in .liameter, and not more than five-sixteenths of an inch for the Kin. .MT (inilier sspeeuluiii. Pi)lltzer'E Miieculum. <nuiller end of the largest si^e. The siieculum .should be of bright. porwlied metal, silver or nickel, to aid in reflecting light, and the walls n{ tiu' instrument should be as thin as possible, to increa.-^e to the utmost th<' space available for ilhimination. For this same rea.«on the (Inihi-r srnculum (Fig, .')47^ i-^ to be recommende.l, as its oval form in .■nws-seetion corn>-<ponds to the anatomical .shape of the entrance to the external meatus, thus admitting of the greatest possible illuimnation. r 1078 TIJK EAR. The position of the pationt with roforonro to tlio lijiht is a matter nf some iiii])()rtan('c, since it is desiraMe to seeure op[)ortunity to manipu- late instruments without interfering unduly with iUumination oi tiic field. This is best aceomijlished by plaeing the light at the examiner'^ li'ii and somewhat above the level of the ear to be examineil. The light must not be too far froi i the observer, since this diminishes Fia. 549. OOOO Boucheron'8 speculum. illumination. The patient should sit so that the ear to be examined is on a level with the examiner's eye. The light is directed into the patient's ear by tilting the mirror. This adju.stment of the reflecting mirror is made by the hand, without ;my movement of tlie observer's held, which is thus allowed to iissumc the most comfortable position for examination. The speculum, after beir % warmed, is introduced Fio. 560. Forci'i* for removal of foreign bodies nmi the ear. into the entrance of the auditory canal by a slight rotary movement, and held in position by the thuiiib and index finger of the left hand, while at the same time the (>ar i.- lifted u))war(l and backward, to straighten the canal, by the index and middle Hngers of the same hand. The speculum must be held so that the axis of its long diameter is parallel with the axis of the canal. To secure the best illumination, m mP EXAMiyATION OF Till .AR. 1079 tlic largost sppouluin which th<« canal will iulniit slioul.l bo usp<l, l)ut „„ speculum should bo forcibly iusortod into tho oar. Indood, all manipulations about tho oar nuist bo froo from anythuiR liko rouph- iicss or hoavy-handod movonionts. In ciwo of tondornoss about tho . -ir examination at first may woU be made by gentle traction on the •mricle under a good light. It us cjuite common to find the meatus Fis. Ul. Cotton-holder. obstructed by exfoliate*! epithelium, cerumen, purulent discharge bv hairs, or by otner foreign bodies. Tho external auditory canal nmst he perfectly clean in order to [)ormit of that thorough in.siK'ction which done can load to accurate diagnosis. The instruments used for this i)urposo are tho blunt curette, the slender cotton-earrior, a pair of light angular forceps, and tho sjTingo. Tho M'lnt curette is FlO. 552. Buck's blunt curette. used much more frequently than tho forceps, while the cotton-carrier, armod with a small pledget of tightly-wound cotton, ls more constantly in tho hands of the otologi.st than any other instrument. Tho synnge i< used for the removal of soft cerumen, foreign bodies, ano for the romoval of pus when it is present in considerable quantity or is of a stringy tenacious character. Following the use of the syringe the Fio. 653. Fio. SM. FT.. 5,^i,.-Nonnal drumhe^ (right e.r). o. Porteriorfold. b. Short process, c. Anterior fold. ''rirS -Normal drumhead (left ear), d. Cone of light. .. I..ng handle of Incu,. /. Imbo. rol.ITZKK.) .■anal should be thoroughly dried with cotton. Examination of the oir should bo bv touch as well as by sight. Tho impn-ssion gained bv palpating an inflamed or thickened auricle is of groat aid in making a" diagnosis; ami an interpretation of tlu- signi.Vanee of tendomos. an.l sVvelling about the auricle and over the mastoid can only be made out by palpation. 1080 THE EAR. DISEASES OF THE EXTERNAL EAR. Sonio of the iirt'cctions of thi' auriplc arc sucli tis are common to tin; fkin of any part of the bodj', and riMjuirc tho same treatment. Among tliese are dermatitis, due to injury, stinps of insects, burns, and frost- l)ite. Sudi as tiiese, whether slij;ht or .severe, and whether simple or infected hy bacteria, causinji erysipehis or any sejjtic process, are to be treated on tlie principles hiid down in text-i)ooks on dermatoiopiy. Eczema is one of tiie most connnon dis(>ases of the e.vtcrna! ear ; nd meatus. It is fre(|uentiy seen among the children of the poor !is a result of nncli'anliness and bad nutrition. I' is more common witii children than adults in any .social .scale, beiiiii with them one of the ex|)ressions of a strumous diathesis. In the chronic scaly form it exists to the tornu^nt of many adults who dig at the meatus with pins, toothpicks, tij) of a penholder, or anythinj; within reach in the etfort to gain relief from the itching. Serious injury is tiuis som<'- tiines done to the meatus or membrana tympani, or, if these i)arts are not directly lacerateil l)y the instrument used, the irritation resulting from the repeated tramnatism ends in inflammatory infil- tration and thickening of th' lining of the meatus and an aggravation of the original troubl". l'>zema of the ear occurs either as an acute or a chronic disease The bony i)ortion of the canal is not likely to be involved, the drum membrane also is rarely affected. The disea.<e is usually located in the cartilaginous ])ortioii of the meatus or upon some part of the auricle, or both meatus and auricle are involved. If the auricle alone is affected it is likely to be at som(> ])oint wher(> the skin is folded ujion itself, as in the fos.sa helicis, and in the angle behind the ear, where the skin is reflected from the ear upon the mastoid process, .\cute eezema begins with redness an<l swelling of the skin, which is soon f( llowed by the api)earance of vesicles filled with serinu. Thi'se break, and the exudeil fluid in the canal is some- times mistaken for discharge from the middle ear. The bursting of the vesicles leaves a moist smface. This after a few days becomes covered with yellow crusts, and exudation occurs imderneath. Etiology. Acute eczema may ocr-ir in this locality primarily or in connection with the disease in otner parts; but the cau.se, unless it be an external irritation, is not easily assigned. Of external irri- tations the most comtnon are a])plications to llii' ear or meatus. In some patients with a sensitive skin the efforts toward cleanliness, by the freiinent use of soap and water, is sufiicient to excite an eczema. An acute or chronic discharge from the middle ear is often sufficiently acrid to cause the disease. Sjrmptoms of acute eczema arr a burning jiain and an intolerablo itchiiig in the ;ifTected part, with redness, swelling, and the f'.>rmati(>n of vesicles. The function of hearing is not impaired, unless the mc atus Ix'comi's ocf'luded from the swelling and the accmmilation of crust.s and des((U!imated epithelium. In acute eczema not dependent upon B n^ DISEASES OF TllK EXTKHSAL EAR. 1()«1 •I pcr-iistPiit caiiso, iis uu otorihd'U, u new epidrriiiis tonus Ix'iicutli tlic fi-iLst of exuihition, an.l, after tlu' latter Ikls been removed, soon ■i^smiies a natural appearance. Freciuently t'le disease eontuiues for sunie weeks, an.l if the external iiritant be kept up or the patient s iiealtli is reduced from any cause, fre.|uent relapses occur and the disea>. passes into the chronic form. In chronic eczema there are dcciK-r tissue chan-jes in the skin. There is thick linj: of the subcu- taneous connective tissue in the more severe forms, and this narrows the meatus. The auricle is enlarjied and hardeneil. In bad ca.ses tliere is a crust formation, underneath which a serous or purulent fluid is exuili'd. The more conm.on chronic form is characterized l.v the format!, -i of tine .scales. There is .some liyi)er:emia and tliick- eiiiiifl of the skill and a constant des.iuamation of scah-s. Tin., is very Imiuent as an affection of the cartilapnous portion ot thi- meatus. With this sometimes occur fissures at the entraiwc to the nii'atus. Thi-se iissures are moisteiieil by a A\\i\\X exudation. The severer forms of <'czema are obstinate, not yieldiiij; readily to treat- eieiit, and fre(|ueiitlv relapsiiif;. Diagnosis. The characteristic feature of this disease is an exudation .md crustinji. The stafje of exudation m.'iy have passed before the I atieiit conies under observation: but the history will reveal a jx-riod ,,i ili.scharse, and removal of crusts will show a moist surface uiider- II nth. The chronic .s(|Uamous form may not easily be differentiated from i)ityriasis simplex: but this is a matter of no ^reat imi.ortance Ml far ar: treatment is coiuerned. Treatment. This is almost wliolly local, yet certain general condi- tions, especiallv with children, .shoulil receive attiMition. Care of the .reiieral health," the rejiulatioii of <li('t, limiting; this to simjiie ea.sny- diyiesteil food, and at rejiular intervals, the use of cod-liver oil. syrup uf\\v' iodide of iron, and Fowh-r's solution will be helpful. Adults niav re.|uire similar care, especially with regard to difrcstion, reiia or cardiac disea.'^e. pouty tendencies, etc The first care in local treatment is to remove all sources of irritation. If this is the too free use of soap and water, suspension of this and the ajiphcation of an ..leaginous preparation will (juickly bring relief. The irritation may be due to an acrid discharge from the middle ear. and it this can" be overcome the eczema will often recjuire but little treatment lor its cure. In a general wav it may be said that for acute eczema soothing applicati(ms should be used, while in the chronic formstimu- lalion is re.|uired. In the early course of acute eczema, in the period of heat, redness, and swelling, a solution of subacetate of lead will relieve the pain. A litlli> later Hebra's diachylon ointment is ;. most .sitisfactory ap])licatioii. The ofhcinal benzoated zinc ointment is also much "used. The treatment of chronic eczema will re(iuire much jiatieiice. There will be periods of imimnement and relai)se. ()n the occurrence of exaceri)atioiis. with redness and a.lde.l irritaiioii, the a.stringent ointments, as those of lead and zinc, should l>e "^J'd. The diachylon ointment is made more easily applicable by dilution I u If 1082 THE EAR. with olive oil or "rold cream." As [)repare(l it is rather hard and stitT. When no progress is being made, when |)ain and other indi- cations of acute exacerbations have long been absent, then stimu- lation must be employed. For this purpose strong solutions of nitrate of silver have long l)een used. In .some eases of an obstinate character, in which the ear is thickened and distorted by tlie chronic proct's.x. applications of acetum cantharidis will set up a renewed activity, endiufi in improvement. The usefulness of oleaginous prei)arations depends, no doubt, in good i)ar\ ujion their (pmlity of protecting tiie .surface from the air and from wat(>r. The injurious influence of the latter in this diseiuse is understood even by the laity. In order to secure good results from any application the crusts must be removed; this is to be done in a maimer as little irritating ius possible. The crusts should be softened by the use of olive oil or Vitseline, after which they can be quite readily .separated. The objection to the use of ointment in the auditory canal, be- f" ^ cause of the risk of obstruction from the accumulation, can be obviated l)y ia-^tructing the patient to wipe out the canal each time before making a new ai)plication. Herpes zoster occasionally affects the ear, but it asually occurs only in connection with manifestations of the diseii.se in other localities. It is at- tended by severe pain of a neuralgic character and the formation of ve.si- cl(>s along the distribution of nerve branches. Pain may be so severe as to call for the hypodermic use of morphine. After rupture of the vesi- cles, application of some sitnple oint- ment, as tii.it of zinc oxide, is to be made. Lupns also is rarely seen, except as accompanying the same disease of the face, and even in this coimec- tion it occurs in but .") per cent. f)f thecises.' Lupus vulgaris and lupus exulcerans are best treated by the galvanocautery. In the latter form the sjjongy graiuilations are first removed with a shar|> spoon, after which the galvanocautery is thoroughly applied. This vigorous trentm(>nt ought to be use<l early to prevent, so far as possible, the (Icforin'ty resulting from loss of tissue aii'l cicatricial contraction. These ca.<es are proper sui)jects for tr(>atment l)y the r-ray. I'rivuirij sjiphililic nffcclion of the auricle is to be mentioned only as a ciirio-^ifv. I'ulitzer refers tn but four such c.nses. Secomhiry eruptions may occur along with the general symptoms, taking on the I Journal of Laryngology, Kbinology ,- and Otology, 1900, toI. xv. p. 451. Thickening and ilelDrjiu 1 y due (o chroiiie ccz^-tiia. il tin* uiiiiule (Baco.n.) DISEAHes OF THE EXrEltSAL EAR. lo«:j H-nuvinour., pustular, or p.ipular f..rin, whichever tlie cutaneous inuni- IVstatiou happens to be. _ u„,„„ \ii(.tlier of the rare affections <.f the ear is cnrnu humnnum, a horm Krmvth sprinKinR fn.n. the outer border of the helix. One svich cuse has come luwier n.v observation. It occurre.l u, a man ab.mt sixty- tliree years of sige, an.l vvjis situated on the upper x.rder of the helix. The erowth stood nearlv upright, although curve.l a little backwan. It wa!s of a dark color, of horn-like hanlness, and .hstinctly striated. Its length was one-half of an inch, and the greatest diameter at the l,a.se one-lialf of an inch. The base was exquisitely sensitive, as a result of the mechanical irritation from accidental movement of the growth in brushing the hair, etc. He laughingly told me that he had suffered much from the well-meant oHiciousness of friends, who. ob- serving the growth in the * iliglit, mi.stook it for a bug or a fly, and with a quick movement, intended to dislodge or capture the bug, gave the ear a blow which caused much pain, because of the sensitive ba.«e of the neoplasm. The growth was removed under cocaine anaesthesia, an elliptical cut being made through the skin, the base dissected out, ■m\ the cut edges of the skin brought together by a few fine sutures. Healing was by first intention, and after four years there is no return )f the growth. . ^ ■ Of benign tumors of the auricle, fibroma is most common, an. sebaceous cyst, perhaps, comes next in fre<iuency. Lipoma and angioma are'said to be exceedingly rare. MaUmant disease of the ear may be primary or secondary to its •mnearance u))on the face or neck. According to Cnnal,' who ex- uIEd the slatistics of the Glasgow Ear Hospital, in 15,0(K) cases malignant disease was recorded six times, four epithelioma and two sarcoma. Epithelioma appears to be less rare than sarcoma, and the former more fre(iuently attacks the auric e, while sarcoma is ottener found in the canal than in the external ear. Conna s case was a spindle-celle<l sarcoma of the canal. The child, a girl of six v.-'irs .li.Ml of recurrence after seven moiuhs. I have .seen one similar ;.asein a bov three vears of age. The growth fille.l the external audi- torv canal " From its color, consistence, and the attending <hscl.arge. it was a.ssumed to be a polyp. It was rem.ned under ether, an.l ..r- tuintelv submitte.l f.ir microscoiiic exannnation, which proy.l it ,„ he a r.,un.l-celle.l sarco.na. Rapi.l recurrence, with extensive m- volv.-ment of the surroun.ling structures, t.iok place an.l the child died ab..ut six months later. In case of malignant .hsea.se of the •u.ricle operative treatment shoul.l be resorte.l to as soon as diagnesis is ,na.le and the entire auricle sacrificl if nece.s.sary. Successful n-sult has been reporte.l, even when the parotid and cervical glan.N had to be remove.! because of involvement.' The occurrence of marke.l an.l persistent pain in connection with . Joum.1 of LarynROlngy, Kl, ..U>Ry. an.l Olology. November, 1899, p. 606. « Buraett. Ear, Now, Throat, isa, vol. 1. p. 161. 1084 riit: EMI. new prowtliM in tlio ranal shmiM cxritc suspicion of miiliRiiancy ami Icail to iiiicrosco|(ic cxaniiiiatioii. TIh-m- cases often come under observation loo late to jHTinit of operatic" with any iiope of suceess- ful issue. The loxins of ervsipeias, as advocated hy Coley, niiniit !«■ tried in so desperate a situation. Wounds and Injuries of the Auricle. It is an anomaly that wounds and injin'ii's of tiie external ear. exposed a.s it is, should he .so inueh rarer than injuries to the nienibrana tyrni>ani hidden away within a bony cavity. Statistics show that a serious injiny to the external ear is a rare accident, while a wound of the drum membrane is a relatively common occurrence. I'erhajjs the most fre(|uently seen deformity of the aurich- due to injury is tlie slit of the lobule from the tearinj; out of an ear-rinp. ICven this occurs less fre(|uently than formerly, witii the jia-ssinj; of the vofiue for wearinj; ear-riufp*. When this deformity exists the individual rarely cares to pi to the trouble of havinji the te.'ir closed, although a tritiirit; plastic operation would overcome the defect. Injuries from blows or falls sometimes cause marked deformity due to loss of substance, either from direct laceration of the tissue or from thi- subse(|uent inflammation and necrosis. The author has seen a ease of the loss of the upper half of the auricle as a result of a fall from the old styli' "ordinary" bicycle to the frozen ground. If an incised wound of the auricle is seen soon after the injury the edjres tihould be approximated and held with tine interrupted sutures, fieneral suniical rules beinji followed. In all operations abo\it the auricle strict antiseptic precautions are of course to be observed. If the wound involves the cartil.age, with the intefiument on either side, it will be well to follow D'-nch's sug- pestion and ])lace the stitches posteriorly, carrying them through the cartilage and into the skin anteriorly. The sutures arc thus jilaced subcutaneou-sly so far a.s the skin of the ex])osed j)art of the auricle is concerned. With laccn.u'd wounds ctTort must bo -nade to pre- serve as iiuicli tissue as possible, to avoid subsecju. : deformity. To this end aid is derived from t!ie use of cil I applications following the injury, thus ])reventing, so far as may be, severe iiiHanunatory reaction. The case ferred to in \\w Journal of Lnriinijoloijii. Rhinol- (Mljl, (tiul Oldoijii, l.v.lii, p. 270, offers en.-ouragement to the idea of pro- serving a-s much tissue a.s po.ssible. In this ca.se the ear Wius com- pletely bitten off by a \niious liorsc and drojjped in the stable yard. No ap|)liances wer.' at hand, so it was simply clean.sed with warm water and sewed on with ordinary .sewing needles and thread. Unioti, with hardly any disfiguroment, took place. The results of contu.sed wounds of the oar vary from a .slight inflammation to that disorganization which may follow a blow from a prize-fighter. Seen early, before extravasation of blood has taken place, cold in the form of an ice-bag or a Loiter coil is to be applied. If extravasation of fluid ha.s occurreil this is to be aspirated and the walls of the cavity helil in contact by pressure of the dressings. The device suggested by Dr. (}. H. Hickok and referred to by Hm-k servos a good ])ur{)ose. DISEASES OF THE EXTEHS.XL EAR. 1086 riic rln-ssinRs arc held in [)lao«' J)y strips of uood plaro*! parallrl to cacli (itlicr in fn.nt ami hack of tin- oar, am I tin' proj<-<-tiiiK ends aUovc arul Im'Iow an- held togftlHT by cljLstic liands. It is possible to adjust the dfKrcc of pri'ssiirc to a iiicity, and the ai)plianc(' is li)iht. If Mippuration has occurred incision must lie made to evacuate the pus. The interior of the cavity shoulil he scraped and packed with antiseptic Hiiuze. Pressure ran Ix- maintained durinR healinR l>y the appliance just mentioned. Frost-bite. Those of m who, in our boyhood days, pursued %viiit<T siM.rts with a zest too keen to Ih> disturbed by tiiiKlinR ears will recall the apiM'aranc<' of a cotnrade's frost-bitten ear. In the first stage, when the muscular walls of the bl(M)dvessels were paralyzed, the ear was of a deep-re<l color, then with greater degr if cold became the waw white of the really frozen ear. This, especially the white color, was likely to 1m> true of a part only of the ear, for the condition was .Mire to be discovered and treatment applied before the whole auricle Kio. .ViS. Fl<i. W>7. OihKmatonia (1^ and the rcniliant deformity (2). (niirBHR.) was frozen. The treatment, too, of ai)i)lying snow while the ear was ihawiiiK out, and this out-of-doors rather than in a warm room, is the same iWi is recommended to-tlay. The aim is to lestore the frozen part gradually to its normal temperature. If the part has remained frozen too long, or the normal temjierature has been restored too suddenly, inflammaticm results which may end in perichondritis or gangrene, with loss of substance. Should this occur it must be treated on general surgical princif)les. Othematoma, a transudation of blood beneath the i)enchondrmm, occurs ius a result of injury. It may also occur without any history 10S« 77/ A' KAIl. of tnturimtisiii, <-!<|)i>ci:illy in the iiisaiic. It him Immmi cIiiIiiumI tliut tlu' alTcctiiiii is |xTiiliar t<- tlic iii?'aiii', that some cfn-hral lesion is r<'s|)(iiisil)lt lor tlx' cliaiiKi*^ whicli lead to tlic traiisiulation of hlooil. It scciMs nion- rcasonaltli', liowcvcr, to attril)Ut(' tin' tissin- cliaiifst' prnhsposiiiK to otliainatoina to tlu- (Icliiiity and tnalniitrition of llx'sr patifiits aii'l to tJK' tiU't tliat tlicy arc pccuhariy iial>li' to violf-ncf, rather tiiai to any patliolojjical coiiditi.in >>f the l>rain. With the nii>re humane treatment of the insane at present, eases of otha'inatoma are less freijiient amoiin them tiian formerly. If the cji-se l)e trau- matic the ctTusion of lilooti is attended l>y considcrahle pain. The swcllinjt is usually in the upper anterior part of the ear, and the color is a liluisii red. If the iLcmatonia aiiris is of spontaneous origin it is attended i)y le.ss pain, lu-at, an.! ♦ • ii than when due to injury. The proKUosis, in tin- ahsenee of sei..'u.> injury to the cartilage, is favorahle. It is less fa%'oral)le in case nf -■■vere inllammatory reaction neces-itatinj; incision anil evacuation of the fluid, and it is 'o he l)orne in mind that ileformity of the ear may lesult. Treatment. If the tumor is recent, small, and painless, it should not he actively treated. If ther" is pain an<l redness, the swelling heinj; of recent orijiin, cold applications are to Im.' employed, as the ice-haf; or Leiter coil. In the presence of pus or of a marked deftree of tension incision should at once he made, anil if the accunnilation he considerahle, the incision should he free, the interior of the cavity curetted, wiished with jin antiseptic .solution, and packed with anti- septic gauze. DISEASES or THE EXTERNAL AX7DIT0RT MEATUS. Impacted Cerumen. .\n :iccuinulati()n of cerumen is the most cmnnion atTectiim of the external .auditory canal. The glands which secrete i-erumen ar(> found almost wholly in the cartilaginous portion of the !iuililnry ciiial, and when the c;mal is entirely filled with ceru- men it is hecause the gradually accmnulating mass ha.s heen forced into the deeper part hy the etlorts of the patient to clear the ear. .Micro.scopically examined, the ceruminous glands are found to he like the sweat glands. The secretion is fluid and of a light-yellow color, and on exposure to air hecomes inspissated and turns darker. Etiology. The cau.ses of the accumuiatioti of ceruiiieii within the meatus are, first, an !if)normal narrowing of the external meatus which thus interfer(>s with the free external movement of tlie cennnen; second, an altered character of the .sei-retion which, heing thicker and more tenacious than normal, is less readily extruded; third, increased (luantity of the secretion from hypera'inia of the lining memhraiie of the meatus. This hypera-mia is often a.s.sociated with n.asopharyngi'al catarrli as a reflex phenomenon. Hypera'inia of the lining of the meatus is fre(iuently induced and mair't.'iincfl by the habit of digging in the ear with a pin. an ear s[)oon, or other foreign NLi..iW»T ^?W frnFF^F^F^mp im lUSE.iSHS OF THE UXIKKSAL AVUITOHY VKATCS. lo87 ImmIv. The paticiitH own j-fforlN to clear the canal often reHiilt in fiireinn the niiiftt*. noft !is it in when first secn'ted, inward toward the lynipanuni. A foreijfn lnKly in the meatus to which tiie eerunien adiieres is sonietinu-s the IM-Riiniing of an accunnilatioti. The writer h,is twice in one individual found a pledget of cotton in the mass of nn<-n removed. This the patient liad inserted in the ear and ;otteii. In another case a cherry-pit was found at the Ixiltoin I'crunK torn ul the mass of cerum<' . This patient was an adult who had not I he remotest idea how .• when the pit wius put into the ear. Symptom!. The sympioms vary with the amount and position of til rumen. It is not unusual to find a large .iceuimiiation, of which the patient is wl-.olly unconscious. S) lotijt a.-< there is no pressure upon the drum memhraiw' there are no subjective sounds, and if there i> even a very small sjiace iM'tween the cerumen and the wall of the meatus hearing is not impaired. < )n the other hand, a small «|uanlity tiiMV he moulded hy » tTorts at removal so as to completely occlude ihf mealus. and thus cau.-^e deafness. When the meatus is iiearly tilled with cciumen the patient may have periods of imcertain and. to iiim. unaccountahle deafness, (iep<'iidin« upon the closure and upeniiiK of the small pas.sajte iM'twet'ii the canal wall and the wix. The hrst heated term in summer is liki-ly to hrinp to one's oflice a ct>ii.>i(l rahh' immher of people whose hearing has become sudtlenly and .seriou.slv impaired by the swelling of the plug of cerumen from the moisture of perspiration. As a result of filliuR of the external r:uial there may be a feeling of confusion, even to the impairment, ill some degree!! of mental processes; this is a reflex symptom, and is not dependent upon loss of hi'aring. There is also a peculiar reso- nance of on(>s own voice—autophony. If the accunuilated ma.ss is so situated as to make pressure upon the tympanum there are sub- i-ctiv sensations of sound, and there may be vertigo as a result of this p;-.-ssure upon the ossicular chain. The walls of the meatus are .-oinetimes much dilated in conse(|uence of desiiuamative inflanmia- tioii, set up by the pressure of cerumen as a foreign b()dy. An occr.- sioniil case of chronic supjuiration of the middl ear is attended by scri((us symptoms because of the interference wnii draiiiage inter- posed bv impacted cerumen. When the <|uantity of discharge is small it slowlv dries in the canal along with the cerumen into a mass Ml <'ement-likf ! ardness. If for any rea.son there is an in'-"ase in the flow < f pus it can find no exit, and is forced inward with risk of riitering tl. crani-d cavity. Diagnosis, lixamination with tiie s[)eculum, or sometimes without 111.' aid of .:istruments, shows the meatus filled with material, the color and c >.isistetice of which will depend upon the age of the accu- mulation. It may f>" a soft, piusty, yellowish-brown ma-ss, or nearly black and of stony hardnes.s. ^ Prognosis. Although the hearing is commonly ro^tored upon ' removal of the cerumen, it is yet wiser to give a guarded prognosis, as it is impossible to estimate the degree of damage which ti ear n^^iBiv It 188 THE E.m. may liavo sufTcrod from prorcdiiifr iiiflainmutdry iirocossos. Suppura- tion may follow the removal of inspissated eerumen in those eases, already referred to. where ehronie suppm-ation is attended hy hut little diseharjie. The ri iiioval of the pluj; does not set uj) the sup- puration, hut uncovers what has been hidden. This situation should he explained to the i>atient. Where the onset of deafness is sudden, as after a piuiifie hath, or after jjrohmRed perspiration, a favorable ])ro};nosis can safely he jjiven. Treatment. In the (jreat majority of cases the canal can he cleareil more ])rom])tly and more afireeahly to hoth ))atient and ])hysician by the use of the blunt curette than with the syrinj^e. The necessary mani|iulations may re(iuire more skill and delicacy of touch than are calieil for in syrinpinp;, yet a little careful |)ractice ought to enable one to do this without causing the i)atient i)ain. The very exercise in such nianip\ilations increases one's dexterity and gives him t'.o advantage of added skill for more delicate work. Should familiarity Fig. 558. Bacuu's ear syriiiKe. in the use of instruinents be lacking, or if the wax is soft, tenacious, and adherent to the drum membrane, then the syringe and warm water nmst be u.sed. If s|>ecial basins are lacking a finger-bowl may be held under the ear to relieve the outflow of water. This the i)atient holds while, with his left hand, the i)hysician lifts the ear upward anil backward to straighten the canal, and drives the wat(>r into it from the syringe held in the right haiui. The stream of water is to be directed along the wall of the canal, |)referably the su])erior or posterior, that the fluid m;.y be insinuated between the cerumen and the canal wall. In this way the wax will soon be dislodged by the return flow of water. If the How of water be directed against the centre of the ma.ss the tendency will be to force it more deeply into the canal. There are eases in which it is next to impossible to use the syringe eft'ectively, since the wax is very liard and fills the canal completely. Here it is necessary to tunnel a pa.ssage through the wax with the l)lunt curette worked carefully along the canal wall. This can be done without inflicting pain if the instrument is carried in ilat and pressure i> e.\crted only toward ihe wax. liasing made the small passage, water can now be forced into it with good j)rosppct DISEASES OF THE EXTERXAL AUDITORY MEATUS. 1089 ,,| ilisloilpiifi tlio appiiimiliition. After syriiijiiiifl the ciinal shmiKl he iliiiioiiKlilv cloaiK-d aiul dricl witli tin- cottoii-canicr, and, especially in cool weather, a small pledfjet of cotton inserted, to he removed at nifiht and not replaced. K. I.. Mierhof commends the use (jt undihiteil snl|)lmric ether, poured into the external au(htory canal. n ther acts in a few seconds, partly dissolviuK the cerumen from ii< attachment to the canal, so that with the most R.'utle syrmjtnis the |iluf; is promptly removed. Circumscribed Inflammatiop. This jiainful affection occurs as tiie ivMilt of an infection, the specific perm, staphylococcus, for example, invadinji a hair follicle or fjland. It is more likely to develo]) m a (anal hatlied in pus from a chronic otitis media, or m one which is ilic seat of a chronic eczema. The infection may he conveyed hy the instrument which the i)atient uses to scratdi the ear. Symptoms. The most prominent .symiitom is pam. hut this varies .'n-niv in inteiisitv, dependiiift upon whether the furuncle is super- ricial or d<"ep seated, or whether it is located in the cartila-jmous or |„,nv i)ortion. It is most painful when deep seate<l and m the hoiiy portion of the canal. Should the swellinji close the canal, deafness and tinnitus result. When .situated anteriorly movements of the jaw are i)ainfiil: if posteriorly the jiain on pressure and the swelhiifr may -iifT^rest inflanimati(m of the mastoid process. The ear .^hould he examined with tlii' utmost p-ntleness, :i.s it is extjuisitely .sensitive to touch when thus iiiHamed. Reflected lijrlit without the speculum will often he suflicient to locate the furuncle. Diagnosis. This jiroci'ss may easily he mistaken for diffuse uiflain- inalion of the canal or, in some cases, for mastoiditis. In diffuse in- ilammation the swelliii;? is more uniform and is concentric: m furuncle it is ioc;iliz(>d. and even with mor(> than one furuncle sejjarate swellings can he made out with some one imint of each which is most sensitive. The pain on ])ressiire over the mastoid is found to he superficial rath(>r than deep .seated, and is greater on pressure toward the ear rather tlian toward the mastoid. Without treatment, or imi)roi)erly treated. (ir if the patient is debilitated, furuncles are ai)t to recur. Treatment. The use of leeches has heeii advised, hut is of little avail in relieving i)ain. Hot applications are somewhat soothing: lint incision is the most etTective means for relieving the i)ain and cutting short the inflammation. I'.ven if done before the formation ,.|' pus the les.seniiiir of tension and the bl ling following free incision l.ave a most favorable infhienc(\ .Vfter incision the ear should be ^ ringed with a warm antisei)tic solution, and if there is any tendency ti.w.ird recurrence or die formation of granulation tissue, alcoholic M.hition of boric acid or bichloride of mercury should be dropped into tl\e ear. The lining of the canal may remain inflamed and sensitive following the eruption of furuncles. Besides the annoyance to the patient, this state leads the more readily to the formation of suc- 1 New York Medical Journal, August 24. 1901, p. 351. 09 mm lOltO Tin: EAR. cossivc series of boils. It is tlicrofore advisahio to inako uso of soiiif sootliiii); oiiitniciit foliowiiifi tiic acute staj^e, ;us tiie (liaciiyloii diluted with equal i)aits of "eold ereaiu," or, if a little later slif^ht stiiiuilation he indicated, uiiji. hydrarfj. aniiuoniati, oni' part to two of "cold cream. " A vi;;(»r()us plan of tonic treatment is to be employed if the patient's jjeneral health is reduced. Diffuse Inflammation. This may occur as the result of injuries to the canal from scratching it with pins, hairjnns, etc., the presence of foreign bodies, or roufjh attempts to remove them, from the instil- lation of irritating fluids, an acrid discharge from the middle ear, or the occurrence of fungi, etc. Flu ."iW). Bacon's cuppiiiK glass. Bacin's >:parilioator. The severity of the symi)toms varies with the i)art involved and the degree of inflammation. The i)ain is more s(>v(>re when the osseous portion and drum are involved. The hearing is impaired mi propor- tinii to the swelling and piling up of pus and softened epithelium. After tile stage of serous exudation an examination of the canal shows it to he narrow and lined with a whitish, sodden membrane made up of epiilermis and [)us. and filled with micrococci. The n^moval of the softened layer uncovers the reddened swollen lining of the canal. Promptly treated, the process may end within a few days, (jr it may go on to the chronic form, to the damage of the canal antl the drum menihr.'iiie Treatment. In the early stage with sev(>re inflammation l)l()o(l shoulfl be abstnicted either bv leeches or with liacon's artificial OTOMYCOSIS. nm Icirli iii)plio(l near the trapis. Irrigations of tho canal witli a hot antiseptic solution is also a(lvisal)lc. If there is much swdhns free incision shoultl i)e iiiade. After the subsidence of tiie acute syin|)- tonis tiie canal is to he carefully cleansed l)y syrinsinR and dried with llic cotton-carrier, and boric acid and oxide of zinc in ('(jual i)art.s siiould be blown in. In case of the formation of granulations, these are to be removed by the curette, and an alcoholic solution of bichloride of mercurv or borolyptol instiUed. Strong solutions of nitrate of silver are often ap])lied at this stage. Constitutional treat- ment mav be recpiired if the i)ati(>nt is much reduced in general health. OTOMTCOSIS. Inflammation with or without discharge from the external canal mav be caus(>d and continued by the growth of fungi. The inllain- niation of the canal excited by this growth is termed otomycosis. I'lic fungus most comiii(.:..y found in the ear is asi)ergi!lus, ot wliich there are .several varieties: only two, however, are usually Fig. r*i. XtpcrKill"" nistrlcans. A. Mjceliuin oovere.l with numemiis fallen s|Hiri's. B. njpha. C. Si-iraiiKiura with rii« i.ports. B'. Hypha. />. Kcceplaeiilum. E. SieriKmatu w.th sixm's. I'ril.lTZEB.) tnr by ill :il' ,'1111 In. ]m ,|c( re;; •t with, aspergillus nigricans and aspergillus favescens, nigricans far the most fre(iuentiy. The growth is most likely to flourish a canal which has been" the seat of disea.se and contains exfoli- •d epithelium, or into which oily solutions have been instilled 1 allowed to remain. Cases are said to be relatively frecpient in lia under the combination of heat, dirt, and dampness. The 'sence of this growth maintains a chronic otitis externa and may ,1 t'> injnrv of the canal an<l membrana tympani. When the ■per layers of the skin are involved a considerai)le degree of pain ults. and in anv case there is itching or irritation. Tinr.itus and m mm^ lori THE EAR. i„„,ainn<-i.t <.f h-'arinp attrn.l the tilling of tlic canal aii.l tl.o uiHani- ination ..f tl..' .Iruiu incn.l.raiu-. The ..crurroncc <-! as!..T};illiis mgr^- cvx^ inav hv mistakci. for cmuiu-n. This error should he rec.nnize.l o'„ reiMoVal of tli<> mass, as its eonsisteney is lu.t that ot eerumeti. •uul the surface exix.sed in the meatus is foun.l to he ml an.l swollen. TlK' niifrosfopic examination renders diaRiiosis eertam Ihe j.roji- n,M-< i-^ Rood. Treatment consists in tlie cleansmj; of the canal and tl„. use of antisejitie solutions. Solutions of l.ichloride of niercury in alcohol have been nuich used and caiu.ot fail to he efficient it „ersiste.l in. Considerable time is often re.iuired. however, and b„ll, the mercurv and the alcohol eau.se much smarting' in the inHanie. canal Dr" Samuel TheoboM' recommends the msutllation ot e<iual parts', .f boric acid and <.xide of zinc after thoroufjlily eleansuift the ,aual. In a tvi-ical case to which he ref.-rs it was necessary to rep.-a the ai.plication but once. This treatment .s adv.se. 1 for the utU'ndan inliammation of the canal as well as to .lestroy the tungi. IheoboUl has employed this treatment for seventeen years. FOREIGN BODIES. Foreign bodies mav be foun.l in the external auditory canal of b„th childn-n and adults; but it is the ear of the chil.l that the „toloKist is most freciuently called ui)on to explore for ost tivasures. The raiiffe of objects which may be found in a child s ear has no limit sav.' that of size. I. adults the occurrence is the result of accident or the entrance of an animate object, as a buR or a tly. The eiiK^ of the common house fly are sometimes deposite<l m a canal containiiiR pus. The subseciuent development of the larva- causes a condition both distressiiiR and disgusting. Short, stiff hairs occa-^ionallv fall into the meatus and rest against the membrana tympani. and the movment of the jaw in mastication causes friction imiduciiifi annoyiiifr symi)tonis. •,<••♦ Symptoms .\ h.reign bodv inav lie in the meatus for an indefinite period and give rise to no svmi.toms. There is no lack of record.M instances of the tindin-i <.f such b.-dies which have lam m the canal for manv years. Oceasi.mallv the dislodgement of such an object, which has "caused no annovance. brings it in contact with a sensitive part giving rise to severe svmi)toms. Some sub.stances. such as bcan"^ or s<'<'ds. which swell on being nu.istened, cause distres.s after sea-bathing, for example, or in case the -anal is filled with pus from a supt.urativ.' otitis media. ( )n the whole, howe' (T, the worst symj-toms caulked bv foreign bodies result from the uiskhful attemi)ts at removal on the i)art of frightened relatives or inexperienced physicians. Diagnosis. If the patient be sec>n befoi.- any attempts at renioval have been made diagnosi> is ordinarily a simple matter. \<mr. I Johns Hopkira Hospital Bulletin, 1898, toI. ix. p. i)l. FOREIOS BODIES IN TUE EAR. 1093 lildrcii. howovcr, arc so iliicc t was inserted, and are so inietinies unal>le to say what kind of an unnumageable that no satisfactory ixaniinatioii can he made. In surh ciu^e tlie i)atient sliould Ik- ether 1(1 treatment are comparatively snnj .ie. In lation ;;',l,;:r cases the canal lias be.-n s.. injured by unsk.iiui 'nx*'"'!'^'^ ";; .....novai that the foreign. J.o.ly is conceal.-.lhy ,lru-d b bod or by the swollen walls of the canal, and the diapiiosis is i iHicult Zgn^s. The canal is .[uite tolerant of fore.gii bodies, and the „n.Knasis de,.ends rather upon the viol.-nce which \v^ been done to e arts by rough attcnpts at removal than upon the character o . , j,.et in tl... canal. Should inH'i"'"'ation a n.uly have extended ,,, ndiacent ,.arts, as the middle .-ar or mastoid, this is indicated by -viiiDtoms iM-culiar to involvement of those regions. , . . . ■ T;eatment. The means to be adoi)ted for the removal of a foreign |„„lv will depend upon its size, shaj-e, and cliaracter, and whether , canal is much Swollen. If the object is not large the syringe .hould be used, since it affords a j-rompt and painless method. If i, 1,0 a s..ed which swells on being moistened, and is not at once re- iMoved bv the svringe, instruments are to be employed Ihe blunt ...>,' ' e hook are hen> likely to be most useful. If the object M such shape that it can be securely gra.spe.l by the slender forceps hi i, t vament mav well be us.-,l; but many foreign bodies are nde ml hard, so that the attempt to grasp them with the foiceps rcis them more deeply into the canal. This instrument, there- re must never be emph.yed unless there is positive assurance that io g asp can be ha.l. When the object is round like a gUu^ l„.n 1 a pebblo, ora fruit-pit, and large enough to quite fill the canal ; . .'tiig a stream upon it from a syringe but forces it further toward . f ndus Bv searching carefully some point will be found where •ri a little Ipace between the object and the canal wall, and the 1 'ouk ia^Jied flat can be pa^ssed behind the body, when, by giving the Fio. 562. ff t^ Fiu. 563. 30C= Hooks for removal of foreign bodies. i,w.n.ment a quarter turn, the sharp p.Mut wnll be in position Jo ,iraw the object out The blunt curette may perhaps be more safel> used- ;l:.nv''event nc-such manipulation is to '--♦^^^J^^l'-'-Ji; ^l' ^ ,„„.l illumination. To lift a sniooth, round body ""' ;^^™7/J ,...,. ,.,„.al the use of a camel's-hair pencil dij-ped in cemen or th cK hu- h s been suggested. The object an, canal must b.- tlioroug..^ dried t a the glSmay harden and sufficient time be allowed for the .'" -,. , T fj . lnna .A.V.-^*' m i f i ; : i ! ii\ ill i!i • J ; !'t: i.i iin ^r li •Mi 10i)4 THE UJi cement or pliio to boromc lixcd.' Wlicii tlic Iditijin IxmIv lias hocoiin- iiniiiictcd ill tlic l)oiiy portion of the f;inai and tlic cartilafiinoiis jxir tion is so swollen that tlie ohjeet eainiot be removed by any ordinary nifans at eommand the radical proeediwe of disiilacemeiit forward of lh( auricle and soft parts of tin meatus must be em|iloyed. I'lider ana'sthesi.: the tibrocartilafiinous canal with the adherent periosteum is separated from the bone posteriorly. A transverse incision is made in the canal as near the drum memi)rane as possible, and the foreign body removed. Should the foreifin body be too larp- for extraction through this opening', Deiich ailvises that the space be enlarjied by chiselliiifi away a sullicient |)ni ion of bone. WOUNDS OF THE MEMBRANA TTMPANI. Wounds of the membrana tympani commonly occur as a result of the direct jienetration of a forei<:n body or from the sudden con- densation of air within the auditory canal. The membrana tympani mav be ruptured in fracture of the cranial bones; but it is liei. a matter of trifling importance in comparison to the lesion which it accompanies. The drum membrane may be laci'rated by any one of the numerous objects which |)atients insert into the meatus to relieve itchins; and irritation. An accidental movement of the ear- Sexton's foreign-body forceiB. (Two-thirds imtiiml size.) spoon, tooth])ick, end of a pen-holder, etc.. may penetrate the mem- brane. The writer has seen one case in which the meatus and mem- brana tymi)ani were woimdcd by the entrance of the tiji of a branch of a tree. .\ younp man en<:ajjed in trimminfr an ai)lile tree made an unsruarded movement of the head to one side and drove a small jirojecting blanch deejily into the meatus. Another peculiar accident ' See I'olitzer. l<in, p. 223. Il^-Jt- M'orSDS OF THE MKMJlBA\.i TYMPAM. lO'Jo vva- sustaincl bv a wniiiiui wliilo walking in tl.c (■..untry Sho was ,„,;,„ a narrow i.atli wl.cn l.i.-yclc ri.lrrs canic u]> l..-lnn.l her. M.e . ,.,,,,,.,1 asi.l.- 1.. atluw then. t.. pass, and n-cMv...! a ponrtratinp womu „f ll',. ,„,.n,l.rana tvn.pani from a small walking' stick winch one of il,,. riders carclcs-!v carried projecting: fn.n. Ins handle bar Lonp- ,„„,i„„e,l sni.pnration followd this ac.'id.^nt. A larp' pcrtorat.on ,,, ,i„. „,e,„hrana tvn.pani remains, and theheann- is n.uch i.ni.a.re.l ■n„. appearance of the wound will deixn.l on the f<.rm an.l size ..f ,1„. nl'jeet which causes the injury and upon the l.-nf:th to time which 1,.,. elai.s..d hefoiv the case comes under observation. H the wound iJ .Made l.v a relativ.'lv laifie ol.j«'ct a considerable cntusion rather ,1,:,„ laceration follow^ the injury, attended by sul.sequent milamma- ,i.,„ and sl.M.sihinf:. All th.-se woiiiuls are .luite like y to be l..llovve.l l,v inllammation and supp.irati.m. perhaps as a result ot diirct mlec ,i„„ at the time of the accid.-nt. The symi.toms atteiul.nR uch an ,,..idei.t are sevr.- pain an.l tinnitus, with fainting or pd.hn.-ss and |n.s of hearing. The acuteiu-ss of the symptoms subsides son...whaf. but the l.ain and tinnitus again increase cm the approach ot intlam- ,„ali,m. bong-continued snpi.uration an.l p.Tnianent p.'f .-rati.... „tt.-n ivsult from the.se acci.lcnts. The thick.Miing an.l a.lh.-s.ons which att.Mi.l \hv inilammatory pr.K-ess result in p..rman."nt l..ss ot h.aiing. The treatment t.. be f..llowe.l in these ca.ses is that Dr acute iJiirulent ilisetuse of the middle ear. Flo. 665. Fio 56*. FIG. 567. F.«. 56...-Rupture la the anterior inferior half of the membrane of a lx,> after a ix,x ou the ear. "";■; " V* inouble rupture o. the membrane of a woman thirty years „. age, caused by a fall upon (■,n.>eil by a large box falling upon her ear. (1'olit/.kk.) liuphircol the wrmhrmm ///'"Z'""' from c.m.lonsation ..f -lir wit'ain ,h.. m.-atus n.av b.' .lue to bl.-ws upon the ear, "a b..x on the ear l„.i„jr the m..st" riv.iuent illustrati.m ..f this torni of in,liiry. A tal , ,m t e ear mav <4iso the sam.- form of .lamag... as als.> the impact wnve hilo i.athing. lAl-l.-sions an.l th(- firing of heavy cannon ;;!.;.. Z ^ause-ltlns injury.' C-rtain con.liti.ms .,f the n.mbraiia .vMH.nni favor the occurn-n.-e .,f this form ..f in,iury. ami these are ,■„' • tn.i.hv calcareous .leposits, an.l cicatricial formal ions, (insure ;,f illi EusUichian tube. to.,, by preventing the reatly escape of air 109G rilK KAK. within the middle oar. favors rupture of the nioinbranii tyinpiini under tlie conditions named. Tiie syniitoin.' eaiised l)y tliis aceident are the s;ensation its (tf a loud report, jjreat pain, giddiness, and tinnitus. The decree of impairment of hearinj; depends upon the (himage done tlie labyrinth hy the roneussion. If this is .slicht the hearing will prohabiy he Imt little impaired, while, if considerable, fiernianent deafness and tinnitus follow. The mere tear in the nienibrana tyni- pani is not a serious matter, for it soon heals. If the case be examined shortly after the acciilent it will be (piite pos.sible to differentiate between it and an old i)erforati()n. The sh.ii)o of the rujjture is u-sually oblong, with oval sides and pointeil extremities. The edges of the opening are thin, sharply-defined, and show blood-stains. Through the opening the inner wall of tlie tymjianic cavity is .seen, not changed in color by inflammation, and thus differing from the apiiearanee in urdinary jierforations. Politzer says that upon infla- tion by the \alsalvan method air pas.sed through the ear much more freely than in the ca.se of orilinary perforation, and. instead of the liigh-i)itclird hissing sound, there is a free, deep, blowing souiitl if the accident has happened to a normal ear. If the ca.se is not c(un- plicated bv concussion of the labyrinth the course followed is usually favorable. Only rarely does suppuration occur, and this is connnonly attributed to unwise and too active efforts to .aid the healing process by the use of instillations. Permanent openings are more likely to result from such interfiTence than if the ca.se be left alone. Treat- ment consi.sts in non-interference beyond simply sterilizing the external portion of the meatus and protecting the tympanic cavity by the use of stoiilized cotton worn in the meatus. Hi : 17 i Hi m ill tin ml i I CHAPTER XXVI. DISEASES OF THE INTERNAL EAR AND AUDITOUY NEUVE; DEAF MUTISM. Hy K. a. CROCKKTT, M.I). Anatomy and Physiology. Tl.o intcmul car consists cf tlic ccrc- 1„;,1 |,.,rti.ii. of tlH- au.litorv iutvc, its trunk, an.l its cndn.Ks n. the lil.vrintli, the latter eonsistinfi of the osseous liihyruitii, cnveloi-mR til,." vestilnile three semicircular canals, and the cochlea, tonclher xvith the membranous lahvrinths contained witlun the former, the -iccule and utricle, memtmmous semicircular canals and nici .- liranous part of the cochlea. The foratnen ovale opens into t e vestibule as also do the mouths of the three semicircular canals, hv two (IpeninRs, the superior and posterior op(>ninR as one Tin- vi'stibule itself is an irregular cavity from 4 to b mm. in its dit- ferent axes. , . , ..• r 4V,„ The semicircular canals lie embedded m the petrous portion of the temporal bone, on the upper surface of which the superior project a^ the eminent ia arcuata. They lie in three i)lanes, superior, posterior, •md horizontal. The exterior portion of tJie latter projects into the inner wall of the tvmpanic cavity behind the Fallopian canal, bach canal is dilated at'its beginning into the so-called ampulla. The cochlea is a canal about 30 mm. long, turning two and one-half times around a central axis. It communicates with the vestibule and •d-o bv means of the fenestra rotunda, with the tympanum. It is ,.nib'e.lded in the petrous portion i,i the temporal bone between the int.TTial auditorv meatus and the carotid canal, with its base toward tlie internal uuiitorv meatus and apex towanl the tympanic cavity. On a vertical .section of the cochlea we see the modiolus ()r central canal, and on its surface an osseous plate-the lamina spiralis ossea - beginning between the fenestra rotunda and the vestibular orihce of the cochlea and running spirally to the cupola, where it ends in the p..inte<l hamulus. Hy this ridge the canal of the cochlea is sub- divided into the scala vestibuli, communicating with the vestibule, and the scala tvnii.ani, communicating with the tympanum by the fenestra rotunda. The two scahe communicate with each other at the apex of the cochlea bv the helicotrema. The membranous labvrinth follows in most part the contour of ,he osseous, just described. The menibranous vestibule ,s sub(liyide,l into the utricle an.l the saccule. The utricle communicates w. h t he semicircular canals by five openings, the saccule with the ductus ( 1097 ) rasra^^H «rf 109« TllK EAR. i 1 1 i * iii cDclilciiiis. lictwccii Ixith and tin- lateral wall of tho vostihulo is a very (Miisidi'iahh- s|»aci' tilled with pcrilynipli. The form of the iiiciiihraiioiis sciiiicircular canals is exactly thai of the osseoiw, and they fill the cavity of tin- latter alxnit one-third. They are station- ary, heinj; fiistened to the sides of thi' osseous canals by connective tissue, and the intervening space is filled with ixTilyniph. The most coniph'x structure found in the internal ear is the ineni- hranous structure and termination of the auditory nerve in the <'o<'hlea. Sprinninn from the free edjie of the lamina sjiiralis ossea to the proji'ctinj; li^i.-unenium spirale of the o|)posite wall is the mem- branous s|)iral lamina. This diviiles the cuial of the cochlea into the scala vestibnli and seala tyinpani, and ihi' former is apiin divided by till' membrane of Ueis.suer, which extends obli(|uely from the lamina spiralis o.s.sea to the external wall mto two canals. One of these, the cai.alis cochlearis, formed by the membraiia iKtsilaris, external wall of the cochlea, and membrane of Heissner, communicates with the saccule and ends in a cul-de-sac at the top of tlie cochlea, and contains the elaborate structure known as the oifiati of ("orti. An exact understamliti^ of the mechanism by which the sound- wave is transmitted from the middle ear to the brain is impossible with otir present knowledge. The vast majority of ol)serV(>rs believe that the sound-wave reaches the labyrinth by way of the lm.se olate of the stajM's rather than via the round window. The perilymph, beinR an incom|)ressible fluid contained in an unyieliling medium, receives re])eated shocks from the piston-like motion of the stapes' ha.se plate. These shocks are first received by the perilymph of the vestibule, then by that of the scala vestibnli, then by way of Heis.s- ner's membrane to the endolymph of the ductus cochlearis. By the vibration imparted to the lamina s])iralis mi-inbranacea these shocks ar(> received by the perilymph of the scala tynipani, and the outward and inward movement of fli<' membrane of the roimd window com- pletes the circle. Presumably the end organ of tlie auditory nerve is to be found in the cells of Corti's organ, and each cell vibrates in sympathy with a fixed t>>iie, and no other. As to the semicircular canals, the results of Flou; early experi- ments have been acce])ted by most writers to prove that they ])oRses.s no part in the perce|)tion of sound, but are organs nf ecpiilibration. The organ of Corti lies in the zona arcuata and consists of an imier and outer layer of fibres, the lower portic^n resting on the membrana basilaris, and the upper ends are coimected together. The outer row present on their upper ends lamelliform processes on which is fastene<l the lamina reticularis. The cilia of Corti's cells project through the oi)enings of the lamina reticularis, the lower jiortion of the cells res' g on the menibrana basilaris, and they are connected with the .luditory nerve bv thin filaments. No exact part in the perce|>tion of sound has l)een ascribed to the vestibule, although some observers think that the otoliths may act as dampers in diminishi.ig the force of the sound-wave. DISEASES OF rUE L\TE1{.\AL E.IU. lO'JD The rxnrt cM)iirs<- of the auditory iktv.- l)(>foiv it enters tlio ix-trous noition of the teiiii)or!il hone is still in disi.iite. It iiris.s in the iixMiulla oblongata hetw.-en the facial a- ' -lossopl.arynneal nerves, and is easily divide.l into two seetions: i. . ..•■r hraneh supph'-s the (dchlea, entt'ring at the modi >lus, and also sends a Itraneh to the ••Micule and ampulla of the vertieal semieireular eanal. The upper hianeh enters the vestibule and supplies the utrieulus anil the amiuillii of the semieireular eanal. The blood supply of the internal ear is derived from a braneli ()f liie basilar arterv," whieh enters the internal auditory meatus with ihe auditorv nerve. The r.'turn supply is into the inferior j.etrosal -inus, and there is an ana.-*tomosis with the tympaiiie vessels through the external labyrinthine wall. DISEASES OF THE INTERNAL EAS. These are primary and seeondary, and have been oonsidered as forming a >mall proportion of the total number of ear disea-xes; but it is eertain that the more careful the observation the greater the number of labyrinthine ca.<es recorded. The most connnon primary diseases of the internal ear are hemor- rhages from fractures of the temporal bone, and from the active changes common in nejihritis, diabetes, and syjjhilis, and injuries to tiie auditory nerve, either in its course or termination, by blow.s on the head, or pressure of new-growths. liv far the most common secondary disease is the invasion of the vestib- le bv osseous changes in the neighborhood of the base i)late <if the stajies. Purulent jjrocesses in the labyrinth by extension of a middle-ear sui)puratioii are a rare but very serious complication. I'ractures of the petrous portion of the temporal bone may cau.se deafness by a direct solution of continuity of some portion of the auditory nerve, or from the resulting hemorrhage ilestroying the nerve fibres. Infreiiuently, severe head injuries may cause hemor- rhages into some jKtrtion of the internal ear, without fracture of the lemjioral bone. The svmptoms in both these conditions are essen- tially the same. The deafness is practically complete in the extreme cases, although, as a rule, aerial tone-perception may remain for >ome portion of the scale. In the le.'ss severe, a portion of the musical scale may be struck out, usually in the high tones, the remainder bring vuiaffected. With this deafness, which is commonly at its maximum iminediatelv, are a.ssociated vertig(,, nausea, or vomitmg, ,111(1 a loud and jHTsistent tiimitus. In severe cases the vertigo may be so "xtreme as to prevent the patient's moving even from side to <ide in bed, or walking without .supjjort. for one or two weeks, and in such cases the vomiting is very i)ersistent and may necessitate rectal feeding. These severe -ises are, of course, ai)t to be confused with tli(> cerebral symptoms ui head injuries; but the as.sociatiou of vertigo, IKN) Tilt: KAR tiaiwa or vomiting, tinnitus, an<i .icafm-ss in tlic aliKcnco of dtlur ciTfl.ial sy!iii>tiMn.s sliouid niakr llit' diaRnosis df tin- average caw p«'rl'ccllv clt'ar. In such patit-nts tlic prognosis as to tiic relief of symptoms is very im|M.rtaiit in a medico-lejiai way. Tlie deafness is almost always incural)le and permanent. l)ut non-progressive. The yertigo and timiitus. esi)erially in ca-ses where only one labyrinth is involveil, often aimoy the patient more tlian the deafness, ami it is extremely dillicult tolw definite as to the leiijith of time they will persist, exri^jit l)V wat<'hiiip the course of the case. The vertino often remains for n'loMllis, uraihiallv .liminishinn in inten>ity. and the tinnitus is fn- (lueiilly a matterof years. ( )ccasionally nystapnus will 1 I>served in laltyrinthine injuries and also in operative interference with the stapes base plate. .\ pr.'ciselv similar .symptomatology is ohservod in the hemorrhages from arterial deneneration in syphiJis, nei-liritis, dialx'tes, and the severe ana'Uiias. Where the hemorrhage is irge the deafness is exlieme. and the nausea, vomiting, an.l timiitus severe. In these persons the attack is often a|M)plectiform: tiie vertigo .seizes the patient when he is |)urs\iing his usual occupation or while asleep, often he falls to the ground without any warning, with severe vomit- ing lasting two or three hours. Such cases are often wrongly tliag- nosed as cereliral hemorrhage; l)Ut in the aliseiice of any loss of consciousness or of any local jianUysis, the group of .symptoms is plainlv aural. Whili- the severe cases are relatively rare, milder forms are common in the practice of every aurist. Transient attacks of giddiness with timiitus, hut no nausea, are quite conunon in arterial degeneration, and, as the accomiianying deafness may he in the upper registers only, it is frequently overlooked. In si. eh cases the e.ar comi)lication may be the first symptoms of the general disorder and. of course, any treatment imist be general and not local. this grou]) of symptoms coming on in the course of sy])hilis is much mori' common than is supposed, and may be either hereditary or acquired. The latter comes either in the late secondary or ter- tiary .stages, sometimes ten or '-'teen years after the primary lesion. Such ca.ses usually yield to ai)l>-'priate syphilitic treatment, and also show a remarkar)le tem|)orary ;;iiproveinent undiT the use of pilo- carpine either by nunith, or better, subcutaneously in full do.ses of one-eighth to one-<|uarter grain once or t»vice a day. It nvist not be forgotten that this is only a transient improvement, and should lie su|ii'lemented by the regular treatment for the usual length of time. In these syphilitic cases, especi.ally in the tertiary lesions, a correct diagnosis is often not made for a hmg time, and unless the proper treatment is begun within a week of the onset of the e.ar pym]itoms. imiirovement in hearing must not be ex])ected: but the use of ])ilocarpine will relieve the vertigo months after the occurrence of the attack. DlSKA.sKS i>F Tilt: ISTKKSM. KAH. 1101 This wnii- uniiip of syinptDiiw in ofli-n pnwiit in slight liihyrintliiiir ,|,pmrati..i» from any ••uumc Thic is particularly triif wIhtc ii tliiikfiiiiij; rxists alioiit tin- stapes l)as<' platf or tin- iiifiiiltraiii' of ihr rouiitl wini'.ow, so that tlif nioWilily of oiu- or tiotii of tl;'' r stnir- hUfs is atTfctfd. Where tliere is any increase of pressiu: in the liihyrinlh coniiM-nsation cannot l)e made, as is usual, liy the outward movement of thene structures, anil vertijjo results. The inerea.se of deafness may U- sli^iit, hut is always perceptible. Numerous attack*' o| vertifjo from this cause are ohserved in the course of fixation of ilic stapes in middle-iar thiekiMiinj!. Suppurative Processes in the Internal Ear. These processes arc always secondary to middle-ear suppurations and form a rare com- plication of thi.s disease. The ciiurse of the purulent iiitlammatiou is usually tlirounh the foramen ovale or the foramen rotuiula. and ilic lahyrinlli alone may be involved: but often tin- purulent process extends to the middle cerebral l'os.sa throunh the internal auditory meatus. In acute purulent inva.sions of the labyrinth the symptoms are iinmistakabh — the vertigo is very st'vere, with vomiting lasting li.r hours. In two cases which the writer has seen the vomitinp wa.s -c, extreme as to necessitate rectal feedinfj for two or three days. The de:ifness is. of course, total .soon after the onset of the attack. If the process extends through to the cerebral fossa' the symptoms ,,l miiiingilis foHow those of the labyrinthitis in from twenty-four to fortv-ei<;ht hours. In invasion of the internal ear a.«< a result of chronic suppurative proce.s.ses, the characteristic symptomatology is absent in most p;iticnts, and wo merely find a deafness of a higher grade than can lie HiM'l'Uted to an uncomplicated middle-ear suppuration In removing secjuestra from the r.nddle ear or mastoid tlu oi'erator will occasionally hud portions of the labyrinth in the desiroyed bone. ;iiid a number of ca.ses of removal of the whole labyrinth have been reporte.l. These slow suppurations are usually the result of neglect (if the preceding middle-ear |)rocess, and are obser\-ed more fre(|uently after neglected scarlet fever or diphtheria or in the course ()f tuber- (•ulosi> of the temporal bone: but they may occur from infection with ;iiiv of the pathogenic bacteria. In chronic caries and necrosis infection of the meninges is nuich le~< likely thai' in the acute processes, owing to the thicki'iiing of the dina over the disea.sed bone. In any extensive caries of the petrous portion of the temporal bone !!ie facial nerve is almost certain to be jiaralyzed, and this may bo the first symjUom leading us to suspect that a simple acute middle- ••.ir sujipuration has become converted into a more serious affair. Such a jiartdysis may bo partial or total, according to the extent "I till- iiijurv. Involvement of the facial nerve must not bo considered as diag- nostic of labvrinthitis, as tho nerve may bo involved in the tym- ■ai^p vil , IMr, .'. Ji<*m tM0a^."im'^f:. \ . < 1102 Till-: ICAJi. imiiic portion, and espcfially in the luigiihoiliood of the niastoiil aiitiiini. Ill llic al)S('nco of symptoms of mcninfiitis, cerebral abscess, or tiiroinl>osis of any of the cranial sinuses, the i)roKnosis of caries (if the lal>yrinlh under treatment may be considered gooil. The fatality is much hij^her in the acute ca.ses than in the chronic. Tiie prognosis as to hea:in>; is absolutely bad. although a few cases have been re- jMirted whi're some trace of hearing remained after exfoliation of the cociilea. The facial nerve will occasionally resume its functions, even after v(>ry extensive .se(iuestra have been removed. The treatment of such ca.ses nui.-^t be determined by the symi)toms of the individual patient. In acute infection oi the internal ear fr<.m the mid<lleeur the most radical surgery should be resorted to in view of the much higlier fatality. In the more chronic ca.-^es, and especially in young children, an ex])ectaMt treatment by .syringing and ordinary surgical cleansing may be advisable until nature has establishe<l a definite line of tiemar- calioii, as in such ea.-^es the risk of setting u]) cerebral inflammation or of woumling the internal carotid artery at some jioint of its course through the petrous portion of the temixiral bone is nmch dimin- i.'^hed. There can be no question about the inunediate removal of .sequestra, no matter what their .size and po.sition. and this will usually be found a simple matter. Such sequestra are of all sizes and shaju's, and involve either the whole labyrinth or any portion. Where no septic or cerebral symjitoms exist cleansing the ear by fretiuent .syringing until dem;ircation is established is often the most rational smgical procedure. Sixteen cases of fatal hemorrhage from the internal carotid artery have been rejiorted. In all instances s(mie portion of the carotid canal w;is carious, and in all there was a direct communication be- tween it anil the tympanic cavity. In each a neglected mid<lle-ear suppuration had exist(>d for a long time, and the first .^^ymjitom was ])rofuse liemorrhage from the external canal. In most ca.ses tlie bleeding was so severe as to leave no doubt as to the diagnosis, as a solid "jet of blood issued from the external meatus, and there wa.s als:> free bleeding into the throat by means of the Kustachian tube; in only a few jiatients a jiersistent oozing gave the first warning of the later severe hemorrhage. The possibility of this contingency should suggest itself in the removal of all large seciuestra of the ii(>trous portion of the tcmi)oral bone. The only rational treatment of such complication is the inune<liate ligation of the internal carotid artery. Neuroses. 1. HsrperaBsthesia. A certain amount of hy|)era'sthesia is normal to all person-, usually in the u|.|ier register, as. for example, the upper tones of the (Jalton whistle, the scnitching of a slate-i)encil, etc. This, of course, is greatly increased in neurasthenia or in con- vjilf^eoncp from exhausting illness, nuiemia. genera! nerve strain, etc. It is also exceedinglv conution in scmie middle-ear diseases, especially in the early stages of the fixatioti of the sta]ies. In some instances I lai U|l dlsi:asi:s of the ].\ti:i!.\al kmi. J 103 the syinptoin persists even after the jiatieiit lias In'ooiiie so deaf as til !)(• unable to j)erceive artieulate sounds. Local treat' 'eiit is naturally of iittle avail, and attention should lie direeted to relii-vinji the {jeneral eoiuUtion of the patient and to nniovinj; tiie particular exciting cause of the synijjtoni wiierever IKissihie. 1. Subjective Sensations of Hearing. Noises '-, t^.,• ImihI or ears are, of course, one of the most common of all the -yniptoins r,f c. lis- ease, whether tlie process is one of the extern! I. nii'idle, or ii * rnal ear: hut we fre(iuently also see a purely funci -n >'i tinnitus, nd it is of tlie latt<T only that this section treats. The sensations of sound may i)e directly leferred to one or both eais, or may be referred to any portion of the head, and may be con- tinuous or occur in attacks. When th(> patient has a subjective tinnitus it is invariably increased by any cause which stimulates his labyrinthine circulation, eitlier by takinp of drugs like (|uinine or salicvlic acid, by alcohoi, by sleei)lessness or nerve strain, worry, indigestion, or many similar causes. A tinnitus of this description occurs in a ])erson witli healthy ears, and may continue indehnitely. The tinnitus is seldom of the severe variety seen in the middle and internal-ear diseases, but usually is a steady sizzing sound, like escaping steam, althougii any of the dilTerent varieties may be observed. In some cas(>s the sound starts immediately after a severe mental shock, and continues for years. As a ruh', it is heard only wiieii the person is ([uiet ; but in a few in.stances it is augment. ■(! i)y surrounding noises. Such tinnitus may last through a i)atient's whole life without any (listin-bance of the hearing function, and is almost certain to hist for a number of years, unless some definite physical cause is found and remedied. It should, however, be rememl)ered that a jiersistent tinnitus may he the early symptom of a middle-ear disease, and esjx'cially of a primary fixation of the stapes, and may jjiecede any other symptom by a liumber of months. It is well, therefore, to keep such ca.-es under observation until this possibility has been ruled out. The treatment of \mvv fimctional timiitus is very unsatisfactory, unless the particular cause can be made out and relieved. .\s in ihe great ina.iority of cases a faulty mode of living is the cau^-e, and ■IS such is almost necessary to the success of the individual under the conditions nf our modern civilization, we are forced to the con- clusion that the timiitus in such instances must continue or the patient's natural ambition '<e sacrificed. In severe cases if may be necessary temporarily to )rt to the use of drugs to relieve the tinnitus or the insoninia: i t, needless to say, such treatment ."should be used with great caution and never continued for a long jieriod. In a few instances relief may be obtained by inflation of the tympanum or bv some form of aural massage, o.-specially the tragus pressure of lloMunel. This is especially the case in functional tinnitus following concussion of sound, a.s in artillery practice or trap sliooting. The ^^W^K^^^^ sei wmm^mmmi 11(»4 TUi: HAH. II H author lias l)con unahli- to ol)laiii any iicrmaiicnt ticiicfil ffom tin usr of clcctiii'itv or vihratiiij; inassafif with iustninu'iits of tlic vihra- jihoiic ivjic or i)v tlic old trcatiiiciil of couiitcr-irritatioii. Ana'iuia is a "coinlitioii frc(|uciitly causiii'; functional tinnitus. a> also do insomnia and overwork in all the conditions. If the under- Kin-' cause is corrected at once the synii>loius may he relieved, hut if the iK-urosis heconies lixed it is much l<"ss likely to he remedied. .{. Functional Paralyses. Besides the orfjanic paralysis from various causes el.s,.wliere mentioned, there is no douht that functional par- alyses, either partial or total, e.xist, and such, for the lack of a dehnite understaiidiiifi of the patholofiy, are usually considered vasomotor or hvstericat. . From till' standpoint of the clinician the vasomotor aih'ctions .seem to he .(uite common in neurotic suhjects. and are usually characterized by a transient vertijio, nausea or vomitin<r. tinnitus and deatne.ss. The deafness is often of a very hijrh <rrade. hut seldom continues l()nf;<'r than a few hours. Such patii-nts are liahle to repeated attacks froiu anv cause which mav increase the intralahyriuthiiie circulation, and, as "the attack is usu'ally of brief duration, treatment is .seldom uece-sarv at the time. Hysterical deafne.-s is ([uite rare, and is usually comi)arative!y easy of diagnosis from the occurrence of the chanicteristic lahyriiithine symi>toms with general manifestations of hysteria. Local aiia'.sthesia ('f the membrana and auricle has been reported in a number of such cases. 4. Paracusis and Diplacusis, Inability to hear jntch correctly is iisuallv <lue to an abnormal tension or relaxation of me portion of the middh'-ear ai>paratus, but may be from affections of the auditory nerve either in its course or termination in the labyrinth. Where not of middle-ear oriniu it is more likely to be central than labyrinth- ine. I'aracusis of Willis is always of middle-ear orisjin. Diplacusis also is by the <;reat majority of writers considered of middle-ear ori<:in, but it may be central. Tumors in the Internal Ear. Primary neoplasms of the lat)ynnth are rare; but they are not es|)ecially unusual in the course of the auilitory nerve before it enters the internal auditory meatus. The new-growth when fouml will usually be an extension from surround- in-; |KUts anil the diafrnosis easy. The usual symptoms of increa.sed labyrii-.thine pressure, vertigo, nause;i, aii-l tinnitus are often absent, ami onlv the -leafness shows the extension of the ilisease to the laby- rinthine structure. The facial nerve is generally involved with, the auditorv, owing to their intimate relation. The "malign.int neoplasms are the most fre(|uent. both ei>itheho- niata ami sarcomata: but the benign tumors aiv occasionally seen, a number of cases of fibroma and iingioma being on record. All of tlii' hibyrinthi!!'' tmit-ir-. :ire inoper'ilive. but t!ie possibility of gumma siioui.l make a course of syphilitic treatment always advisable before the case is regarded as hojieless. m^mafw^mT^mrvs ■^w^HiraFWi i)i:.ir MiTisM. 1H>5 DISEASES OF THE AUDITORY NERVE. Tliis nerve is ;i|ii':iiently rather rarely involved in ititnicTaiiial irrnwths, hut sueli cases are oeeasionally seen. Tlie diafinosis is, as a rule. (Villieult. (iwinj; to the ah.senee ot .syinptonis. The verti^'o, ii,iii>ea. an.l sinnitus invariably .se.'n in the diseases of the lahyiinth are usually ah i-nt where the trunk of the ner nly is nivoiyeil, and deafne.ss is the onlv syMptoni noticed. I'urulent infiltration into Ihe nerve is occasionallv seen secondary to a purulent nienin<ritis, hut the most common lesion is atrophy. This is seen after pressure from intracranial neoplasms, and has also been reported as a com- plication of disease of the spinal cord, jiartiiailarly tabes. Degen- erative processes in the auililory nerve are also reported by a mnnber of ob.servers after !on;i-coMtiiuied disease of the labyrinth; but this is not as common as alroiihy in the gan}ili(«nic layers of the cochlea. DEAF MUTISM Deaf nnitism may arise as a secjut 1 is either |)artial or tota •I of many (iisea.''es of the oar, _ I. In partial deaf mutism the whole ference with the pa.ssafje of the sound-wave may be in the middle he labvrinth is always involved. In ant interterence e.ir: but in the total cases the hil)yrintli is a eonsideriiif; the etiolofrv of mutism we must remember that more or less disturbance to the sjieech function nnist result from extreme deafness at anv time of life, l)Ut that mutism only results fiom deaf- 'less incurred "before the siieakiiifr afre. or before the fifth or sixth vears, when the child may h.rp't what woi.is it has already ac.juired. Ill an examination of some two hundred individuals m a deal mute institution, recentiv made by the writer, it wa> found that nearly .■)() per cent were deaf from some easily i.revented cause, either the suppurative diseases resulting from scarlet fevi-r, measles, or the (,ther child affections, or from the adhesive middl(>-ear processes set up in con.se(iuence of the presence of adenoid vegetations in the phar- \ nx. The other oO per cent, were largely the se(|uel of an epidemic of cerebro-spinal meningitis which had prevailed in New Kngland .some vears before, and a hnv cases were the result of pneuinococeua •uid other infections of the auditory nerve in the course of acute dis<-ases in earlv life. In the entire 2()() cai.es there were only 2 in which the absence of an easily assignable cause made the probability of a direct inheritance po.ssibh'. It is the writer's belief that these statistics are fairly rei)r(>sentatiye, and that a careful analysis of cases will .show the process causative of the deafness to be acciuired and not hereditary in the vast ]ireponilerance of patients. Pneumonia in iiita.ncy. cerebro-spinal meningitis, and adenoid vegetation ui the naso- jiharynx are the three most common causes of (leaf mutism. Next to these come heail injuries and inhcriteti syphilis. 70 mm n(»6 Tin: .AR. if! ii i .1 • I if B> The diagnosis of this ;iftlioti(in may prcsoiit many unoxpcctotl .litti- pultics, particulaiiy ii; youiis !Sul)j(Tts. liy far tlic larpii'st mimlxT of cases will !)(• hrmijilit to the auiist about two or two ami oiio-liall years of ajte, beeause they liave not yet bepun to talk. In these till' hrst and most important consideration is as to whether the ease is not one of delayed development, and this consideration alone should deter one from making too positive a diagnosis. In older children we must be most careful to eliminate the factor of iip-readirg which many a deaf cliiM ac<iuires instinctively at an early age, and at which they become very proficient. In testing hearing at 'iny age allowance must be made for the perception of vibration in ail loud sounds, and particularly in those of a low pitch. In children of two or three years of age or younger a (hagnosis will often be imi)ossible at a first visit where the physician is a stranger to the child; but much may l)e learned by a careful (jbservation of the patient in its own home or in .surroundings familiar to it. At these ages hearing-tests can only be made with sounds, and esi)ecially with sounds incapable of imparting jierceplible vibrations to sur- rounding objects. .\ whistle is one of the best tests .;t this time, or striking the edge of a tumbler or finger-bowl with n(>tal. At five years old or over the voice will be the best test, and ye may try tone-] )ercept ions by the tuning-fork and the (ialton whistle. With the voice vowel sounds are naturally better perceived than conson- ants, and the phvsician should pronounce the vowels one after another with the lips fairly close to the patient, or, better, through a con- versation tube, having the child re])ea1 tlie sounds. .\, ll, and O will be found the most readily heard of all. If the vowel sounds are perceived the ca.se should then be tried in the same manu'-r with simple words, and in all i)atients old enough to answer correctly, an exact measure of hearing should be ol)taine<l !)y tuning-forks, and, whenever jio.-isible. by some exact instrument likv- HezohTs tone ■series. It shoul<l be rememlxn'.l that the ca.-<e may be deaf in()ne portion of the scale and hear relatively well in the other jjortions. As a matter of clinical experience, total deafness will be found very rare, as ]M>rception of sound in some portion of the musical scale is ]ires(>nt in nearly all cases. Testing with tuning-forks by bone con- duction will be found impossible in all young aiul most adult patients, owing to their inability to discriminate between vibration and tone ])erceplion. The exact definition of the amount of deafness ])resent in the indi- vidual p.'itient is exceedingly important, as even a jxirtion of the musical scale may be utilized in the educati.)n of the child. High grailes of (h-afness are also caused by neglected suppurative middle-ear diseases in childhood, and in such ca.ses deaf mutism may result. .Appropriate treatment in tliese ca.ses ma\ >ieid iunX]i<ried results, and the middle e.ar shoulil always be brought to as normal a point as possible before the ca.se is ;ibandoned as hopeless. ■■U iU. ■WU'Wff!^ raSWB^^ pi:af MrrIs^r. 1107 Treatment is ofton of iiKirc iiiii)()rtancc in tlic ciirly stages "I dciif nuitisiii thiin is ordinarily supposed. It lias been the author's cxpe- lirncc that all casos of ccrchro-spinal, pncuinococcus. and mumps infections of tin- auditory nerve and iahyrintii are incurable as far as treatment <roes. The prognosis in the head injuries, of course depen<ls upon the severity of the injury in the particular instance under observation, and if the damap' done is not too great the nerve may recover itself and resume its functions. 'Phe affections of the auditory nerve in consociuence of inherited )hilis are al.si> very intractable: but if the case is seen <'arly a .,i)rough trial of the usual remedies for syphilis should be made before it is abaniloni'<l. The prognosis of the lesions resulting from adenoid disease in the ntisopharynx is imich more hopeful, and the growth should always he r(*inoved in all patients at whatever age they are seen. In the cases ojK'rated on before three or four years of age a great imi)rove- laent mav be expected in many instances. The author has had -everal siicli ca.-<es which obtained nearly half the normal hearing, .ind were al)le to attend the public schools instead of s])ecial insti- tutions for the e(hication of the deaf. Where, after a careful examination, the deafness is decided to be hojieless.'so far :is treatment is concerned, or where the api)ropriate treatment fails to .show any result, the future education of the child '^liotild be consi.lered: but"^ the child should never be referred to a special institution for the educatiim of the deaf until it is decided that there is not a sufficient amount of h(>aring to enable it to be educated in the ordinary way, and that it is imi>ossible to obtain such hearing bv treatment. . .\s JKUs been before mentioned, many deaf mutes are instinctive lip readers, and in all instances where treatment is of no avail the imli- vidual shoul.l be speciallv educated in this method, beginning, when- rv(-r possible, at the usual school age. In this country this education i~ ensitv obtained by even tlie jioorest children at some one of the special institutions which are found In ni'arly every State. i i en AFTER xxvir. IM'RriJlXT INFLAMMATION OF TIIK MIDDLE KAIf Hv IIKNHV AU.NOI.I) ALDIIHTON. M.D. In tnkinj; up the suhjcct of punilciit iiillanmiatioii nl' ttic iiii(kll< car stnictiiics it is prcsiiinci lliat tlic reader eiilier lla^■ already ired t Wdrkiiij; know led<;e of the aiiatoriiy and pliysiiilo^y t^ ti )rgaii (if lieariiifi, nr else lias at coiiiiiiaiid iiKulerii text-books treatinj; of anatomy and pliysioloj;y, to wliieli li II refer. Briefly, the middle ear 'Fig. "HKS) hegiiis at the pharyngeal mouth of the l-lusta- View of the middle-ear cuvitif^ iroin within. 1. Mafltoid antrum. 2. Posterior liffHment of incus. 3. ^usiiensoryli^amentof hummer and incus. 4. OpenInK In the plica tmrisvemt h. Tendonofthe tenwir tym|iani muscle, li. oixMiinRS of cells around tympanic oriliceof the Eustachian tube. 7. Isthmus ol ti'lic. 8. I'harj-nifcal mouth of tubt'. ii. Superior posterior horizontal cells of mantoid process 10. Large cells in tip of maiitoid pnwcss. i From .Siebenmann's Anatomy of the Midille Ear and Labyrinth.) chiaii tube as a canal with walls wliieh are ir'ternally partly oartil- aginow.s and jiartly membranous, and externally become entirely osseous tij) to their entrance into the cayity of the tym])anum by an aperture in the anterior wall (juite a little aboye the floor. The cayity of the tympanum is completed externally by the drum mem- braiio and the downward extension of the superior wall of the osspous external auditory canal (Fig. 5()9), and internally by the petrous (1108) ■■■■m PVRILE.ST ISFLAMMAIKIS of Till: Mll'Pl^J-: /■'■I''- 110!) IKiriion of tlic tciiiporal Ih)Iii'. I'osti'iioiiy, at tlic superior aiigli'. iinotlicr l)ony canal, tlic (iililiis lul initnnn (l'i>;. ")7(»), coimmiiiicatcs with the Mia'stoiil aiitriiiii, from which diverge in various directions, mostly downward and hackward, communicating cells between the iiied tliroufihoiit In- mucous the membranes of the drum Fig. STO Vltw of tymiianiim from in front. 1, 2. .\tlic-. 3. Incus. 4. Suspensory ligament. 5. Uammer. (. l'ai<epit>mi»inica and wall of f.tli.Tn,il far iMmal. 7. Tendon of tensor lymi«ni muscle, 8. -brapnell's membrane. '.». In™.l.>-slni,ediftl artieuialion. 10. CmU). 11. Tympanic membrane. \i. InUTnal auditory canal. 13 Turnolc.Kdilea. 14. ITomontory l,",. Carotid canal for thecarotld iirlery. (From 8|iecimeil in the author's collection.! outer anil inner tallies of lli(> skull. (Fifl. "i<>>i.) These c.>lls extiMid for varyinf; distances iu tlilTeiviit skulls, even into the adjacent occip- ital lioiie. The tympanic cavity is iiKMiihraiie, and its walls, excejit for inenitinine proper, the round and tli(> oval window, and the cartilag- inous portion of the Kustachian tube, are of bone, unless, as some- times lia])pens. Nature Iiad failed to complete her work and has left here or there an aiiertiirc in the bony casement cIosimI only by tibroiis membrane. Sech apertures, or dehiscences, sometimes leave ex- poseil important structures, as, for instance, the jufrular vein, the car- otid artery, the facial nerve, the ^ijimoid sinus, or, occurring in the roof of the tympanum or mastoid antrum, the dural covoriiig of the intracranial cont(>nts. , • i Within, or jiassing tlin;ugh the tympanic cavity, are the ossicles or -uial! bone: of the ear the chonla tyinpiini nerve, th.e tetidons of the tensor tvmj ani and sta|)edius muscles, and various folds or bands of mucous inenibrane. (Fig. 571.) Outside of the bony casing of view of irembrane and oesidcs from within. 1. Mcmbrana vihrans. i. Eustachian tut«. :t. Hammer. 4. Incus 5. Antrum 6. Aditus. ". Tensor tympani tendon. 8 chordatympani nerve (From specimen in the author's col- lection.) 1110 T1I£ IJAIt. Fia. .'.71. llic iiiitldlc-car (■••ivitics lie tlnw .-;lnictun's the prcsciicf of wliicli, in siicli close coiitifiuity, icmlcis iiiiy punili'iii iiitlaiiiiiiiition of tlif iiiidillr ear a factor of the fircatc.-;! jiravity. Swell are the cerehnmi. the eerelielliim. tile lateral and .sifjiiioid simi.-<e.-<, the liiilli of the jugu- lar vein, and tiie carotid artery. That the existence of such a purii- l<Mit intlaniniation of the tniddh- ear is a matter of };rave impor- tance is shown 1).\ the fact that in- vestipition of the mortuary sta- tistics of one of the larfrest jjeneral liospitals ha.< sho«ii that one death in every 1.").S resulted from theeoniplications arisirifrfrom this condition. Durin}! the ten years immedi- ately preceding; 1!H)1 there were .mis'.) ear cases treated at the -...Q Urooklyii Jive and l-iar Hospital: i)7()"), or aliout 27 per cert, of tlie.se were atllicted with someone of the ditTerent purulent diseases of the middle ear: ;{.'{47. or nearly Ojiercent., had the ilisease in its acute form: (Jll.S. or nearly IS per cent., had the disease in itschronii' form. Besides these there were 142.5 ca.<es, or nearly t per cent., showinfr cicatricial conditions, evi- dently th(> result of a healed sui>- purative process. In other words. al)out ."{I |)er cent, of all ear cases .ipplyinfr fur treatment at the Brooklyn Vac and V.iiv Hospital were sufferers from conditions directly eonnecteil with suppurative |)roce,sses in the middli'-iar cavities. .As miiilit lojricajly he presumed, purulent otitis attains its <;i'<'!itest pre\alence in cliildliood; hut no af;i' can elaini immunity. The acute processes are as likely to in\ade one ear as the other. .\t the Brook- lyn !",ye;inil liar Ilos|)i'.tl durinjr the year 1!)()(). 1022 cases (»f purulent otitis media presented tnemselves. Of these 4!tO were in fcTTiales and .").']2 were in males. This slijilit diserepariey nia\' e.asily he accounted for 1)\' the e\tri hazards usually attend.mt upon occupational and playful pursuits. Sex. as such, does not. therefore, seem to influence the appearance of purulent otitis. There would seem to exist in certain fatnilies an hereditary ten- dency to purulent middle-ear disease, mostly in connection with tiie strumous .'ind tuhercular diatheses, or with various p.'itliolf)}rical con- ditions of the nasopharynireal tr.act. n(.lahly lymphoid hypertrophy. IVe-exi.stinji affections of the rni<ldle ear or of the external auditory meatus would also seem to exert a predisposinf; influence. View of tympuuum from behind and witbiu. 1 TeKuicii . ■-. Suspensory liguiueiit 3. Allie. t. Htimmer be;iil. ,'>. Iuimis (i. clionia tymtiani nerve, 7. Tenilon of tcni^r tynipaiii mui^ele. ?*. Ensiaohian lube, tt, Munnbrhiin, 10 Stajies, II, Teuilon of siapedius muscle, IL', ryramld, i:i, Tyni|«iuie membrane, iKroni ^iieeimeu in tbe aul.lor J* eoUeetion.. t'lRVLESr IMLAMM.irioy OF Till-: MIDDLE EAU. 1111 rMiiillv tht' nii(l(llf-«-:ir iiifiainiiijition follows cluscly iilK)n or is ,.uinci(i."nt with an i.itiaiMnuitiui. involving tl.c nas..pi.arynncal cavi- li,.< Such •■niulitions (.i)taii. as ih.' result of an acute curyza, ol t,.,.thin.' scarlet fever, nicitsles, sn.alli).)X. diphtheria, mtluenza whou,,intr-c.,ut;l syphilis, etc. ()c.-.asio,.ally Xh,' ^^ is m.luce.l l.v a .Irauiiht ( c.l.l lir i etratii.-l the external auditory meatus, „r i,v the entranc(> of c.ld water int.. .he same canal, m swimming or diviiiji. Injurie-' to ti.e hearing or-an may likewise he causative. Thus fractures ..f the temporal hone, forcible entrance of water in -urf-l.athin>;, l.lows over the auricle, entrance of fhud into tlie tym- „i,nuin while Imthinn. usinj; the nasal douche, snulhnj; of li-iuids into 'the nose foicinj; of vomit. .1 matters into the tympatium, and hually, imratvmpanic operations, .\monf: other cau.se.-« we have t.. reckon with mumps, phthisis, tvphoid and typhus lever. p!iemnonia and bronchitis, diabetes, malarial diseases (Harr). tuberculosis, erysiiieUus, Mild the puer|.eial state (Hacoii). local manifestations of acute articu- lar rheumatism (WoltT), ai-d carcinoma auris. The ivlation of scarlet fever, mea.sles. and (hphtheria to purulent otitis media is of such imi.ortaiice as to warrant si.ecial consideration ..v.-n in such a bri.-f article as this must necessarily be. Artluir H. Due! of New York, because of his connection with the .New York Health Hoard, has iiad exceptional opix.rtunities for iiivestifiation lion.' this line, and it is mainlvfrom his article that the followitiR facts iK.v.^been fjleaiied. Me states that .a purulent mi<ldle-ear inHamma- ti„n mav app.^ar at anv tin..' durii.f,' the course of these diseases. That it occurs in about 20 per cent. <.f the cases ot scarlet lever, in 10 p,.r cent, of tli.- eases of di|.'>th.Mia. and in 5 per c'lit. of the ™ ,,f m(>a.sles; while in those cases in which tli.' two diseases scarlet fever ;,Md diphtheria w<.re combined, the percentage of cases ol purulent ..titis media mounted u|. to b.^twe.-n .W and W percent In measles. ,U,. car trouble usuallv i.ursues a mild.'r cours(> than m the other two • li^eases. In diphth.-Via it is usually mon> .s.'V<Te than m measles, but less severe than in scarh't f.>ver. is more likely to make its appear- ;n,ce durin- th.' acute stafie, and in ..ver ha, 'he <Mses is In a eral. In scarlet fever, the discharfre is much nion likely to ai.|)ear later in the diseas.-. about th.- s.'cond ..r thinl week, an.l, beinR of a much <,.v.M-er tvpe. is pr..n<' to cans.- much destruction ..f the tympanic structured. In all ..f thes.- dise.as.-s. m."asl.>s. scarlet fever an.l diph- th.-ria till- t.-ndencv is toward the involv.'inent .>f both .-ars The followiiifi inicro-orfranisms hav.> been foun.l m the (hscharges in cast's of iMirul.'iit otitis m.'.lia: the strei)tococcus py.)f;en.>s. the .laphvloc...-cus pv..>i.'n.'s albus an.l aureus. Frank.M's pn.'um..c.,ccus .,, ,liplo.'..ccus. Fri.Mllan.l.T's piu-umolmciUus. th.- tulxTcle bacillus. an.l th.- bacillus i.yocyaii.'us. In the majority of ca.ses the infectu.n is. or soon b.'comes. a mixed one. Be-rinninn with a more or le.^s .activ. con-estion of the mucous ,„.-ml.ran. coatiiift the mid-lle-.-ar cavities. in.luc.Ml by the various ab..ve-menti.med causes, there succ.-e.ls an iufiltratu.n of the tissues 111-2 THE EAR. with l)l(i(iil ciniiiisclcs and ruiitul cells, prodiiciii); swdliiin, :'>"! '1''^ is rulldwi'ii Ity an cxuilation from tin- free .surfact's of the niiirdiis incin- liiant'. .\\ times, especially in inlluenza, tiipfure of tlie oviT-ilis- teiideil caiiillaries is l)niuj;lit almnt liy tlie intensity of the congestion, and the escaping lilood either finds its way into the tyinp.anuni, lifts the mucosa, formin<; intiatym|)iinic hulLe, or lifts the ilermal layer of the ilrnm memhrane or external auditory canal, forminj; hlood- lilel)s. which protrude into the external meatus. These hulhe or blebs tend to rupture, leavinj; behind a raw, unprotected surface prone to infection. The exudation from tiie mucous surface may be serous or mnco-serons and, the lumen of the luistachian tuiiebein^ closed by swellinfr. may collect in c<insider;ible quantity in the tyin- pannm. Heyond this the intlammatory process may not go. Or tlie exudate may be from the first more or less purulent or may become so. In .-iex-ere cases, the !iiiddle-ear condition m:iy brinjr about a similar conjiestion of the lal)\ rinth or of the adjacent portion of the external auditory meatus. .\s the swelling; and the i|u»ntity of intratynipaiiic exudate in- creases, the drum membnirii- is put undi-r extreme tension until it beconi(>s.so thinned and weakened that it finallyjiives way, or, because of the intensity of the inflammatory process, a portion of the mem- brane sloughs, so permittinir the escape of the contained secretion. .Most commonly this penetration takes place in tlie lower half of the drum membrane and is accom|)anie(; more or less heniorrhajie, l'!xceptioiiaiiy the dium membrant i be so stroiifily built that it is able to resist the pressure arisinji from the swelling and tiie ac- cumulated exud.'ition. When this happens, the secretion contained within the iniildle-ear c,i\ities is forced to seek other outlets, either througli the luistachian tube, the mastoid cortex, the carotid canal, the lal)yrinth. or, finally, the inner table of the skull. Such a condi- tion of things I, '.)i a ins relati\ely more freiiueiitly in children: the drum menibr;ine heic offering greater resistance than the tissues which bind together thestil! imperfectly united bones. In the majorny of cases of acute |iuriilent inflammation of tlie middle e;ir. the process, after perforation, naturally tends toward resolution, with lie.aling of the perforated drum membrane. Less fre(|uently, especijilly when occurring in the course <if the infectious diseases, the process tends to become clironic, generally through the establishment of an area of localized caries at some point in the bnny wail or on the o.ssicles. It is rare, indeed, tiiat a primary attack of jjuiulent otitis media leads directly to serious complications in the way of intr.acranial ilise.ase, and, as Macewen well says, " When such occurs, the invasion is generally .so ra})id that the intracranial involve- ment occurs befoH' o])i)ortunity is given for radical intervention." The tissues still retain, usually, suflicient vitality to successfullv with- stand the invasion of infectixc material. Slionld tlie intensity of the inflammatory process be unusually severe or result in a continuance into the chronic stage, then the }'lRri.t:ST IShhAMMATlUS OF Tilt: MIDDLE h.Mi. HI,} iiitfKrity of various inlratyiiipaiiic strMcturcs may !<!■ jco|.ur(liz<-<l. rims, tin- small Ixnifs, malh'us. incus or slaius, may suffer a urcalcr ,,r lcs.scr ilcgrcc of caries (Fig. Tu2), or may even have their .ittach- Fio. .-.TJ. ^^/r 6 7 ^8 9 10 II 12 13 -€> 19 20 ^ \ ■' and :i Siinnul ossicles, hammer, incus, aii.l sl«i*s. 4 ami 5, <'ari..us aiik>M(»cd Inrus and n„.'lk'US from two cKsi^s of pn Ke.1 Mlfporation. 6 iiiM 7, I'ortioii. of lurli mu.I han.il,' of inal- i,.i,. all ib,a «■«- apparently left in lluw two case-, h and 0. 1'* and r.>, -M and .'1. Carious mallei tnd'incM.li Kroni*'.! a.-, tlicv were renumnl, 1:1 and 1 1. Carious hammer, healthy incus. 10, ii. and Ij 1.-,, Itiand 17. Carious incus and hummer, and in each case a sequestrum fnnn tymi«nic wall. hrom specimens in the autlior's collection ) View of Irtemal half of middle ear. 1. Adlfis. 2. Stapes. 3 and 9. Facial caur^.. oval window ft Promcmtory. 6. (Xdlular etructure of floor of tympanum. 7. t. windov. 8. Stapedius tendon, lo. Horizontal »einicireular canal. U. Antrum, i. Fossa nl Baa of round illt Tin: em: ! incuts tit till- iH'ijililMiiiii!; -itniiliiri's ilfstmycil iid Itr carried oiii ..f 111." car l>y llic i>iinilciit .liM-liariJc ur !>> llic suliiliniis iw.l in ^y\ \\\vi\\\il. ( M' llic (.-.sides, ilic incus is liic least resistant to pallmloKie.ii cliaiijie. Itccaiisc III' the delicacy of it > li|iaiiieiits and the incajjreiie-^ of its vas<'iilar siii.|iiy, ()cca>iiinally the intlainniatory process may invadi' the l'ailu|iian canal (Ti^. .")7;{i and cause nioie or h'ss iiijin\ to the facial nerve, with resiiltiiic paralysis. This occurs with s|M'cial ease in those cases ill which there exists a defect ill the holie lietween theciina! and the tynipaiiiiiii and is also of more fre(|iient occurrence ill children, hecause of the natural lack of complete ossification ot the parts. If the structures of the laisiactiian tiilie are frravely involved, the intensity of the infection may I'liiiji altoiit the forma- tion of an ahscess in the walls of the tuhe; or the pus from the tym- p.annm may dissect a way aloiiir the liihe walls and presently appear as a jrravitiitioii abscess in the nasopharynx. It is al.«o possible that the purulent intlammatioii may extend to tin- carotid artery tliroiinh a series of (•oiinectinjr eelU lyin<; between the tympanum and the carotid canal (well shown in a speciini-n in tlie author's collection - liii. :>u. W;a I'nibc itfisat^il ihrmiuh chain of cells liehinrt OHrntlii cKiiiil iiiiil loiumuniculini! «lili tin- tympanic cavity. 1. Kxlcriiir Miiilitnry inciilili-. i«i«lori.ir wall. -•. Annnlils an.l n-ninunl nf ilnini nrcTnbmne .t. liiiunil Hinilcm-. 4. I'nitK-. :.. Adilus, c SUii«». T. 'IVnaur lyin(«Mi niilsc'.c. » Canilid lanal ;i. Prnl«-«liii«li.i; tbrmiKli Iho tliili wall ..I carDtiil canal. Tifl. ",\\ and opening into both, or tliroi , .i dehiscence in the bony wall between the carotid canal and the tyi..panum; should this occur, thrombosis of the carotid artery may result, or iaial hemorrhafie ensue, as in .Mibe's case. The existence of a similar defect in the bone between the tymi)anum and the sii;m()iii sinus or the bulb of the i-ini i.i:.\r /.>.■;. i.w .v. i//'>a "/ /'"/• mii>i>i.i: i:m: m:, jujriilar 'i\ii. .'i7.")i iiiii' liki-wix' n-r^iilt ii> tin' diri'd (•xtcii-*i«iii of ilir imriilfiit i.n.cff's ti. llic Vfiii. In rarr niw'r*, pus aci-uimilatiii): al">ul llic aiticulatioii i>( tlif Iuwit jaw may ultitiiati'ly i-aus<- fn.sic.ii of flir rajisulf (MacfWfii). n.i .•.7.-.. a a. IKhlM*nm m the h..iiy w«ll between the tympsnii- isvfty ar ; . -lernal auditory oaiial and the- luKUlar bull., iille.1 !»■ Ilbn,ii« tliwue 1. Pmun,,, .xternal .-aim . i. Dehlncences both ulUe. of annulu-. X Ai,i.u:ii» 1. <-,irutid canal .. -^ - «. Mtain-lMi. timl.m. 7. F.«ia of oval window s I'mmonum. », fell Fniiu a «ieelni. i. lu- anihorN mllectloni iVrtMiii cliaiiKcs in tlic iiiiu-oiis iiiciiibranc soiiictimcs nrnir as a ivsiill nf iiniloiiiicl su|>|)matiuii -iicli as (icposit- nf lime salts, or. all iilccralivi- procfss is troiim ,,i), with tiit- I'l ■ ' ■ h caries oi tlic iinilcrly' oil. ^utii a.^ (u|"'.^n' '" iitii' .-.».. whcri' all iilcfi-atiw process is >:oiim on, with tin- formation of graiiu- lalioii tissue usually associateii with ' *' '""■'■ where all uiceraii\e |)ioti» i,~ ^i.ni^ "n, .. •>. r. lilion tissue usuallv associated with caries of the unilerly'M.j; hone— I he formation of polvpi reaililv follows It. 'JTS cases of aural polypi uliserveil at tlu' Brooklyn Kye and Kar Ilosi>ilal, 144 were in males anil i:U in females, slmwins; a sli-rht preponderance in favor of males. \s to ;i(;e, ahout as inaiiv were found in patients over as under twenty years of age. We are," therefore, justitieil in tliii.um« thai neither ...r'.. !i,,r <.'v hits mudi to do with the icirmatioii of iiolyiH.id ;:P.\vtlis. I riironic supiiuratioii. polypi were found in '_'!. l'olyi)i are not .iuavs sinjiie. sevi'ial niav coexist in the same ear. Cases in whicii ihe tVmpanic attic is tlie'seat of the dis(>ase. with perforation of the iMcmi.rana tlaccida. or ShrapiK'H's meml.rane. fre.iuently jiroduce poly- poid enlarfieineiits, I'resupposinK tliat the inllammatory process is either intense or nroloiifred, ll..' inuco-pcriosieal pn.feotivp iininj: -f the ,„;,!a!e-ear civities naturallv tentls to disintegrate, thus exposuif: the underlying I.OIU- to the sam'e infective attack. This, top'ther with the pressure IIIG THE i:ar. Flo. of the acciiiiHilatiii<i purulent sccn'tioii, lniii>;s :il»>ut canes and necrosis of tlmse parts of tlie l)ony cellular structure of least vitality. From the nuicous ineruhraiie coveriiif; the tyinpanuni, the intlaniina- tion spreads, liy continuity of structure. throu>;li the aditus to the mastoid antrum, and from thence into the larger connecting nm.stoid cells, which also are provided with a nnicons memhrane. The giving way of these cell walls permits the jnirulent collection to hnd its way into the surrounding cells which may have no direct coimection with the mastoid antrum, and some of which may lie im|irovided with a nmcous tiieml)r:uie;or the inllammato"-y jMocess may extend indirectly tiirough llie veins or lymphatics into these isolated cells and result in a localized jiurulent collection which does not eonununicate with the mastoitl antrum; or, without the formation of any marke<l col- lections of pus, the intensity of infection Uiay |)roduce a more or less gen<'ral deiitii of the hony cellular structure, which be- comes darkly discolored and friable. Coincidently with the accunuilation of pus and death of bone, nature attemj)ts to form a line of demarcation by the pmlifendion of granulation tissue from the still living tissues. This granula- tion tissu<' becoming exubenuit, we have cavities in the bone filled with pus, gran- ulation tissue, and the detritus of decayed bone. Sometiiiiis the inflanunatory jiro- ce.ss extends, at the same time, through a series of small cells which occasionally conununicjite with both the tympa.ium and the mastoid cells. Occasionally the accmuulation of pus in the antrum or a<ljacent cells easily linds its way into the external auditory canal, because the Ixmy wall between is thin, or even at times defective (Fig, oTtii; or i; may pas- along a j)ersistent mastos(iuamosal suture to the soft tissues covering the parts back of the auricle. This suture (Fig. 'u~) has been found I)resent by .Maceweu in (17 out of 4">() adult temporal bones. Or the pus, having gravitated to the cells in the mastoid tip, or having formed there as a localized collection, may penetrate through the thin iimer wall of the tip into the digastric or occijiital grooves— a condition first noticed by Hezold, of Munich, and conse(|uently named Rezolil's mastoiditis. In children, the juis contained in the tympanum has a tendency to dissect off the periosteal lining of the jiosterior and superior external nuditnrv i-.uv.il walls, forminsr a channel through winch the pus escapes to the soft parts lying behind, above, aiid even in front of the auricle. But much more frequently, the pus finds it.i way, in children as in adults. ImiitTfect devcloiiment of bony wiiUs of extiTiittl auditory canal. 1. Tym- jianic inembraiii'. 2. Anterior wall of canal almost atwent. R. Hiatus in bony wall under annulu". 4 Posterior wall of external canal, with oiwn cell.", i'. and an ojieninK into the nia.itoid I'ells. 7. Apex of masinid process (From a Bfieeimen in tlie author's eolleclton.) X ill < s : ? > U ' li,^ rrinLEsr iM-i.AMMAi'ioy of the m/ddij-: kxh- 1117 li,vt t.. the mast. ml aiitn.in, aii.l tlicncc, by ilic ,lcstnicti..n ..f tho l„m.', ..!• thnuifih the s<iiiiii.U)n.astni.l lissuiv. or l)y tl'c vessels to ,|„. outsi.lf soft parts. Hccausc of the structural peeulianties of the l„,„e ill .■hil.lreii, thev are more liable to liave necrosis of eot.si.lerable portions of tlie mastoi,| j.rocess. usually in the form of a seiiuestrum -urrounded by pus and jiramilation tissue. Fig. 57' A.lult U"inp.ir..l bone will. !«isl8tent miuitnKiuamo»al suture. 1. PersUtent mMt.*iuamo«al -iiinn-. 2. TemiHjral rMKu. 3, Suprawieiital n>i«e. 4. Mb«U>1.1 fossa. (From O. K.irneri. Die KitriKcn Erkronkungen des SchUftnbcius.) The direetion usuallv taken by this destruetion of t>>e bony parts i< toward tlie ma.stoi(i i^ocess: but, exceptionally, it may proceed inward and forward, so that, as Macewen says: "The whole of Mie interior of the petrous bone may become, in extreme cases, hollowed Milt, leaving a shell exfrnally. The labyrinth, bi'inj); encased in ' sinteRratinfi i)rocess. Such extensive de- a.s a tubercular disintejtration. Occa- are similarly affected." In other cases, ioic cells IvinK between the superior wall ,„ ,„,-,,„.-,„.. , ,■ ,..nal and the" inner table of the skull forniins the floor of the middU" cerebral fos.sa; from these cells it if ly extend lo those present in the posterior root of the zygomatic process; or, In.ni the nuistoid process, the destruction may involve the diploic reils in the occipital bone. In fact, wherever there is diploic tissue in the vicinity of the suppurating middle ear there exists the possi- bility of extension (Plate XXXIV.), especially rapid and widespread if tlie inilammalorv proces.s is tubercular or syi.hilitic. \'ery generally it may happen that tho persistent irritation of a liarder bone, resists t' -t ruction is met \v' . -ionally lioth jx'troi it may spread into n >f the external autliti.. I I i I I 1118 THE EAll. !i cliionic piinilciit inflaniiimtion liiuitcd to the iniincdiate rpRion of the tynii)amim iiidiin's a coiulciisinfi osteitis of the iicij;lil)(iriiip; Unu\ (•si)C('iaily liiat of tlu" mastoid process. This condeiisatioii of the hone has l)eeii deiioiiiiiiated "ehunialion," and it is (juite a cotmMon con- dition wlierever the suppurative i)rocess is of a low, te(Uoiis ty])*'; hut it does not hy any means necessarily follow: for example, the writer did a radical o])eration n|)on a young girl, aged nineteen years, who had he(>n a sufferer from chronic puruh-nt otitis media since an attack of scarj-^t fever in infancy, and in whom there existed so much atresia of the external auditory canal that the small ear ])rol)e of Hart maim w!us inserted with difticulty, pushing before it a protruding valve-like mass of granu- lation tissue, yet the mastoid ])rocess still re- tained its original extremely pneumatic forma- tion. Nor does it necessarily follow that the ossicles are carious in cases of chronic middle- ear suppuration; thus, ihe writer has removed, from a young man who had been a victim of this disetise since childhood, the two large ossicles in a jierfectly healthy strte. Unfortunately, howevi r. this so-called ebur- nation (Fig. 578) of the bone does not always rake iil'ice at every point in the surrounding wall: if this were the ciise an efficient barrier would lx> raise<l to protect the intnicraiiial con- tents. More often a carious process is making inroa<ls at some locilized spot that is destiTieil to HMider abortive all of nature's elTorts to guard her citadel. The carious i)rocess advancing upon the bone attacks most fre(|uetitly the mastoid process; next, the roof of the tymi)anum or antrum: next, the sigmoid groove, and least freipiently the i)osterior wall of the external auditory canal, or tiie floor of the tympanic cavity toward the carotid canal, or the jugular fos.sa, or the petrous nortion of the temporal bone. P>om the middle-ear cavities the purulent infection spreads to the intracranial structures in various wa\.-. It may ; ..ss along a suture to the dura mater: this especially in children, since for obvious reasons the lines of junction of the ossitic centres are here very vju*- cular. .Again, it may |)ass through the minute veins which form com- munications between the middle ear and the suiK-rior petrosal and sigmoid siiuises; in chronic inflanun.-ition of the middle ear these veins become enlarged and are, therefore, of greater importance. Again, along the nerve sheaths, either along the facial or through the labyrinth to the auditory nerve in t!ie internal auditory meatus. Finally, the infection may spread through the lymphatic vessels in- ward to the skull contents. In the majority of cases the pathway of infiH'tion is vi.siblc because Mastoid procew of poiii- liact tiMiie, not patholfigi- cal. Resemhics "eburna- tioii." Mastoids vnry in texture between this and the pneumatio. (From a s^iecimen in the author's collection.! fSRO'vnwfBai PURULENT ISFL.IMMATION OF THE MIDDLE EAR. \l\% ,,f the discoloration of the l)on(', its carious comlitioii, or tlic pres- oiicc of u fistula. The hone is turned to a dark grocnish or hiackish color. Maccwcu hclicvcs that -the ri-rht side of the head is iiion- (.ftcn affected by intracranial si'(iuela' from otitis media than the left." , u- 1 1 The dura abutting upon the infected bone becomes thickened, livpera-mic, <rdi'matous, and, when exi)os('d by osseous erosion, cov- ered with granulations. If the i.us from the middle ear. under press- ure, follows the breaking down of '''c bone, tlw dura is strijjped up and a .so-called extradural abscess is formed in the resulting cavity between the dura and the Ix.ne. Such extradural ab.-*cesses tend to spread upward toward the vertex rather than downward toward the l)a.se, because the dura is more loosely attached above. Tiias the writer recentlv had a iiatient who.se mastoid jirocess was intact; but the pus from the middle ear jjasseil through an erosion in the tegineii, dissected off the dura upw, rd to about two inches above the external auditorv canal and, at a point one and threcMiuarter inches above, IK'netrated through both tables of the skull, appearing externally under the periosteum. (Fig. (Mil' > • • • i \X other times there is produced a localized pachymeningitis, with- out the loosening of the dura by pus. ami this inflammation, .spread- iug to the other membranes of the brain, with the evolution of more ,.f less plastic material, may cement thom together around a centra .•ore of infection in direct connection with the bone disea.se. Shomd .III accumulation of pus take i)lace in this central core, between the pia and dura mater, and surrounded ami |)revpnted from dissemi- nating by the i)lastic efTusion uniting the brain enveloi)es, then we have what is commonly called a subdural abscess. In the majority ..f such c:i.ses there occurs coincidently, or directly following, a super- ticial ence|)halitis, with or without ulceration. If the infective material gains an entrance into the subdural space ihrough the dura mater before this adhesion of the membranes ha.s occurred, an acute leptomeningitis, either serous or purulent, will very iiK.bably be set up. In the serous variety of leptomeningitis, there i- lyiHTa'mia, followed by the exudation of clear serum, often contain- :m Hakes of fibrin, leucocytes, or a few pus corimscles. Such an effu- -ion mav result either in internal or external hydrocephalus. Macewen -iat<«s tiiat occasionallv such subdural efTusions may be localized. In I he ()urulent variety tliere is, in addition to the hypera'inia and serum. I marked exudation of leucocvtes, degenerating in places into purulent loci, together with more or less encc])halitis. Such a leptomeningitis tends to s]>read rapidlv and widely. Infection spreading along the Mirineural sheaths gener.ally gives rise tolei)tomeningitis: thus it may ,.a.ss from the middle to tl'ie internal ear and from thence backward iloiig the sheath of the facial and auditory nerv(>s, or from th(> facuu ij.wardand f'TWiird through, the foramen enclosing the great petro- -al nerve. In voiing children, purulent otitis media is ■■)t to give rise to purulent lei)tomeniiigitis, the infecticm passing thiough the 1120 TtlK t:.iH. luimi'ii.us veins and ihtvc slicatlis: this is csiu'cialiy true of the tuhi-r- ciilar atTcction. .\.s lias Ix-eii said, nu.rc or less cnceplialitis must neeespanly W foincident with or follow dose upon a purulent leptomeningitis, because "of the intimate relations" existing between the pia inater and the l)rain. and "the maimer in which the bloodvessels dip into the cerebral sui)stance, carryin}; aloiif; with them their investment of the pia mater." Also, the purulent leptomeningitis, extending along the pia mater wher(> it dips into the sulci, may bring about a collection of pus in these sulci, which may take the form of a localizeil ^- , ricial abscess if the line of inviusion is ch)sed by plastic adhesion ... ,.ie membranes. A localized encephalitis adjacent to this absee.ss usually results in ulceration of the brain surface, adding to the size and extent of the abscess. Sucli an abscess, although involving the superficies of the brain, is not entitled to be termed a brain abscess, it is more proj>crly an ulceration. FlO. 57». 1. Carious ..penlng in tympanic ro..f. 2. Thickened dui» tamed b«ck. but when in position coTera cariouK opening. (Bacon.1 A true brain abscess is brought about by the extension of the infec- tion along th(> bloodvessels into the brain -ubstance proper, inducing (edema of the surrounding brain tissue, with exudation of leucocytes and red blood corimscles in varying proportions. .\s the (rdema and swelling increjise. degeneration of the nerve tissue en.sues, and then finally results an area of purulent encephalitis; in other words an abscess "made uj) of pus and disintegrated brain tissue. It some- times hatMX'Hi^ tl'sd the death or necrosis of a considerable area of cerebral tissue results in the presence of sloughs within the abscess. Such sloughs mav be caused by infective embolism or thronibo.sis of the main vessel" supplying a iM)rtion of the brain, leading to ana>mic gangrene: emf)olism of "the main veins inducing gangrene from the 9-n^ ^^mmmmm VVRl'LEyr IXFLAMMATIOX OF rilE MII>I>I.E EM!. 1121 ii tense pressure set up by the extravasation due to the bloekiiiK of thu exits of the blood stream, hemorrhagic necrosis; localized pressure ,1 the part engorged, with extravasation exerting influences upon \h9 .1 i^aboring brain tissue, leading to its disorganization and death, tlie intensity of the inflammatory action depending on the nature of the micro-organisms, inducing rapidly advancing necrosis (Mac- i.\veu). The brain membranes are rarely involved in such u slough. As a rule, there is ocular evidence (Fig. 579) of the pathway taken by the infective material in reaching the i)urulent collection within the brain; the majority develop by direct extension from the nuddle car. But there may be no visible tract, the infection spreaiUng inward through the vascular or lymphatic system. Tubercular disea.ses of the middle ear seldom give rise to bram ab- scess; this is due to the fact that they are more apt to set up a rapidly fatal tubercular leptomeningitis, and the extensive bone destruction permits of free e8ca])C of the purulent secretion. The sanu' micro-organisms have been found in the purulent collec- tions of leptomeningitis and encephalitis as in the otorrhoca. The brain abscesses caused by purulent otitis media are usually .•situated in the temporosphenoidal or cerebellar lobes, and are much more frequently consetiuent upon the chronic than upon the acute I process in about the proportion of six to one. \bscesses of the temporosphenoidal lobe range in size finn'. a few drops to a number of ounces. They are single in 87 per cent, of the cases, according to Macewen. Together with the disintegration and • loath of the afft :;ted brain tis.sue, the surr-unding living tissue l^egins to throw out material which is eventually transmuted into a fibrinous membrane, at first non-vascular, but later supplied with bloodvessels Mild of a verv low grade of vitality. Thus a capsule is formed, which, when complete, generally brings the suppurative process to a stand- still. How long it may take a cai)sule to form is dependent upon the character of the inflammation. Abscesses three weeks old have been found without capsules. In acute abscesses tht; surrounding ti.ssue is actively inflamed, with a surface flocculent, shaggy, and irregular, docked here or there with minute sloughs. The escape of blood from tlie small vessels has been jirevented by thrombosis in advance of the molecular disintegration. But it may happen that disintegration is M) rapid tha+ thrombosis does not occur, and then bleeding takes place into the abscess cavity. In older abscesse.'i there usually exists a rounded capsule, varying in thickness from one to more than five millimetres, whose internal surface is generally smooth, while the oxternal surface is rather ragged and flocculent. Occasionally the poriphery of the cajisule is reinforced by a layer of connective tissue, !iiid at times this lai'or is more or less calcified. The contents of "a cerebral abscess, consisting of pus and disinte- U'vated brain tissue, is usually of a giwuish-yellow color. When there has been blee<ling into the cavity the color is dark })rown. In other cases the contents nuiv be thin, serous, fetid, and contain many 112: rHK EAK. minute sloughs. "^<»mctiiiuvs the upper part of the ahscws eavity may contain more or less fetid gas. It has liappenetl that smother abscess may form outside of an encapsulated abscess, because the compression and i onsecjuent irri- tation of the original one hiul induc(>d a purulent encephalitis, the encapsulated absce.«s remaining intact. Again, the inner surface of the capsi le may begin to graimlate with the production of more ))us and th'- largement of the original ab.scess. It i. . ^ibie for a cerebral abscess to be absorbed. The fluid por- tion of the pus may become absorbed, and newly formed vessels originating from the living brain tissue and f)enetrating the capsule may bring about tlie absorption of the purulent tlebris through phagocytic action. Brain abscesses have discharged l)y (>rosion through the tegmen tympani or antri, through the external wall of the skull, and through the internal wall of the mastoid cells. But it rarely haj)pens that a cure is brought aboutin this way. Usually the abscess breaks through the surface of the brain, setting uj) an acute leptomeningitis, or into the ventricles. The infective process, originating in the middle ear, sometimes picks out a course towartl the sigmoid groove, and when it hai)pens that the osseous wall is deficient at any point, being replaced by fibrous membrane only, the infection may quickly extend to the contained sinus. More usually, caries of the bony wall results in erosion, with ultimate exijosurc nf the sinus. (Fig. 580.) Less frequently, i^ there are veins from the tympanum <■ ijjtying into the sigmoid and jx'trosal sinuses, a vein may become thrombosed and the thrombus extend into the sinuses; this generally pro- duces thrombosis of the sigmoid sinus first, extending tlience into the other siiuises, hut occasionally the petrosal sinuses are first affected, and the sigmoid is implicated later a.s a result. However, vei-y few cases of sigmoid sinus thrombosis occur without extensive disease of the bone. This is especially true in tul)ercular affections and in carcinoma auris. .^s the right sigmoid groove is generally wider and rjeeper and is projected more outward and forward than the left, it is but natural that it should be somewhat more frecjuently affected. Infective thrombosis of the sigmoid sinus occurs chiefly in adults. l'«rt (if skull „f yniing girl who •lied of infective sinus thnimbosls. Shows internal dnrnl wall of sintis rellecteil liack, cxiKj«ing i)erfora- tiou in wall ol sigmoid groove; also the dark, diseolored appear- ance of i.inns wall cunlng to the edge nf the tione. Arniw fxiinls to sinus. I b'rom a sfieciineii in the amhttrs collection.) "S^ I'VHVLKST ISFI.AMMMIOS OF TltK MIDOLE EAR. 112.1 , Nc.-i>»ionnllv in children, and rarely in tlie aged. It is often asso- liaK'd in its later stages with meningitis, and not infrecjuentiy with (•erel)ral or eere'-'-llar abscess. As hai)|)ens in all cases of venous thronilwsi.'i, tlie internal endo- tlielial lining of the sinus becomes roughened through swelling, soften- ing, disintegration and desquamation of the cells, and the fibrinous constituents of the blood current find a lodgement on the roughened -urface; the mass so formed gradually encroaches upon the lumen of the vessel until it is jiartially or wholly occluded. WTien the sinus i< whollv (.cciuded, the clot spreads for a greate- or lesser distance above and below, and so effectually stops the How of blood through t he sinus. At this point the clot may become organized, the \nrule ice Fill. .'«!. I^^J-ommHntcanonihrongKparitial fitmmen with txtemciwlm of AM. Ext.jugvlarvetn Inl. jugular vein I .i„..ram showing the foramunloitlon, enisling between the sui^rior longitudinal «n.1 lateral slnu«e« and the external veins, Indicated In the figure by •. (Lki'BE.) of tlie infection having exhausted itself naturally or because of opera- tive interference with the affected bone, or the clot may l>egin to ilis- iiitegrate with more or less formaiioii of pus. This disintegration icxults in a purdent fluid, greenish brown, grumous, and often streaked with pus, collecting around the original site of infection for the «inus, and beyond this in both (Urections, upward and down\vard, ilicre usually extends a healthy clot. In some cases, sloughing of the external wall of the sinus occurs, with evacuation of the fluid c.jn- i.nts into the mastoid process; the extension of the olxstructing clot vvithiii the healthv •>ortion of the sinus preventing any hemorrhage, 1124 rilH EAH. ius a rule. Shoulil tlio visceral layi-r of tho sinus bocomo iiffprtcd, an acute lt'i)tom('iiinKitis, wliich may hv loralizod, usually results. Tiic Immic and the soft tissues, in the immediate neighhorhooil of t'>e dis- inteRratiiift jiroeess within the sinus, get to be dark greenish or brownish in color, an.i the surface of the bone becomes roughened or eroded. Finally, softening of these tissues takes place, if the ])atient lives so U>ng. Kio. :«% Anl./aciuXve:.i Fxt. Jttfful xvin Communication ivithveitiM at back of neck IMagram showing the communlratlons exlrtlng between the lateral and cavernom »inus«!- and the external veins, indicated In the figure by *. (I.ki'be ) The infective sinus phlebitis may CAt'.'nd downward into the internal jugular vein, and even into the superior vena cava. The soft tissues .surrounding the affected veins may become a'deinatous and infiltrated with plastic material, and tho cervical lymphatics involved fnnii a continuous line of swelling down the neck under the deep ccr\-ical fascia. The swollen ma.^s may undergo purulent disintegration, form- ing an abscess in the neck, sometimes directly connected with the It.'.^t! ' ^1^^ ."w ll,-^-.M-J l i ' jivm ri'Rl'LKXT ISFLA.VMATIOS Oh' TIIK MlintLK EAR. 112.-) (lisintcp-ating thrombu.s within the vein. Evon hen-, however, there (xists often ocntrally a firm thrombin which for a time prevents fiirtlier (Usscniination of the infective material. Infective material mav be carried into the general circulation by wav of the internal jugular vein or by way of the posterior condyloid v.«in the occipital sinus, or the mastoid vein, which communicates indirectly with the subclavian and innominate veins without passing through the internal jugular. (Figs. 581 and 582.) Whiting states that "there is great likelihood that general infection may also take place bv Ivmphatic absorption of the pyogt>nic organisms." Maeewen say^ "Infective matter may spread through the sinus walls into the neighboring parts, where it may be taken up by the cong<«8ted vessels and periva.'icular spaces and carried into the circulation. " Within the skull the dura may be stripped up from the bone by purulent exudation or bv the evacuation of the purulent contents ot the sinus, and the pus may seek an exit externally by way of the mastoid foramen or through the posterior condylar foramen, where it form.x an abscess under the deep fascia in the upper third of the posterior cervical triangle. When the pus forms on the visceral side of the sigmoid sinus, it may gain an exit through the anterior condyloid "occiusionally the cerebi-ilar veins become thrombos<>(l, thus admit- ting i)athogenic organisms into the cerebellum. From the sigmoid sinus, the disease ma> take its way to thecavernous sinus, from whence it may extend along the ophthal- mic vein into the orbit, inducing a purulent cciii. litis. (See Fig. 582.) . . Septic material once m the cir- culation is carried along until de- posited in the lungs, brain, intes- tines, or muscular structures; lea.'^t often in the kidneys or liver. Wherever the septic particles tinally lodge there results a metas- tatic abscess. There exist two tracts by which the infective process extends from the middle ear to the cerebellum. First through the labyrinth (Fig. .583) with the neighlwring portion of the ma.stoid antrum land second, ^, ^ n i i ♦„ through the sigmoid groove and sinus. The f^rst usually leads to Ihsce.! in the median portion, while the second leads to abscess in the lateral portion of the cerebellum. • „ ;„ u=a There has been no record of a cerebellar abscess forming in less time than from two to five weeks. These abscesses are usually small, Fio. .'V'W. 1 View of middle «nd lntern»l ear from In front. 1. Floor of tympsnum. 2. Membrana vlbrans. 3. ehorda tympanl nerve. 4. Handle of hammer. .'>. Incus. 6. Fallopian canal. 7. SUpen. ». Vesllbi • ibyrlnth, with open- ingsofsemlclrciila. .- .». (Fromaipeclmen in the author') collection.) 1126 THE t:AR. although they may grow so larnt* its lo lia\e i • npacity of four ouiico Only one cif«' has dccurrtHl hofon- \:A'. furlh y«-ar. ThfV an* v('r\ rare in th«' first ten years of life ami fter t rty, and are imwt fn*<ju('nt Ijcfwtt'n th«' agi-s of ten and thiriy yoar The oldest |)atient was fifty-five years old— a female. Koch fAld«'rtnii's translation) be- lieves otic abscesses are nearly iis fre<|U(vit in tiie eerel)elluni an in the eerebnnn. K(wii also states that cerel^jllar alseesses oepur twii .• as fre (i.ently in males as in females. T'l.' r, in a -^I'^ht preference for the right hemisphere— tifty-three in ti\.' .i'.hl to forty-eipht in fhe left. Thev are usually situated close nii'li i tiii 'ortex, tlic cortex itself usually offering an ai)precial)le rsi- "in', fn a st-rics of 44 cases, a capsule was present in 26 an<l al>n ;• in 1 I duitiple alwcesses were found in It) out of IH fatal eases, •> »veio, mii 'pie al)sces.se8 in the same hemisphere, 2 had one in ( ic ;ieiriis| 'icn 1 li.id set tij) metastatic abscesses, and 7 had anoihir al'Sif ither in he tem- poral or occipital lobes. As with the (i'li'^r in;' 'raniul s»quela- of purulent otitis media, cerebellar al)»ci' - usually foH.iws u!H)n the chronic form; in only 15 (mt of KX) cases did it sih .-tv, ■ to the acute form. The figmoid .sulcus is the usual place of commuiiicatiuii. and the majority are in direct contact with the igmoid sinus, wliiil; is often thrombosed. In 63 out of 76 cases of rlmmic otorrhcea \' rii cpreli*'l- lar abscess there were present on the anterior wall of lin' posterior cranial fos,sa marked and important changes. The area of attack of the carious process extends from the superior to the inf(>rior f>t)rder of the pasterior surface of the pyramid and fruin tlic posterior edgt of the sigmoid groove to the anterior edge of the internal auditory meatus, occasionally involving the tip of the pyramid. Tlu arus is not in the sigmoid groove in the majority of ca-"s, but antcri.c to it. Koch says that the situation, position, and form of the sigmoid proove ha.'^ little to do with the genesi.^ uf cerebellar absci •>. The whole de- velopment of tho cerebellar abscess is inward into the :iie(lul!ar>' substance. Cortex abscesses are much rarer than in the temporal lobe, a'though the cortex may bimme so thinned as tvi diF!'- pear, and the dull or tentori'im e.tiie to form a wall of the abscess. Cerebellar abscesse- .-cldom contain such pieces "f necroti< brain ti.ssue as do temporal abscesses. The contained pus is usually of t creamy coiLsisteicy, of a yellowish or greenish color, frequently fetid, but free from f;:Ls bubbles. Blood clots have Ijeen seldom found. The neig^'iorhodd of the ab.sce.ss is usuallv microsc-ipicaily intact. Sometii les there is a surrounding zone of red rr white softening, in which may exist small hemorrhages and small ab.scesses. In several instances the cerebellar abscess and its .accompanyinc meningitis ha'-e produced a state of internal iiydrocephalus. Tf rui turc •;-(-ur?, ;!ir pus may entvr the aiachnoid :^pa"-% - *'in«^ up ;i y--- lent leptomeningitis, or, a cementing of the meninges previously ocr - ring, the pus may form a subdural absc< . s by spreading between dura and the brain, especially under the tent'rium; or. ami thi / ^ Pl.ATL-; XXXV 1 in Mii.niT K\K KilKirtioii .if ihe s KMiiijit. wiUiiii ttic 'rvmjKmuitl : Ciirxcd Injccliiiii .>!' llu- K.-iiliatiiiK CaiMlliirics mikI 1-n. I Ciiki.Mi Sik"is c.\r\riRn in Tyini,anic Miiuhrane. with Cnlltclicin c,f StM Fluid l.iiu in I i.iiil ot tlic Iml«i I-'li.. •. Aci 1 1 c \ I \KHii M. I >i n IS Midi . the Mallcal PUxn- I'li. ,;. A..rri. SrriTKATiM otitis Mki.ia Miukt-il lliilniiix .if the I'.istcrior- suiKTi.ir yua.lrant. Iliiliim Hiniillc .if llHinmei . Kccliym.iwi. in (In- Kngor(;eil Tyniimnio Meinlirane Fl.; 4 AciTK Sri'lMR iiivi, OTITIS MilUA Tviiipaili. Mfnil.rane (.-.iMKeslfd ; .mlv thf Sli..rt Process an. I riipfr I'art of the MaMul.riniii is Visil.Ir . a Small I'lrf.iration in the Anli-ri.ir inferior ijuailrant. lhriMii:h which i.inl.l lie seen a I'lilsatinK I,i«ht Keflex ' ITIS Ml iiM iliirinK an exactrl.ati.ini Ki.lney- ,nm li'lye Miu-.Mis Mtinlitane <if Tvnipannm Conxesteil. l-l... 6. CltH.iNU l.rane ; Incus Cari.ni Fu;. 7. Chri.nh Sti'iTKATivK UTiris Mki.ia. I'crf.irati.in .if ^hn.i.ncll~ Memlirane, through which I'r.itrudes a I'olylKii.l Cianulali.in Caries of the Walls. .f the Attic II.,. H. TllK RKSl IT F.il.l.iiWlN.. IlKAIlN.. ..I \ CHR.iMC Smi RATIVK OTITIS MKl.lA. Chalk I)ep..sits in Fr.mt ami Hehiii.l Mannl.rinin : Ki.lnev-hai*.l Cicatrix occupyinu Inferior Half .if Tymimnic Meniliralie. ■ I-r-MH Br'thi"' Aii:i- ;kr ohrcnhcilUilli.le. ; Fl.; 5. Chronic St'i'iTHArivi ( ^hajieil Perf.iratj.in with c.ranula Si iM'ik A ri OTi ris Ml I.I ■, I'erf.. ratio sliraiinells Mem- I'VRl'LESr ISFhAMMAriOS >>F THE MIDDI.K EM!. 1127 frcciupnt, a tistulii forms through the dura to the petrous bone. Kx- (cptionully the abscess may break into tlie fourth ventricle. Only one case of spontaneous heahng of an otic cerebellar abscess iijis been noted, the healing resulting in the formation of a thi<k cic- atrix. Otitis Media Purulenta Acuta. This form of otitis media is a continuation of the process described under the heading of serous exudation, much intensified becaus(> of the greater virulence of the infection. Symptoms. In the beginning the same ymptoms make their appearance: hardness of hearing, a feeling o. fulness or stuffiness, and tinnitus, which is nmch more marked. The tinnitus is of a hissing, roaring, iiulsating, or throbbing character. Pain is <iuickly in evidence ; it is usually intense, radiating over the affected side of the head, and seems to be worse at night. There is a sense of heat around and in the ear, together with a feeling of numbness. If there is great intratympanic pressure the patient complains of dizziness and vertigo. The bodily temperature ri.ses sometimes to 101° to 103° F., and occa- sionally there is delirium. Sometimes there is impairment of the senses of taste and smell. In children the condition sometimes simulates an attack of meningitis, the temperature ri.'-ing at times to 105° F., with great restlessness and s'-reaming. In them the attack sometimes begins with a convulsio.. 'r vomiting. In infants the hand is frequently applied to the affected ear. Some patients refer the pain to the teeth; unless the attendant is ac(iu,,inted with this fact an error in diagnosis is possible. Those patients who have a ilefect in the bony wall of the Fallopian canal may experience nui>- cular twitchings due to irritation of the facial nerve: rarely facial palsy may appear, due to the same condition. In the tubercular form of the aff'ection the process is very insidious, often painless, and sometimes exists without perforation of the drum membrane. In the.-ic ca.ses the lymphatic glands around the auricle are frequently enlarged. Caries and necrosis of the ossicles are apt to occur. Objectively, there is noted congestion of the drum membrane Ix'ginning in Shrapnell's membrane, along the posterior of the hammer handle, in the jjeriphery at the attachment of the membrane to the aimulus tympanicus, and in the capillary twigs radiating from the piTiphery toward the umbo, the rest of the membrane being dull gray :ind lustreless. ( Plate XXX\'., Fig. i.^ Soon this congestion spreads over the whole surface until the drumhead becomes pink, or red. or .■rimson. If the infection is very iutonse, for instance, in cases caused t>v the grippe or sea-bjithing, the capillary twigs may rupture antl the hemorrh.age raise the dermal layer until ipiite large blood-blebs :ippear on the outer sufac(> of the drumhead and neighboring parts of liie canal wall, wliicli is also congested. The congestion is usually much less marked in tuberculous cases. Serous or purulent exudation may take i)lace within the texture of the dnun membrane, forming 11 I'M rm: i:.ni. serous cysts or lociilizoil abscesses, or tlie life of the ileniial layer iiiav be destroyed so that it finally exfoliates. Before exfoliation takes jdace tiie a|)j)earance of the dniin nicnibrane is apt to bo deceptive; one niipht think that the dull leaden looking drumhead concealed no active inHaniniatory process within the tympanum: but the use of cotton on a cotton-carrier gently rubbed over the surface removes the exfoliating dermal layer, leaving behind a smooth red surface which may bo mistaken for a polypus. As the congestion increases the landmarks normally present on the drum membrane are obscured and finally become invisible ; thus, the light reflex, the hammer handle, and often the antciior and ])osterior folds, are gradually lost to view. The increasing (juantity (jf fluid in the tympanum begins to exert l)ressure on the tym|)anic membrane, which begins to bulge outwardly (Plate X.\X\'., Fig. 3), most frequently in the posterior half, but some- times at the site of Shrapnell's membrane, or both of these sections may be involved. Kxeeptionally, bulging may not appear, although exudation exists. The lymphatic glands behind the auricle and over the l']ustaehian tube may be enlarged and tender, especially in chil- dren, and in severe cases there may be an area of tenderness over the mastoid antrum. Shortly, unless the condition is relieved, perforation of the drum- head takes place in anywhere from a few hours .;) a number of days. Immediately following perforation a discharge makes its appearance: at first serous or serosanguinolent.it soon becomes purulent or muco- purulent, except in cases of tuberculosis, when it is apt to remain thin and watery. The perforation is most usually situated in the inferior half of the tympanic membrane; exceptionally in Shrapnell's membrane, if the inflammatory process is mo.st intense in the attic. (Fig. 569.) The perforation is generally round, uiJos- there has been marked necrosis of tissue, such a*' occurs with alarming rapidity in scarlatinal otitis. In children the drum is naturally thicker than i.i adults and the Flustachian tube is wider, permitting the escape of fluid, for both of which re:u<ons perforation may fail to take ))lace or occur much later than in adults. ICven in adults a well-marked jturulent inflammation i. ay exist in the middle ear without any jx'rforation of the tympanic membrane. (Jenerally. after perforation, con.'<iderable relief from the subjective symptoms, especially pain, is experienced. As the discharge con- tinues, the skin of the external auditory canal may become congested and swollen and, in children, an eczematous dermatitis extending to the auricle may be set up. Acute purulent otitis media seldom leads to intracranial complica- tions. Krysipelas, usually beginning in the auricle, has been noted as a complication, and may extend to the scalp and face, occasioning considerable constitutional disturbance. In children a secondary otitis externa may arise, which later nuiy extend to the mastoid peri- osteum, forming a subi»eriosteal mastoid abscess. The most fre(|uent cuniplication is that of mastoiditis. I'lltlLKSr ISt'l.AMMATlDS OF Till: MIIHiLE AM/.'. 112!» Tlif iiiHaiuniatory process, if intelligently treated, tends to reso- lution in from a few tlays to as many weeks, usually with the return of good functional ability. The jjcrforation heals with or without the formation of a cicatrix. In soim- cases the membrane is left permanently thickened or in jiarts calcified, from interstitial myrin- jlitis, and occasionally adhesions form in tlie tym|)anum. Should these changes occur, the hearing may be considerably imi)aire(l. The prognosis is vmfavorable in patients suffering froin cachexia, whether scrofulous, tuberculous, or syphilitic; when the disease occurs in the course of severe attacks of influenza, dijihtheria, or the exan- themata: and when the inflammation is mainly confined to the attic, • witli perforation of Shrapnell's membrane. The diagnosis is indicated by the presence and course of the symj)- toms a.s detailed. The presence of a pulsating light reflex on the .sur- face of fluid at the fundus of the canal is usually taken as jjresump- tive evidence of the existence of a |)erforation ( Plate XXX^■., Fig. 4) ; but it may be due to the great va.scular tension within the tympanum transmitted tlirough the drum mcml)rane. If stringy mucus is found in the di.scharge it must certainly have come from the tympanum through a jierforation. Inflation of the middle ear may cause a blowing, bul)bling, or hissing whistle when a perforation exists, unless that perforation is situated in Shrapnell's membrane, or in a i)ortion of the membrane covering a part of the tym])anum shut off from the Lustachian tube by adhesions. Suction, exerted by means of Siegle's otoscope, or inflations of the i liddle ear, may show the pres- ence of a ])erforation by the appearance of <lischarge in a canal which has previously been thorougl)'> dried. Harr well says that "obscure illne.ss in young children, consisting of feverishness, irritability, and symptoms of cerebral disturbance, are sometimes explained I *'ie ultimate api)earance of a discharge from the ear." Occurring .u the course of infectious diseases, its ajtpearance is usually marked by a sudden accession of temperature. In the tuberculous form the jjerforation tends to enlarge l)y the melting away of its edges, the tissues are pale, and graimlations are rarely present. My colleague. Dr. Hurnett C. Collins, found oiily 4 ca-ses in which the middle ear was involved in 62 j)atients with well-marked tuberculosis. This is ab(>ut the proportion usually reported. The tareatment of acute sui)puration of the middle ear may be divided into that a]iproi>riate to the condition before perforation and that after. While there are many methods of treatment in vogue among aurists in g(>neri ' ;nost of which are of value in appro- priate cases, the writer beii w at the object of tliis article will best be met by confining hi^ i •' iption to those methods which he habitually uses in his own pi • .• and hospital practice and which have stood the test of his expciience. lie does not believe in the use of the various anodyne instil!ati<jns or suppositories sometimes recommended for use in the external auditory canal. The patient 11. -iO rift: i:.\n. w\ slioulil 1m' jnit iii)on a liglii Um mitritious diet, alcohol and toliaccn anil coffee siioiild l)e den-.d and, if jxissihle, rest at homo shouM l>e enjoined. A mild (■l'.,>l:if.;.>Sin' laxative should he administer<'<l ut the very heginninjr. iU'd M'lier. iiarcotics are given for ])ain the con- stipating tendency slinuK! ''C overcome hy the sinuiltaneoiis exhi- bition of a laxative. When there is iuark<'d fever aconite in small and repeated doses is of great value, preferably the tincture in minim or half-minim doses hourly. There is rarely any time t( correct eridrs in the general health. The inflammatory condition existing in the nasopharyngeal cavities should receive the indicated treatment. \'ery gentle ixilitzer- ization is sometimes of great licnefit in the very earliest stage, before there is much exudation and bulging; afterward it often does harm by increasing tension and driving the infected exudate into the fur- thest recesses of the middle-<'ar cavities. Politzerization should only be used after a thorough and painstaking clean.sing of the nasopha-ynx. Local bloodletting, by means of Bacon's .artificial leech (Fig^. .i.59 and 5()0) or l)y the live Swedi.sh leech, is fre(|uently of great ^alue. but shovild onlybe used insturdy.plethoricpatieni:. never in tho.se who are weak or anaMiiic. They are to be applied either immediately in front or behind the iiuricle, as close to it as ])ossible, and from two to four of the natural leeches must be used to obtain much of an effect. After- ward, if it is desirable to encourage hemorrhage, tiic bleeding may be prolonged by the use of lukewarm watiT. The bleeding is usually well controlled by jjressure; but occasionally styptics have to be used. Needless to say, the skin before ai»i)lication and the wounds after- ward should be rendered aseptic. From lie beginning heat should be ap|)lied to the esir, either by means of the hot-water bag, the hot-water douche, or both. A mild antise])tic may be added to the douche. The writer believes the thorough drying out of the external auditory canal, after each douch- ing, to be of the utmost importance if the skin of the external ear is to be maintained in a he.ilthy state. This drying should be done by means of cotton pledgets formed on a cotton-carrier, then removed fiuin the carrier and gently introduced into the ear canal. The douching is to be re|)eated every two hours, and between times the hot-water bag shouM be ;(pi)lied freiiueiitly. In the intervals a soft wad of cotton should be placed in the covlia to i)rotect from draughts. At night the patient shouhl sleej) with tiie head high, on two or three pillows. The writer would heartily indorse the remarks of Duel, which are a.s follows: "In dijihtheria and the exanthemata the only way to be sure that ;in acute otitis is not developing is by daily in.spection sif the lympanic membrane. In.asmuch as this is impr.acticable, it would seem wist- to liaVf tjie oaiiai r^torilized daily by irrigations with 1 ; KXK) bichloride solutions in order to avoid infection in those ca.ses where spontaneous rupture occurs without warning s\niptoms." I'lvery meilical attemlant on a severe case of these disea.ses .should feel a VVHlLKyT ISFLAMM.xriOS OF THE MIDDLE EAR. H.Jl moral nblipation to have a competent aurist periodically examine his patient's ears, at least as frequently as once a week, since the field of prophylaxis here is as broad as that of treatment. Many a child consigned to the despair of a postscarlatinal or pt)stiliphtheritie chronic otitis has good grounds for condemning the criminal negli- gence of his family physician. Incision of the tympanic membrane under the most careful anti- septic precautions, including thorough treatment of the external ear canal, is always indicated in the ca.se of intense pain unrelieved by treatment. Also, in the writer's opinion, whenever tiiere is bulging, liowever slight, if accomjjanied by pain. It is undoubtedly trxie that in the majority of cases we wait too long. Karly incision ensures an a.septic field and a probably les.sened intensity of infection: this is especially true in influenza, diphtheria, and the exanthemata, llarly incision has the added value of ensuring against tissue necrosis and of being at the point of election for the most efficient drainage. The operation of incising the drum membrane is j)referably begun, under the use of nitrous oxide anaesthesia, near the |)osterior border, on a level with the umbo, and carried around parallel to the inferior border until a point is reached anteriorly at the end of a line drawn through the point of begin- ''""' ^^ ning and the umbo; in other words, the whole in- ferior half Of the drum membrane is turned into a Hap. (Fig. 584.) The knife should be a straight or curved bistoury, and .should he carried through the membrane only, not so deej)ly as to score the inner tympanic wall. If tliere is bulging, the cut is to lie so modified as to include the most de- pendent part of the bulg. . An entirely different form of incision is indicated when the attic is in- volved, with bulging of Shrapnell's membrane. Here the writer be- lieves in carrying a bistoury from just above the short process of the hanmier upwaril and inward, to divide any folds of mucous membrane imtil the bony edge of the superior canal wall is reached, .ihence the incision is continued along the junction of the posterior and superior canal wall to and including the part overlying the mastoiil antrum. SiN)ntaneous ru|)ture does not always provide for drainage efficiently: in which ca.se the perforation should always l)e enlarged along the lines above indicated. Following early incision, and only when done under the strictest antiseptic precautions, the writer habitually introduces a slender Kaiize wick up to the fundus of the canal, being careful not to i)ack it into the canal, then loosely packs gauze into the concha, and covers the dressing with a layer of alworbent or raw cotton, held in place '>v a strip of ^inc nxidf* plast/r .attjiched to the auricle. This dressing should be renewed at intervals of twelve hours for the first few dress- ings, the discharge being removed each time by aseptic cotton pledgets, .iiid often the ear is found to be healed after a few treatments. If the I.i ne of incision on tym* panic membmne. 11. Jl' Tin-: EMI. pauzo wick is saturatcil at each dressing and ilic irritation in th(< iiiiiiillf car and canal increases, tliis form of treatment must he ilis- continued in favor of syringinp. Some cises do well simply l)y dryinj;- otit the canal at fre(|iient intervals— every three hoiirs--hy means of ])ledjiets of absorbent cotton, without syringing. The ear failiiiK to do well under the above methods, then resort must be had to syrinninp. As the n'ain ol)jert of syringing is to re- move the discharges, this is best acr<..(ii)lishcd at home by the use of the hand syringe, either a Davidson or a Goodyc ir one-ounce hard- rubber ear syringe ( Fig. 585) or a Davidson aural and ulcer soft-rubber Flo. ."«.■>, Bulb syringe. Eur »>rinKC : hard rubber. bull) syringe. (Fig. 586.1 The douche in the patient's hand rarely meets the indications at this .stage. A pint of hot water should be ased at one sitting, and the sittings should be at inter- vals of two or three hours. The auricle should be held out from the side of the head and the nozzle of the .syrii>ge introduced to just within the external orifice of the canal. Any of the antiseptics in ordinary use, boric acid, bichloride of mercury, or carbolic acid may be added to the water, which should always bo boiled before u.se. No effervescent remedy, such as peroxide of hydrogen, should be employed in acute ca.ses, for obvious rea.sons. The writer prefers tlu> bichloride of mercury solu- tion, when he does not u.se ordinary sterile water, in strengths (>f from 1 : 3000 to 1 : .')000. The syn-ingo between treatments should be placed in a solution of carbolic acid or bichloride of mercury, having pre- viously been Hlh'd from the solution. Always after syringing, the ear canal should be gently but thoroughly dried out by means of pleilgets of iuseptic absorbent cotton, and a soft wad of cotton should be placed in the concha. The injected fluid sometimes enters the middle ear, the Kusfichian tube, and the throat, in which case care should be taken to use only the milder antiseptics. The writer does not believe in the u.^e of powders in acute cases; they blur the picture and an; prone to lead to retention. Some ])olitzerization, at intervals of one to three days after free incision, is gen<'rally very beneficial. After the subsidence of the inflammatory jirocess and the healing of the perforation, the ear should i)e inflated gently from time to time and a soft cotton wad worn in the concha. Precautions should be taken against tho.se things likely to cause recurrence of the trouble, such as exposure to cold or bathing the head. i'iiui.i:si' i.\FL.iM.MATio.\ Oh' Till-: Mii>J>i.i: i:Mt. \\:\:\ Otitis Media Purulenta Chronica. Wh<>ii \\w iinitc process pfi- ~ists for a period longer than iive or six weeiis it is usually considered to have entered into the chronic phase. Hardness of hearing, of varying degree, i.s usually present : hut it is by no means invariable. The hardness of hearing is due to presence of secretion, to swelling of the .soft parts, to existence of newly formed fibrous tissue in the shape of adhesions or bands, to rigidity of the ossicular articulations, to presence of granulations or polypoid growths, or to accumulation of cholest<'atoniatous ma.s.ses. The existence of a perforation has little to do with the loss of hearing. Painful .sensa- tions are not usually present imle.ss there is retention of purulent products or an infection of the structures of the external ear canal. Sometimes there is complaint of more or less dull headache, especially by weak and ana-mic patients. Noises in the ear or head are not |)roinineiit, as a rule, and are often absent. Dizziness or vertigo at varying intervals is an element in certain cases. (Jbjectively, enlargement and tenderness of the lymphatic glaiuls ill the neighborhood of the ear is often noticed, j)articularly in children ; if the infection is .severe, even the deej) cervical lymphatic glands may be involved. The skin of the auricle and canal may be the seat of a dermatitis or an eczematous inflannnation, and, in children, a pustular eczema may spread to the siile of the face, due to the irritating ((uali- ties of the discharge. The discharge varies in character from thin serous or serosanguinolent to purul.'nt or bloody: often fetid if tlie parts are not kept scrupulously clean. Especially in children these discharges may enter the j)haryny through the Eustachian tube and bring about a general toxa'niia. The drum membrane is perforated, thickened, or calcareous in parts, and of a grayish or pinkish color. The |)erforation is u.sualh single; rarely, a number may coexist in the same membrane. The jjcrforations (Plate XXW'., Fig. 5) are round, ovoid, or kidney-shajjcd and may have granulating edges. Sometimes the edges are adherent in places to the inner tympanic wa'l. When tiie perforation is in Shrapnell's membrane the outline may be irregu- lar from erosion of the bony margin, the pars epitymjmnica. Perfora- tions are usually situated in the lower or posterior halves of the mem- brane. The drum membrane is probably never entirely destroyed. Through the jierforation may be seen the intrat^'inpanic structures existing opposite its location, more or less modified by the inflamma- tory process. The mucous membrane lining of the tympanum may l)e thickened, or granular, or ulcerated; it is usually red in color from congestion. In very old or sluggish cases the mucous membrane may be grayish or yellowish in color. There is often present carious degeneration of portions of the bony walls of the tympanum or of the ossicles. Granulations and poly|)i ( I'late XXXV., Fig. 6) are frecjuently -'•en jirntrudit'g through the j^erfuri'.tion, especially when the attic is involved and the perforation is in Shrapnell's membrane, ^>ry rarely these granulations may be an outgrowth from the dura exposed l)V osseous erosion. ll.U r///-; t:.iJ:. The diagnosis is mii(l(> by tho history and the i)rcsciK'o of the above symiilcins, subjective autl objective. The element of tviberoulosis is indicated l)y a brachial nieltinp away of tlie tissues of i:ie drum mem- brane and tympanum, the constitutional condition of tho patient, and tlic presence of tiie tubercle bacillus in the di.scharge. The prognosis depends to a considerable extent upon the state of health of the patient, there being always less chance of a cure in those afflicted by the tubercular, scrofulous, or syphilitic diathesi.s. So long as tlie ]>roce,ss jx-r.-ists there is always danger to life from intra- craiii.il complications. The business, habits, and jMisition in life of the j)atient exert more or less influence; the more favorable these are, the better the chance of recovery. Certain conditions obtaining in the affected i)arts adversely influence the progress toward healing: thus, the presence of granulations or jjolypi indicating a deep-seateil affection, atresia of the external auditory canal, retained and de- composing purulent or cholesteatomatous material, and caries or necrosis of the osseous walls or ossicles. The lack of intelligent hoine treatment very greatly milit.ites against a favorable prognosis, as does also failure with long-continued treatment. The prognosis as to the maintenance of hearing dejMMids uiw)n the amount of interference with the vibrating power of the sound-con- ducting apparatus. As none of the middle-ear structmes except the membranes of the round and oval windows, together with the foot- plate of the stapes, is absolutely essential to function, we hence (piite fre(|uently see ))atients who hear well, notwithstanding the loss of the dnnn nieml)rane and larger ossicles. Such obstacles to hearing as inspi^sated secretion, polypi, and the presence of fibrous bands and adhesions are always susceptible to removal, with im- provement of function. When healing of the mi(klle-«'ar inflanmia- tion takes place with a persistence of the perforation, the edge.>j cicatrizing, the so-called "dry perforation" results, and the patient is more expo.sed to a recurrence than when the jierforation is doseil by cicatricial ti.ssuc. ('losure of the perforation sometimes les.sens the hearing ability. Ir is not inrni^sible sometimes to bring iibout the cicatrization of very old jHTforations. even when of consider- able size. There arc certain seipiela' which may result from a chronic purulent inflammation of the middle ear. '.'aus may be mentioned aural polypi, peiioslilis of iju- iiuL-^loid process, nia.sloid i^b^cess, choie.s- teatoinatous tumors within the mastoid i)rocess, facial paralysis, labyrinthitis (especially in .syphilitic subjects), and the various intra- cranial infective lesions. The semieircular .'anals (Fig. .587) are View of lympanlc iiuic from Hbuvi'. 1. External wall of uttic or |«t>et>ityint4iTiiea. i>. llair.- intT hcacl, :1. Incus 4. VnUit- liian canal for facial iicrvf .'>. Vertical scmicircillHr CH^al. t',. Ilorizontal semicircular caiml. 7. Aiitruin. M. Iiicu'lostajH' dial jitiir.. Folds uf luciilbninc noftrly shilt off the attic from thcatriinn. (From a speciiaen ill tlic author- collection.) I'VRVLEST ISFI.AMMATIOS OF TlIK MlliDLK EAR. H.'Jo xniietiim-s, altliough rarely, affectcil, diHturbaiices uf (><|uilibriuin and u'iildiiifss beinj? produccil. A faciid paralysis arising from middle-ear clisca.xe is a lesion of the nerve and is usually niueh more complete than when the cause is in the central nervous system; in the latter the patii-nt can generally close the eyelids, and the face is not so (wpressioiiless. The ai)pearance of the drum membrane after healing varies greatly. It niay be thickenetl and opacjue, may contain calcareous plaques Plate XXX\'., Fig. 7), may 1h* adherent in j)laces to the inner structures, may present cicatrices (Plate XXXV., Fig. 7) which are darker in color, with well-defined edges, maybe atrophied in spots, or. finally, may present one or more "dry perforations." DiKkc M pulypm unarr. Ill the treatment of chronic suppuration of the middle ear the first essential is thorough cleanliness of the accessible parts. Next conies ilie establishment of as perfect drainage as |)ossible. and, finally, the vriiioval of diseased tissue when not contraindicated. In order to meet the first two indications it is essential that any marked fibrous atresia or stenosis of the external ear canal should be remedied. Also ilial any ]iolypi or jiolypoid graiiuiations should be removed. Polyj)i, if iarge. should bo removed by the aural snare, Blake's (Fig. 588) Fii. ^-s. Hartinann'fi ear forceps wUb cutting edge. 'liinr a convenient form, under cocaine antesthesia. Polypoid jjranu- aiii'iis may be removed by the sluup curette or by Hartmann's . metfe-forceps (Fig. 589) or by the use of caustics. After the re- ii.ti; riih: h:.\i!. iiioval of a polyp the Imsi' slimild Im- treated l>y eurettan'' •"" 'aiifei- izatioii. In ai^plyiiij; causties to ftranulatioiis eare imist he cxercise.l not to touch tlie skin of the "Xternal ear eanal or any other pari than the jjranuhition: tlie >tranulatin>t snrfaee mIiouIiI first lie thor- ou^lily 'Iri''*! <•""•• "f^'"'" •'"' eauterizins applieation has Ixeii left siifliciently lonp; to proiliiee the desired effeet, thi- exeess slionid he syringed imt. Tiie usual caustics einph.yed are chromic acid, tri- chloracetic acid, or the solid stick of nitrate of silver. A small ImnuI of the solid silver stick or of the chromii- or trichloracetic aciil crystals should he fused on the end of a prohe previoii.sly heateil over an jilcohol lamp. In sensitive patients the parts should first l«' cocain- Klii. VJli. ^^ .\ulluir's caiitila Biul |ius basin III usu. ized. Always wait for the .slouuli to separate hefore reapplyinji. The i)arts should he made as a.septic as jxis-sibh' hefore any uf these operations, to guard against infection. It should always ho home in mind that tlie granulations may he an outgrowth from the exposed dm-a, and an ■ittem])t should he made with the prohe to discover the true condition hefore undertaking any measures. Chnmiic acid aj)- plied to graiaiiali'Mi^ in ihe region of the Fallojiian canal rau.sed an attack of herpes i cialis from irritation of the nerve in one of the writer's patients; ui anniher patient it set up an intense localizeil intlanunation invilving the facial nerv.', which lay expose.l un<Ier- I'VRILKST ISFI.AMMATIOS itF TUK MIIHX H E.iR \\:\1 iicalh the granulntiims, and caused a facial palsy, relievtHi only by tlio radical o|)cration. If the j)rrforatif)n is tew small or iK)iitinR, it should 1k! enlarged by excision, including a sufficient portion of the surround- ing drum menibrane. During the period that these measures to secure drainage, where necessary, have been instituted, the parts shouM lie kept clean by syringing at home and at the ollice, after the method ile.s<'ribec| in the treatment of the acute i)rocess. Likewise, attcnti<(ii should be devoted to the removal of any pathological conditiotis in the nasopharyngeal cavities, especially adenoids in chiltlren. Coinci- dcntly, improvement in the general lualth shoultl be brought about, if possible. For routine cleansing at the office, the writer is very fond of an apparatus (Fig. 500) that he has devised for use insteail of the ordin- arv ear svringe. This apjia- ratiis consists of an Alpha " E " "" '""_ continuous flow syringe, made by Parker. Stearns & Sutton, of New York, weighted at the inlet to keep it in the solution, and provitled at the nozzle with from two to three feet (if small rubber tubing which carries the solution to a glass or metal catmla for introduc- tion within the ear canal. For iirdinary syringing the glass surgical nozzle answers very well. Uiiiler illumination this canula is carried well within the orifice of the c.-mal. The returning .solution is caught in the pus basin devised by the writer, which ha.s an outlet in the bottom fitted by means of ,1 water-tight joint to a hollow metal tube from six to eight inches long and about one-h.iif inch in diameter. This metal tube serves the purpose of a hanul for the patient to u.se, and has a half-inch rubber tube attached us lower fiid to carry the liquid into the wa.stc receptacle. (Fig. .");»!.' At each visit the ear should be thoroughly cleansed by syringing with, any good mild antiseptic solution. This procedure is much tided, wiienever the tym])anic mucous membrane is swollen or liyper- irophied. by syringing out the discharge in the canal, then drying ind applying to the mucous menibiane a 1:5000 solution of adre- nalin chloride. In a few minutes the mucous mcir'Tane will so shrink that a further syringing will empty many of the tympanic Mces.ses which otherwi.se could not be reached, and so further the ' ffect whi'ii a remedial application is made. Tlie tympanic cavity .\ulhor*(» P'ls liiLvin (or ear H!*e. li:w TUt: /■; I H must Ih' tlinroujjlily drifd aftt s syiiii^iiiK In'fdre !iny remotly is up- plitd, whi'thcr by instillation "r oiliiTwisi-. VVhativtr remedy is ime«i, it inaxt never be forKutteu Ihtt there if» no panne*"'., and that no remetly eau take the plaee of ilioiouKii cieai.-iini! and ^txid dridnage, and that every remedy derives its grt'stestt etlicacy from ♦••'w meas- viret". For home treatment the |. lient should syinge the ear two vT three times daily ui'h boiled water or mild antiseptic solutionw, using u pint at a time, uiviays. of course, warm; afterward dryinjj out the ear ean.i! ttioroughly with j-bsorbent i-otton wr pjkhI on a toothpick. When tip iiatient com[)laiiis of vertigo from syringing, reniemlx^r that it is geni rally a matter of ten;perature — the water is used either too hot or t'K) cold. In a few eas«>s it may be necessary to 8\Tinge with the patient in the recumbent picture. Tl:e remedy to iw us<'d at home, after syringing, depends on the condition present in the middle ear. If the mucous membrane is hypertrophic, astringent sohitions are indicated, such as chloride or sulphate of zinc (five grains to the ounce): if granulations .ire jinsent. alcohol more or less diluted at first and containing boric acid or l)i<liloriile of mercury (1:5000); if fetor is present, the alcohol and bichloride .solution or .soluticm of peimanganate of potassium (lifj. pot. jwrnian., Hlx-xl; a<|., 5i^)- When there is :i greai ileal of e|)iili(Iial debris in the discharge anil in the middle e;u', peroxide of hydrogen may Im' useii ix'fore syringing, to bleak up the collections. After leaving the.se 'irious solutions, always warim il belore using, it. the ear for a few niiiiiit"s. the canal should again Im- thoroughly dried out by me ! s of cotton on .. tooth- j)ick. The above treatment may ;dso be used al the iffice. and is much aided by a previous inflation of the ear to drive out any fluid retained l)y capillary attraction. The writer is also very fond of nitrate of .silver in solution, the strength varying according to indications. ii-\ially beginning with from fi\(' grains to the ounce and increasing for effect. In attic ca-ses, with perforation of SliraiiiieH's membrane (Plate XXXV.. Fig. 8), after syringiiig the canal, a Hartm.-mn canula or thai form of it a.s modified by tlie writer (Fig. .")9()), should be attached to the rublxT tubing and, under good illumination, carried into the per- foration so a.s to wa.sh out the attic. Remedies may then be intro- duced into the attic by means of Buck's glttss |)i[)ette fFig. 592) or Blake's miildle-«>ar syringe (Fig. 59.'J), the former being just ;is effi- cient, much cheaper, and non-corrodible. Care should !»■ taken not to use force in .syringing into the attic. A.S the (lischarge (hminishes and the (lathologica! conditions l>egin to disappear, re,'.Grt may lie had to one of the various forms of the Ko-call;-d "dry treatment." Thu? the p.itient, at hf-ne. -u-iy simply dry out the discharges instead of syringing, and may use insufflations of powder afterward once or twice daily. Very littie powder should V)e used at a time. Pure, finely divided, boric-acid {lowder is probably I t'VnVLKST ISFl.AMMATIOS ,,f THK MlltltLK FAR. l\Mi the l>c8t all-round jwwder for (his {)iirpo8f\ Occasionally boric arid iriitntofl the niucous nw'iiibraiio, in<iupii>^ a watery discharKP, in which case its use must be diHcoiitiiaied. The same treatment may l)e iisid at the office. An awptic g.iuie drain sometimes suffices to carry the patient from one office vi.sit to another. ri'i. w; <- ^^ lOii'k'i gUua plpe(l». If, notwithstaiifling a thorough ivr. I intelligent trial of these meas- ures lor a lengthy period (a number of months), the middle-oar inflammation continues, then the (juestion of removing the ossicles comes up. ffemoval of the ossicles, however, even although they art- found to l)e more or less carious at the first visit, should never be considered unlc^^'^ the above consi-rvative treatment has been given a fair trial. And all cariou.-^ areas in the accessiijis. portions of the !'"lo. .'iHS. Blake'i mlddleeikr syriiiice. tympanic bonv wall should first hf curetted and placed in a liealthy state. It has frequently l)een the w Titer's good fortune to see liealing take place in cases that looke<l niost unfavorable l)ecause of carious areas involving the tympanic walls and the ossicles. Ossiculectomy must also be considered, even although tli<- proceas heals at times, if recurrences of the inflammation occur i^ quently with retention symptoms; but, where yiossible, the o|)eration should be avoided if 1140 THE EAK. FlO. 9M. 9 10 11 « S' the hearing ability is anywiiere near normal, for, while the operation frequently and generally improves hearing which has already been gravely impaired, it also in some cases makes the hearing much worse, and sometimes has been known to leave behind a paralysis of the fpcial nerve. In other words, the operation of ossiculectomy should not be considered simply because there exists a chronic purulent otiiis media, if the latter is of a mild unirritaiing type and the hearing ability is serviceably good. Many patients live out the allotted span of life and many cases recover completely from a long-enduring sup- puration, cither by natural processes or by j)rolonged treatment. Generally, however, the existence of an obstinate chronic middle- ear suppuration, with areas of caries on the ossicles and tympanic walls, and especially with periodical recurrences of symptoms of retention with or without gravely impaired hearing, is sufficient indi- cation for the removal of the larger ossicles. (Fig. 594, and see Figs. 569, 571, and 573.) The frequent occurrence of giddiness and head- aches and the presence of cholestea- tomatous masses in these cases still further emphasizes the necessity for operative interference. The writer always does the operation with the patient sitting upright in a conve- nient chair and under the influence of nitrous oxide aniesthesia. This form of ana'Sthesia is preferred be- cause of the quickness with which the patient is ana'sthetized, the lack of danger, the ability to keep the patient in the most desirable posi- tion, and the rapid recovery from the effects, usually without nausea. Just before the ana'stlietic is given the ear is made as nearly ."urgically clean as possible, and a warm 10 to 20 per cent, solution of cocaine hydrochlor- ate is instilled into the ear and left there for five minutes, after which the solution is thoroughly dried out. A warm solution of adrenalin chloride, 1:.')(KX), is then instilled and also left in jilace for five minutes. A sufficient number of cotton jjledgets wrapped on tooth- picks has |)r('vinusly been prepared to wipe out blood. The patient is now anirsthetiz«'d and, under good illumination by reflected light, the operation is proceeded with. The remnant of the drum mem- brane is freed from all ailhesions ami a straight bistoury (Fig, 595^ eircunici.ses the membrane about a line from its attachment to the annulus, continding down on eacli side of the manubrium to the View of tymiwiiio outer wall from uitltin. 1. Annulun. J. Tymiwnic membrane. ;t. UamiiuT handle. 4. Long procets t\i inoiw ■n<li«orhi(Milar)K. .'>. <'lioniatyini>ani nerve In foUl (if niucuiis membmne. 6. Cut tendon of tensor tynjpani muscle. 7. Ilody of Incu?. 8. Short pnK-esa of incus, 9. Suspensory liga- ment (tf liatnnicr, 10. .\ttip. 11 Tegmen. I'J. liead of malleu!! or ha nmer. (From a specimen in the author's cotiectiou ) \ \ rVRVLKSr ISt'LAMMAl'lOS OF THE MIDDLE EAR. 1141 umbo; the detached nu'rnhruiie is then removed by forceps. Tiie tendon of the staixnlius muscl(! is now cut with the same knife. Tliis is followed by dividing the ineudo-sta{)edial articulation, if intact, by means of a sickle-shaped or spade knife bent at an angle and by severing the tendon of the tensor tympani muscle. To do the latter, the point of the sickle-shaped knife (Fig. 595, r, and .V) is carried up- Flu. .">9.). Uartmann's inMrumeiiu for oiiemtion on the middle ear. wiird under the posterior or anterior fold until the shank touches the fold, when the cutting edge is rotated forward or backward behind the malleus, so as to engage the tendoii, which is severed by a sawing motion. The anterior and posterior folds are ne.xt cut through close to the hammer. The manubrium is now gras{M»d close to the short process Fio. 59«. McKay's ear forcci«. by McKay's (Fig. 596), or a fine alligator, or Hartmann's forceps fFig. 597), and traction from side to side and downward exerted until the bone descends into the tympanum, when it is turned on its side and renuned by one end from the canal. Very often the removal of the malleus brings the incus, generally its long process, into view, and . 1142 I'HK KAR. its removal thon follows. Shoukl tho incus be out of siplit, it is drawn down into the tympanum by means of Ludewig's im-us hfH)k (Fig. 598, H ) or, what has served the same purpose in the writer's hands, by a right-angled spoon (Fig. 598, G ). The hook or tlu si)oon is .^arricd up behind the pars epilffmjxinica in a vertical jjosition and llartmann'B ear fcrcepji. as far forward as possible until the shank touches the bone. It i.s then maintained in the same position, but carried backward close to the inner wall of the pflr.v until it reaches the position where the body of the incus shoulil ho, when the end of the hook or spoon is rotated IV r« » ^*-« i i i ] s^^^ MBvwewiTi. 8 " y» PnlitzerV inslrunuiii". backward tn\\:inl !h<>aditus until it engages the incus, which is then brougiit ititn view by faction in :i downward and forward direction. The incus is then removed by lln' t'orctps. The use (if cocaine and adrenalin makes the oijeration practically a l)l(Hi(ll{'-s ( ^• it) tlio great majority of cases. I'VRVLKSr INFLAMMATfON OF THE MIDDLK EAR. 114:5 The chorda tympani nerve is almost necessarily destroyed, but the loss of taste resulting is very generally only tempora- y. The attic is now syringed out with an antiseptic solution to remove pus and cholesteatomatous material, and what granulation tissue exists in the attic is carefully removed with the curette or with All- port's curette-forcei)s for use in the attic. (Fig. 599.) The curette should not be used in such fashion a.-< to endanger the facial nerve or a possibly ex|)().sed dura. The prob<" should always first be used to discover an\ erosion of the tegmen. The writer has not made up his mind as to" whether the introduction of a gauze wick at this stage is desirable or not; but, if used, it should be of plain aseptic gauze and not bichloride or iodoform, either uf which may act as an irritant. \Vhen gauze is not used the ear is simply thoroughly dried and the concha filled with absorbent cotton held in place by adhesive zinc oxide plaster. The patient is instructed to lie as much as possible on the operated side to ^-r or drainage. The dres.sings are to be removed at intervals of twelve to twenty-four hours for the next ' I FlO. 5W. Alli>ort'8 ear forceps. few days until all irritation has subsided. The patient is directed to keep in the recumbent ixxsture, the diet is restricted, and the bowels are kept open. Formerly the writer was of the opinion that the incus was fre- quently destroyed or that the portion lef >vas .so aiikylosed to the neighboring parts as to be impossible of removal; but, with the increased expertness which comes from doing the operatic.ii fre- quently, he rarely fails to find some remnant of the body of the bone (Fig. 572), and suspects even then that a small fragn nt may have been paslu'd out of i)lacc by the manipulations. In fact, it has ha))- pened that the jjostoperative syringing has brought such a fragment into view. In but one ease was it certain tiiat ankylosis interfered with removal, and in ihis ease, after fraeture of the manubrivun by traction, the ankylosis of the hanimer liead and incus to the sur- rounding bone wiCs so hnn as to turn flic right-angled curette against the binding screw. Wliere the manubrium i.s brittle from disea.sc it ireqiientlv fractures; but a hold can usually be obtained on a levrj witii the sliort process by which to remove the rest of the l)one. 1144 TlIK EAR. When the pars epilympanicn is found by the probe to lie carimis it may be removed in part by the use of Dencli's punch (Fig. 60(1 > which is the most satisfactory instrument for the purpose, although not as efficient as one would like. A secondary jiost-auricular operation, with turning out of the membranous canal and the use of the chisel, is nnich more efficient. Bacon recommends the use of a sharp sjioon for this purjxjsc. Complete recovery immediately follows the operation in a certain l)roportion of cases; but, in the majority, after-treatment is neccs- (•viichVear punch. sary in order to bring about the cessation of the di.scharge and the cicatrization of the cavities. This after-treatment, in the writer's hands, consists in thorough cleansing of the affected attic, aditus. and antrum by means of absorbent cotton or syringing, using ii special canuhi dcvi.sed by iiim fur tlii.- purpose (Fig. (>01) and the Alpha "E" syringe, iis described above. After syriisging. the parts are thv»roughly dried by means of cotton on a fie.xibl(> applicator which reachi's up into the attic, and even into the aditus, the head being bent forward from time to tirr.e to drain the antrum. The parts being dry, the indicated remedy in powdered form or in solu- n'RCLKST ISFI.AMMA'noS OF TUK MIDDLE EAR. 1145 Fm. iX)l. tioii may be used. The patient is« not iKrniittrd to treat the ear at home, other than to (!ry it out, if necessary, but i" directed to call for treatment at the office, even so fretiuently as twice a day during the first few days after the operation. The time the discharge takes to reform indicates tlie interval.< between treatments in the later stages. Treat- ment is ivept uj > utii the parts have remained free from discharge for from one to two years, the intervals between treatments toward tiie last being to ifing as t -vo or three months, some scal)- bing, though no ilischarge, necessitat- ing treatment. Stacky reports 24 cures in 29 ossic- ulectomies. In 18 there was no im- provement in hearing. The writer has taken notes of 22 consecutive cases of ossiculectomy in private i)ractice, for chronic suppurative inflammation of the middle ear of long duration, many from childhood. Cure resulted in lo, 4 were improved, and 3 were not. Of those inji)roveil 2 were cholestea- tomatous cases and only suffer at lora; intervals from some scabbing. Of those unimproved, 1 is a scrofulous ;firl in whom only the hannner was removed, 1 an ansemic hard-working w man, and the other a man. rill' liearing was made In-tter in 13, remaineu about the same in 5, and was made worse in 2; unrecorded in 2. Two of the unimproved <:i.-<es and one of the improved cases did not continue after treatment. Ill no case was the facial nerve involved. Following ossiculectomy, patience aiid attention to detail often woT'k a wondrous cure. There is no doubt in the writer's mind that this operation should nlways \h' done }>y |)reference before undertaking the radical opera- tion.' He is fcrtain that it will show .is large a percentage of cures; it floes not en<lfinger life or health, .iiul there is no resulting deformity. It idfn(>st iiiviiriaiilx relieves the dizziness and headache, not due to intracranial lesions, when these have been pre,«ent; but, as las pre- viously been said, the operation is only a step toward cure, the after-treatment being fully as important. The radical operation will be described under the heading of Mastoiditis. It is often desirable to attempt the inijirovement of the hearing 111 cases of otitis media purulenta chronica, which have healed with marked imjiairment of function through the formation of adhesions. This iiiiprovement may often be brought about by dividing and re- Author's cknula for nyrliiging out Ibe attic, etc. 1. For use after oMlculectomy. 'i. Forme in place of Hartmann'j canula. The Drat la In 'wo shapes, rtghl and left. (Made by Miv lOWiTZ.) lUK rilK EAH. inoviiif; such baml.s wlicrr thi-y luiid (Idwii thf iiicu(l()-sta|)fili;il articulation or the stajx's to tlio fossa of the oval winilow. Where the haiiuiicr is Ijound down ti. he promontory division of the adhesion rarely iini>rii\cs the hearinn; itut when united to the inciulo-stapedial joint, division followed hy traction on the inanuhriuin.oreven removal of the inanultrium. is sometimes very i)eneHcial. Often tlie removal of the chalky |)lai|ues in the anterior and ixtsteiior ((uadrants of the ilrunihead will improve the hearinp:: thus the hearinjt for the whisper was permanently advanced from 4 feel to 20 fi'et l>y such an operation on one of the writer's patients. A patient wiio ha^ a healed chronic suppuration of the middle ear nmst Ih" cautioned ajrainst the danp-r of getting water into the ear. ei;her in sea bathing or in ordinary washing. Acute Mastoid Periostitis. Harely primary, it is then usually due to iiiiurv or to cold. It is generallv due to extension from an Fl(i. tK Flo. 0)3. Front anil tfur view of &uch 11 cHse in the practice of the author. otitis <'\terna or from a purulent process in the middle ear. It is most fre(|uent in children, and is usually due to extension from the mastoid ceils or through the niastosi(uaniosal suture. Occasionally a superficial ah.scess forms over the periosteum in the suhcutaneou-; tissue: this form generally results by extension from fiirunculous di.sease of the external auiliti>rv canal. In children the pus from the middle ear sometimes dissects away the membranous canal from the bone and ap|)ears under the jieriosleum l)ack of the ear: bur even in these cases there is o>- linarily in\(ilvenieiit of the mastoid antrum. When the subperiosteal abscess has followed mastoiditis.it sometimes ha|ipei;s iliat large necrosetj masses of bone are fouii<l iii l-lRII.E.\r l.\ht.AM.\fAriO.\ OF TIIK MIDDLE EAR. 1147 the niiustoiil. The boundaries of the abscess are generally fornie.l bv the sutures, where the periosteum is adherent, and, tus the i)eri- ..steuni is less adherent in an upward direction, the abscess tends to spread above, and even at times in front of the auricle, over the temple and toward the eve, inducing great oetiema of the aflected ^ide of the head. ( Figs. (M)2 and 6()3.) It is a rare complication ol cerebral abscess and is a usual accompaniment of an extradura abscess which has perforated the siiuamous portion of the skull and apjH-ared <"xternally. dironie periostitis is a frequent accompaniment of sinus thrombosis if the miustoid vein is involveti. Prompt evacuation gives immediate relief, but the lundamental cause shoultl be searched for and eradicated. Mastoiditis. This condition occurs with about equal freciuency in adults and in children: but the disease is much more frequently acute in children than in adults. Perforation of the mastoid cortex with subperiosteal abscess is more than thrtn- tunes as fre<iuent in children iis in adults. Intracranial complications occur much more frciuently in chronic ca.ses. Duel states that in from 4000 to oOOO cases of infectious diseases 26 mastoid abscesses occurre( 1 : 2 m measles ■> in scarlet fever, 20 in combined scarlet fever and diphtheria, and "' in combined scarlet fever, mciisles. and diphtheria. Edwin W. Pyle reports that 4o acute cases, mostly in children, furnisheil i.i per cent, of intracranial complications. ^ ^^ while 55 chronic Ciuses furnished (Mi per cent. The mastoid ^Figs. 578 and 604) is most freciuently affected as the result of a recurrent puriil(>nt otitis media or as the result of exacerbation of a chronic process. In children it is more apt to lollow an acute otitis media purulenta than in adults: also it is more apt to follow an acute influenzal otitis media. The jmtients usually complain of (min. ■ither deep within the ear or in the mastoid ])roce.ss. This pain fivquently is of a throbbing character: in others I here is present simply a dull aching paiii. There may or may not be fever: usually, however, low fever is present, somewhat 'ligher in the evening. Pul.s'iting tin- nitus is a signilieant symptom, as indicating intense vascular tension. Discharge from the eiiV is g( nenilly evident, although there are cases 111 which no discharge occurs and the drum membrane is intact. The lischarge when unusually profuse is always indicative of po.ssible mas- •oid involvement. Temierness is usually present, except in those ca.ses >f long-standing chronic suppuration in which the mastoid process las become sclerosed or " eburnated : " in other ca.ses, however, it may liso be absent. The tenderness is usually most marked in one or I'neunialic mmtolcl. 1. I.arge cull ill tip lined «iih luurous memlirane. J Mastoid antnioi. 3. .Sigmoid gnHue. I From ft spciiiiieii in the uuthor'a ool- b'ction.) ^1 . 114S Tllh: EAR. all of throp Idoaiitifs, cither ilircctly over the iiijustoid antrum, nr over the tip of the mastoid pr-ccss, or ovor that portion of the ihi>- terior-.sup('rior canal wall which overlies the position of the antrum. SwellinR and redness in the neighl)orho<id of any of the abow; three positions may be present, more often in children than in adults, ami indicates the l)eRinninn <>f " periostitis due to the underlying disea.-e of the bone. In Hozold ctuses, the swelling begins under theti|)aii(l si)reads downward in the neck. Slecples-sness, due to pain, is an important symptom usually. Lo.sa of appetite is freciuently present, as well as a furred tongue, fetid breath, and constipation. Headache is com|)lained of at times. In some cases, fistula- opening on the external surface of the mastoid process or througli the posterior canal wall may l>e |)resent. In some, .symptoms of cerebral irritation may app'^u . None of tliese symptoms are invariable; any may be absent in any pariicular case, and the intensity of the .syrnptoms does not always serve as an indication of the amount of disorganization. It may hajjpen that a numb-r of these symptoms may coexist, and yet on operation the mastoid process may be found not involved. The diagnosis is made by a consideration of the symptoms j)resent, usually in connection with the {)resence of a suppurative process in the middle ear. A mistake may arise by confounding an external otitis with this condition; in external otitis the tenilerness is usually limited to tlie auricle and most marked on traction of the auricle, there is swelling in the outer portion of the ear canal, the pain is not so deeply located, and rational treatment usually soon clears up the picture. The treatment may be divided into the abortive and the operative. Tlie abortive treatment consists in esr.iblishing as free drainage iis possible tliiough the middle ear and tympanic membrane by a gen- erous incision into the membrane, carried along the posterior-supe- rior wall of the osseous canal, when there seems to be present peri- osteal irritation in this region: frequent hot douching through the canal combined with the application of the hot-water bag over the mast(<id j)rocess; withdrawal of blood in vigorous patients by the arti- ficial or natural leech applied in front of the ear (it would be preferable to apjily them back of the auricle did not the -rritation from the Icecli bites produce a localized tenderness which masks theclinical appearam afterward): rest in bed. light diet, the administration of cholagoguc laxatives, and the exhibition of tincture of aconite root in minim doses every hour or two. Formerly the use of the ice-coil over the mastoid process was highly recommended by most aurists; l)ut it was found that while it gave great relief to the pain, it so numbed the nervous sujiply of the parts as to mask the symptoms, the process within keeping on in its destructive work meanwhile. For the same rea.son it is ii't well to give narcotics, if it can possibly be avoided. Poultices are also objectionable, for evident reasons. Should no marked and progressive improvement in the .symptoms follow imme- diately or soon upon the installation of the above treatment, then I'VRllESr L\h'l..lMMAri".\ OF TlIK MIUhl.E KAIt 114!> „,,orati..n «lu.ul.l l- rc-,.urte.l t... Tlu- ..,,.;ratu.n in itself h free (nmi .lanKor to lifo: ih.' mn.litioa of tl.o inasu.i.l may and frctim-ntly iloes imperil it. Thon-for.., one shoul.l always .Tr on the safe M<le and „t,?rate oarlv. An nnne..-ssary o,.<'.alion .> much pref.-ral.le to one that is done too late, and an early operation is the best prophylaetic ..K,.nt against intraeranial eon.plieations. How sor.n disintegration ;,f the inastoi.! may set in is well shown by the histor> «•/ Y"- '" tt,.. writer's service at the Kings County Hospital, Brooklyn. The patient, who was an alcoholie with a tubereiilar family history, was uud-r treatment for a general c.nM.'.aint inthe h..spital. On u i^atur- ,hiy afterno.... he began to eomplain of pam in li.s right ear which logan to discharge the ne.xt day without relief to the pain, and some fever and headache appeared. Monday mormng the mu<U'.<\ was lender over the tij) an.l antrum, aiul toward afirrnoon .swelling l-.gan lielow the tip. At 8 I'.M. Monday, the writer ..p.-nued ai;d found a localiml coli..ction of pus in the cells of the tip and anuiner purulent ....llection in the antrum and neighboring cells, with exposure of tlu, aura over the tegmeii aiitri. Beuv-en these two foci the bone was congested and softened. . , , • .1 ifinn A'> \l the lirooklvn Kve and Ear Hospital, .luring the year 1900, 62 .■ases of nuisf.idi'tis were a.lmitted. an.l 42 of tlu;se came to operation \s ca«es an. not a.lmitte.l to the hospital until the mastoid symptoms ;.re prominent, this fairly wll shows the proportion ^^^»;»> ;»" ^e abort.-.l; in private practice, with .■arlier attenti.m an.l better sur- roundings, the proporti.in shoul.l be greater. . . , ^ , Th. iimstoid operati.>n varies in extent from th.' original Schwartze „„cration, in which the mast..i.l .-ortex is p.>rforat.-.l ui. to the antrum .n.l which is appr<.priat.> t.. the cases of acute mast.n.litis follovnng :™te purulent ..tit's media, to the so-call.-.l "ra.lical operation," in which the cellular structur.'s of the mastoid process up to the inner lancl inchaling th.. tip. ti,:- p.>stciior wall of the external cana ,b.n-e a line .Irawn .liag...udly iron, the tl..or ..f the orifice to the floor I ,h,.a.i.;>-,the pars cfut,fmp.,mcr. an.l the larger ossicles are vmovetl. Th.. various m...lifications of the original Schwartze .n'rati.m have simplv been tentative steps toward the final ra.hcal o)erati.>n; for instan(.e, the Stacke. rh.- Ivuster, etc. The oatient is prepared f..r the ,, K-ration in the usual way. wheie „os.sibl,', bv a laxative the nigb.t prece.ling. followed by a «ilme in ho m.. ning an.l abst-.ntion fn.m f...Kl f..r rom f..ur to five hours lH.fore the tin.,. s..t. Th.. instruments an.l -Iressings aiv prepared ,he wav usual to all surgical operations. Half the scalp .uid th. huirv parts around the ear ..f the affected si.le are shaven f.n.r or veh. urs before the time ..f operation, the parts thorough^- scrubbe. wilh s'mp solution. wa.«hed .,ver with al.-oh.>l or ether, then dressed with a moist bichlorid.? pack and bandag<>d. , . , . „, Just iH.fore operation, the patient being a.uesthet.ze.l, th.'^e.ar canal is first ihor.,utrhly cleans...! with a bichl.mde solution of 1 . oOtW, dried out .111 ,1 packed with aseptic gauze, and the skin in the region 1150 TlIK EAR of tl.o (JM n.rk, aurirlo, nii.l sralp ijuin scnihfxvl. uwh.-d witli oU . r an.l scruhfMH witl, l.ichlon.l.. .nlution. The ., titer half of the h.-ul' th.- iHTk. an.1 slM.ul.lrrs arc (-ov.r. d by stcril.- towr Is I„ ,„,it.. ca^.^ It the nHMnliran.' m'.'<is inrisi,,!, for hi-ttrr (irairmgc, il,,' aauze wick is^iiovv withdrawn, th.. wicisio,, ...ado. (h.- cai.al aKain drip.! ,„,< arui the pauze w.ck r.;.,, w^. If a.. ..rdii.ary Schwartz.- o.MTation is done, then the auricle is hel.J forward l.y an assi.fai, and a scaiiJ.! or straight bistoury, held with tl..- ....ttinR e,!,. at an a'.e'aS';' the line of moision and not (.eriH-ndieularly, is inserted at a point a quart.-r of an inch above the upper aitachr^ent .,f the auricle to the side of the head, directly above the orifice of the ex(. ma! auditorA- canal and carried backward and downward parallel to the tmsterior auricular fold, and a quarter of an inch from it until the p.'sition of the antrum is reach.-<l, and from (his ,h.u,( the incision is carried rZ'ri'f t;'' l^^T.^^'/o the apex of the tip of the mastoid. (1-ig. 605.) It should be the aim of the ojierator to reach the bone by this first incision : if this is not pos- sible, then the jXTiosteum must be di- vicled by a .second operation. Thi' in- ci.sion may, if the operator prefers, begin at the tip and progress upward; considerable hemorrhage follows, and should be contrt)lled by the assistant with sponges until the ble«"ding vessels are cauglit uj) by ha>mostatic forceps. There will -iJH be present more or les,s general oozing after the large vessels are iindi-r contioi; but this usuallv .soon eea.ses aft«'r the fjcriosteum hiis been elevated. For convenience of exposure in the Sehwartze, and as a neecssii; in the r.idical operation, a horizontal incision is made on a level with the centre of the external auditorv canal, beginuins^ ,it the primary in- cision and ruT'iiiiig backward for one inch. A periostfal elevator, guardeii by the index finger of the left hand, is now inserted under the anterior and „ , . , . posterior flaF)s of the periosteum, an.! the membrane stripped from the bone lorw.-.rd to tiie posterior canal wall an< I backward for a sf)ace suflicient to expose the mastoid process. At the tip it is necessary to cut away the tendinous inser- tion ol the sternocleidomastoid muscl<> witli a pair of blunt curve. 1 •scLssors. lletractors are now applied, one to the anterior flap, ii>- eluding the auricle, and one to the posterior flap opposite If tli- retractors have been placed on a level with the external can:-l tl,- mastoid proces.s is sufhcientlv well exposed and the surgical Itivi l.lnos of liiri-i. ii ill oi^mliug mi tne mHstolil. I Iijii I. 11 (or the ordinary or sthwArtK' ojiemlton. ooniliiuoci ii|.H»nl; -' for llif ■ralloal o(«r«tloii," ami u, I'litir the klt;inoiii ((HKHc or pontcranlal fos.-a: 3. for eniinii? the uiKiilIo cranial fa^HJl liacUwan.. I'VRVI.KSr IXFI.AMMATlO.\ OF THE MIIHHK EAR WTtX iiiarkrt vimble. (Fig. 577.) Al»ovc in neen the t«'m|K>ral Mfif, niit»Ti<trly tin' iMwterior cdgp of tho orifipe of the pxtrrnal canal, with Achwkrtie'a bajronet-Kluiped chisel. Via. ril9. Hoh»art7^'a HtniiKht aural guuge. Fio. 611 gchwabt's stralifht iHlifc aural clil»cl. Imtrumeuls used in operallont on the mastoiil. ?1 MICROCOPY KESOIUTION TEST CHART ANSI and ISO TEST CHART No 2 1.0 t ii£ mil 2.0 11.25 iu 2.2 1.8 1.6 ^ APPLIED IIVHGE Inc — ' ''6' *e^ CJOO - Phone lir,2 THE hAJ!. Kl'i. f'U. O" o— o Buck's ear ciiri'tli'. Kto «|:i. I> 3 U I M,. '- 2 iival nmstoi.l runlk. Flii. r.l-l. Kl,^. lil Mastoid Ruicleuml in-oleclor. Vir,. iliCi. llarimRnns ri)iigiMir fnroci*. Fiii. i;i7. ilartliiuiiiiM roiigi'iir l'orci'|is. Itl^lru^lCIlt.■! used in op<'rali.,u» <m> liie luai-ioiii. I'vnri.i-.sr im-i.ammatiox or rnr. miu'h.e em:. \\-v.\ Km. lil". Kici. ilJU. Slaolie's pnileotor lor ladal nerve. Km. liJl. ^ I'lililzi-r's knifi'. Buck's knile. lii>lrMiuMii» iiseil In (ipcrauimKim Hw inii'^i"i'l. 78 I 1 04 rill-: i:.\u. the si)iii!i-su])rimi('atuiii al)()V(', below the apex of the mastoid \\\<. Just lu'liiiiil and al)()ve tlic spina and hetweeii it and the tenii)oral ridfte is a fossa inarivinj; tiie j-osition of Macewen's supraineatal tri- angle. It is now necessary, in the writer's opinion, to proceed with artificial illumination, j>referahly in the form of a good in'candescen' electric lijiht, hacked by a reflector, and held l)y an assistant in such a position that it thoroujthly illumines the operative field without heiiift in the way of the operator. This method is much better than the attempt to dinct light liv means of the forehead mirror, which needs a<ljustineiit ; this adjust- ment caimot be managed !)y the sterile hands of the o]>erator, and is unsatisfaetory when ilone by an a.-*sistant. The writer now takes a fair-sized gouge or clii.sel. about three-eighths of an inch broad, and with the hammer proceeds to drive the cutting edge, slightly inclinci to the bone, into the corte.v for an eighth of an inch along the line of an oval half an inch in its shortest horizontal diameter an<t one inch in its longest vertical diameter. The anterior edge < ' this oval lies abotit an eighth of an inch back of the posterior wall of the (>xter- nal canal, the ui)iier edge lies an eighth of an inch below the temixiral ridge, and the lower I'dge goes pretty well down to the apex of the mastoid tip. This button of bone is then lifted off fi-om the mider- lying jjarts by a broad chisel held horizontally so as not to penetrate any deeper than an eighth of an inch into the bone: the button usually coTiies off in one piece. As a rule, the removal i>f this button exposes the cellular structure of the mastoid jH-ocess, and it has never been deep enough to endanger the sinus, in the writer's experience. From this opening as a base a pyramidal section of bone is removed to the antrum, under illuminati(ui and the constant u.se of the probe. Thi' upper surface of the |)yramid is made to ])a.ss horizontally inward, care being taken not to penetrate the inner table into the middle cerebral fossa; the anterior sin'fac' of the |)yramid passes inward parallel to the posterior canal wall in its up])er part until it reaches the position of a line drawn from the floor of the orifice of the canal to the floor of the aditus; below this it gradually shelves into tlie inferior surface, which is cut out along an extension of this line to the tip r)f the mastoid: the posterior surface is inclined forward and inward, keeping a constant watch tor the iimer table overlying the sigmoid sinus. In other words the ai)ex of the pyramid is (lirecte<l upward, forward, and inward from the base. As th(> operator ap- proaches the region of the antrum careful inspeciidii i'l necessary to avoiil the faci.'d c;inal, the horizontal .semicir"ui:i' canal, and tin- middle cerebral fossa. The two fotmer can usually be recognizc'l by the greater com])actness of their l)ony wails. When the antrum is reached a spoon is introdi:ce(l and its external wall carefully reamed out. Before this, a s|)oon should only i)c used in cavities to remove necrotic bone, granulation tissue and pus, under the careful guidance of the probe. If the sigmoid groove encroaches well into the mastoid process, it is necessary to modify the o])eration by keeping above and i'riiih;:.\r /.v/v. i.w.u.r/vo.v nr riii: mii>i>i.e i:mi. ii.V) forward of its ix.siti.m. which ca.i only 1)P rccognizcl by the jireatcr roinpactiH-ss of its l.<.uy wall. If the mi l.ll.' cerroral fossa .lips ,lown into the t.on.^ .Iccpor than usual, similar precautions arc to he taken. kcopin>i the upi.cr surface of the hone wound just i.eh.w the iiuier table. . . . . , • , The object of every nia.«toi(l (.peration is to . > the niastoi.l antrum, and nothing" short of this .satisftes the indications. The ■mtrum is now cleansed of purulent debris and jrranulation tissue •uul its walls searched for areas of erosion, .vhich are to be curetted carefully, or for the presence of a fistula. In acute cases of mastoid- itis following acute suppuration of the ini.Idle ear, it is l>etter iiot to curette the aditus or attic for fear of disturbinp; the ossicular chain, •,nd so impairing the hearing. The oi)eration wound may now l)e rently Hooded with sterile water or a nuld antiseptic solution, no fi.rcible ini.'ction b(>ing permitted to carry infected material into unaffected regions, or the wound cavities may simply be dne<l out with aseptic gauze sponges. The gauze wick is now removed from the <>xternal auditory canal ami the blood and .secretion •I™''' ""t. after which the ."Uial is finally packed with sterile gauze. I he b.me wound is then firmlv packeu with the same kind of gauze, which shculd be in the form of narrow strips with selvaged edges, so that no threads are left behind on its removal. T.sually the bloo. vessels in the soft parts are already occluded or are easily controlled by torsion: very exceptionally i. ligature is nee<l<>d. The incision in the ^oft i)arts is not sutured (except the horizontal portion), and the wound is then lightly packed with gauze. ( »n er this a pad ot gauze is placed i)osterior to the auricle and up against its posterior surt.ncc to give it supix.rt. r)yer all. auricle an<l wound, is now placed a larger gauze pad; this in turn is coverwl by a pad of wood-wool or Hudson's cotton dressing, which is held in place by stnps of adhesive i)laster. . ■ i „ Finally, tiie whole dressing is included in a two-inch gauze h'lndage carried around the head, but not around the neck, in this wiv the dirssing i^ kej.t firmly in contact with the head, and is not disturbed by changes in position which, after the oozmgs have hardened in tiie dressings, are so painful if the dressing .uis been loosely applied. , i • i ■ There are certain anatomical points to be remembered in <lomg a ma.stoid oi)eration. In infants the antrum is the only cell in the mastoid !>rocess. and is nearly as large as in adults: in older children ui) to i)ubertv the structure outside of the antrum is cancellous and dois not usually becom.' pneumatic until arouiul or after puberty. ( iccasionallv the mastoid process is double. Th.« lower border of tne posterior root of the zygoma is about on a level with the root ot the mastoid antrum and near the level of the floor of the middle cerebral Figs ()04 and 027.) The depth of the antrum, m the a<lult tossa. from triang.e varies the external >urface of the miustoi.i process at the supr tal from one-eighth to three .piarters of an inch, rarely 1 1 .vi Titi: i:\i! so little as the tmiiicr and occasionally iIcciht than the latter rnoa-- uremcnt. The writer does not believe that the aiitruin is ever ahsent or obliterated: he has examined ix'tween two and throe hundred temporal bones taken consecutively from the dissect inp-room without onro finding this cell absent. The sijimoid fjroove may encroach so far into the mastoid process that its anterior wall is the posterior wall of the canal; but, usually, there is sufficient s[).;ce in the region of the suprameatal triangle to go above it to the antrum. The de{)th of the inner tympanic wall from the posterior edge of the orifice of the osseous canal will indicate approximately the ])robable depth of the mastoid antrum. The facial canal should be looked for as the antrum is approached, lying as it does, just interiorly and externally to the floor of the aditus; an assistant should keep watch for any twitchings of the facial muscles during this stage of the operation. Just above and internal to the facial canal, where it lies in relation to the aditus, is the external semicircular canal. Granulation masses should l)e removed carefully, under the guidance of the probe, in this region. The nvnnbei of assistants required varies: it is desirable to have, besides the antesthetizer, one a.ssistaiit to retract the anterior flaji and sponge, one to retract the jiosterior flap and hand instruments, and one to hold the electric light, with one or more nurses to meet ordinary demands. ()f course, every operator meets cases where he is fortunate if he lias one a.«sistant anti ;i nurse besides the aniesthe- tizer. Iodoform dre.>;sings, powder, and gauz(> are much used, hut are apt to cause much irritation and even jjoisoning in sensitive ])atients. Mttcew t'ii>* l)iuT- Macewen prefers the dental burr ( Fig. (>'_*.') i to tlu' hammer iiiiii chisel: it should be of the globular form, with a very sharp and har'i spiral '^utting edge. If the mastoiditis is of the chronic variety or follows a chronic mid 'le-ear su[)i)urati()n, then tlie Schwartze operation ha.s to l>i' inr .ified to meet the indications, a lywhere up to the so-called "radical rri!ii.i:sr imi.ammmjos <>r iiii: Minni... t:.\it \\:u „i..'riti..i. •• (FifJ. ti-'(i.) The radical ..iM'ratioi. ••an n.-yer be tnily K L it i^ an anatomical i .ssihilny t.. oxt.'nd the ol)orat.ye i'i to It ..- .Iti.nat.. ra-niHcluions ..^f tl.c cellular structure m ehtio ith tl... n.ast.ml pn.cs.s an 1 have the p-t.ent survive It nu^ ah^v he a con.pn.mise. and ts such th.- operafr sh.mlcl nut en mfShv i: su.. other than ' 'at xvhich ...■cv.rs u, the ordnuir> ;;, ;;:X,pemt?v.. attack, sin,>ly !.e. ..use it n.ay chance to be anaton>- Klii. IVJil. =:3Ht-=St=;=,:=:r:=r= - i,..illv relate<l to the cellular structur.' of the niastoi.l St..tter has lown that th.' radical operation as performed by its ongmators il to u e in a considerai,le number of cases. The fact that thrs o l„es not detra.-t from the value of the operation m appropriate c^L^es but does e.n,.hasize the necessity of usiiiR ordinary surpica common sens.> in not attempting Ih.' impossib e. I' or instance t . t be nec-ssarv to remove the tip of a densely eburnated mastoid ;! he entire pathological pn.cess is confined to the neighborhood f he . trum, aditus. and afic. Something ha.s to be left o nature, . „d t " onlv our dutv to make her work as light as p..ssible. Ihe Scd oiKTation is alwavs in.licate<l when a chronic suppurative ; df -e 1 la.nination persists after tlu.rough treatment through r'u.a including ossiculectomy, especially when the patient com- an more or les^ of perio.lical attacks of dizziness a.ul hea-lach,-. 1 1 .-.s Till: i:m! \\ liiij; tlic lailicul u|)('r;itii)ii. Ihc nitiT lliiiiks it licst lo n IIHIM tlic hirircr ossiclfs and rciiiiiatits of (Iriiiii iiiciiilnaiic fiist, tlnuiiirli tlic cxti'inal car canal, timlcr niirmis o.xiilc ana-stlicsia. \vitli the pafii'iit in the ni>ri}rlit |Misifiiin. After tliis has been ditnc, the [laticnt is Irt ildwn In llic hnriziintal |M)sitiiin, and citlicr nitrous oxide anaes- thesia luntiinied tlinmsrhout the radical o|>eration or the chaiip' <|uickl\ made to ether narcosis. In either case the |)rirnary stap' of anasthesia is greatly shortened. The ineinhranoiis external auditory canal is then se|iarated from the hone, cut across liy tlic ]ieriosteal elevator or by Stiicke's knife, at its junction to the aninihis, and witiidrawn from the os.seous caiiiil hy Hartmann's clamp or l.v a t;i|K'. The antrum is reached in the ordinary way. and then iV\g. (»27i all of the posterior wall of the external canal ;il)ove a line drawn from if the orifice to the floor of the .•ulitus is removed liv tlie the fl( combined use of the chisel and lione force|>s. Sutticieiit of the supe- rior wall of the canal is also removed with the /^»r.s fiiiti/mfxiHica U< ijive a <:oo(l view of the tegmen tyni|>ani. making a smooth surface directly continuous with the tepmen. Staeke's protector should be Klu. tliJ(. Kli. i-T A|i|i«'Mranio "I l»inu .ipimti-il ii|»ili afliT llii> " rmlinil uii'lhi)il." except Ibnt the tlpmul cells arounil fni'ial laiml have iH'eii lell li> five relative liK-aliciis, 1. .Vililus ad anl'uni, ■-'. Tegmeii. :'., llori/diilal si'niicireular eanul. 1. Inner wall oraritnim. :<. Wall of >iBinoi«l griK>ve. ♦». Aiwrture lor vein to sif^'ltinid siini>. 7. /.ytionialie pnK'ess. s. Fossa ot (he oval wiihlovv. *,*. Kustachiaii tube mouth. 111. Fallopian iniial lor lacial nerve. II. i'oslerior os«e.iils eviernal eanal wall, eut i>tI'diRg- onalh up\\ard and muard. t .'. Tip of ina.'sloid priM-ess. Flo. i.Js.—Deiorniity loUowmc a |>erlehoiidri(i> ami eliondriii-, .liie to liiei.sions In the eartilage ol the •-anal made in thedoinj^of a radical o]H.Tation, (From Trantniann s (l|K.Ta'ionenairi liehiirorgan. - introduced into the aditus during this stage of the ojieration to protect tlie sliuctures of the inner tymjianic wall and the liorizont.il semi- circular and facial canals. The cellular structure of the mastoid tip is now removed or may previously have been removed to the inner table, and. hnally. '.lie mastoid tip is itself removed. The civity of the aiitnim. aditus. and attic is now made smooth by the removal i;i:ri.i:yr i\hi. i.w.v i/7o.v or riii: v.tnni.i: i:.U!. ll.V.i an fmiiul of c-lli.lar partitions, aiul fistula- s.-arcli(.l Inr, If tistnhr IVrsonallv tho wriK-r .loos not l.clu'v.- n. tmnii.j: st-m Haps K.nu. 1 fn ,M th -Ifrinr osU-rm\ rartila^i.K.us .-unal ,»to ti..- l'<"-.^^;'" 'j ; . . i. i of tl.- ski.. ...al<cs the op.-„i..K f.'o... ti.r <;a.K.l •"<" " II sin;., pori.-ho,..iritis a...i .•ho..a.-itis "f J'"" I';'-"';;,; s, "^ an. mo.r apt to .Icviop, a...l (■.■r..n.i.H.us .■oiiect.. ..s •"•< 1>' ' ' .(•..,• wl....Tvrr tho ski.. (•o..tai..i..S oo.-........o..s jrlai.as .s oarr. ll. thinks it nmch proforahlo to n>...ovo o.,t.,oly tho sop..o„t ot tho -oft oai.al wall opposite tho bono \vou..(l. ,, . ■ , . ^.u., ., \ft r ....oiatio. tlH' parts shouM ho thonmjjhly .rriRatod vv.th a lixi 111 ri.l.' solution, unless th.- .lura is oxposo.l or a h.stu a xi"^t^tl en ro shouhl U- oxoreiso.l a.xl tho o..ti.-o r^vtv 'I'orough y Irio I o bv ,.le.l«ots of Rauzo. The ty.npa..ie eav.ty .^ then packed "h :;nHnUuzo'pie.i,Hs, with or ^7'i-"vt';;;:t'; . otrt z" ^.l^lt thl'^K. way, aftlr whieh the ...o...l,ra...u.s ami carUUj«- ,o,.s canal is replaced a..d hel.l in pos.tton by j;:.u/.o pa ck . g. My L n.astoid cavity is packed and the w<.«nd .hos o, ... the way ,lo«oril)ed above with reference to Schwartzc s oporatioi . '%"' th..e dJri... which the original dressing '-^V -J^ .- ^J ; ;' varies. If .... c....trai..dicatio.i arises, such a.s undue ' '» « ^^^^^^^^ , , or .......plications, it .i.ay b<- left i.. l.laco for a week ... ><" « ^hat '■ ,r The.-o is ..uito a.. . bjoct in U'avb.g it as l.mg as practicable, Hr«t .lr<>ssinir to adn.inistor nitrous ..xido gas or t.. gn. .preMous'v '"ni dm .1 hi Sin of ...orphi..o and atr..pi..o. osp...-ia ly . ho aS is .10.10 so oariy that granulation has ....t ..ccuit.mI a.i.l the i.r.>cess is b.iun.l to be unduly j.ainful. ,„„,.»„. thnn Acceding .Iressings should be .l..n<- at intervals no groato than '•■■*j1m *..v... .1.- "»i >• ■" »- t\"ti'';,,;.r'i»,;': • . \u- ,> 1 of tlic phnmic iiuniio.it otitis i.i.'.ua. oui a ll(il) Tin: h: Ml. I car process, especially if tlieic is a cliolcstcatoiuntous coiiditidii prc.>- oiit (I'iji.d'JItlniil' I Ik o|)ciati()n has Im-cikIoih' upon iidiatlietic patieiii lint even in these ca.-is the safety against intracianiul coniplicutinn- h;is lieen vastly increased. K ■*'. shuwlni; |n>i»Uli'nl li>iiilii, i'|.Uli'rini/i''l. A'vi ihc incisl<Mi!i iii TrauiiMaiiir«<ip«nitliiii forllsrIOLUri' Thi' iwoiiiiiiT IIhih urv «t'H n iiiiicthiT. iiiiM ihcn tlie two ouIiT (lii|i« art' lir.iuithl tom'thiT over Ihi'm Hn<l Ht»t«<>un. iTrHUttimiiii''« OiHfriiliMiieii hiii iit>li<irnrKiin. i Intracranial Complications of Suppurative Inflammation of the middle Ear. Th-'se occur mm h more mMiuently than was formerly su))posed. Those most commonly met with arc external pachymi'M- injri'is with extradural al)scc>>, suixhiral abscess and ulceradcr of the brain surface, leptonienin<;itis, c(>rebral or cerebellar abscess, and infective sijriiioid sinus thrombosis. Pyle noted at the New York Kyc and Ivir Infirmary in IIM) mastoid oDcrations, .3.'5 per cent, of intra- cranial complications in the ca.-^es of icute mastoiditis, mostly in chil- dren, and (■>() per cent, in the ca.-^es f)f chronic mastoiditis. He did not state what relation these complications bore to acute or chronic suppurative processes in the middle ear, and he ;ippareiitly classed amoufj the inlracraiiial complications simple cMosure of the dura. Most observers state that such complications are comi>ar;itivcly rare as sequela' of an initial acute purulent otitis media. Pacbymenin£' is Externa with Extradural or Epidural Abscess. This is the most /r |uent of intracranial complications. .\ low grade of pachymeninjiitis e.xterna fre(|uently exists over the tcfimen tympani or antri. can.sed by the nnderlyinp bone disease; it is chronic and essentially protective. The dnra ;it these ))oints becomes at.t.ached to the bone and nnich thickened by the development of fibn.iis tissue; but no pus or }:ramilations exist between it and the bone. The rriiri.Hsr isilammmios df iui: mii>i>i.i: t:Mt. lUit oatinits ut tinu-s n.ini.laii. uf .lull hea.liu-h.' a.i,l s(.iiietin..'s havo dizzv MH'lls. I...ti. .iue to the lunilizcl irritation, lu other eas.-s, pus Kaiiw access to the dura an.l, Htrij.pir.K it fro... the ho.ie. f<jr...s a.i extradural abscess; the dura is the., usually coated w.th a layer of granulatious, at the saiue time U-mfi thickened a.id hyi.erie....c SymptomR G.'..eral!v the presence of an extrad.jral collect..... of pus is onlv dis,.ov.>r.-d'a. th- tin.e of operat..ig unless .hiis found V way t.."the ext.>r..al s.,ft tissues through the ho.,e o the s.,uan a Fie ft Mi) ..r al....«si.le ..f th.' ...ast..i.l ve.n <.r through the co...lylo.d .Znen Its pn.s....<r ...uy Ik- suspected if the pat.c.t ......p a...s „f co..tinued lateralize.1 h.-adacl.e. .nore or less .l.zz.ness, "W fever (s<.PM-tin..'s al.s,-nt), fnd.-r.iess, a..d perh.nps swellu.g .nvoUing the .k>ep cervical gla...ls in th.- sui)erior porf . ..f th.' posterinr cerv.cal trianEle- if th.^re is an area of persistent t,.„.lerness .,ver the s.p.ima or cerebell...... s..n.....le..ce, .)Ccasionally nausea and vo....t...g, a..d s.,.neti.n,>s stifr.u-ss ..f the ..ck, or swelling a... lt....,ler...-ss around the exit of the ...ast..id en.issary vei... Ot these the .nost ....l.cative Ire the lateralized p.-rsiste..t hea.la.-l.e. with low fever or no..e at •ill the areas ..f teu.l.'rness ..ver the s.niaina or c'rehelluni, and the "tclderness an.l swelling in the superior p..sterior cervical triangle or over Mie .nast.)i.l en.issary vein. Prognosis is ah.iost always had, exce|.t when the pus h.i.ls a., a.le- .mate outl.'t externally (which rarely happens), unless the cas.^ js .Iperate.! ,.po... A tho.-..ugl. operation ge..erally results .n a con.plete """'The Teatment c.u.sists in the extcisio.. of the mastoid operation to the region affecte.l. If th.' .lura is exp-.s.-d by carioifs en.s..m the [re\ .,f erosio.. is t.. be ei.large.l until all parts of h.>in.s cav.ty a u.Kler .,b.s..rvation. if possible, up to the hue of a.lh.-s.on o the du a uVthe 1 .on.-. iM ' '.lie iM th.' du.^a -> t.. be searched f..r an.l explored with a vi.w to p.>ssn4e .■o.nplicat..ms. If the internal table is no brok.-.. < 'Ugh. then rhe ii ^d.lle ..r p..steri..r 'al f.jssa; are to b- Sc V ....?.-re.l ul tlK- . expo.sed ac ' ..■ . -k to the ...d.cat.ons ff." . bv the ..vmpt..- n.e "US is evacate. and granulat.on W re.,.ov..d. a,.d ' h.- ity .hvsse.l with p..w. ere. lo.loform or "^^" ..der. 1 lift to 4, a.i.l io.loforni gauz.-. aoiil.l ' I.).!'' veiy gently. The writer 1 .>f !!i. Mia. lie or p.isteri.tr f.)ssa from ili\v:inl a. id backward rather 'ban iod.)forni and boi'i. -m If syri.iging is .-.s.^rtt m believes in .iiioveriiifi i ■ ' the wound in the mast., in the US',' of the ti-ephi Subdural Abscess. 1 ])ractically inipos-ible, ih. Th.T.> is 1 narked pain nv. perature ru.is hi^rl.er thaii i; in McKernon's ca.se). the p dence of sepsis, such as f.nil bn may be i.n^sent, an.l then n. (iverlving p.n-ti.ms .)f the i^^kull. ;iiii)n is rare, an.l its .liagi i^ if uii..n being found .luring o] tion. atTcct.'d sid.' of the heji.l, the ten.- i-a.lui-al abs.'.'s^ (as high as 102° F. is III' >-e fre<|U»'nt tha.i noii..al; eyi- fun-, 1 tongue, pr.ll.n-, and ana'mia. ir...r. ;f :--~ -rnd.'ni'-';^ on the «n<i i .blc I.I he skull is usually 1^ IK.:: ////•• h:\H criMli'd ami tlu' iluia ilisculuri'il. Tlicrt' U nt'lcii sii|iriiicial ulci latini <<i the liraiii. 'I'lif dura is iiiciscil, the pus evacuated, ami tlie cavity very ncnli\ syriiin«'d with a ! : U),(MHI sululimi of liicliinridc, prccautioiis Ih-iihj taken tu 1 ..vide uiiipiy fur the uuttlow. Tlie cavity is now dried iiiid tlie iiidot'iirin and Ixiric-acid powder silted in, after whirit it is loo.-<ely packed with iodoform Kaii/e. No drainap'-tuhe is reiiuired if till' opeiiinifs thronnh tiie te^cnien ;ind dura have licen sntliciently free. Serous Leptomeningitis. The syrnptum^^ this coiMlition an' very similar to those of cereliellar ahscess: heat' '»e. dizzines!*, vorjiit- iiift, ci-nstijiation, often slow pulse, j;enorall. aormal temperature, except ion.ally fev( r l.'t.stin^ a day or so, optic neuritis in the nmjority. The patient is very restless, and delirium may alternate with sopor. Convulsive attacks or cramjw were observed in one-third of the cas<s. Disturli.'ince- of si^ht ire frp<|uenl. The occurrence of deafaess, loys of taste and smell, \. i j infre(iuent, point toward meningitis sero.sa when present. Sen. menuigitis ainl ahsc-ss frequently coexist; in over ")() per cent, of .ne cases of cerehellar ahscess, accordinji to Koch. (Quincke's lumhar punctii;e may lie einployed to determine the presence of jin excess of arachnoidal fluid. Treatment by dei>letion of .all kinds, by inunctions, and by lumbar jjuncture may .sometimes modify or oven cure the disease. ( )perati()n to remove the infectiiwr tissues is of first importance in the majority of ca.ses. Purulent Leptomeningitis. This inf{anunato;y |>roce:s is apt to follow acute purulent otitis media in children who h-ive the tuber- cular diathesis. It may follow pac'.ymeninjtitis ex' 'a. with jM-r- foration of the dura or infective sinas thrombosis, or ilt from the ni|)ture of ;i subdural or cerebral or cereb' il'tr abi s. .1. Oriie (irecii states that "in more than half the ''ases i; exists alone, and is du<' either to a general sepsis or to infectii 'i of the ;traohnoid and l)ia through the minute blootlves ■ ' " It i.i,. ;>u'sue either a rapid course, endinp fatally in from fo- ' r ii\(> iioii'- to several days, or the jtrocess may be protracted ii|. lo two oi- lhr."e weeks. "It is the most serious and ra|)idly fatal of the pyogenic infective brain diseases." The onset is often marked by a chill. Headache is very intense, at first confined to affected jiarts. later becoming general, and .at times subject to remissions; it usu.ally jippeais e.arly. Fever is apt to run higli (104° to 100° F.). ami may in the jintracted form alternate with normal or subnormal temperature, but usually becomes continuously high toward the end. The pulse is usually more or less rapid, and constipation is usual. There are restlessness, irrita- bility, dizziness, nause.a, vomiting, over-acuteness of all the senses CTvlually jiassing on to delirium, convulsions, involvement of the cranial nerves, |)erhaps inonoplegie or hem' logic jiaralysis, drowsi- ness, and coma. Optic I'ouritis is infre(|ueiit. Ai)hasia is occasion- rii;ii.i:\r />>/. t >/ 1; i rin.s <>, riii: mii>i>i.i: iah ilti:J \u , „....i.t Th.- Mirlac- ..f tlu- l-o'lv i-^ «.nt'riillv hyi-crMiisitivc w -1. ...l- '•crt.cn.l .■■■rrl.r.l n.cniiiKit.s, as !i rule. atT.Tts Loth puiaN ; ullv ••....' -v a.r th.... .•untra,.|.-.l .a.til tl..- pn-sMT.- symptoms 1. ' ; ati. U., ' up..rv....... .h.n .1.. y both Ix.on... .hlat.,1 an. f.x.. Sh;t;/;h..m.n...n.nial....n.pli..a.i..n...fsu,,a.n.nv.^^^ !..,,tn,n.n.nK.t.s ..,,i,„,„„is is ..asv in th.' rapi.l variety, .Mi::tl f - ■ .. m.iSl.-.la.-h...an.l tlu- hn.in irritati..n fo 1. ■ r.v paraly-.i.. syn,,t...n.. U-av. n.. .L.t.hl wh.-n tiu- .i.^jo o 1. .-.r .nd ..I tl.- l...n<- has In-.-n ahva.lv rcoKniz.-.l. In th. pro L '. ' ,.ti.' as p..ssi»,l.-, has sav.-l lifo in a f.-w instam-s. ' i^ertive ThromUsis oi the Sigmoid SinuB. Symptom.. Th,s ,...S. ••.■u^m..r.. .■..n.n,..nly in aclol-s-.-nts an.l - "H^- •" >-'-; ... ho rieht si.l... It ..ccurs much nioro frciiu-ntly than hra n i iwli-ilv •.(•.-.■ntiiateil >v the (.(•.■urrcnce of a niarKo.l ".• ^^""' : fn' .'. V rop..at.-i. folU-w.-.l hy a high f.-v.T. her.- is ;:ft:n, ;;.,!:.:::/ vluniti^.,. ii.-a.uu.h.., if .- '••"^i^':';:-;;, ;'^::x ftw V u pn.fus.. porspiratu.n. T.^o tnnp.-rature /I-.p f|31 . ?,;. ine Tin mt • t fr.-ls Joak atu! >, k.uu.I has no apiH-f t- Von- S;S, ^I/h^sfr........ later h>.^^^^^^^^^ ^^^ r^Z, „,o„lv pr."s.-nt, an.l wh.-n it is it iiMialU m u(. a i ,.;„■. .!,...■.-«« in whicii caso consciousiuvss is gpn<>rall\ lost m tne . u .M t .e il .-a^' Locallv. thoro is gem-rally ..torrh.va from sup- T. li-rness ov.-r the nmst..i.l is fr.-.iu.-ntly present, ,-speeialh in tlK 11ti4 THE EAR. neighborhood of the mastoid emissary vein, where (v(lenui may also lie present, sometimes extending over tiie whole mastoid jiroeess. In a good proportion of the eases, there is swelling and tenderness in the I liniPnl (hurl, vhiiuin.; Ii'rii|.i'ralun' atnl pllNi' rircml \n .i rase iil iiifi- limi- -inn- lliroiiil...«i- nppiT part of the posterior eervieal triangle due to lyniphadiiiitis of tiic d<'ep eervieal glands, to phlebitis of the ])osterior condyloid vein, or to the bin'rowing of pus which has passed from an extradural culiee- rri:ri.i:sr /.v/v. i.vw-i rms or riii: mii>i>i.i-: emi- I itt.-i ,,., ,. the ,...ste.w condyloid foranjo. ^^^^^^^Z^^^ toad, brow, and face, ''^ 7;f 'J;;;'^,'„"7Xk^^^^ i„„, ,1„. internal !: ' T.h'ri^Ua y\uffiStr:^^^^ .nrr„nndin„ ,l,e Jufular pa?,: ;5' ■;::: ..o.i;,,|»»* ,';>;;rt"rrSeSroS their appearance. I he Jx"^ "> '"; ™ » ,|,^ y^j i,„„, ,he dis- ;;::;:; -^It'flh^cSVr become moi.t and the expectoration 'i;;":j;.;?'™S'r5LSe enteritis is set up eiti^er by ingestion of nfect V > n at er from the Eustacinan tube or the lungs, or because Senerd ?ox.emia develope.l. Von.iting is incn-ased m frequency tu ^^-iblniinal pain, tympanites, or meteonsm; diarrhcea of the } X m^r voe ieat prostration, and often nmttenng delirium. Vh riSi« 1^^^^^^^ i" ^he course of infective sigmoid sinus ,h^SS^tadache 'becomes violent, ;'-;-•-£;'— I 1 :™i. ♦i.r.i-o w irii-it excitement and iriiiaiinuv, uyiiti !;:SnS.S.£c.:tn;;.Sl;^(tomc and donic,, or evanescent . ,^ flue uat nc paresis, and later, delirium t<.llowed by coma. N , t Site d.rn>sses o,.,.urring in the muscles or art.culatu.ns a.j ,na!te.Tln a Hgor, increased fever, local pain and tenderness, swelling, "* The diagnosis in ca^es that develop typically is usually possible; hn h<Te m n,anv cases in which the symptoms are not marked ' rS;^-;:='.rrirzx:,;or^^ o purulent otitis media if there is .hmmu tion "'77^='^'^';,^;^" dUharge coinci.lent with the a,)pearance of cephala g a. Ig cm ! ^i with marked fluctuations rigors, '"'^'T''!';^; ,"" S" As both the mastoi<lan.l con<lyloid .Mmssarv u.ii. ma> bt a!). em, external signs may fail. ll«)fi Till-: i:.\i! Prognosis. W'itlioiu 'iicriition most <• :is('s ciu fMtall\ ut Ma (•('Wfll reports that " instances oi long-standing ol)literati()n of tin' internal jugular and sigmoid sinuses, in eonneetion witli infeetivi' caries and extensive disintegration in the tein|)oral hone, liave heen discovered at autopsy." At tiie present time the iiereentage of iccoverii's afte th lit: .., .. _ ^ ous ligation ot the jugular iha;i without; according to various statistiei.aiis from altout "(• per cent. in the former to about -"hi l)er cent, in the latter. Temperature a> high as 106° F. indicates great intensity of infection and the prol)- ability that \u t. .. stases or other unfa voralile complications will ijevejop. Recovery is prohable if the case is operated on before metastases appear, su])posing the o])erative attack to be thorough. Hut with the appearance of metastatic formations the gravity of the projrnosis increases, thus Hcssler for.iid only 12 recoveries in 29 operited metas- tatic cases. l']vidently, thi-refore, oi)erative investigation should b(! atlvised just as soon as the condition is iiistli/ suspected, without waiting for certainty of iliagnosis. Treatment. As the jn'rcentage of recoveries with ligation of the jugular \cui is higher than witiiout, I'very operation should be undt>i- taken with a view to ligation. Hut ligation is not to be i)ractised until the sinus is uncovered anil found to be thrombosed: th<' more so. since ligation is not a certain preventive of the dissemination of infective ])articles, which may find a way into the cii'ciilatioii through the ])osterior and anterior condyloid \('ins or through the occijjital sinus. (Figs. .">S1 and ")82.) But when the sigmoid sinus is found to be the seat of an infected thrombu.s, the jugular is best ligateil before clearing out the infected clot, for fear that l(K)sened jyartides may be carried down into the circulation during the oi)eratioii. This also i^revents the jio.ssible occurrence of aerial embolism, a fatal case of which has been reporteil by Kulm. The operation begins with a mastoidectomy which shall meet t!ie indications existing within the middle-ear cavities. The mastoid tip and cellular structure is removed up to the internal table. The knee of the sigmoid sinus is generally on a level with the upper part of the osM'ous extern;il .iiiditoiy canal, and the depth of the sinus from the external surface of thi' mastoid process varies so jireatly that the only safe rule is to look for it constantly .after removing the external cortex. Of course, if erosion has already exposed the dura (Fig. oSO) or a fistula exists, the difhculty is much simplified. Chiselling is to l)e resorted to until tiie diiral covering is in view, when the exposure is to be sufficiently increased by the use of the bone forceps i.Ian.sen's. Ilartmaiurs, or Hacoirs). The whole of the knee and descending; portion of the sinus is to be laid bare, .^^omi'- times it is also desirai>le to uiieover a good part of the lateral simis as well. In using the bone forceps, the diiral covering should be puslied back away from the bone by a director, while introducing one blade of the instrument, otherwise tlie s.mis wall niiglit be nipjietl: this, liowever, has never happened in the writer's experience. The ■WS??-f !^FP-f^^^*lW I'liiri.Esr IM i.AMMAri<>.\ or Till-: Minni.i-: i:mi. iui7 n..nnal dura has ii ftrayisli-bluc, Rlisteninp. tciMiiiH.us api-caraiu-e whore it forms the siiuis wall, whoroas the same mcinbrano looks very .liiTcrciitIv wh.'i. a pcrisinus abscess or infected thrmnbus exists The dura is then eith-r covered with granulations, thickened and dulled or discolored. The i)resence or absence of pulsation (jfiors no certain iiulication as to the condition of things within the sinus, ■w -^uch pulsation niav b.- derived from the brain. It pus and granu- lation tissue cover the sinus tiiey are to be removed to their mi.rmost limit and the cavitv reii.lered a.se|)tic before investigation ! the .inus The writer clo.>s not iM^liev.' in the use of the aspirating lu-edle to .leterinine 1h<> condition of the sinus contents. Its hiidin<rs are unreliable and its use may carry infection where none previously '""it-'now it is believed that the sinus is affected, then the next step should consist in ligation of tli<> jugular. The skin ot the neck having b<.en already prepare-K an incision i.s made along the •Ulterior border of the sternocl.'idomastoid mu«ele. beginning above, ',t or near the lower termination of the mastoid i.icision, and ending 'below as far down as the clavicle, if there is reason to suspect throm- l,„si< of the vein. The muscl<. is retracted and the vem exposed by opening the sheath. In two of the writer'.s ca.ses the vein was .lui e collapsed aiul, ti.erefore, .lifficult of r.-cognition. This .lifficultx also exists if much inHltiati<.ii and lymphadenitis be present, matting the uarts together. If iiiHamed Ivmi.hatic glan.ls are present they arc to be rcm.ov.Hl. Then the v.-in is ligated at the upper and lower an-des „f the wound, care being taken not to inji-e the luiderlymg 'hvpoglo.ssal or i.neumogastric nerves or -.rotid i.rtery. Ih.; >cial vein ne.Mls ligation also. The vein is now cut across a short di>. ncc inside of each of the two ligations and, if found to be involved, re- '""Before op.-iiing the sinus wall the exposed parts should be carefullv examine.1 to .liscover any fistulous tract leading to the brain. 1 such tract is found it should be explored an.l the indications met before incising the sinus. The operation wound shoul.l now be gently H....ded. not sviinge.!, with 1 : .5000 bichloride solutu.n, which is then thoroughlv dried out ami the cut surfaces of th.- bone j.rotecte.l h> irauze nle.lgets while incision and evacuation of the dot is in jirogress. The ii cisim, is made parallel with the long axis of the smus an.l is long as the aperture in the bony wall will permit. Hu.d or grumous material is tluM. moppe.l out, and the walls of the containing cavity "ilbbed out with sponger dipped in alcohol before a '■""^"r ^^ I" 7; duced to remove the obstructing dot above and bd.nv. Tlu < lot m 1^ hiteral sinus tc.ward the torcular shoul.l first be dis odged l.y n' he cureue. until circulation is re-established, then the clot in "jugular bulb and upper vein is curette.! out. If tl... .,ugu lar has ,„,. ' i:„ite.l then the Inilb mav be washed out with a 1 . 5(K)U bid ..ri.'l.^ solution. Hem..rrhage is c.,ntr..iie.l by pr.-ssmg the .mU-r 'irus wall against the inner with io.loform gauze ,.le.igets, outsi.le IKiH Tin: i:mi. of wliifli till' oidiiitiry mastdiil drt'ssinjis arc applicil. Whiting rccoiii- mciuls i)lafiii)i a pad of cotton over tii(> jiijiular vein of tin' opixisiti side to ininimizc tlio prcssiwc from tlio l)aiidajr<' around tlic nvck. He also stron<rly counsels ai;ainst "placitifi tlic nozzle of the syrin};e in tlio divided end of the jugular near the bulb and \v:ishiMfr (dc' contents forcibly upward and out of the oju'iiin}: in the sinus wall," for fear of disseniinatinfr in ection. In this, as in other proloufred u])eratioiis on the i, racranial con- tents, symptoms of collap. e may aj.pear, and stimulation must hv resorted to; transfusion of about sixteen ounces of normal saline hoIu- tion is the most immediately efficient, introduced either into the median basilic vein at a temperature of 108° F., itito the cellular tissue of the abdominal wall, or injected into the rectum. Hypo- th-rinies of nitroglycerin, strychnine, or whiskey are also of service. As was hinted at above, metastases may make their aju'^arance after ligation of the jugular. If these occur in the lung--, kidne>o. or liver the outlook is bad. If they are peripheral, the usual treat- ment of local j)us collections is eminently successful. Involvement of the lungs, digestive tract, or meninges is to be met by attention to these conditions along the lines in general use. Infective Thrombosis of the Gavemous Sinus. This subject will receive attention in its relation to ear disea.se only, ft is here always a sequel of the same affection in the jjctrosil or si.<rmoid sinuses. (Figs. oSl and o^'?,.) It is frequently a.ssociated with basilar menin- gitis and occasionally \vith purulent thrombosis of the oi)hthalmic veins and abscess in the (.ii)ital cavity. Macewen reports that in more than half the cases the thrombus spreads through the circular sinus to the cavernous sinus on the opposite side. The symptoms indicating involvement of the cavernous sinus .are exophthalmos, o'dema of thi' eyelids ,'ind root of the iidse, and move or less chemosis, all due to the venous obstruction: |)tosis, strabismus, and jiupillary manifestations due to paralysis jiroduced by ]iressur<> on ttie nerves siuTounding the cavernous veimus plexus. .Myosis is g<'nerally present at till' outset: but as the jin'ssure becomes greater stdbilr inydr;a.sis ensues. <)i)lithalmoplegia may b.- complete tov""''d t!ie later stages. Defective vision exists. ;md later there is amaurosis from |)ressure on till' ojitic nerve. If the other eye becomes alTected it is a sure indication that the infective process ha^ extended over to the oppo- site sinus. The symptoms .are a|)t to become [H'ominent, and then recede in one and then in the other eye, which fact forms a diagnostic distinction between infiammatioiis confined to the orbital cavity ami cavernous sinus thromliosis. Infective thrombo.^is of the other sinuses rarely gives pupillary symptoms, while the pro|itosis, stabilf mydri.'isis, and blindness, first in one ey- r.nd then in the other, make the diagnosis easy in ca\ernous sinus thrombosis. Be.-idf.- ihi'.-c special locali/Zllig .--ymptonis ;ili liie general symplollis of sinus thrombosis are jiresent. The termination is invariably in death if the tliroinbus is infected: but if the symptoms .arise simply 9fr rri!ii.h:.\r imlamma ri<)\ nr rill-: mii'DI.i-: I'-Mi llHn \t('iisi()ti fioin tho si}?iiioi(l siiiius, aiu froiii ;m olistnictiiif^ <.'lot by i . this dot (Iocs iK.t iM'Ponic infcfto.l l.ci-aiisc ..I i"!irly opcnttivc later- Iciciicc, iiiav not iccovcn Im- possil)!!' ? Infective' Thrombosis of the Petrosal Sinuses, llns ((UKlition .im|)lv fonus a part ..t tl.r natural l.ist..ry of i.itVctivc thnmihusis uf th("' •^i'Miuml sinus, wiictlicr lli.- petrosal sinuses become afiected nriinariK'aii.l later involve tlie sifrinoi.l sinus, as rarely hapi.ens. or bee(.ineatteete,l s. mudarily by extension from the si>rnioi(i, as g(>n- erally happens. .1 • i t »i „ Otic Cerebral Abscess. I'iti stat.- that almost one-thira ot the eases of brain abseess are due to disease of tiie temporal bone. Iho vast maiorilv of ntie eeiebral abscesses occur in tin- teinporosphe- noid'il l('.be " ( [''iff. <«->.) Thev follow chronic middle-ear suppura- ■ j f1 , |.ri>„«ry »b>ee>s .•avitv ..onnoct.^ with sinus in tyn„«nlo r.K).'. J. Secondary «l>»cefs ..avity in lemporoM.I..-n..i.t«l lobe. Ilmh aWess oavi.it^ f.mn.l free (Vom pns at nuto,*y. '" ''-"N • tiou from seven tii nine times as fre(|uently as the acut( process. Thev are jiei"M-allv connected with the diseased temporal bone by a tistulous tra; t. (Viji. ■")79.) Korner found that in 06 per cent, the abscess lay within the brain and was separated frnm the bone }>y normal brain tissue. ,..,,•,,• The svm|)toms of bniin abscess have been divided inl.i lour .stages: the initial latent, manifest, and, hnally. tli(> terminal. .\s a matter of clinical exi.eilence, it is generally only th<' two latter stages tluvt come under observation: the first two stages pive rise to indeHnable symptoms which are usually attributed to the middle-ear disea.se or lu other causes. Tl-.e symptoms during the initial .stage, according to Maccweii. are otalgia with oxcniciatiiig neuralgic pains radiating from the eai-. 74 I mk^pn^ 1170 Tllh: KMi. often vomiting. giMU'ially a rigor, sliglitly elevated temperature coated tongue r)rostratioii, and, !us a rule, the otorrhani ceases or lessen.''. The symptoms during the manifest stage are of most miportance for diagnosis, for it is genendlv in this stage that the patient demands relief. Von Hergmann has cla.-isified the symptoms of this stage 1. Genenil Si/mptouis. Lo.ss of appetite, furred tongue, foul breath, cachectic appearance, general lassitude and weakness, low tempera- ture tend.ing to intermit. There is u.-ually no rignr, and emaciation often appears as the disease progresses. 2. Brain and I'l-e.^sitrf Si/mptotn.^:. Versi.stent headache, moderate and referred to the region Df the ihscess or to other i)arts; often, but not invariably, slowing of i)ul.s(«, sometimes fluctuating: nausea and vomiting, dizziness, constipation, slow cerebration, and (Irovvsi- ness are very .;ommonlv pre.seiit; the patient is incapable of sustained attention: there is usually no delirium: tenderness on i)ercussion over the affected area mav beVrP-^ei't; convulsions of the extremities and of the facial of the opi)osite side may appear if the iiressure is con- siderable: oi)tic neuritis, usually slight, is frequently present, more pronounced on the at^ecteil side: respiration is regular and may bo slowed. Tlieic is occasionally retention of urine followed by ove--- How, incontinence, and th(> urine sometimes contains albumin. Th.' brain pressure^ s(>ems to exert an inHu(>nce in lowering both the tem- perature aiul i)ul.se, since the moment jjivssure is relieved by evac- uation of the abscess, Macewen says, there is a sudden rise in pulse- rate and temperature. Hut the abscess ..lay exert no pressur>", occu- pying the s;)ace of the destroyed brain ti.ss-,c. and in this ca-se the slowing of pulse and subnormal temi)erature will fail to appear. The eyesight is seldom much affected. Little dependence can be placed on the reflexes, superficial or deep. 3. Local Brain Si/mptom.f or Localizing Symptoms. These ;ue only occasionally present because the abscess is situated outside of the motor area", in the majority. Oi th<- cranial rerves the thir.l or inotor oculi is most fre(iuently implicated, on the same suie. Hemiplegia of the opposite side is occasionally found in large abscesses, due to pre.ssure or inflammatory action. '' If one finds paraly.^is of the third nerve on the same side as the lesion, paralysis of the opposite side of the body, commencing in the face, answering to the tests of i)ar- alvsis originating in 'he motor cortex and remaining most marked m the facial muscles, then involving the brachial nniscles to a less ext(-nt, the lower limb remaining free, and all these being present without loss of sensation, the great probability is that the lesion is a arge one situated in the temjioial lobe" f Macewen i. Facial paralysis, when central, is on the side opposite to the lesion, and cortical. The pupil is generally sluggish and. not infrequently, the pupil on the «'une side may either liecome myotic or mydriatic, accompanied by a degree of stability. Knapp believes hoim,..; lous hennanopsia. which has been notell in seven cases, would be found oftener if regu- rrnri.Ksr imlammmios <>i- inn Minin.t: /•-i/.'. 1171 f lurly sought for. Aphasia sometimes accompanies left teinporosphe- iioidal abscesses ; sensory aphasia indicates involvement of the pos- terior portions of the temporal convolutions; motor aphasia, mvolve- ment of hrain near the fissure of Rolando. Word deafness and psychic l)lindness, due to disturbance of the first temporal coiivolu- tidn and angular jivrus. have also been recordf-l. The d agnosia is generallv not possible until the manifest stage is reached, and even theirit is often uncertain. Emaciation a^o- ciated with headache, low temperature, slow pulse, and constipation in a case of ciironic j)urulent (.titis media should direct attention to the brain. Caries of the tegmen tympani or antri is a matter for investigation: sometimes ])us may be seen oozing through an erosion in the tegmen tvmpani. The presence of an excessive discharge of pus is sometimes significant. The diagnosis is made easier if local- izing symptoms make their appearance. In most cases the abscess is only found by following up the: infective tract from the nuddle The duration varies from two to six weeks from the time of its formation in the case of an acute absce-«, to a number of months or vears in the case (jf an encapsulated chi )nic abscess. " There has l)een recorded but one case of spontaneoas recovery from cerebral abscess. If not interfered with, death finally results from profound exhaustion, probably the most common termination, or bv rupture into the ventricles or on to the surface of the brain, or bv the development of complicating sinus thrombosis and menin- gitis'. Death occurs with gradually deepening stupor and coma in case it is due to cerebral pressure and oedema. If rupture into the ventricles takes i)lace. the pupils become widely dilated, the face livid, respiration greatly accelerated, the temperature rises to 104 - 105°' F. and the pulse to 120: there occur mu.scular twitchings all over the bodv, possiblv convulsions and tetanic seizures, followed bv coma and "death in from six to twelve hours, as a rule. Rupture on to the surface of the brain sets up an acute leptomeningitis, unless •idhesion of the membranes has i)revi(Uisly taken place, in which case the pus mav find its wav to tiie skull wall, and so externally. E-en when discharge of the p"us thus takes place through the bone, it is a (luestion whether permanent recovery ever takes jjlace. The result of surgical interference is very promising if the pus ca>i be thoroughlv evacuated and the abscess cavity rendered aseptic. Often there is left behind no impairment of the mental or bodily functions. Macewen obtained 8 recoveries in 10 temporosphenoidal ab.scesses. , , ^t r The tempor<)si)henoidal lobe may be uncovered by the use o the trephine or bv continuing fhe use of the hammer and chi.sel upward from the niastoid woun.l to the s(iuama, the mitstoid incision h'lving bion previously s-xtended uinvard for a suffiru-nt distance iti)()ve the auricle. (Fig. BO.'i.) In every case the antnim i]ient ■d first and the middle-ear cavities Explored, especially over the 117-2 tcniiicii nf the tyiii|i:iiiui Tin-: F.M!. tract. If ^'U{•ll a tract is cotiforiM to tlio iliroctiou II and aiitniin, for the presence of a fistulous found, the ();)eratioii should be extended to it tak( lous tract, tlie oi)erator may Without the existence of a fistu- chisel upward from the mastoiil wound I foi- an area large enough to admit the hiting until tlie dura is expose( ^ ^- .. Made of a pair of Imne forceps, after which thorough an<l extensive exi)osure is ea.sy. The exi)()sure of the dura should he sufficient to make possible t"he thorough exploration ot the tegmeii tympani and antri The .lura is to be rendered thoroughly asei)tic by scraping otT granulations and treating with antise|)tics before the attempt is made to explore the brain through it. The dura wnll usual y be fo- 'd discolored ov<t the site of the abscess and the brain .should be incised with a straight bistoury at the centre of the (hscolored area care being taken not to penetrate far enough to endanger the ventricle: the knife mav be carried to a depth of one inch with safety. Macewen recommends "the use of an exploratory camda devised by iiimself ■ but it s(>ems to th" writer that the bistoury is more certain and no more ilangerous. If the abscess is of considerable size it will produce bulging of the brain into the bone opening, which may help to locate the abscess. In oi)eniiig the dura do not extend the incision quite t<. the margin of the bony oix'ning, so that if a vessel is divided it mav be easily secured. If the trephine is used, the centre-pin of a half-inch trephine is placed at a point three quarters of an inch above the posterior root „f ;l,e zygoma on a line with the posterior wall of the external osseous canal. Personally the writer prefers the method of enlarg(>ment of the mastoid wound with the hammer and chisel and bone forceps: the aperture may be made large enough to meet anv indications. , , , * i 1 1 + \fter the aliscess has been incised and the i)us evacuated, a blunt curette or a pair of forceps should be used to remove any sloughs that have not been ( arried out bv the |)us. .\t the present time, the pre- l)onderanee of opinion seems to be against washing out the abscess cavitv If washing out seems desirable, then a very weak anti.septic s,',luti(.n is to oe svringed gently into the al)scess cavity through a camil-i alongside o"f which a much larger canula for the outflow has b'een simultaneously inserted. If any resistanro to the current is met with the tubes are to be withdrawn, cleansed, and the attempt made over again. No force is to be used, .\fter the stream returns dear the head should be inclined to the affected side to drain out the fluid before withdr.awing the tubes. Whiting has invented an in«trutTient which he calls an encephaloscope, consisting of a tube with an obturator, for the purpose of examining the interior of the abscess cavilv and, on withdrawal, the fistulous tract. He also introduces gauze drains through it. Decalcified bone drainage-tubes „,.,. : p u^od or the c.avitv mav be lightly packerl wath gauze, after dusting with the iodoform" and boric-acid powder. The outer dress- ing'^ are the same as for the miustoiil operation. If all goes well the first dressing may be left m place for a week iTiiii.i:\r i.\Fi..\MMrrin.\ dh mi: Miinn.h. i:.ii! n;:'. „r so. proviil.'d tiu' t.-mperiiture is iiorinal and tlietc is no stain thn.iijili tl.c dressings. .Xftt-r the first dressing, the wound sl.ould he dressed daily, with or without syringing. If lewder is used, hone aeid shouhl now be sul)stituteil for iodoform to avoid iodoforinisni. Ihe i.iitient sliould he Itept in hed for from fo r to six weeks and on a milk or fluid diet for two or three- weeks. If the bowels have not moved spontaneously hv the end of a w<>ek a mild purgative shor.ld he given. The patient should not be permitted to leave the recumbent posture until the wound is well on the road to healing. After ev'icuation. the absn-ss walls sink into iipiK.sitioii and the eavitv becomes .(uicklv obliterated, as a rule. Often adhesions form between the brain and dura or fibrous tissue at the «/pening m the bone; sudden movement is then apt to cause shock, with faintncss or transitory unconsciousness. Otic Cerebellar Abscess, .\bscess of the cerebellum occurs usually in one hemisi.here, generally in the anterior portion The majority are in more or less direct contact with the sigmoid sulcus Kocli believes many of the abscesses occurring in connection with chronic middle-ear supjxiration are acute abscesses caused by a rtmidescence of the trouble. , The general, brain, and brain pressure symptoms are much tne same as in cerebral abscess. Localizing symptoms may be altogether wanting, and frequently are. , , . • Excessive vomiting is more apt to be pn-seut; headache is never wanting and is usuallv occipital, but may he referred to other parts; the speech is sometimes jerkv and syllabic: optic neuritis may be present, but is of n.) special significance. Marked dizziness is present in about one-third of the Ciuses. Macewen attaches significance to rigidity of the masseters. There are disturbances m eqmlibnum, in eait, in breathing, and ii. motor speech. Amaurosis, without atrophy of the optic nerve, mav be i)resent. "There may be total blm.lness, prohablv attributable to severe hydrocephalus mternus. .\.s no case of temporal abscess has, as vet, been accompanied by double amau- rosis, this coPU)lication is of diagnostic value" (Koch). Convulsions occur esijcciallv m children, and probably indicate the presence ot internal hvdrocephalus. Paresis of the facial nerve of the same side mav occur .Vs meningitis develops, retraction of the head and neck makes its ai.ix-arance. Heri)es facialis was present in Ca.se Xl>. ot Macewen's; the patient died. Macewen notes that patients often vomit when raised from the recumbent posture. Weakening or paralvsis of the bladder and rectum are more apt to occur than in cerebral abscess. (Vrehellar abscess only occasionally involves the motor oculi. 1 )ouble-sided involvement of the cranial nerves is rare : rarer still is crossed affection ..f the nerves. The nearer a cerebellar abscess reaches to the middle line, the more it is ai)t to produce f<ical symptoms. " If the abscess occurs in the pons, localizing symptoms may nut appear unless the abscess is large, in which case crossed hemiplegia. 1174 Tilt: EMI. (louhU! hoiniplcKiii. t>r other liiU-ra!, hiliitcnil, or shifting palsien may 1*0 prospnt, apcdrding t(i Derciini. OculoinDtor symptoiiiM may aluo exist. In come cases the syinptonus present arc referable to the over- lying meningitis, the abscess itself producing no symptoms, or the abscess symptoms are masked and ovcrsluulowed by those of a coex- isting sigmoid sinus thrombosis. Koch noted a clo.se following of the al>8cess u|)on the ear affection in one-half of the cases. In others the interval may vary from sev- eral weeks to .several months. The length of the terminal stage varies from three days to two and one-half months, the average being two weeks. Macewen observed one case in which abscess symptoms had l)een present for eleven months. In one-half of the cases the final cause of death Wius not determined ; meningitis caused death in one (juarter, progressive encephalitis in some, rupture into the fourth ventricle, hydrocephalus interims, sinus phlebitis, or some other complication in others Death .sonu"- times results from the encroachment of the abscess uiion important centres, such as exist in the medulla. As with cerebral abscess so with cerebellar, the diagnosis is usually only determined with certainty by operative investigation. The natural termination is in death; by means of operative inter- ference about 50 ])er cent, of the cases may be saved. The treatment consists in operation. Tlie horizontal incision jiom the mastoid incision is carried backward, so as to uncover the occip- ital bone over the situation of the cerebellum. The sigmoid simis is then uncovered for investigation and the Iwne wound continued backward over the cerel)ellum by the use of the bone fcjrceps. As most cerebellar absces.ses are .situated in the inmiediate neighborhood of the sigmoid groove, the operation through the mastoid has great advantage over the method of trephinirg behind the process; it also enables us to examine the sigmoid sinus at the same time. The remarks made as to locating, evacuating, and dressing cerebral i bscess also apply to cerebellar. In the latter large sloughs of brair tissue in the abscess cavity are rare. In operating, sometimes suspension of breathing suddenly occurs, due to the ana'sthetic increasing the cedematous condition of the brain. When this hai)pens. the operation should be quickly pro- ceeded with to evacuate the abscess and relieve the pressure exerted on the respiratorv centre, meanwhile using artificial respiration. If the period of anaesthesia is shortened by the preliminary adminis- tration of nitrous oxide gas this unfortunate occurrence is less apt to manifest itself. Differential Diagnosis. The fact of the existence of suppurative ])rocess in the middle ear is of great help. In ieyitomcningitis there are hiph temi>eraturf' and rapid pulse without marked remissions, irritability, general excitement, restless- ness, and hvperresthesia of the sensorium. In inf(>ctive sinus thrombosis there are mental depression, rigors, iTiiri.Hsr i.\hi..niMMii>.\ of int. Minin.t: h:.\H uto coiistiiniti.;.., iruiik...lly HucUmting fcbrili- inuvf.nont . an.l in ilur freniicnt pulse. . . , i , , It t e tl'mi.(.roai)hcM..i.lal abscess W large we may liuvc oculo. .,tor an.l uupillarv eha.iges. weakness and convulsions of the opi -site side of the r)o<ly. perhaps various forms of aphasia, and. pos^ hlv, "'Tn mehenar .l.scess there arr exces.-ive vomiting, rigi.lily ol he back of the neck. 9t:iggering gait, "cerebellar sper.h. and vert -o. In both brain abscesses there are slow pulse and low fever sonte- times subnormal temperature, slow cerebration, apathy, and droxysi- „ess' but the fact that more than one intracranial patlu.logic«l o^idition often coexists in th^ same patient should n- ver be oyer locked, and we shoulo Ije guided in our u.agn. ' uper.Un interference by the remembrance of this fact. CIIAI'TKW XXVIII. ( llltoNK N(»N-SIIMMI!.\riVK \i!l>l>l,K KAII lUSKASK. Bv AHTmii II. CmiATLi:. F.K.C.S. Km; Kzamination of the Patient. riii!< .should Im> cairicii out with gri'iit ciin- anil lliiirdunhiicj^s in iinlcr that a proiHT (liajjnosis ran U' made, anil al.>*t) that the surnt-oii should he ahlc to jfivc a |)roKnosis, which is often of ^n-at nioiiiciit. The family history siiould Ih' hist in(|uircil into for evidence of heredity. The life-history of the patient liiinself must then Ix- inves- tigated from a ^reneral point of view. Then will follow the hi.story of the mode of on.set and |)rojtress of the annd trouhli'. .\ll thes<> things haviiiK In-en noted, the examination of the patient can l)e maiie. This is never complete unles.s both i-ars, the no.se, the pharynx, the nasopharynx, tojjether with the jjeneral health and surroundinjts have t)f>en minutely in.spectod and in(|uired into. It i.s always wise to make careful notes and drawinir-s as Jie examina- tion proceed.^. The lliiirinij I'ouir Must hr Mmniina. l'"or this various methods are used, the most useful Iwinj;: 1. The Watch. It is useful to have two. one with a very loud and the other with an ordinary tick; both must have \tovu carefully ineasjired with normal hearing in order that eacl. , ay have its standard. In t(s,mK with the watch (or in any other test) the eye.s and the ear not under examination should 1h> closed, .iiid the w;itch liaviii^ been placed close to the ear for the patient to :i|ipreciMte what he is(>xj)ected to hear, should then 1h> taken to the extreme ranjte and slowly approacheil until it A'lNiiniUT is heard, the <listance being measured l)y a tape measure. 2. The Voice. The whisper and ordinary conversational voice and. if n(!ce.s.sary, shoiiting should be u.sed. "'Ms method is a u.seful but rough one, a.« it is almost iiiip(i,<sil)Ie to liuuge the voice acour.ately lor each exammation. .'^ The Acoumeter. I Fig. ().^'i. I Th.s little iustrumc . invented by Pulitzer, is of great value, as the note struck is alwavs of the same iIITli) riii:i>\ir \'i\ sii-i'i i;.\rni: Mihin.nh.Mi hi>i:A^h: |I77 •t' iiliuut fully tVct ill a i|iiiet roi Thr vuliir. It lias a lanp- nt aMuu . iiiohilityiif tin- iiii-mbrai.a tyiiip'iii aiul iiiallciis should hr li-stcd liy usinj! SicRlcV piiciiniatic spcculimi {\'\n. M\). with whicli the Ih'- havicir of llic incinliram- when thi' cohimii of air in the iih'o'is is cxhaiistnl or coiiiiirrsscil rail Iw cxainimMl. Sleglc'n pneumgtlc «jieciiliim The heuriiig power in these several ways having In-en tested it is neeessary to establish the diagnosis of middle-ear from internal- ear disease. The history of the onset and eause of the d less will aid considerably. 1. In middle-ear disease definite changes in the membrane are sometimes seen. Internal-ear disease is often marked by attacks of vertigo and vomiting, the special f)oint regarding true labyrinthine -.ertigo lieing fh'it objects appear to move in one direction or another. Vertigo is not found in uncomplicated middle-ear diseases. In middle- ear disease the deaf'ii'ss is markedly aorse during a cold, in internal little or no increase is noted. Paracusis, or hearing better in a noise, is pathognomonic of middle-e;<r affections in their later stages; in internal the hearing is betli-r in a quiet room, a noise confusing the patient. H )Ughlv speaking, in middle-i-ar troubles low tones are badly heartl, while the convf ise holds in internal: in comi)anng the hearing distance for the watch and voice this sign is often of value in the difT(>rential iliagnosis. In order that this may be more accu- rately tested the following may be used: limit i-t|: (Fig. ();io) is u.sed for testing the ui)pei- •^ -"V of value if the deafness is extreme. It 117H ■/•///•,' /•;.i/.'. has a range from tlie liighe.st appreciable pitch to near the rnediuii], Th(> whistle is made by comi)ressing the rubber ball, the pitch being varied and measured by turning the cylinder. .4 seric!' of tuning-forks, such as Bezoid's or Hartmann's, for testing the lower and middle ranges. Hartmann ha.s a set of five fork's- V. r + 1, C + 2c, C + 3, C + 4. In middle-ear disease the deafness never becomes absolute as in internal. As a rule, the patient's own voice is heard loudly in middle, while in internal it may not be heard at all, so that if it is of long standing and bilateral the voice becomes monotonous; again if one ear is affected with internal-car disease the voice will not be heard at all on that side, but will seem to travel over to the other. On gently scraping the membrane in advanced internal-(;ar disease The action will be felt, but not heard. Inflation of the middle ear lenders the hearing vorse when the internal ear is affected. In the normal ear nir is better than bone conduction. In middle- tar disease the bone conduction is increased and is better than the aerial, while in internal bone conduction is diminished and the aerial is better than the b( ny. These phenomena are tested in various ways by means of the tuning-fork, a C2 being the best to u.se for the purpose, as it is free from overtones. 1. Schwabachs Test. In this method the length of time the tuning fork is heard on the mastoid of the pati.'iit is comjiared with that of the observer, whose hearing must be normal. If the tuning-fork is heard on the surgeon's mastoid after it has cea.sed to be heard on tliat of the patient it demonstrates that bone londuction is diminished and that internal-ear trouble e.xists. while if the patient can hear it after the surgeon, bone conduction is in- creased and indicates middle-ear disease. The number of seconds of increa.se or diminution arc counted and noted. 2. Weber 8 Test. In tiiis test the vilnating tuning-fork is ])laced on the middle line of tlie skull, vertex, bridge of no.se. or incisor teeth. Tf one ear is affected witli middle-ear di.sease the sound will be heard l)rincipally in th.at ear. wliile if botii are affected an-! one is markedly worse than the other, the .sound will be heai'd better in that which is more affected. If the internal apparatus of uiw ear is affected the sound will be heard lou<ler than in the normal, while if both are atfected with internal-ear disease, and one is much worse than the other, the sound will he louder in the less affected ear. If confusion should ever arise in the mind of the student in con- nection with this test, or, indeed, in any of the others, the clue can readily be found if the student closes one of his own ears with the finger, thus imitatins: middle-ear deafness, and, on placing the vibrat- ing fork on the middle line of the cianium, finding that the .sound is louder in the closed ear. ciiHosic .\<>.\.srri'ri!ATi\i-: miodle-eah i>ise.\sf.. nvii p ■ 3. Einne'8 Test. With tliis the air aiul bono conduction are com- pared. If, in the normal, when the fork has cea-sed to be heard in the mastoid, it be removed and the pronps are placed in the air close to the meatus the sound will be heard again, showing that the air is better than the hone conduction. This is called positive Rinne, ;ind indicates either a normal ear or. if deafness is present, some affec- tion of the internal ear. while if it be heard on the ma.stoi(l after it has ceased, when placed in the air close to the (>ar {negatire Rinne) b(ine conduction is increased, thus indicating a middle-ear affection. 4. Gardiner Brown's Test. This test is based u])on the fact thai, given trained fingers, the vibration of a middle C timing-fork placed ■ .aMiner Bniwn's t\inin(;-fnrk ; mliidle C, of r>12 vlbratioiu per stoind lone-third imlural sizei. un the mastoid in a normal case can be jell by the surgeon for pre- cisely the same length of time as they can bo heard by the person under observation. In the middle-ear .affection the sound will be heard longer than the vibraticins can be felt, while in internal the vibrations can be felt for a more or less period after the sound has ceased. This plus or minus should be counted in seconds and noted. Fl,i. iMT. Anwultntinll ,JiHKil,)Vli,' till,,'. A diagnosis of middle-i'ar disease hav- ing been iiuido the middle ear should be inflated through the Eustachian tube by me.-iiis of I'olitzer's bag or a Kustachian catheter. During inflation a diagnostic tuU' should be used, passing from the patient's to the surgeon's ear, in order that it may be certain that the inflation is efficient, that any obstuction can lie not«d, or that fluid in the tube or middle oar can be diagnosed. IIMO /■///•: i:ai;. Politzers Bag. Tlic most iisct'iil is ;ni ci^jlit-ouncc one witli Prii- chanl's nosc-picrc wliicli is mjidc of vulcanite and coiiiicctcd witli the nozzle of tlic liag hy means of a i)iccc of i Mlia-nihticr tul)in)r. Tlie iiictlioii of lioiiiinj; the haj; is well sliown in the acfompanyiiiu cut. Tlic haj; is (•omprcs.<('(| wliilc a sip of water is l)einji .'swalloweil, or when tlie cliei'ks are blown out. or on saving "liic;" all thre(' methods, hy (>levatiiiK the .soft palate and tluii shutting off the na.so- pharynx from the i.harynx, compel the air to enter the Ilustaehian tuhes. If one ear only is to he inflated hy this method the j)atients hea.i siiould !)(> turned on one side with the affected ear uppermo.st and. with the finger closinji the sound ear. inflation should he practised through the nostril corresponding to the affi-cted side. Eustachian Catheter. The most useful catheter is a short silver one whicli caji he hoih'd. Km. ii:i«». KuMui'hiuii rathi'ler The most certain way of intro(hicing it is Loewenbeig's. .Uter tilting up the jwint of the no.se, the instrument with the point hori- zontal is passe<l over the elevation of the ticjor of the vestil)ule to reach the floor of the nose, the outer end is then brought up hori- zontally and the instrument pa.ssed liglitlv along to th<> p().sterior tiasopfiaryngeal wall, when the beak is turned horiz(jntallv inward and gently withdrawn until the back of the .sep'r-u is fi-lt. The beak is then rotated downward, outward, and upv. i . until the ring on the outer end. whicli corresponds to the beak, ixiints to the outer canthus of the con-esponding eye. .\ir is then blown through the catheter by means of a suitable bag. If the tube is found to be much obstrm'ted it may be necc.-^sarv to intro(hrce fluids or a hoiif/if through the catheter. Before introducing the latter accurate measurements nmst be made m the following way before passing the catheter. The bougie should l)e pa.ssed down the cathet<-r until the point just ajipears at the imier or tube end: rm ink mark is then made uii the bougie at the point corres|)onding to the entrance of the outer end. and frotu this ink mark the length CM t(j :iii mm.) of tiie llu.stachian tube is m.'asured off and again marked. In this way can be told (n) that the bougie IS at the month of the Eustachian tube, i/l) how far uj) the tulte the bougie has i)a.>;sed, and (c) at whicli part of the lube ob.stniction is most marked. The passing of the bougie shoiiM he doii'' gentlv .Mnd 111 a rotatory manner when passing through the tube. Lubricating the bougie with paroieine before intro.liiction will be found uscfuL f///.'o.v/r so.\-siri'ii!.\Ti\h: Minnr.KiiMi disi-.ask. hm AtttT inflation lias Ijccii effected tlie rostilts on the membrane must he inspected and tlie liearinp jiower ajiaiii measured and noted. Th(! effeet on tinnitus, if |)resent, should lie iiKjuired into. ViTtiiai Mitioii ot the imsoplmryiix, «iih tin- iiitheler intrixluiiil liUo tlic Kustachmn lube. A Inleri.T t\irl.i.i..te<l hone II. Mi'Mli' tiirhiiwH'il bciiu'. C. l^tlperior turhilialeil hone. P. Hani palate E. Vtliini paiali. F. I'DMerlor phnrj-HK™' ««"• u l<nscniii(lller'sf.)«sa. U Posterior lip • f ilit'oritii'i' (it the Kustnchiaii t\il>e .Phi.itzki: i The effeet of massnur. of tiie membrane by means of Siegie's specu- lum or D(l>tanclie's masseur jiently npplieil on hearing and tinnitus -sliouhl be inve.stigated. Ki(i. mi. Itelstanche's masseur. Jl \IH2 /'///■; EAH. Massafte may be api)lie(l under two conditions 1. With Ihc vieaial air exhamlcd, \vl ind in fus will he niostiv affected. len liie niembrane, in: '1 eu- 2. With the mcatal air compressed, when the stapes is thuiirht u i)e reached.' Classification. Difiieuitv is always experienced in chissifvingiu,ii- supjmrated nii<idle-ear di.sea.ses on a patholo<;ical basis, as.'aithou.'ii p-eat advance lias been made of late years, tiie ojjportunitv for inves- tigation m their earlier stages is neces.sarily rare. The followiiii; must therefore be acceftted tentatively and tor purposes of descri]" tion. Clhiically, it is often difficult or impo.ssiblc to draw haiil-;tii,|- fast lines between them: A. Hypr-rtroijliie catarrh. 1. Chronic catarrh of the Kustachian tube. 2. Cliroidc catarrh of the middle-ear tract. B. Atrophic catarrh or sclerosis. C. Changes in the lining membrane due to variations in pressun-. D. Changes in the lining membrane due to deficient blood su|)ply. A. Hypertrophic Catarrh. This is a di.sea.se which has its ori<'iii prmcipaliy in early life, having for its chief characteristics deafnT— a.ssociated with definite changes in the membrana tvmpani. and sonn pathological conditions in the nose or nasopharynx. Causation, The causes must Ix' any condition which will 1. Predispose to attacks of acute catarrh. 2. Teiid to make acute catarrh become chronic. '.i. Maintain a chronic catarrh. The.se cau.ses may be local or general: the local condition abov. all others is chronic liyi)ertrophy of the iia.sopharvngeal tonsil (aden- oids), a disease chieHy of childhood ami earlv life, although not uncommon in middle life, and occasionally met with at a much later period. Hypertrophied tonsils (although often associated with aden- oids), if they are present alone, will help to maintain a chronic catarrh. Other local causes are secondary syphilis, true or false hypertro])h\- of the turbinal bodies, suppuration in accessory cavities df the nose, atrophic rhinitis, nasal polypi, irritation due "to noxious fumes, to- bacco, etc. The general causes are exixisuie to wet and cold, aiuemia. tubercle, in fact any disease which lowers the vitality of the organism, rendering infection ea.sy and hindering return to a iiormal condition. Pathology. In considering the pathology ,,i this disease we will consider shortly what a catarrh is and what changes are produced by it: but liefore doing .«o the reader may be reminded that tin lining membrane of the niiddle ear consists of three lavers- 1. I';pithelial. 2, Subepithelial, containinj; lymphatics, nerves, and. comparatively speaking, large bloodvessels. .'{. Fibrous, which is adherent to the hones. TrHllsiicf.n^^ of ill.ilngicii' ConKri'ss, l.^M, ciuioMc .vo.v-.s/'/'/t/my/ia; Minin.K-H.m inshAsH. iih;{ All aculo i-atarrh is an acute iiiliaininat;.yii of a mucous membraue due to either injury or infection. At present we are unable to say (Jefiniteiy wiial niicro-orsiuiism will produce catarrh: but, as far as is known, any pathogenic organism has the power. Th(! immediate result of infection is acute swelling and reddening of tht; membraue, due to the engorgement of vessels and the presence of exudation, especially in the subepithelial laye.-. Exudation is also poured out from thesurface, being serous, s'romucoid, or chieHy nmcoid. At this point resolution may take place, leaving ik trace, the I'xuilation in the subepithelial layers being carried off by the lymi)hatics, and t!ie vessels returning to their normal size. But if. from some local or general cause, resolution does not occur, the engorgement of vessels continues, a'ld more or less exudation per- sists, that which is poured out from the surface being a marked clinical feature in some ca.ses. The chronic engorgement of vessels leads to local proliferation, especially of the hbrous tissue in the subepithelial layer: this fibrous- tissue proliferation undergoes contraction, the exudation ceases, the epithelial layer by stretching becomes atrophied, and the whole lining m.embrane Incomes ultimately converted into a layer of thick fibrous tissue. There ari'. therefore, four stages which run one into another when the acute period is past: 1. Chronic engorgemcMit of vessels with exudation. 2. Resulting proliferation, especially of the fibrous tis.sue. 3. Contraction of the proliferated fibrous tissue. ■^. The ultimate .stage of cicatricial condition which may be called post catarrhal. The results of such changes in the middle ear can be easily imagined when it is remembered that the lining membrane, besides clothing the bony walls and inner .aspect of the membrane, forms folds and pocket /around the ossicles, their joints, ligaments, and muscles. At first the ossicles and membrana tympani are hampered by the swollen membrane and the exudation. Later the contraction of the proliferated fibrous tis.sue causes further and permanent fixation. Th(( membrana tympani is drawn in by the same cause, aided by the non-aeration of the cavity through the Kustachian tube, allowing external atmospheric pressure to exert its influence. The folds of lining membrane are converted uito fibrous bands, binding down the ossicles to the neighboring walls, the incus to the outer attic wall, and the stapes to its niche. The tip of the handle of the malleus coming in apposition to the promontory, the opirosing epithelial layers become rubbeif off, and allovv of adhesion at this point. The os.sicular joints become anky- losed, the muscles fixed. The exudation becomes inspissate" r confiiici in pockets of the lining membrane. The Kustachian ml^c, sharing the same changes, l)ecomcs narrowed, so that an originally pink, moist, thin, somewhat movable, lining membrane becomes IIM.J THE i:.\i!. smooth, wliiU', dry, mii.I tliick. Fiirtlipr fliaiijics df the liiiiii^; iiitim- l)raii(> sometimes oeciir, such as eah-Uicatioii, fatty deKeiioration, ete. The tensor tynipaiii atul stapedius muscles (indorgo atrophic depen- < Tat ion. Aiikyliisis (if ihi- |,liil.-..f till' -luiic-s will, the fem'slra ovHli«. .MiiT(i.s(.|i|,lc -eolioii lhniU({h ihi- .taiv.lUn-.'slihularw.iiiircll.ui. ./, IloH.l ..f the Ma|t->. ',. liase ..r Ihc stapes. ;,. rroiiinnlnry .. ■ipuriims a(lhi-si..ii i.f the Ix.rdtT ol Ilie stain's with the fenestra nvalls. *•. Adhesio.i ,if the anierl-ir tninler. the e<l(;e ln'iin; -liil llotieealjle liy the iliirk line. ■ l'.)i.n/KK.! As the trouble may be limited to the Eustachian tube or may involve the whole iniddle-ear tract, each will lie con.sidered sepaiately, with their symptoms, sijins, prognosis, iliapnosis, and treatment, as far as possible in their difTerent stages. (I. Chronic Eustachian Catarrh. This may be limited to the orifice of tiie tube or extend some distance up the cartihiftinous portion. If loiif,' continued, chancres may take place in the whole tract; these will be considered under the chanpes produced by variations in jires.surc. Sv.\ipt:)Ms and Sions. One or both ears may \w aflected: if both, one is often worse than the other. Deafness is marked, but m.ay \ .try from time to time, improving sometimes on swallownig or on blowing the I lose: but the im|>rovement soon dis- ai)i)eais, or, if permanent changes havi, not occurred, the patient, after suffering for some tim(>. may feel a crack in the ears, with ,subse,|uent complete res- ( oration of hearing. ()n inflation with Politzer's bag or the Kustachian catheter imme- diate and [lermanent improvement may occur in the limited early *:ircumseri!x'il aiihe sioii of the niembrana tyni|iAiii to the pri>- nmtilory iniilertieath the haliclte t>t the malleus, n. I'laee nl adhe.sioTi on the pni- inontory. (.Mieraiire- paratiotiol iiilne. itow in the rnil^eniii of the f'olk'K*.' of Chysieians, in I'hiladeli'hia. ' 'l'<i l.IT.'.KH. : riiiioxic \o\-srri'cnATivi-: mu)I>lk-e.{r disease, hso stage, or, if thp discaso is of long standinp. pspociaily if it has pxtended some nay along llio tul)o, difficulty may l)0 oxpcrienrod in getting the 1ul)0 open, and the resulting improvement, although great at the time, sooner or later disappears. On listening with the auscultation tube during inflation the air can 1)0 heard at first in the distance, entering with difficulty l)efore clearly entering the cavity of the tympanmn. In the exudation stage distant bubbling may Iw at first heard. The patient complains of a distinct feeling of oppression of the head on tlie side affected, and mental dulne.ss may be felt, especially if both tubes are blocked. Titmitus of a rushing character is heard. The patient's own voice sounds to him louder on the affected side, and if both ears are implicated it seems as if he were talking into a hollow ves.sel. The auricle and surrounding parts feel numb when lightly touched. On looking at the mcmbrana tympani all the signs of (lepression will be seen. If permanent changes in the midt'Je ear have not been produced the pink lining membrane may show through, unle.'^s any opacity be present. The white short process of the malleus is prominent, and the handle foreshortened and drawn somewhat backward. The folds running forward and backwanl from the slu^-t process to t!ie iKriphery are marked, the latter especially. The triangular light reflection from the tip of the handle of the inalleus is internipt<>d, shortened, or absent, depending upon the amount of depression. The structures hi the middle ear and the inner wall may be clearly visible. In the posterior and superior segment the descending process of the incus, with the sta- pedius muscle running backward from close to its tip, and the chorda tympani nerve running from behind upward and forward across the descending process of the incus, may Ik- seen. The smooth curve of the promontory in the inferior segment is well marked, and below and behind it the round window appears as a dark patch. On looking at the nasopharynx a catarrhal comlition of the lining membrane may lye seen, it being red and swollen, with exudation lying on its surface. Sometimes this can be seen involving the lips and orifice of the Eustachian tube and rarely a plug of exudation may be seen Iving in the orifice. Proc.nosis. In the early stages this is very good; in the later it will depenfl on the amount of constriction produced and whether the tvmpammi is also involved. Di.\GNOsis. Simple chronic Eustachian catarrh will be diagnosed by the marked improvement of hearing, by inflation, and the absence of permanent changes in the membrane. Trf:.\t.mkn r. Any cau^es in the nose or nasopharynx must be removed, and treatment directed to improving the patient's general condition adojjted, especially change of air and tonics. In the early stages a single inflation may be all that is necessary to open a tube which has been perhaps blocked by a plug of mucus, or the sides of which have stuck together. If the trouble has extended some distance up the tube, inflation will have to he repeated, the intervals u wmm 118t> riih: EAH. betHccii tli(> proccoditig ilc|K'n<liiiK on the <-tTcct produced and tl i lenjith of t imc iriiprovctiH'iit in hoarinK remains In the later .staues, when eontraction api)ears to heeonie a definit. feature, e.siM'eiaily if tlie eartilajiinous portion is affeeted, inject I alkalnie solution or of paroienie. or the jjassage of a houRie throupli the Eustachian catheter may Im" necessarj-. Combined with this treatment the chloride of ammonium vapor, obtained by means of Godfrey's or Hasdon's inhaler, drawn into the mouth and blown through the nose for ten minutes niRht and morniiiR, with a few autoiiiHations into the middle ear by means of Valsalva's method when the mouth and nose are full of vapor, is often of grer.t use. An alkaline and astringent solution gentlv syringed down the nose after the inhaler is often useful. In the la.st stage it will Im« u.sually found that further changes in the upper mid(lle-<'ar tract have occurred either by extension of the catarrh or l.v changes produced by the variation in pres-sure. The treatment ii the.se ca.ses will be consid- ered later. A useful i)oint when .lithculty of oj^ening the luL-'tachian tube by ordinary inflation is ex[)erienced, is to place a few drops of pure chloroform into the bag before inflaticm. h. Chronic Hypertrophic Catarrh in the Whole Middle-ear Tract. Symptoms and Signs. These will depend on how far the disea.s«» has prf)gro.ssed. 1. Stage of Chronic Engorgement of Vessels, with Exudation. Although a certain amount of exudation from the surface is present in all cases yet in some it forms a very prominent clinical feature demanding special description. It must be stated that ca.ses of this variety are undoubtedly rare in Creat Britain. It is impossible to .siiy what determines this excess of exudation; undoubtedly in .some cases the excess is more apparent than real, being due to the collection of exudation ;n tlie tympanum owing to coexisting Eustachian ob-struc- tion. The character of the exudation varies, b-ing .^erous, sero- mucoid. or mucoid: and here also it is impossible to .say definitely on what the varying characters of the exudation depends. The history of these ca.ses in which exudation is marked usually is that, after an acute catarrh of the nasopharynx, deafness in one or both ears persists. The exudation form may be present on the one side, with sim])le I'iustacliian ob.struction on the other. There is a feeling of fulness in the ear, stopping short of actual pain, and a sensation of something moving, especially if the exudation is serous, with occasional bubbling, especially after blowing the no.se. Im- provement in hearing occurs temfyorarily, but is onlv of short dura- tion, and may vary with the position of the head, the patient may hear bubbles bursting, especially after inflaiion. Hushing and occa- sional piil.xating tinnitus is })re.sent. The head on the affected side Icels heavy, and numliness of the auricle and .surrounding parts is experifiKed. The patient's own voice .sounds unusually loud. In- ability to do mental work is often complained of, and sleep may be rillloMC .VO.V-.Sf/'/T/M77rA' MIIHH.E-EAH hlsEAsi'. HhT ¥\r, (A\. ili.stiiii)0(l o\viii)i to tlip l)iil)hlirij; ami cracking wliicli goes on in tlio car. When tin- mucoid cicnH'iit predominates l)ut)l)ling on variations of posture are not marked. Sometimes, especially in olti people, the membrane may rupture on blowing the no.sc or on inflation, producing perhaps a suppurative process resulting from septic infection from the meatus. In infancy and early childhood rupture seems to readily take place in the early stages. On examination the apijoarance of the membrane varies according to the character and amount of the exudation, to the length of time it has been present, and to the degree of clearness of the membrane. If the exudation is slight and serous the malleal ve.><.sels are some- what injected, and the fluid can Ih' seen occupying the lower part, its upper level, which appears as a thin line, vary- ing with the position of tlic head, or, if greater in amount, marked bulging, u.>iually in the post<'rior segment, is seen, j)erhai)s completely hiding the handle of the malleus. On inflation a distur- bance of the Huid can Ih- seen with the forma- tion of bubbles, or if the auscultation tube l)e used, clear bubbling can be heard. If the mucoid element j)rep(inderates a whitish-yellow appear- ance of a more or less bulging membrane is seen with dilated vessels coursing over it : there is little or no movement ob.><ervable on posture, and on inflation through the catheter, as t!ie bag is often not effective, the air can be heard at first in the distance, and then to gradually enter the tympanum with sticky rales. In the later period of the exudative stage the exudation partly escapes from the Eustachian tube, while some becomes inspi.ssated, the membrane in the meanwhile becoming pale and depressed, with perhaps localized collections of exudation. In tho.se ca.ses in which exudation is not a mnrkvd clinical feature the symptoms and signs are not so aggressive. Deafness, improving on blowing the nose, with gradual return to the former condition, and tinnit.is of a rushing an<l pulsating character, are complained ci". The membrane is somewhat depressed, the lining membrane s«>en through being dark pink in color. On inflation slight bubbling may be heard, the improvement in hearing produced being greater and more lasting than in the cases of marked exuilation. Phoonosis. This, if the case h? pre )erly taken in hand, is. as a rule, excellent: but if long contimu.. " untreated, resulting in further changes in the lining membrane, as den.,instrated chiefly by the amount of itiipruvfur'iit in iir-aring jmiduced by efficient inflation, renders it proportionately worse: tlu>refore, liefore giving a definite opinion in long-standing cas(>s, it is well to await the effect of treat- nie!it. Ai'c'iiinulation of Huid effusion in the Inferior portion of the tympanic lavlly, marked byabright line. (POLITZER.l WHH I in: h.Mi. (■uses (if iimrkod cxuihttion jtivc (Icfinifc 8i>ji».< |)lA<iNKSI.H. 'I'' From a collt . if pus tlicy arc diajftioscd hy llio ;il)sciico of anitc rctl'.css of fl't" iiifiiihrauc, ciironicity, ami IIh" ahscticc of pain ami fi'Vf,-, If the cxticlatioti is mucoid a general whitish api^carance i> seen, instead of a yellow or greenish yellow, which is s«'en when the c(>ntents of the tympanum are pmiilent. The effect of tn-atnicnt will also help. In tho.se cases in which exudation is not a marked clinical feature lnihl.ling is sometimes heard, and Ili(> umisually dark and swollen lining memhrane seen through the membrana tvtnpani. together with the |K'rsistency of the symptoms and effects of inflation, mark them from simple liustachian obstruction. TiiKATMK.vr. .Vt this stage, a.s we have w-on, it i.s poHrtibie for the disea.se to Ik' completely arrested, and no means should l)e spared to prevent fuHher progress. The treatment is local and general. Tnose ca.ses in which ixiidntiini is m.-irked will In- first '-onsidered. If this is slight ;ind .serous the tr-atment adopted for simple I'lusta- chian catarrh will suflice. ,\s ix'fore stated, it is impo,<sil»le at first to say how much Kastachian ohstnK'tion is responsible for the collec- tion of exudation in the tympanum: .s(,metimes cji.ses which at first apiM'ar to demand more radicid measures yiel.l to simple treatment. In the ca.^^es in which simple remedies ('', not effect a cure a collection of exudation (KTsisting. and especially when the nmcoid el<>meiit liredominates, ihey nmst U' suppli'inenfed by intratvmpanic injec- tions of warm sterile alkalie ilutions, such as bicarbonate of .soda, five grains to the ounce, or of jiandeini'. ("oiinter-irritation behind the car, or ma.s.sage from ;d)ove downwjird behind the ear and up|K'r part of the neck, may al.«;o U' used. If these niea.sures do not .suffice the membrane nmst be opened, perhaps more than once, as the inci- sion spee(lily closes in sjiite of inllalion. The inci.sion nmst Im- made und(T strict antiseptic precautions thn.ugh the jiarl in which tiic bulging is most marked, or. if no bulging is present, in the po.'^terior and inferior segment; it should Iw free and parallel ' . the handle of the malleus. .\t the time of incision inflation slioi , Ik- practised to clear the middl(> ear. the exudation being then gently niopjx'd out. The meatus should then be lightly |)luggeil with the "antiseptic dressing. The simple treatment of the nose ami naso|)harynx with the chlori<|e of ammonium iidialer and nasal solution should" be con- timied meanwhile. Massage by means of Siegle's .speculum will Im- found useful in hastening absorption and preventing adhesions. Change of air to a high and dry climate with tonics ;:re esp(>ciallv benehcial. In those cases in which isititnliim is not warmer/ simple treatment, regular infl.-ition, ma.s.sag«> of the membrane, together with tonics and change of air, will u.sually be found .sufficient. In the.se cases, again. 'oral trouble in the nu?e or irasopliarynx must al.-o be removed. 2. Stages of Proliferation and Contraction. In discussing the following stages, they mi'rge .so gradually one into the other that it is impos- sibh' to separate them completely, the ])r(igre.ss of the cases being ciiiiosif M)s-.si-rrci!.triyi-: Miinn.t: i:.\u i>tsE.\sh: |]s<i juilKfMl accunliiij; to tin- amount of iniprovi'iiu-iil <)l)liiiinM| l»y tn-at- iiiciit and flu- cliaiiKt's [iri'si'iit in flic iiu'tiihrano. \\V may ili<cu.xrt till' stajtcH of proliffratiun ami coiitrartinn tonctlicr. This is a com- mon iH'iiod for patients to pnscnt tlicmsclvi-s for treatment, as tluv liml tliat the deafness, whicli tliey tliouRlit would pass otT in tim<', has not only fjorsisted, hut is jiradually getting \vors<'. Sv.MlTuMs AND Sic.Ns. The history of these patients, usually younp ailults, is that deafness has persisti d after a eold or s<'ries of colds, or has ttradually come on since, or that in childhood occasional deaf- ness was noticed, with a history that points .stronitiy to the fact that adenoids were pn'sent at that period. In fact, they often jireseiit the appi-arance due to chronic nasal ohstrudion. They also state that they are worse with every cohl, with perlKi|>s marked permanent deterioration. In tiie later siiipv, when far advanced, the .-symptom of hearing iH'tter in a noi.se may henin to show itself, indicatiiift the j;radu:il onset of the (ix:ition staitc Deafness is well marked, both ears, as a rule heinj: alTected. one. often tlx- left, heinjr the worse. The fact that the patient cannot hear peneral conversation, or, when at a dinner ]>arty. he camiot hear conversation distinct'y on one side, may Ik- the sympt<im which comix'ls him to come for troatmetit. Tinnitus, rushinj;. roarinn. clanjiinn. or machinery-like in character, is often a source of jireat trouble, heinn worse when the patient is (|uiet. especially at nifjht, sometimes jireventinn sleej). Diplacusis, usu.ally ilisharmonic, is sometimes com|)lainetl of. On examination the membrane is pale, often opiuiue. with perha])S i)atches of chalky de|(osit (phosph.ale of lime), the signs of depn'ssion beinji marked, and in the latter stage the i)ink lining membrane cannot 1)0 seen, even if the drum is ck ar. On applying Siegle's speculum it will Im> found that tlie membrane and malleus do not move freely, or perhaps the posterior segment will alone Iw freely movable. On inflation through the catheter the air will be heard to enter with ditii- culty and dryly, with perhaps a whistling sound. The amount of imjirovement in hearing produced will vary according to how the j)athological changes have jirogressed. On examining the membrane after inflation little 'ir no alteration is seen. The no.-^e or nasopharynx may present some pathological con- dition, and it is often possible to detect, even in middle life, remains of adenoids, which, if seen during a cold, may be considerable in size. PitO(i\()sis. For this we rely upon the progressive character ot the deafness, which i.- wor.^e with each rold, and the alisiiii-e of iiiternal- ear trouble, as sho\..-. by the tuning-fork. etc. From the exudation stage, by the absence of moist .sounds on inflation, the depression, Ihirseslioe chalky de lKH.it ill the mombraiia lympHiii of a woman llilrly ycaniol age. Hum- liitiioftiio fflrdiwcaR'. tun yearn. Tiiiiiluis wldoin. .^eoiiineter M era. S|«'eeli 3 in ilNiLir- /KK.t ll!Mt 77/ a; Htlt Jix.iliiiri. and opacity of the incnil iraiM', ami llir aiiioiint of iiii|)i OVC iiiciit producMl l,y iiitlalioii. From tlu' last sUinv. hv the aiiioiint of irnf.rov.iM..nt pr.Mlu.i'il \,y inll;.';..ii, the ahM-iicc of faranisis, whirli thoiijfli i-riMiit ill th.- later slap-s of rontraction, ap|H'ars to iiulicat.- that the tinal stajr«' i" Iwinj; icaclicd. I lu; ATMiA r. If, on inflati<»n. the iiiij)rovcini'?it in licarinjt is marltc.l \vc Katli.'f that thf contraclioii stap' ha.« not advanced far. .in.l w.- nuist ado|.t tr.-atnicnt which will, as much as po.^sil.jc. cut short the prolilcraiion or limit the amount of contraction. In order to do tlii> defmite local troiiMes in the nasopharynx or nose must U" iv- movi'd. followed liy rejjnlar inflation hy means of the hag or Kusta- chiaii c.-itheter, the intervals l)etween the inflations iM'inp judged hy llie leiijith of time improvement in heariti); la.sts. .Ma.ssa^te hy ineiins of Siejile's speculum or Delstanclie's mas.seur is also useful. The chhiridf of ammonium inhaler and the nasal solution, with tonics and clijintre of air to a hi>jli ami dry climate, should Ix' comliinrd with the other treatment. If the Kustachian ohstructioii is a prominent feature a l>ouj{ie may lie jia.ssed u[) the tulx', or paroleine may l«> injected through the catheter. If the results pn.duced hy this treatment are not great we must mfer that contraction is well advanced, and we may have 1o consider, if the deafness is extreme, the (piestion of operative tri'atment. which will he presently dealt with in considering the treattnent of the po.stcat.arrhal stage. Sometimes iodide of pota.s.siuni in small do.ses, combined with anmionia, given in hot wafer twice a day for a fortnight or three wi-eks. jiroduces good results. With regard "to tinnitus, the treatment wo have indicated will usually do as much good as is po.ssihle. as it is mecli:inic.,ll_» produc<'il. an. I depemi- on the h.cal changes. Tonics are useful in rendering the patient more ahle to stand the noises: bromide of pota.ssium and diluted hydrobromic acid are soinetimos useful as .sedatives, Klectricity may be tried; if. at the first sitting, neither the anoile nor cathode alters the sound the ca.se is unfavor- able: but if the noises ;ire diminished during the pa.s.sage of the anodal current the tie;itnient is more hopeful. ;ind shoulil be continued.' .{. Cicatricial or Postcatarrhal Stage. This may \>e looked upon as the ultimate condition resulting from the unchecked progress of the di.se.'ise, which may have occu|)ie(| ;i longer or shorter lengili of time. Symptoms .wd Sicns. .\ history of gnidual increasing deafness of cat;irrhal (irigin, ilistinctly worse on colds, until » pitch of deaf- ness h;is .•irrive.l. which, although never ab.solute. neccssiiates a loud voici' close to the e;ir. Paracusis Willisii, or hearing better in a noist>. i-^ a pniminent symptom: this phenomenon is suppo.sed to be due to vibration produced by jolting or loud noi.ses, enabling tlie rigid ossicular chain to more readily transfer .sound waves. ( iccasionally l!i'- i'Mtif^iiN will -t;itr fh.-it Ihey ,i.<rft ((. iicar iif-Tter ill a noise. Tlii- I l.fwts Jones, Arthlvcs ol oiolnity. vnl. .\.\lv. rminSir MtSSll'I'lllATiyh: Mlhhl.K KMt DISEASE, iitii iiitiis !■< i)ft(ii \iry iliMlrcsMiiijj, somctiriH's n'lnltTidjf life !ilin(»Ml iiiilM-ar- mIiIc, itml in ;i IVm even suicidal fciKli'iicit's may Ix- pn'scnt. Tin- palifiits arc iiionisc, intr(>s|M'ctivc, Im-Iiik, to a large extent, cut otT from the outside world. Many actinii'c in some deurcc the power of lip-rcadiuK. unil tliey will <'oiisc(|iiently hear Ixtter when the sp<'aker is facing tiieni. A low hut clear voice is lieard iH-tter than shoutitig. Iligli tones will Im- distinctly heard letter than low; for instance, a watch will Ix' heard coinp.irativcly hetter than the human voice. On looking :tt the menilirant it will appear markedly de- jjressi d ami oita<|ue. Hy means of Siegle's speculum thi' malleus nuiy Ih' seen to Im' firmly adherent to the promontory, the membrane perhaps ti.xed to the descending process of the incus and around the malleus to the promontory. On inflation the air enters witli diflioulty, and produces no change in the position of the malleus or niemhrai.e. Improvement in hearing is either absent, or, if slight, is of short duration. Dimiimtion of the iioi.so is sometimes produced. I'HtXiNosis is extremely had as regards hearing and tinnitus; deaf- ness is never ah.sohite, and the j)atient may Iwcome mon> <tr less used to the noises, which may vary with the state of the health. Opera- tive measun-s may produce improvement, if not in hearing, in tinnitus. Di.viiNosis. From the previous stages it maylx' diagnosed i)ytiip fixation of the memhrane, th;' ohstruction of the tul)o, the paracusis, and the slight improvement on inflation. The tuning-fork and tone- hearing tests will distinguish it from intern.'d-ear disease; but we occasi'iUally find that the tuning-fork in these cases itidicates a certain amount of internaU'ar implication: the history of j)aracusis will lx> sufficient to stamp the case as having originated in the middle ear, esjM'cially if other symptoms of internal-«'ar di.sea.-ios are absent. Tnie auditory vertigo does not occur. Tkk.vtmknt. It follows fromthe|)athological condition that ordinary local and general tieatment is useless in efTecling useful or any per- manent improvement in hearing or tinni'.us. The treatment, however, descrilM'd under tlu- [nevious stage should he given a fair trial. If the })atient is satisfied with the temporary and slight improveni'i i which may l)e effected, especially if li|i-reading lessons are taken, oiiihuiry methotls of treatment should he from time to time etiijjloyt d. Hefore undertaking openitive measures care must Ix' taken that the internal ear is intact, and it must !«' pointed out to the p.itient that they are more or h'ss of an experimental nature. It is well to fully explain to the patient the true condition of tilings, and leave it to him to decide as to whether they should be undertaken. It is V ise to first operate nn the ear wiiich is more afleeted. These oj)era- tions fall under four headings: 1. Those undertaken to relieve tension. 2. Those undertaken to diminish undue fiaecidity. ,3. Those undertaken to allow sound-waves to reach the lene.-tra} direct. 4 Removal of some part of the i)ony labyrinthine wall. 11!»2 77/ a; i:.ii{. K cautions ono )f tlicni should l)o undertaken witliout strict antiseptic p I. T/)i)sr Vmhrtdkcn to HvHnr Tcnxinn. These romprise division of adhesions, section tlir -usrh the posterior fold, tenotomy of tiie tensor tyini)ani, an<l <!;,•< ;„' l^t'aments. These have not realized ■\ is i)roduoed speedily disap- ;iiK takes jjlacc: therefore they expectations, any n. j ■•■(,v.'in( nt »,li pearing as soon as t ■■ ii ■•iltahic he may he j)laced on o, .> f'^U\ 2. Those Un(hrt(ik(. . ■/ ' ' -v ,, ,./ /',),/,/(. Flaccidili/. 'When the mem- brane or some part of the niemluane is seen by inflation or the Siegle speculum to i)e unduly flaccid, due to atrojdiy or too energetic infla- tions, or the result of .•( cicatrix, especially if marked improvement in hearing occurs when it is i)ut ou the stretch, multiple incisions made through the flaccid j)art with the idea of producing cicatricial contraction m.'iy he undertaken ; hut the result is often disappointing. Collodion painted over the fl;iccid portion and adjacent meatal wall may he of henelit. :]. Thiisf ('nilriidkcn to Allow of Sound Wores Reachinci tlw Fcucs- tnr Dincl. It has long been known that the artificial perforation of the memhrane will, in some cases, produce great improvement hi hearing: hut. ;is healing always takes place, and no method of keephig the perforation open has yet been devised, some further procedure heconies necessary. As to wheth(;r further proceedings should be adopted, exploratory tympanotomy is a useful guide, for if it produces improvement in hearing or tinnitus, w;- are encouraged to proceed to more radical measures; but, even if it does not, and given that the internal ear is intact, and the case is not one of atrophy, we may, if the pjitient so desires, adojit the more radical measures, as it may me:in that the absence of improvement is due to fixation of the stapes, or the blocking of the round window to a cicatricial tissue. Erplornlori/ Tj/mpaitolotn)/. This little operation is best performed under gas ana'Stliesia by cutting ;i flap with its apox uppermost in the posterior and suiierior segment, by means of a sharp-pointed knife under a good reflected light. Preliminary inflation of the middle ear I' be useful ill separating the membrane as far as possible from the IK. .die-ear wall. Further procedures can be divided into two stages: a. Removal of the membrane, malleus, and incus, which, if not l>roductiv(> of improvement, even after an artificial membrane has been tried, may he followed by 6. Mobilization or removal of the stapes and reniov.-il of cicatricial tissue from over tlie munrl window. o. Tlir liiinovul oj tlw Mcmhrnnr, Mnlhiis, and hiriis. This should he jierformed under a general anar-sthetic, the head being slightly Tria!)Kiilt*r itx-isinn in iIr> |x)storiifr->.iJiK.'rli»rtiimilratit fur ex[xtsii)g the ftrticiila- tioiioftlieiiu'iisHipl sta)>i'«> (E'oI.I1ZKR. 1 H ciinoMc \o.\-.sci'i'n!ATiyi-: miihhj: f:.\n ihshas/:. mcj raised on a pillow and turned three-quarters over to tlie opposite side. A good reflected light is necessary. An incision is made with a sharp- pointed knife, starting from immediately behind the short process of the malleus, sweeping around as close to the i)eriphery as possible to a corresponding point on the anterior aspect of the sh..it process. The handle is then freed from adhesions which may be |)resent l.>e- tween the membrane or malleus and the promontory. The tensor Fig. cat. Sexton's fmx'c'iw hikI knives (m ivm>i\\u« the meiiibrane unil dcsicles. tympani is then divided, either l)y DelstanclieV extractor or by a small curved knife. The malleus is then .seized as high up as possible with a pair of strong curved forceps, being pulled first downward to free it from the attic, and then outward. The incus nmst then be turned out from the attic by means of an incus hook, which, being intro- duced into the interior part of the cavity, is rotated downward and backward, pu.shing the ossicle into the 1o\v»t middle ear, when it may be removed by forceps or by syringing. Numerous incus hooks are made, the most useful being either Delstanche's, Lake's, or Fvudwig's. The middle ear should then be gently mopped out, a gauze dressing should l)e lightly introduced into the meatus, and a general dressing and bandage applied. If antiseptic precautions have been eflicient dressing will not be required for a week or ten days. At the end of ;, fortnight or three weeks the hoarinsr power should be t(>sted again and the amount of tinnitus noted. The dressing should not be l(>ft out until healing is complete, when an artificial membrane may be it 11!»4 77/ A,' HAK. triod if no in lovrinciit rosulfs. SoiiiPtiiiips an advontitious mem- brane forms .ii'riiss, annulling; any gooil effect, and may reiiuirc removal more than onee. b. Mubilizntion and the Rntimal of the Stapes ojid the Removal of Cicatn'eial Tistme from onr the Round Window. Before tfiese opera- tions are performed t' r should Ix- allowed to heal soundly, allow- "ng the condition of tni: inner middle wall to be plainly seen. Adhe- sions binding down the head and crura of the stapes should be divided with a fine, sharp, shouldered knife, such as Politzer's, as close to the ossicle a.s possible under eueaine or cocaine, the stapedius muscle being also divided and the stapes mobilized by means of a suitable Kl(i. 649. Pelstanche's malleus exlractnr Fill. ilV), 1 i lAki''s attic iiiri'ttt aiiii iiict:s liiiok. probe. If im])rovemenl occurs nothing more should be done; if it does not, we may again try an artificial meml)rane: if tins Is in- effective we shoulii remove adhesions obscuring the round window as far as possible, a rather difficult procedure, on account of the anatomy of the part. If this is insufficient we must infer fixation ol the base of the sta{)es. With regard to removal of the stapes more exi)erience and inves- tigation are necessary. If niol)iliz;ition has not been possible attempted remov.a! will, m all probability, result in fracture of the crura, leaving the foot-plate still in position. The attempted removal should be m!;d(> by means u W- ( iinnsic .\ti.\ sii'i'i'iiATivi-: Mn>i>i.h:~i:.\n ihsease. ii{),j of a tine hiiok iiitrodiict'd hctwi'cn tlic crura from al)()vc, and with a >;ciill<' side t(i-sidc iiiovciiiciit. It may he that, in t!ic futiirf, opfia- ti(.;is (HI till' ifiiKT middle-car wall may he of hcneht. A more radical methiid has lieen proposed ami carried out hy .Malherhc,' who opens the anirnm from hchind, divides the adhesions in the middle ear, and introduces a celluloid tuhe throufiii the meatus into the antrum. The results have not been lirilliaiit, and until further experience has hi'cn obtained it may he fairly stated that operations throufrh the meatus, as described, are e(|ually I'tficieiit. 4. liiiHoidl of Simii- I'nrt i>j Ihc ii»n)/ Lnhi/riiithhie Wall. Mr. Charles Hallance broufjlit forward a case at the ' Hological Society of the I'nited Kinjrdonr in which, in the course of ope-ating for .supjmrativo extension from the middle ear, he found it necessary to open the vestibule from behind. After the sui)se(|uent skin jirafting tlic hearinjr, which had been lost, returneij in a .surprising degree, and tlie giddiness ami stafrjrerinp which had been extreme, totally disap- peared. Following this ca.«e Milligan and Hallance have operated on non-sup|)inative middle-ear disease in the latest .stage'' by — after opening the antrum and laying it open into the middle ear, as in the complete mastoid 0{)erat ion -removing a ]>ortion of the promontory anil immediately applying a skin graft. The results in some cases were somewhat encouraging, especially as regards tinnitus: but a verdict cannot at present be gi\-en. 11 Atrophic Catarrh. Fixation of Stapes. The chief character- istics of this form are the very gradual and insidious oTiset of the deafness, with little or no change in the membrane, and no obvious cause in the nose or na.soph.-irynx, the majority of cases occu-ring in women between the ages of twenty a!id forty years. Causation. The causes are obscure in the highest degree. Heredity is certainly an important factor. Occasionally a vague history of a bad cold or .series of colds is obtained as a .;arting point Some severe illness, such as rheumatic fever, is thought sdmetiines by the ])atient to lie the origin, and <iccasionally chronic rheumatic affections are ( xistent. .\na'mia is often present. Tarturition is intimately connected with this cla.ss, the deafness either apparently connnencing after labor, or being made considerably and permanently worse thereby. Pathology. This ajjpears to be an atrophy of the lining membrane, with a marked tendency to the fixation of the base of the stapes in the oval window, and .sometimes im])lication of the internal ear in the later stages. The onset is so gradual that pathological investi- gation in the early stages is wellnigh an impossibility: we are only familiar with the ultimate results produced. On removing the roof of the middle ear affected with the disease thr first thing that strikes one i^ the wideness, whiteness, and dryness of the whole cavity, the ' I'ripoee lings .it the Sixlh IiiterLintiniml roiii<ri's> iif Otoloxy. IWW, ■' TmiiMi'liotis, tv'.i IW, viil. i, I MilliKiin. TninH«riii)ii«i)t(ili)liiKic»l Suclcly. IsiKt-lWHi. vul. I. 11!m; TUh: EMi. in mtaincd structuiTs Ix-iiig fk'arly dofinod. Fine iiifiiibriuiousl'seiita irious parts can 1)0 scon, and arc a])i)arciitly tlio atropliiod rc'iiiains of the fol( the liiiiii<; IIICIIll iraiie. A \v('ll-iiiark('(l mcinbranc soiiictiiiies seen niiiiiiiif; ii|> iVoni tlic toi. .im dl tlic tensor tynipani to the roof. ()n microscopic cxatniiiatioii the layers arc atroi)liicd and liie distinctive characteristics cannot he made out. The ha.se of tiie ."tapes is fixed to the oval window, either h\ calcification or o.ssifica- tion of the lifiamentous rinjr, or hy deposit of new-formed osseous suhstanc(> upon the inner surface of the foot-i)late. and a complete bony uni((n of the wall of the oval window may exist (Politzer). The condition is thoujjlit by .«ome to be due to a troj)hic lesion, as. especially in the later stages, little or no in.jection of the malleal vessels takes ])lace on eflicient inflation: but tliis may be due to the fact that tli(> ves,sels share in the atrophic i)rocess, or are constricted. The fact that ganglion cells are found in the lininji membrane sujrf;ests that some change in them may possibly interfer(> with nutrition, trophic causes, however, will not account for liony ankylosis of the base of the stapes, a condition which jxiints to some irrit.ativc peri- osteal cause, perhaps irritation due to some chemical causi-. Tlioina, in his work on ])atholo)xy, describes an atrophic catarrh in which the mucous membrane becomes thinniT luid atrophied, and it nnist be allowed that ~uch a process will most readily account for the condi- tion found. With rcftard to the secondary afTection of the labyrintii, impair- ment of fmiction may result simply from di.sea.se: but in some ca.ses. at all events, further chanjres nnist exist. It may be that the atrophic process is continued to the cavity of the labyrinth, with resultinfr decrease of secretion of the intraJabyrintliine fluids, the i)erilymph in |)articul;ir. Some cases with symptoms chh-^i'ly resemblitifi tho.se seen in this proup have been found by Toynbee, Politz<'r, Bezold, and others to be due to .i priin;iry affection of the labyrinthine bony capsule, pro- ducinj; ankylosis of the ba.se of the st.-ipes, without any patholoiticai lesion of the lininj; membrane. Symptoms and Signs. The onset of the symptoms is so insidious that, as a rule, the jiatient does not come for treatment until the disea.se is well advanced. In some a slijjht hissiufr *imiitus was present for some time iiefon- the deafness was noticed, a frradual decrease of hearing in one ear, usually the left, being unnoticed or disregarded until the other ear becomes seriously affected: both ears then grad- ually becoming worse. In other ca.ses tlie patient's friends are the first to notice the diminution in function. The tinnitus is often not distressing, the patient getting absolutely u.sed to it: in others it is one of the n, ist jiromlnent features. When the disease has aihanced eoiisideral)ly 'n !)otli e;irs paracusis is a marked .symjitom. Tin- he.'iring is usu.ally worse during a cold. Occasionally the disease a|)pears to sto|) short, or to |)rogress \ slowly, when the later riii:o.\ir .vo.v-.sr/'/TAM 77r/-; middlk-km; disease. \\\q 1^3 stfific- lire rcaclioil, and coinplolo stone deafness is never ohserved. On intlation n very slifjlit iniprovemenl in iiearinj; is jjrodueed, Imt soon disappears, and. as before nie"tione<l, little or no resulting injec- tion of tlie nialleal vessels can 1m> seen. In some the inflation may not he felt in the car, although the diagnostic tiihe clearly indicates that it has heen successful, .\ttacks of true auditory vertigo arc not experienced. The JMistachian ttibe siiows no signs of oi).struction, hut. on the contrary, seems unusually patent, the air entering very clearly and dryly. On examination the inea+us is usuallj' clear of ceruin<'n; in fact, patients sometimes complain that their ears seem dry. On looking at the memhrane the al).sence of gro.ss changes is very marked: it often looks unusually hright. clear, and thin, with little or .10 signs of dej)ression. The memhrane and malleus move freely with Siegle's speculum. The nose and naso])harynx in the ma.jority of cases a])])ear perfectly normal: sometimes the nose may ajipear dry, the patient stating that a handkerchief is not often neces- sary, and the lining memhrane of the nasopharynx may ajjpear thin, the lij)s of the lOustachian tuhe standing out boldly: hut it is never dry and glazed. There apix'ars to he no connection, as one would exjx'ct, between so-called atrophic rhinitis and this disease. Paleness of the .<oft ])alate with a blush on each side is usually present (Urban I'ritchard). Prognosis. This is always extremeh' bad: no treatment has any power, apparently, to check its progress: the deafness. goes from had to worse, hut may stop short at .some j) «int, absolute d -afness never resulting, the patient being always ■ ' <■ to hear something. Diagnosis. The age and sex of the patient, the insidious onset, the apjK'arance of the membnme. the absence of I'aistachian obstruction, freedom .'Uid dryness of air-entry on inflation, the slight improvement produced thereby, and absence of any cause in the nose or na.so- })harynx separate this from other middle-ear diseases. The tuning- fork, etc., will distinguish it from internal, and in those cases in which internal-ear results are produced by tlie tuning-fork the presence of paracusis will give the clue. In cases of primary disease of the laby- rinthine caj)sule the ])ink lining membrane can he .seen through the membra na tympani. Treatment. .\s before stated, we have as yet no treatment which has any jjower to check the disease when once it has .started; it remains to he seen whether operations on the labyrintiiine bony cap- sule are of real and permanent value. The general liealth of the patient nmst he put in the best possible condition. The local treatment is merely jjalliative, and even this must be usefl with extreme caution, or the patient will be made dis- tinctly worse. Occasional catheterization, with injection of paroleine or inflation with the hag. especially if a few drops of chloroform be pre- viously introduced, produces a slight amount of imi>rovement, and is a comfort to the patient. The chloride of ammonium inhaler produces little or no benefit, except thit a tendency to colds is held in check. ll!tH ////•; i:.iu. Miiss;i<;(' witli Sicfilc's spcciiluiii in tlic (inliiiaiy way must lir \it\ cautiously and j;i'ntly applied, as in the great majority of eases it is distinctly detrimental. Too prolonged application of inflation or massage will produce luiilue Haccidity of the inemimine, and so add to the trouble. At the Sixth International Congress of Otology, in 1n!»!». .Mink stated that he had produced good etTects hy using Siegle's speculum in a modified w:. /. The memhrane and malleus arc first compressed hy air. stoi)ping short ot ,,ain. hefore massage is ajyplied: this method, whidi aims at moving tin; l)ase of the stajies, has not received a fair trial. With regard to operative intratympanic measures the general experience is that they are contradictecl: hut perhaps it is only fair to .say that tliose on tiie stajjes and inner niiddl(>-ear wall are still on their trial. With regard to artificial aids in the extreme stage, lip-reading le.s.sons are of great value, and may entirely alter the patient's outlook on life. Mechanical aids are mainly useful (dt indi- vidual conversation; when ohtaining one. all va ' 'ties should he tried; as a rule, die ordinary speaking-tuhe will he of the greatest service*. ( '. Changes Produced by Variations in Pressure. Negative Press- ure in the Tympanum, ("oncerning this little is known; hut the adop- tion of a separate class for it is warranted by the deafni'ss which occurs in those who work under increased atmosj)heric pressure, such as deep-sea divers, and in those cases in which deafness resuii.' as a result of chronic mechanical oh.struction of the tuhe, such as cica- tricial contraction, pressure of tumors, etc. It may he stated, however, that it is difficult to exclude the previous forms of dise.'i.se in these cases; hut. on th'* f)ther hand, some of the changes described as having resulted from a chronic catarrh in;iy he due to a long-continued negative ])re.ssure. Causation. These are of two varieties; (I. Long-contimied or often-repeated increa.se of ;itmosiihi'ric press- ure on the memhrane. /(. Non-aeration of the mi<ldle ear, owing to; 1. Mechanical occlusion of the tuhe by cicati'icial contraction, pressure of tumors, etc. 2. Xasal obstruction due to any cau.se, especially wIh'u atifecting the inferior meatus, as this place is practically a contimiation of the mouth of the lOustachian tuhe. ;{. Paresis of the Eustachian muscles, as occurs sometimes after diphtheria, preventing, by their in.-iction. i)roper aeration. Pathology. Of this we have nothing hut conjecture to go upon: but it can readily l)e conceived that if air is j)revented fn.m entering the middle ear hy the atmospheric |)re.ssure from without, or hy obstniction fmni within, a long cnntinued i>r i>ften repeated Tiogati\e pressure in the tym])amim will produce a chronic dil.atation of the vessels of the lining membrane, with resulting hyf)ertrophy of the tissues and fixation of the ossicular chain. ciiiioMc Mi.\ srirrnATiyH mii>ih.i:-i:m; ihskasi: ]|<)(^ i Symptoms and Signs. Tliosi' of tlic liyiM-rtnipliic class, plus the obvious cause wliich exists apart from catarrliai conditions. Prognosis. Tiiis will (lo[K'n(l, tiistly, wliftlicr tlio cause can (>(■ re- move.!; and, secondly, if removal is po.ssible, on the results obtained by subsequent aeration of the tyinpanuin. Diagnosis. As far as can be judged at present this dt pends on tiiiddle-ear .synipt(jins and sipis combined with an obvious cause of non-aeration apart from catarrh. Treatment. In those working under increased pressure care must be taken that there is no hindranc*' to the entry of air thmuKli the tube. In those cases in which non-aeration is (lue to obstruction in the nose or nasopharynx, removal of the cause, if f)ossible, is indicated, witii subsequent aeration of the tympanum. With regard to the removal of septal spurs or hypertrophied turbinals, a good rule to observe is dia they should not be interfered witli unless marked blocking of the inferior meatus is present, or if the passage of the Kustachian catheter is ijiterfered with. When once the ol)struction is reniove<l and subs((|uent aeration fails to produce improvement, the question of intratympanic operations directed to n moving the rigid ossicular chain may 1k' considered. I). Changes Produced by Deficient Blood Supply, of this form little definite is known, but cases are met with in the later Ijeriods of life when the clinical features — local and general — suggest that the impairment of hearing may Ik' primarily depenclent on inter- ference with the sound-conducting aj)paratus due to defective !iutri- tion of "he soft structures of the middle ear. The subjective symp- toms are a gradual deterioration of hearing power without timiitus, one ear lieing usually more affected than the other, and varying with the general health and condition of the patient. On objective examination the membrane may be normal, but sometimes looks thinner anil clearer than usual. On inflation the Eustachian \\iho is patent, but very slight if any improvement results, the injection of the malleal vessels after inflation iKMiig also slight. \\'itii the Siegle sj)eculum the membrane and malleus often move well, but as a nile with no good effect. When tested with the tuning-fork it will be found that the internal ear is also impaired; in some the internal- ear impairment seems to predominate. Paracusis and true auditory vertigo do not occur, fin some cast>s (iardiner Brown's test gives a normal result, owing t(> the equal impairment of both middle and internal ears; this sign, first pointed out by T'rban Pritchard, is of gn-at value.) With regard to the diagnosis of this condition it must t)e admitted that it is usually difficult, even in the presence of marked evidence of general arterial disea.se, to clearly separate these cases from those of senile nerve deafness. Tlie treatment in tliese cases is general \ no local trentrnertt is of any service. INDEX. Alxliiction. niirinal.(li'i:ii'''iil. I'>1 t 1(1)1 (KNS pan >!•<. 17(1 i\ tosliiin pnwiT lit'. ItH) Abi'rratidii, clirumalic. •>."• incrcnsc of. willi incn'a"!' oi -ir.r nl' iihjpct. fi.'i splicrii'al. (i."> Absct'ssof brain, ill iiiastiiiililis, 1121 rrlaliiiii i>\. (i> (iiscnscs of tlic i-Yf.lVM rcri'bollar. in iiiiclillc oar, 1121 otic, 117:i iliauiin-iis of, (lifTiTcntial, 1171 svinptoiii-(ir, 1 17H lii'aliiicnt (if, 1 171 ccri'bral, in niic|illi--car di^iasr, 1120 ot ic, 1 1 1,1,1 (liagniisi-iof, 1171 cliiilocv c.t', 11(1!» ■^yinploiiis 111', 1 100 Ircalnirnt nf, 1171 of lonjiincliva, 2S(i of corni'.i, .'tO.'i of eyelid, 210 of middle ear, extradural, 1110 peritonsillar, 00:{ pharynpeal. 007 retropha'-yiiseal, 1017 subdural, 1101 symptoms of, 1 lOI treatment of, operative, 1102 tonsillar, liOll, Ot):{ Aceessory sinuses, diseases of, 022 Accommodation, Ii7, 77 amplituileof.OO in astifiinatism, 103 in liy|K'ropia, Oil measurement of, tiO mcehanism of, 07 Helmholtz's theory, t)7 Tselieriiiii(!'stlieory,O.S spa,sniof,.Sl. ls;{ variation of, with age, 00 Aceommoilat ion-eon vergenee, 1,52 Aceoiiimodative asthenopia, 109 effort ."IS a factor in the causation of glaucoma, "iH myopia,. SI power, estimation of, bv means of te.st-letters, 7:{ .\cid caustics, 7.")0 Acne of the conjunctiva, 202 Acne rosacea, nlalioiiof, !<■ diseases of theeye.fuiO Acromegalv, relation of, to diseases of the eye, 0^0 ■ Adams' o|i<'iatioii for ectropion, 2.V1 Addison's disease, relation of, to diseases of the eye, ."iN.'i .Vdduction, normal, degree of. 1,")4 testing power of, l.'iO Adeiiocarcinom!! of nos<', p.'itliolog\ of, 71S of throat, pathology of, 71s .Adenoid tuberculosis, 701 vegetations, 102.'^ iliagnosis of, 1020 etiology c.f, 102:5 prognosis of, 1027 svmptoms of, 102.'i treatment of, 102S operation in, 10'20 tecliiii()ue of operation in, 1020 Adenoma of caruncle, 203 of conjunctiva, 291 intrana.sjd, !S9t) of larynx, 7'20 of nose, pathology of, 720 papillare, S,S.S diagnosis of. 8S.S prognosis of, 888 symptoms of , 88S treatment of, 888 of soft palate. 980 of thro.at, palhologvof, 720 After-cataract, tS,-i, 497, .V21 .\lbinisni, 371 treatment of, 371 Albino, ophlhalmoscopie representation of an eye-ground of an, 52 .Mbinotic fundus, 340 .\lbuminuria, relation of, to di.^eascs of the eye, ,598 .Xlbuminuric retinitis, 423 425 .\leoholism, i-elation of, to diseases of the eye, ()0t> .Mderton's pus basin, 1136 .Mlport's ear forceps 1143 .\loi>ecia of the evebrows and evelashes, 031 .Mteniating convergent strabismus. 174 .Vmaunisis. infant ilc, 440 uru'inic, 424 -Amblyopia ex anopsia, 172, .573 ti ' ( 1201 ) I •_'()•_' iM>h;\ \lnl'l\ii|>iii. .Ill.lH't llUi-trl. \||. rU„U II , ("i^ v> .1. I(>.i>> 1 1' ■:i iri\ ( (i-t:rir. ."t77 Imiii lnriHtr-fliMi;!', .*>7^ li\-lrri,-.-il,.'i71 HcMii lij;iiliiii'« llii-li, .■>7S iii;il;iil.'il. .">77 <|iiiriirii', llil i.ll.A, ,-,7!i ■.iiiiiil:ilr.l.."i71 iiiit-riiii', ."(77 \rMilni|ii:i, I'lirri'i'tliiiiiir.Sd • litVii^Miri iinap'-' in. 77 7^ \ i~i(in in. 77 ViiMii'^i.'i, \ i-.ii:il. 171 Vinyl ;il('i>lii>l .'i> .'i i':m<r nt lllilllhll'^.'^, liori \nnloiil (liM-.M-i- 111' llii' iiiiijuncliv.'i, 'J.SI \njini:i nl miM-. lis'.i ri'l.'iliim III. Ill ili-i'ii<i'- 111' ilir CM', \n:t'-llu'>i;i 111 iiiini':l. 'I'J'J 111 l:ir\n\. KUti III 11 I(l|(l lit |ili:ii\n\, 10i:{ ■ liiiluu'viif, lOlii -vin|iliiin-iiif. KMH iir;ilinrnt nl, l(»i:f ATiii>;nii-i;iki'- ;inil Hiil/'< ii|irrMi inn I'lir iriilii.-i-i~, 2'>'J \n:i|iliiiri;i, 17li \n.ilrii|ii.i, 17r> Aiii'l'- lai'i yinal M I'iiitfi'. 22(1 Ani'MriMn li> an.'i.-tninnsis, orliilal, 201 ri'l.'ili r. til ili*i':i-i>* 111' till' I'M', t'lUCi \ni:iii.-ii|iii:liiitii|r,i.si:i l.niiwi).''.-. l(il:i inrnilinniiiu- i nmi-iliplii ln-riii! i, !!!)."> i|i,'it;nii-i» III, 'Mt't ilitTiTi'tiliiil. liOli ■ ■liiiliiiiv 111, !!!•.'". ^\ rniitiiin" uI', W.'t tri';itnii nt of, !t!lli Ajjirii'iiia III run juni'tix ;i, 2.*i!* .iliyi'liiN.211 intranasal, sxs. i ,n'. . Iiil raMa>,il Aii- i;iiini;i, i 111 Ian ii\. IHI2 111' iHi-i', |iatlLii|iii;\ 111', 721 111' iirliil, 2(11 111' >iill iialati-, !IVI 111 Iliriiat, pallmliiLM m'. 721 111 nMila.HSH An({ioiirMrii>i>, (ilM) \ni.'li:il|ilia. \r,:i K.inirna, 1."i:< inilrr. 1.V2 \i--ii,il, 71 \niii(li,i,:tlS iniici-nital, ulai'i'iiina InllnninL'. ■"i">2 \nis()iori;i, Ml Xnisiiini'lriipia, Kts pn -riiliinj; ;;ia»i> I'lir, \.i2 \nk> liiiiii|iii,M-iin, 2.'i."i Xiniiilai' piisiiaiiir ^vtuTliia'. :{,')() \nii-.inia, MKiS >vtnptiiin»iir, KCC.I l( prii;;iiii«i. nl, l(IH!l iri-alinrnl nl, llCt't \nn.plni-ia, I(i:is Itinliim nl, l(i:tS priimin-i-nl, l(i;t!i >\ inplnnisnl, l():t!i lrr,iliMiail 111, l(i:VI .VnliiiiiMJiainlii'f, H.'tfi I'li.anilr- ill till . HI priniai\ irlaii- inin,a, .">:t(l I'Mlilatiiin iiiln. :tl!t, :(,M 1,'i.iilriiina InllnwinK <'pith<'littl l\ its in llir, .'l.'!! Iirninrrliaur illln. .'<li2 Alitliiav 111 (liiiyvliil, 21(1 \n(ilii\n. ilani;!'!''- nl, in (rratinrnt nf iliplillirii.i,.V{.'> .Xntriiin i\>l« nl, <>7'.>. [Sn .Miicncclc.) <lriip«v nl, !t7!». i.s'fc Miiidcolr \ 111 iiii:liniiiri', <*2:< llrM'Inpnii-nl 111, It2(i Aphakia, 177, ,V2:i Apliakir lyr, .V.) A()ili'nns Iniinnr, :(l,'i i-liaiici-i in ilii-, in piiin:ii\ ulau- I'liiiia, XVA .\riii> M'liiii- rnrni\r, :tl7 ViUxll-IIiilirftoiii (ipir.atinn mr rrlropinii 2.-1 1 pupil. .!2 -Vryyvia rnnjiinit i\ :r, jss Arcymsis, 2ss Vrlt's iiii'lliiiil 111 l.li'pli,ai-iifila>(y. 21,"), 21('i n|ii|-.al inn Inn ((rnpinii, 2.VJ. 2.")."> \rli'i-,a iinlialis let ilia, ,!:{:{ .".rtciii-. ,1-iiniliiii: pliarynci-al, 1(K).S annnialirsiii ilis(rilmli(iii of, KMIS Artifiii,ij iyi>, IKi .\>ili npi'iaiiiin. I't'J \-nill-, -ii|i'ln-('ii|WMil', l()."i .\-lrniiil livalili~. li.s.l .X^lliriiiipia. Kin ai'cnini:iii(latiM'. KMI ri'plialalci.i. l(l!l ilnlcns, KHI irrilans. I(in niiisi'iilai', 1(111 paiiiiniMia, 1(M( iTliniii. KMI simpli'x, l()(t tarsal. Id!) Astliina, SdS i-linliifty nl, ,Sds palllnlnux 111, ,SdS tn'atini'iil m, S(hi \sliKinatii' clnik-l'ari-, vise nf. in ilctif- niiiiiiif; rrfraci inn. 125 .Vsticni.'ilisin. 7t) alwiliiti' icfrarliM' -lato in, !»!), 10(1 arroiniiioilalinn in 10:t rninpniiiid liypi-inpir, KKl <i)rri'rtioii of, lo:!, 107 ilt'dTiiiinatinn nf, (ly skia.Tnp\ , 122 iM>h:.\ IJO;! E X-ni^iii;)! i-iii. <lt-mrii)iiali<»ii o] I nrrii-al Vihlitor c'iii'\.'iliitr III, li\ kc'iMliiiiiilr V I I I ilrMlii|i|iiiM; 111. lis ilillii-iiiM iniMi:r-(iii, ItHl. Kil .liriil. !t7 fliiil.iUy III, lis liliii|uilillr. Its illKli;r< III :i Hill' t'ol'lliril ill, lllj illMTsr, !t7 irrr(jiil;ir. !I7 ilrtiTlnillMlion III'. Ii\ -ki;l-ni|i\, I L>:t iiii'i'iill,'in,'il ,'il'i rnitiiiii in, !)7 iililiiHic, H7 |i:illiiilii)!l<':il, US. m |ili\>iiiliit;i<':il. lis liiiscrilmiKKliO"''^ lin'. l-il |iiiin:iiv. (IS ii'Kiiltir, !t7 .'iK''ii>i>l till' nilo, '.(7 with the lull'. !»7 M'l'miil.iry. lis. !i!i ^-iiiiiili' li\ |ii'i'ii|iii'. KKI luyii|>lr. 1(11 >\ luptiillis III l'l'll;liliv llli;llll'>. ilifl.'iMllll.'llliill III, ilil- lllv. IIKNI i'iioliii:\ I.I. Iiumi -Mii|il -111. KKKI iii'.iiiiii'iii III. \m\ mrM'. ilisi'a-K'- III. I Kt."! ii'iiriiM'-.. 1 102 \llrlrlr, liti»l-l.ili' 111. Ins.". -v|illililir,llVi rlliill-..|. IIISJ «iiiiiii|i iiiiil iiijiini'- III. KIM i|i'M'rl|iliiMi III, IIISI lii'iitiiHiil 1. 1, lost. MIS,-, \\l:il liy|H'i'ii|iiii. !!.■> iiivopin, HI, S."i 1).\('< >N'S iiipiiiiiu-Kln--. HHHI ) I'lii- Nvriiitif, ll)HS Hurti'riii. siiiliiiim inr, ill x<'<'tiuiii uf lUi' cvi'luill. fi-SO Kiimliili'l krralitis, MU l<iisi'ilii\v'> ili-i'a.s' 2()S I'l'll" inn .il, liiili-.r,'l-.i'-iil tliri'M', .VS;i MiiiiiiraM' li'iiM's, III no Hii'iinvi'X li'M«'>, 111 vHUiii III. III! Atnipliic ratarrli nl iiiiiiilli' car. 1 l!l,-i laiisiliiiii III, I lll.'i iliauniisi-' nl, 1 Mt7 |iath(ili)ny III. 1 l!t,-> |ir<imiii>i?* Ill, 1 11*7 syiiiplDliis 111, \\'.H> IrcaliiH'iit ol. 1 1".t7 na'^opliiiiyiisiiis. 1022 pliarynirilis. 1012 *\lMpl(llMS 111'. 10i2 lii-aliiiriil 1)1. 1012 iliiiiilis, 71ti. 7.S!» ijiairnii^i-' "I, 7'.t.'i I'lioliiCy of. 7!M) prii^iiii^is III'. 7if."'> s\ inptiiin-i III. 702 Irraliiiriit 111. 7!'.''i Ali'iipliy. ('Iiriiiiii' iiifl.'iiiiMialiiui willi In ili'iii'y (II, 7l(i III i'<injuii('ti\a. 2S."» 111' I'.vi'liall, :i7!l laiii'ial. Ill lyiiipli I is. in-. 72ii pallidldcy III. 72ti 111 iMMpliiiiil tis>iii'. 72.-) nf Illisi'. 7lli foiiii'^ 111'. 7111 111 rt'tiiia. 122 iif tlinial, 7lli liiriii'^ 111', 7lli Alropinr, iist'iif. a>a ryi'lnpli'^ii'. 1 12 \tnipiMr-piiisiiiiiiiir, n'latinn nl. in I'asi's III till' rxi'. 2H,5. 007 Aiulilniv iiii'aliis. I'Mi'i-ii.'il. ilisi'.'ix's 111' lOSli iiiilaiiiiii.'ilinii nl. lirciiin- sirilii'il. 10S<» lii.'l^llnsis 111', lll.sii Hiiiiiciiiar field nl lixaiimi. liiiiiti nl', Lili visinii, 71 ■ lila.k I'y.'," 2.->li Mlaki''s iniddli'-i'tir syrinmi', 11:111 P liypiis siiarr, 1 l.'l.-> Mlriiiinrrliii','1, anil ', nl iniijiinil i\ a, 27(1 Uliphaiilis. 241 jx'ilii'iiliisa, 212 li|ipli;iriipla.-.tv, 21 1 .Vrll's iiii'tlind. 21.'). 24li l)irtTi'iili.'U'ir> iiii'llinil. 2ll> Krirkc's iMi'tlinil. 21.-) Kliapp'" nirtlind. 21,-). 217 'iVollf's iiictliiiil, 2111 Uli'pliaiiisp.i-tn, 2:11 Ili'alMirlil nl. 2:)1 HliniliH'ss, ciilnr. .'it'iS ila\. .■iSO iiililil. '"iSO '^nnw. ,*>SI • MliiikiiiK.' 2.1-1 lllnnili^ilpply In iiiiildir rar. ilcrK'iciit.l IIM* rliaiiKi's pmdiu'i'il liy, ■<'<)'.> diagiinsi.s (if. 1 1'.tlt svinptDins and ■ siKIlSllf, 11<»<) liralnii'iit of, 11!M» HiKWiutli''* nasal .siw. 7'u siiari', 7(>1 s|)t'i'iilnni. 7:11 Kinirliiriin's s]H'riiliiiii. llt7S Ilnwniairs int'iiilirani', 2it.*i npi'ralinn nl slitling ll"' I'analinilii^. 221 prnlii-. 2l!», 221 iin'llinil 111' iiisiTliiiii. 222 ill posilinii 22:1 I'tiiilony (if, lOHit Uraiii. alisccs.s ol, in niastoidilis, 1121 syniplmns of,10S!) ii'lalinii of, lo dis<'as»'s nf ilir Iri'.-ilninil nf. lOSll cvr. (i:i4 dis 1-Jllt iMii:\ lll.lin. (Ji'M':i»i-'< 111, fllrrl it|. upon t It' r\r, Ihil.Thtl ilijllll>- 111. itTi 1 I 111 U|iiiM III- i\r, 1 1.".! I r.niNilrnii'^ turn iw, lo:i(l llniini'-ni. rrl.'iliiiTi iil. In ili-i :i.i ., hi i In IV1-, {Ant Hriiiicliuil (ulii'», ril.iiiiiii ill ilw.i-i^ m. to ili-i .i-iH 111 lliiTM . :,'.>:, IliiiHu'i \|iin:iii' l:ii\ iiv'' ill »\ miii;i-, !tl;i liiirk'H liliiiil (•iiri-ilf. IIITM )jl.i»s pi|M iti\ I l:;!i Hiilli.'ir p.'ii.'ily-i-. iil.'itiiiH 111. til ili-i;i>i'» 111 till- i\r. lil.'i liiiiiniis kiiviiiii-. .nil HiiplillialiiiiK. ;i.'l piiiti.in , "i.Vf Hull-' Imi-ilhir li;i tiii.-l:it. IIMIJ /'.\N \I,. hv:.li.iil. .{|l. •.I.-. \ Ml I'liii. 17ii -rliliiiMir-. :!•_•".. :(:i'i, :ill. ;il.'i i.'iii.'ilinili. Jl I -tiMlli-U 111'. 'Jilt < .■iii.-ilinilii- kiiiH'. U ' ■ -, '.'•-•.• t.'umlii.|il:iM>. S.is ('•■Jilt I iiiiv. i'ts <':i|' !i ir i'ill:ir;ii I. |s."> iipacilii-^. I'.IT. .'Vlii Cup-iiU' liinip-. ."ills rilmll'-i. 1 I'l I'nrimn -iupxiilr pni-niiiTii:. n latjnii iif. in ilisi'.'iM- 111' Ihi- i\i'. Kill. IKIii ('.•ulillliilr ill' r\i-liil. 21" I 'arriiinfna. inlr;uia-al, N!I2 ili.'illii'i-ii 111. VI.'S 'miM^ 111. S!K1 p.itliiiliiirv oi. .s!t:t -\ lllplnlns 111. SWt of i:irvii\. '.Mil iliamiiivi- III, 'Ml.'i illlii-ITljIial. (HI.-) ili.iln!.'y III'. !HI| pallioliiuy III, (HM pmiriiii^is 111. !KMi 'yiiiptiiiii^ ot'. '.Ml.'i irr.-iliiii'iil 111. '.Mlli ol iiaMipliaryiiN. Ili:i."i nl nci-n', pal liolous i.l. 71s 01' Mill palati-. !tMI -yiiipliiin- III. !is'i III' tlirnnt. patliiiliiL'v ol. 7ls iit'lim-il, IINK ili.-iiiiiiiNis 111. KKT. Iialliiiloirv 111, l(H)4 in .•itini'iit 111'. HHI.'i 111' iiMila, (ISII -\ inplnin- 111 . !tsi» CaniTiilr. aili'iiiiMia ol. 2ii:i ihalk\ i|i-pii-ils ill. -J'Xi ryslir I'Tilalirrinrlll nl', 'Mi piipilliiiiia of, '2U2 ra.=^r!hrrrv^ '.uyiit. .li i!iii,,iii, •,ini tni>ili(iiil Alli-ii -naiv, '.US ''ntaplmna. 17li ( '.■ii.ir.'H 1 , ai'iiT-, IS.", I'.i7 t alaiai I. In uniiiiiiL'. Is7 i.'ip-iilar. IVi iiiliiiiir. Is.'i pii-iiriiii. Is,",. |i|7 • linrolilal. .Vr.' riilliphi.'lli'il .MM) Iri'alnii-iil nl'. ."ilHi ninicriiilai. i'iiiilii|;\ ui. .'iiNi iiiiiii-.il. I'M ilmliiLM III, "iim r\lraitiiiii 111. ."idtl ai-rii!rlil- illinm: lln' iipitalinn, .Mi( liltrr-llvalMirnl nl. ."ils alliilli.'llir- 111 lll'.'lillll!, ."lis illiiii I iipiTatinll, ."llli I liiirniilal lii'iniirrliaiii' I'lillnwine, .".17 uilli IihIi iimin , .")10 « iiliniil iriili'iliiniv, ,"i1 I Ili.lMhrr nl .'IppKlliL' i'ir-<.«iiitrs allir. .•.!:( tllni|i|ir.llinM- 111 till' npiTatillll, ."ll.-l -iiii 'i. Inn .ir ."ilitt fiilliiHiii, IoimIiIii, I!MI fri'ipiii ula-,-lilinMr-. |S7 ill ! 1 r.-iiT, ts7 In pi'iiii.iliiii H l.'iiiii'll.ir, I'.Hi Irnliiiilar, isii liriiiin-rrilii'il -talimi.in- Irrat- IMI'llt 111. "ilM rliiiir:il -tairi's of, li\ piTiii.'iMire, i!i;» imipii'iil. ■\'X\ intiiniivsivnt, 19:', iiialun', W.{ swiijli-ii. »!•;{ ..iui-i.iil'. I!tl> il.a>;iiii>i> nf, ,l!i:i iliiilnity nf. ISti patholo(ty of, 4S7 pmciinsis of, 4iH) i-\ niploiiis nf, 1111 lri.;itini'Mt ol, ."ifM priiL'rr«>ivi., ."lOI UM' nf Miyilrialirs in, ."iO."i 111 iiiyiitic- in. "lO.") -Miiri;:ii;nian, l!M iiiiilrav. I!i:{ polar. IS,") anti'riiii. IS,"i, |!)7 |if)sli'rior. )s.-,, |s(i 1(17 "ripi'," l.'vi scrondarv, I!l7. ."i2l 'Oin'lo, ISS, IS't, KMI, MM ti-aiiinalii-, isl I'tiiilojix III. 4S2 trralini'iil of, 4s,i trralinrnl of. ."id:! zonular, l!l(» I rral inrnl nf, ,~id i Catararla ai-iTrla, H.')! rntarrli.-il iliplitlicria. ti!t7 'piirlniiitis. si:; iM>i:.\ I2<W> C'liliilrnpia. i;ii Caiintii'. iiihl. 7.Vt Cav"'riiiini:i nl' riiujiiiuliv.i. J.VI C":i\'TiHni* ^iiiti**, llirinrtliiwis oi , '20\ .■iiuiuitv ui, -jcn iriK rll\r. I lliH l-lil.lHdV 111, 1 lllS |ti'<iiriii>>is Ml". 1 Hi^ -vinploiii" 111. lliiS ^s iit|iiiiMi-t III. 2t)2 iM'UlllM'lll III. 'JII'J ('.■ll-i, itllM.l.l.lllI, <CS ■•iiiuliiiiiv 111. 'f2S ilr\i'lii|Mni'iil III. ilJH OIluliliiMl (liiM.rliil. I'.l.'i CcrrliiH.ii ali-i'i-i-i ill Miidillr-i-iir ili-M.':!.*'. ii'.M. il-.':> mil-. Il7:t ili:iHMii-i- ill. ililTiiriili:il. 1171 ^\ in|itiiin* 111 . I I'-i liciitiiunt III. 1171 CiTi'lir.i! .ili^n-^ III iiiiilillr-c:ir ilisi-ii<c, 11 JO iitir. Uli'.l ilianiiii^i-' 111. Il"l fliiiliiay 111, I Hi!' syiii|ii(iiii< 111, I Hill trfllllllrllt of. 1 171 nii;riiii 1. ril:ilHiii iif, tii ilis<'as<'S of llii'iM'. t,:il lii'iiinrrliHU' , rcliiliiiii nl, m iII^k'Sisi-^ iif tin- I'vr. filU llV|Hnriliiil, irhiliiill nl. In ili-|.;iM..- ' ,if till' eye, li:il I I l|ii|ll:l, li;l«,ll. '■''>■! I if in 1^1', [Hit 111 ill 'i;\ 111 , 7JI Iif iirliil, '.'01 iif ihriial, |iilliiiliitf\ nl. TJI (■llnliliti- Ilnilii.il, S'Si llilltflln-ii of, 'iJS fliiil(it{\ 111. ^J'' ■•ymiiti.iir. nl, ^J*< Irrlllllirlll iif. VJ7 ClinriM nl l:irMi\, lOl'l (,'liiiniinlilllti« ililTll«.-i >\iiliilit;i:i, :ilia«- lillc iiiiil rilaliM- r\n)l >rnlniiiiit;i in, :i7l pijjiiii'iila, iniii niiliiiM nl \ iniial liclil ill, ;{7.'i >\ pllililii'. irlllril :lli-nlllli- llll'l rilii- livr <|.nliifii:l ill. )i7 I ('liiiriiiil. iiiiatniiiv 111. :II0 atrnpliy nf, m ijlaiirniiia. .V!H I'liaiiiti'^ ill, HI iiiyii|iia, .'i7l> ill |iriiiiiiry Klaiirniii;r, .VW rnlniinnia nf. H7I ilrlai'liliii'iit nl, il"*! liyiM-ra'Miia n|. :t7-' iiijiirit'- nf. :(.s:t iitTvi'^t (if, :ti I i)|>!itlialiiiii«iii|iir :ip|iiaranii' nf the, nxsifiralinli i.f. :(,S() |H'ni-t rating \miuih1- nl, IIMI piiiiiiriit -liniiia. I I'll- nl, ml nipliirr nf. ;>.M Irratiiinit nf, :isl -.'innina nf. .{Vl srcliiral 1 .iiii rail inn in, 37.J tli'.KTriilar i|ipii>il- in. i(7li plnsis 1,S2 ,i.|rni«i». ililTii-i'. iilalinii nf, (n di^- ( hnroidal <alarai't , .Ml'.' i-a-i- nf the rye. I'll'.' riiiK. 1>» Ori-lirn->pinal nii-niiiniti.-, ri'lalioii I. In pi)!iiiriil, fnnilinii nl, lit lisi'asrsnl till- I'Vi', li:i'.t liiinnri'liu'a, Idli >lianiiii>i> nf. 1012 itinl.itfy nf, 1012 <ylllptnlll- nf, 1012 rrraiiiiiit 1 4, 10i:i Ctniiiirii, inipacli'il, lOMi (li.'is:nn-.i^ nf. 10.S7 ilinliit;\ nf. lO.SIi priiKiin^is nf. 10S7 -viiiptnms nf, I0.S7 trfalMiriil nf. ItLSS Clialazinii, 212. 2l;t forci'p'^. Iti'sinani - '-'IS trcatnii'iit nf. 2lli ChaiiiiliT ailjn-Ial.li- -f.it :iiiil ili'>k. 1 11 Chapiii'^ liiiij:i|i' (lrpri>»~nr. 7ii."i Clii-i'k lisaiurM. i\!.-rnal. l.'iO iiilri'ii.-il. l.'iO lilj.'iiuciils. aclinn nf. | .">0. !.")1 (Jhcmii.sis nf riiiijiinilna, 2*<t "t'lioroiilai ili-tiirliaiH'i'." I>>7 (linroidili-c .'intiTinr. ,'i7'i arr<ilari<. :i7.'i cintrali.-i. 'A~'> .liffii-a, :i7li ilis.scniin.-iia, :i7ti olirniiica, p.iiaii-nlral and |)f'ri- icnti'al M'olninata in, 374 i\iidali\>', aciilc, 372 rnlll-M' nl. 372 ftinln>;y nf. 37:< syinptnn.- nf, 372 tri'attni'ni nl, 373 varirtie.s of. 37."i >iippili'aliva, 377 rniir^f III. 377 I'liolniiy of, 37.*^ pi'ii^nnvis of. 37*N syinplnms of, 377 tri.'itinrnt nf, 37"* ( 'liinnialic alicrr.'ilinii, 11.' Clilnral-poisiininy. ai'iitc. n'lalioti nf. to Chrysarnliiii, im jiinctivilis duP In, 2Sl) di.^i':iii"iiif till- i-vr, CilMi Cicatricial cctropidii, 233 Clinlcra. rclatinn nf. In ,|i„-aicvnl llui-vc, cut rnpuiii, 240 1120 I'ilia, 231 Chnlotcrin cryslali- ill till- \iiii'nM-, 3s7 Cili.ary hody, clianitc-^ in tin', in primary Chondroma of larynx. 'Mr' slaiicoina. .")32 V2m IShEX. (ill: lii.dy. Ii\ jirnniiia ol. M'.t >pi :lll;lt()liiv <il'. :{;{s iijiini-li\M. I>I(mmI Mipplv hull ipir ;iii;iliiiMy iil, XiS i'pilli('ll< cfHiKt'sI ion. 21 niTvis, :{»:( Cilici-rciiii.-il :iiliT\ . .'il Circiiliiliipri, ili>niiliaiiccsiir. in rrlatidii to cliM-a-csol tlii'iiosranilllircial,{>.S!» Ciniilatiiiy >y<trni, i-lTcct- nl i|iva-i-s cf, lipiili the ryi-, .V.t.'i C'iniilii-* ariiTiosiis iridic uiajiir-. :il2 niiiidi-. :i\-2 f'irnjinciiriH'al loiicr^tinii. 21 C'irfiiMilrntal -pai'c I7(i C'Irl't ivilatc. !IMi, llMi."> .•tidliicy 111'. l(Mir> iipi'ialidii ilrscrilii'd. l(Mi!l syiiiptoins 111. lOliti trriil nt dl'. 10()(i Oicaiiii'-poisiiiiinj:. ri'lalion oi, to ili.-ca-o of lliiTvc. 2S(i. liOT iiM'of, ill i|israsi-< ol llir riosi' ami tliniai, 71.'> (-'olirii's larviiiri'MJ coitoTi-lioldiiii: lorci-p., Jf.l2 jPillold drdcMiMalion. T2."i pallKilogy ol, 72."> rrailioii lo ~iaiii>. 72."> O'lolioina. clioniidal. :i71 srcloral I'oiili'aclioM diii' lo, :{7I ol'iv.'lids, 2H.S iiidis, HIS ol' iris. i-oMj;i'niial, His Klaiiroiiia liilhnviiiir. .V)2 l<'Mlls, 177 ol -lif.alli ol ilii' upiic iicrvi'. l.VI Color liliniliios. .Vis I'lioloyy ol. .")71 inriM< ol. .'■)70 li'-l- ior. .")71 \i.--ioll. ^'olllll;-H^lTIlllol^/ ihrcrv ol'. ■i7() VoiiM(i-Hi'lnili.ili/ iliiorv ol prodiii'- lion oi. .")( Coinpoiiiid li\ |«'ropii' ii-lii;iniiti-m. l(l(( opiic.il <y<ti'iii,~. liH (onc.-ivf i\lindir. Idl mirror, u-r oi. in ~kia-copy. 12(1 < 'onca\i>-ron\i'\ Iimi-i'-. Iil CoMHrslion. ini\i>d ioriii< oi. 21 Conii'.il ■■■.riic-,(. Hl!(. H20 I'onJMualr iocal ili^iancc-. .■>7 ioi-i. ."i7 l.-m oi. IKi ri'l.'ilJM' po-iiioii- of. .■)7 ', |'aral\-i-. Isl prou'no~iv ,,i. is| tri'alinini oi. I>2 roliJMIlrti\.'|. 2.">S .il.^cc— ol. 2Sli ain , 2'.I2 adi'iioni.i oi. 2!ll am\!oid di-:ca--.- o! 2s I aiialorny of. 2.VS .■inirioiiia oi. 2.Vt ! .-itropliv of. 2s."i catarrh of, dry, 2.Vt caMTiionia oi. 2.")!l I'liaiifT"' in. in priinarv glaucoma, .V2S clirniosi" oi, 2S(i 'ondi'tiilal alinornialilics of, 2.V.> lysl- of. 2ill di'rniiiid iiinior* of, 2.">!l drvclopiniMI oi. ;{;ili I'lrlivino-iis of. 2.S(i rinpliysrin.'i of, 2s(i t'rcalnicnl of. 2S7 I'pillii'lionia of, 2V2 tiliroina of. 2.".!l, 2!M Koiit of, 2li7 Irratmcnl of, 2(>7 granuloma of. 2!)l liy|«Tainia of. 2,V.) injurii's (o, 2S7 trcatincnl of, 2S7 Icpid.sy of, 2.sa lipoma of, 2!M lii|>ns crytlii'TnaloMis of, 292 lympli.-itii- M'^srls of, 2r).S nioli's of. 2.">!t myxoma of, 2!M ni'rvr supply of. 2.')!( ocular. 2.VS osseous growth of, 2"i!t osteoma of, 2!ll p.'ilix'liral, 2.5.S papilloma of, 2!ll pitrmontcd palclics of, 2.V.I .sarcoma of, 2112 syphilis of. 2S;{ lars.d, 2.VS tcL-iniricctatic crowths of, 2.")!t lulicrciilosis of. 2S2 pri.nary, 2S2 secondary. 2S.'{ timiors of. I)c!iifrn. 2!tl inaliKii.'int. 2tl2 simple cystic. 2!>l Conjnnclival loiiticstion. T.i sacs. 2.W • 'onjiiiiciiv itis. 2."i!t aciite contagious, 2'iS coinplii'alions of. 2li!l cont:i)rioii-' i|U,'ilitii's of, 2*)'.' diaunosis of. 2tiit prognosis of, 2l>'.* prophylaxis of, 2ti!t symptoms of. 2tls trealnii'iit of. 2(i'.l catarrhal. 2lUI I'.'il.'inlialis astiv ;i. 2lil chronic. 2M ti-eatieenl of. 2s."i classi(ic;iiion of. 2.'>(l diplitlH'rilic. 27") c:ms4' of, 27') '■"iTipiirai itniv of. 277 diatnosi" of. 27li ji.itliolocy of. 27ti |*^ciidorrictnln-;mous. 27ti i.M ;:x. 1207 I'oiijunctiviti^. (liplitlii'iiiic. tifaliiiciii m, 277 f rzciimtoNi, 27'.t folli<'ular. 2ri2 causi' (if. 2ii2 syni|)t(iiM~ III', 2(i2 tnalmciit iif. 2ti2 gonorrhd'al. 27(1 iicutr slanr. 270 cailsr 111. 27(1 rlilll|iliralli>li< of, 271 (liaciiiisU of, 271 pallKilii^y of, 27."> propliylaxis of, 271 Iri'.'itirii'iii of, 272 granular, 2(i2 call*' i>f, 2til iliaKiiosi-^ of, 2(>.'> patholoKy of, 2(j.i prognosis of, 2ti.") Iri'alMU'iil of, 2('m lacrynial, 2(i(l iliagnosis of, 2(>() trcatinrni of, 2('i<» lithiasis. 201 Ircatnii'nt of. 2i>l nic inliranc.iis, 277 <au.-«' of. 277 cliagnosis of, 27^< In'atiiirnt of, 2li() .snhacntr, 27(1 iMiis.' of. 27(1 ctintagiousncNS of, trcatniriil of, 27(1 to\i<', 2.S.-1 27(1 lo atnipiiii', 2.H"> to hill's of insiM'l<, to rhr\saroliin. 2St> III corailic. 2S(i to I'srrlhi*. 2S(i 2S(i lIlH llllr ihii illH ijni tn'.atnn'nl vi rn.il, 2til caiisi's of, 2(il iiatliolocy 111, 2li2 prognosis of, 2(12 syinplonis of, 2(il Irratnii'MI of. 2tl2 2S(i i; trrattnrnt of 27,S iion-spi'citir lorins of. 2li(l I'arinainl's, 2117 faust' of, 2(17 tri'altnrnt ol 2(17 phlyflcnular, 2711 oaiisf of, 27! (liaKiiosis of. 2S1 patliolouy of 2SI tn'.'itinrnt oi 2S1 pnt'lltliororcic, 2(' >t ciiiitairioiis qiialitii's of, 2ti!t (jiagnosis of. 27(1 prognosis of. 27(1 pTirnli'iit, 27(1 simple. 2(1(1 causes of, 2(1(1 progiiovis .i| . 2(1(1 syinptoin* o! , 2(1(1 ('onus, annular, s7 eongenital, ^7 terraced, S7 ( 'onvergcnce. 152 acconuiiodatioii-, 152 insulticieney of, 15H negative, 152, 15s paralysis of, IS\ pinu'tuiii proxiniuin, reniotinn, 157 wi'akncss of, 1.5H Coiivergeni sipiint, 172 straliisnius, 172 Converging meniscus, (11 (,'onve.\ spherieal test, ItKl Cords, vocal, |Kilyps of, 714 Cored opia. Ills Corel vsis, ,{7(1 Corne.i. 2<i:{ alisccss of, , 05 ana-sthesia of, 52!l ai'lloniy of. 2!1H anterioi- epitlielial layer of, 205 lilood-staining of. .'{22 treatineit of, .i2'.i liurns of. :r2:< changes in tlie, in priiiiarv Elauooma, 52!l conical. ;<HI, :{'2(l deiKisits upon posterior sinface of, in cyclitis, H51 development of. :W.5 ectasia of, ;U7 fistula of, ;{(I5 treatment of, MH't foreign iHidies in, :121 treatment of, :{22 inliltralion of tin', originating from the p<isterior siuface, :Uli injuries of, .'521 manner of testing sensiii\enessof, 27 nerves of, 2!Mi oblique section of, 2!Mi sc'tioual view of, 2D1 '■ s.M-p.Mit iilciT"of, :t(Ki, :<(it smallne-s of, as a factor in tin' caiisa- lioii of glaucoma, .511 striated opacities of. 'M.'t treatment of. :!l(i ttunors of. :(21 ulcer of. acute sloughing. Htll infected. ,■«)() eiiural, :i(12 serpent. HtKl. ;<(M -iinple. :iiKl variolous, M)'t Corneal curvatun*. applicalion of I'la- ciilo's disk ill (lelermiiiiiig. Ill epithelium, iiiiule of ilcmoiistratiug loss of. 27 loiip, 25 rellex, e\amin;itiiiii of the, 21 t'ssne, regeneration of. 2'M'> Coriiii hmnaniim of evteriiMl car. Kixii Corlic.il calar.ict. Kit Cough. rcHc\ nasal. I(l»:{ 1 I ll'OS im)j:.\ "On'ck ilutri Crow H i|), ili|ilitliiritic. s:t2. (Si:e l.aryiiKeul IHplitlicTia.) iliacmisis of, 815 ■ liology ot, SU |>.itlu>l());y of, Sl,"> pruRiiosis 1)1, SIO •ymptuins of, .Sl."i Iriatiui'iit 111, Sltj Crusta lactca, 2;i!( Cryptorilillialinos, 2;<!S Crystalline lens. t>3 anatDniy of, 47 J clianjji-s ill the, in primary glau- coma, a.i'A Kiloboma of, 177 lOMjrcnital abscnri' of, 177 anomalies of, 177 lortcx, 471 ili'formity of, in a cataract from chronic glaucoma, 50.'{ ilcvclopmciit of, ;{:j2 ilislncation of, 47'J glaucoma liue to, 549, 550 into the anti'rior chamber, 480 into the capsule of Tenon, 4S0 into the vitreous cliamber, 181 ''iuliryoIog\- of, 47t) e(|uivalenl rcfr.-irtive inilex of, lossa j>ati'll:;ris, 17t> liyaloiil f(wsa, 47<i Icni-ocylic infiltration of, :>22 IMldcM* of. 174 upai itiesof. 4S5 |)oles of, I7t> |irismatic fibres of, 475 wounds of, 17H glauciiniaibie to, 54H Cm-ctlcmeiit of laiynx, !M<1 "urvature hy|x>ropia. (t5 myopia, pcrniainnt, 85 lrai]~icMl. xt •o's laryngeal foreep>, !ll<i .clitis, couise of, :i."i,'{ etiology of, :{51 prim,-iry. .'!55 se(]uehe of. :!.">:( Ireatmeiit of. a:,s -erou<. glaui-oma following, ."ill Minploms of, :!52 treatineiii of. :(.'i(l Cyclophona. 15S detection of, l.v .\la.l.lo\ (h.ulile prism. 171 ii'eatrncnl of. 171 Cycloplegie, rjielhoil of instilling a, 112 f'yclopleL'ii-;. necessity I'or using, ll:i 't^'' "' . Hi defeitnniihg ri'fr.n-tivc errors, 112 in ^kiax'opv, 121 (Miri.l.-r, e,,nve\, I(i:{ (Jvliiidi'!, determination of i:is t lie axis of a, distortion produceil by a, 138 t'ylinilers, tipplnation of, in corn'ction of astigm.atisiii, 107 bisyinmetrical method of indicating tim .axes of, 105 crossed, lo,s p.irallcl method of iiKlicating the axes of. 105 symmetrical method of indicating the axes of. 105 CyliiKlrical lenses, <>() IVsticorcus cellulos;c in the vitreous, 388 of retina, 13S Cystoid cicatrix lollowing extraction of cat.'iract, .521 Cysts of .-iMl rum, !I7!». {Sre Mi celp.) of conjunctiva, 2!tl of eveli.ls, 21 1 of ii-is, 35!l of lacrvinal gland. 217 of l.irynx, 722, iXIl nasopharyngeal, 722 of nose, palhologv of, 722 of orbit, 20S polypoid. SNO. (Sie I'olypoid Cysts.) of throat, pathology of. 722 of tonsils, pathology of, 722 hACin'itADKNiriS, acute. 21li treatment of. 2l(i chronic, 21(i tre tmi'nt of. 210 li.icryocystitis, 227 .symptoms of, 227 treatment of, 22s l>acr\ops. 217 Dalrymple's sign in eM,phtlialmic goitre, 209 l)aturine-|)<ii<oning, relation of, to dis- ea.si ., of till' eye. 1107 Daviel's lens scoop. 511 l>ay blindness. .5S0 Deaf nnaism, 1 105 etiology of, 1105 svmptoms and di.agnosis of, 1100 treattnent and prognosis of. 1107 1 >elstaiiclie's in.alliu- e\tr.Mior. ll!tl m.c^enr, lis] Dench's ear punch. 1 1 1 1 Dendritic keratiti.-. :(07 Di'orsumvergenee, 1.52 Di'pression. o|><Tation of. in lieatmi'iit of cataract, ."lOil Deriniiid lutiiois of conjum-i i\a. 2.59 of iris. :i5!l Dcsi'emet's ne'mbr.Mni', 295 Desiccation ker.-itili-. :i07 Desmarn''s chala/ion fi.reeps, 21:1 lid retractor. 22 secondfiry knife, 51 1 De Wecker's iridotomv sei-^ors. :((i5 iris .scissors. 51 1 iM>i:x. 1"J(>!» Diabotes iii-iipi(lu<, iclatidii of, to ilis- fascs of t he cvi'. .">S<) mt'llitus, relation of, to diseases of the eye. oSti Diabetic atiiblyopia, 4,>S n'tinitis, 42(> DietTeiibaeb's metliod of blepliaroplastv, 2UJ Diffusiori eircles. 7i> iinaties ill ametropia, 77, 7H in astiniuatisin, 100, Ktl Digestive system, effeets of diseases of, upon tli<^ eye, oitl Dioptre, definition of, ti2 Diplitheria. intubation in, 837 after-treatment o''. 8J,'? instnimeiils for, .S3S nieehaiiiriil treatment in, 8117 cii«Tation of, teehni(iue of, 839 when to operate, 844 to remove tube, 84,1 lar\MKeal, 832 (hagnosis of, H:^',^ |)atholo)»y of, 832 s<'(]uehe of, 8.'t4 symptoms of. S33 treatment of, 834 dangers of antitoxin in, 83.". iia>al. S20 definition of, 82!t chaKno>i> of, 830 differential, 830 etiology of, 829 pathoK'.gy of, 830 -^vtnptoms of. 830 treatment of. 831 of pharynx, 831 diagnosis of. S32 (litVerenlial. 833 pathology of, 831 treatment of, 834 relation of. to diseases of the eye, (ill varieties of, ti97 Diphtheritic ronjimetivitis. 27.") croup. (.S'(( Laryngeal Diphtheria.) DiplacMsis cif inttrnal ear, 1 104 Diplobacillus of Morax -Axenfeld. ile- scription and pathological significance in diseases of the eye, (183 Diplooocpus of acite folli(ular latarrh ( psi'uilogonocoi'cus ). <lescrlption .and p.'ithological signilicance in diseases of the eyi-, (i81 laneeolatiis(pnemnocoeciis)of Iraen- ki'1-Wciilwlbaum, description and patlioliigical significance iiidiseasi's of I he eve, ('.83 Diplopia, monocular, 103 Diri'ct asligmiitism, 97 illumin.j'.tion. determination of refrae- tion l.y, 117, 118 i>phth;dinoM'opic examination, 40 Disk, optic, 18 Distichi,i>is, 218 Divergence, l.")2 fusion near |H)iiit, l."i2 Divergent squint. 17") strabismus, 17.") Diverging meniscus, til Dropsy of antrum. 979. (Sir Mucocele.) Dry catarrh of the conjunctiva, 259 Duboisine-poisoning, relation of, to dis- ea.ses of the eye, 1107 Duphiy's nasal speculum, 731 Dynamic strabismus, 1,")8 Dysphagia, hysterical, 104(1 ^j'AR, examination of, 107.") J instruments used in. 1077 technique of, 1079 external, cormi humanum of, 1083 dis(>as<'s of, 1080 malignant. 1083 eczema of, 1080 diagnosi- of, 1081 etiology of, 1080 symi)toms of, 1080 treatment of, 1081 foreign bodies in, 1092 diagnosis of, 1092 prognosis of, 109.3 symptoms of, 1092 treatment of, 1093 herpes zoster of, 10.82 lupus of, 1082 tumors of, benign, 1083 internal, anatomy of, 1097 diplaeusis of, 1104 di.seases of, 1099 functional paraly.sis of, 1104 hy(K'ra\st hesia of, 1103 paracusis of, 1104 phy iolog) of, 1097 suppurative processes in, 1101 tumors of, 1104 middle, ab.seess in, cerebellar, 1121 cerebnd, 1120 extradural, 1119 anatomy of, 1108 atrophic catarrh of, 119,5 causation of, 119.") di.'ignosis of. 1197 pathology of, in.i prognosis of, I lit7 .symptoms of, 1196 treatment of, 1 197 cereljeljar abscess in, 112.") pathologx of, '. 12,") changes produced in, by defi- cient blood supply, 1199 chronic non-suppurntivj dis- e.as«'s of, 1 1 76 classification of, 1182 vasctilar engorgement, with evi!:!alion, llSfi ili.agnosis of, 1188 etiology of, 1186. (.rognosia of, 11,87 symptoms of, 1187 1-21(1 iM>t:x. Kar, iiiiililli'. (ic'licii'iii IiIimmI ll!t(t iipply to. LIcpliaiil' l>ls ilMhlllll. 11 •a«'^ 1)1 till' v\i\ iVM) 'l.'iti .1'. 1.1 (lii iaM>;r> priHliici'il Klliptiral lenses, tlO liv, ll'.t'.t iliaKiiiisis <>r, I I'M) svinptiiMis ami siyiis ol, ll!(!l Irealmeiit ol', ll<.li> ■ •i»easeiii'.iioii-siippMralive,cica- trieial stage of, IHH) iliaitiiii-is 1)1', I I'.M propiosis ul. 1 l!ll symptiiiiisiir, ll!H) treat iiieiil ol, !l!ll iiiMTative, im2 stages ol proliferation and eoiitraetioii in, 11S.S prognosis ol, US!) svinptoinsof, USII treat inent ol, ll.sy lyiieral inleetioii in, 112") livpirlrophie eat.'irrli of, I1S2. llSti canses of. 1 I.S2 pathology of, 11S2 stages atiil svniptonis of, list) iiife(li\(' Ihroniliosis in sigmoid sinus, 1122 iridainm.ation of, piinili'iit. IIOH etiology of, 1110 pathology of, nil prognosis of. 1 112 svinptoms of, 1111 inflation of. I lT!t leptoMieniiigilis. anile, in. 1111* paeliynieningitis in. 111!) sinus phleliilis in. I 121 Iiil>eieiil;ir disease in. 1 121 rtlatioM of diseases of. to diseases of the eve. ,-><».-) KctasiM', >elenil, ;12S Kctopia lent is, t7s piipilhe. :US Ketropion. 2.") I eieatrieiid. 2:V.i. 2.")1 organie. 2') I spasMiodie, 2i")l Ke/eiri.a of iMernal ear. lllSIt di.'ignosi, ,,|, Ki.M eliiilog\ of. IIISK ~>rnptiiins of. KISII tre.'itnienl of. KIM of eyiliil>. 2:{'.l rel.-liion of. to disease- ol the eye, (i2!» Kivein.-itoiis keratitis, 2!ir Kgyplian opiilli.alniia. 2112. 2V) Kleeirie liiilli with nlleetiir lor i.s,. Ill operations on the eve. iiii:i K|ei.tif.|y-i-. Tr,2. !»!''' 'ippliiatioii (It, 7.")2 niel.'illic. 7."):f .■111 ion .-ind ii»e of, 7.');i u~e and iiiiiiialion- m, 7")2 Kmliolisni of central jirleiv of retina. 1;12 if ei'i-ebral els. rel.-ltiol I ol. to disi'a.ses of the eye. Ii;{:{ Lininelropi.-i. delinition of, l>4 Kinmetropie e\ . 7") Kinotiolis, depre^-iiig. a- a faetor in the eaiisation of glaiieoina, oU Kinphyseina of eonjiinetivii. 2S») Kinpveina of aeeessorv lavitie- of nose. !»,S2 signs of. !t.S2 ill any aeees-ory e:i\ ily, 1t;i7 syinptoins eoinrnon to, !i:{7 of anterior ethmoid ei'lls. <M,s diagnosis of, (Mi'.t freqneiiev of, itlis prognosis of, !(72 symptoins of, (Ml!) tre.ttment of, !t7lt of antrilin of Higliniore, (112 diagiiiiMs of. !t4K symptoms of, '(12 exploralorv piini lure. 'J4.> iiis[M'('tion. '.)12 tK>stiire te-t. ".Ml test of traiisillumina' tioii, <t41 treatmetit, !t|S eanine fos«a operation, after-tre.-tlnii'iit of, <);">.■) Ieellllii|lle of, !t,")l indie.atiiiiis for. !t.")li through .dveolar sm- laee. ilUt lliroiigli l.ic-ia! ^iirlaee, m'.t through na>al suiiaee. !)tS • liriinuli iiaiiir.il orilire. ills eonipliratioiis of, inlraeiaiiial. din prognosis ol. im treatnieiii of. "(11 e\ideiiee presumpil\i' of. li:17 eiiimier.ation of |Hiiiils. 11:17. ICIS gellir.ii alVeelions, 'll(t reinot' ^\ miitoins. !».l!t svmptoins in ni'ighlioring re- gions. It:i7 pngiiosis of. nil treatment of. lUI Kiicrjiiiaiociii' of orhit. 2t')ii Knelioriilroin.-i of orliil. 2111 Knophthalmos, I<)1 Knosto.sis. n.'isal. Sill l'".nto/o;i ill \ it reiiiis, ;iss 1 i.\i>i:x. 1211 Kiilropioii. ciiiilriciiil, Jlil Kutautlms, 2112 -^PMsiimhUc, 2I!> iiialiKiia. 21(:< Kniii'liatidi]. (i|H'r:iiii>ii nl. 112 Kii..,.i<liiaii catarrh, iliroiiii-, llsl ilaiij!^ i> ,unl ;iil\;iiil,it;r< of. 411 iliatfiiosis of. 1 IS") Kpiciiiitlms. 2.'iK proKtiosis iif, ll,s,-> svmptoiiis ami si^ns of. Epiplioni, 21,H 1IS4 I'lidldKy (il, 21N trratmrui of. Ils.'i licaliMciit 111. 221 catliiliT. 1 ISd Kpi.scliTilis, lintiiiidiis, :t2.") Kvcrbiisch's o|H'nitioii for iiirrritioii ot v»n^- (il. :t2."i ptosis, 2:t."> Iri-aiiiiciii III. :{2"> Kvisfcratioii, oprratiou of, 410 IHTsislflH. ;<2.') dancers ami ailv,-intaKis of, 414 cause <i|, H2l> K.xciitfratiiin, ii|«ratiiin of, lit) pnipiosis of, ;{2li dantriTs ami ail\aiitapfs of, 414 Iiratinriii ol. .T2ti of orliit, 2(17 Kpisi;i\is. 7is Kxophoria, S4, l.iS clicddjjy ()t\ 7 (s (lotcrniination of, hv parallax lest, trcatiiicnt i>l, 7t!l Hi;} I'-pitlu'lioma «>(' i-<iiijiiiuii\a. 2')S. 2! 12 i'tiolo)ty of. Hit Ill c'Mrriial rav, l().s:{ Maililox's roil-lisl lor, lli2 III iKisc. patliiilii^ry ul, 71S symptoms of, l(i,") ol tliioal, patliolotfy ol. 7IS treatment of, lii,"> Kpillii'liimi. iiliiitiiin tiiiiiiir.-* ul. 722 Kxophthulmir Koitn^, 2(1S, .5.S1I KrKol-poisiiiiiiit;. rrlalioii nl'. In i lisi-asfs Kxophtlialnios, I'M ol' the cyr. 11(17 intennitlent, 2(14 Kry>i|H'las III ryrliiU. 2H!» piilsatinu, lit!' rrlatioll ol". to disi-.'iso ol' llir i yr.till etiolojjy of, 2(1() Krythciiia liiilliMiiu. i>!M proifiiosis of, 2(K» niiiltiloriiii'. relation of. m i isi-asi's symptoms of, llMl of till' eye, (iliO treatment of, 2(M1 Krytliriiphla'iiii', elTiTN of. upoi rolor Exostosis, ivorv, of frontal sinns, 2(12 \isioM. .'tM) na-ai. Sill" Krytlitop.sia. .Vsl Exotropia, l.iS, 17.") Est'rinc-poi.ioiiiti^r. irlatiou of, in . israsrs External anilitor' meatus, disi ases of, of tlio lyr. 2sti. (MI7 KISli Ksophoria. l.iS elieek lipanient, l,"i(l Maililov's iiiil-ioi 1,11. 102 ear, iliseasi's of, lOSd syiiiploius of. 1(17 ophthalmoplegia, istl ircatiMi'iit of. Iti7 E.xudation into anieiior clhimlier in Ksoiropia. 172 ryilitis, :!,"il KthiMoiil ri-lU. aiiti'rior >iippiii:ilioii in. in iritis, M'.> !M.7 into posterior eh;tiuliei* in ('X'clitis, il"si-,|. illiS ;<.")2 iliattnosis o . 'M\S ill iritis, liVI I'tiolojsy of tIDM into stroma of the iris. 3411 •symptoms if. litis into vitreous in evelilis. H.'yJ Irratmrtit if. litis E.ve, the aphakie, oil n\n-n. lati'iit or maiii- hloodvessels of, ,'{41, .U2 Irsi, (Ills ett'eits of eonstitutional ilisea^es symploiMs if. lltill iilMiii. ."),s:{ tn'aimi'nt if, 117(1 of diseases of the liraiii, ti;il );tliiiiiiiil..l ,■,!!,>. !I2S of i-iriiilalor\ traet *)l*"> anatomy of, !t2s of dijrestive system, 5111 siiMls. alTri'tioMs of. irralnii'iil of, 2i:{ of nerves, (),il rrl.HtioM of ilisr;|si-s <i|. o (lis- of iispiratory trail, .")03 1-a-i'S ol llir ryr. .'")(l| of sexual organs, (iOl Iri'atmi'iit of atlfciion^ o . 2i:i of skin, ()2!1 sinusitis. (I(>7 of spinal eord, 04,"> siippuratioti. !I72 of urinary organs, ."ills ilianiiosis of. i(72 of iiifeetions diseases upon, liOS inatiiu'nt of. 072 of injuries lo ihe lirain and iuilii-ations for. !»72 »pin,al eord iiiHin, ti,ill of poivius ii|Min, litll Ktlimoiilitis. 7(),H liistolojjy of, 70N of liiiphoneiiroses upon, (ilH Willi ii;isal polvpus. s,s|. SS2 eiiiliryojogy of. :t:(l 1212 I.SOhX •. <'iiil)rvniil(' lildiiilM'-MK 111', :(;{;{ c'iniiirtriipic. 7."i I'Xainin.'itloii ui. I<l aiitrrinr t-li.-inituT, 27 li<'li;ivio|- III (lie pupil III (|i>i';l!it', M III Ivi-i>rls of the ixliiior of tlic>. J-i liliarv or cirriiiiuiirni'al lOii- ^I'stitm, 21 coMJiiiiiliva anil il~ ciil-ili'-sacs, 22 (■<mJMiicti\al I'oiigi'stioii, 23 roiiiia. 21 toriu'al reflex. 2! tlireet iMS[HH'tioii of the eve anil its appeiiila^es, 21 liy ilireit iiis|Hilion, 2t> liv iliicii iiietlio<l, 4ti fainil> anil (MTsonal history, 20 treiieral eoiisiilemtions, 19 physieal condition, l!t inilireei nietliod, 45 iris, 27 laervinal apparatus, 22 I ills,' 22 niixeil loriiis of congestion, 21 normal eyegrouinl, 17 ocular history, 21 ophthalniosiopic e\ainin:'tion, Ks'liils. aliseess of, 21(1 atiatoniy of, 2.'<l anKioiiiata of, 21 1 anthrax pustule of. 211) carlmncle of, 2lli eiilohonia of, 2H.S eon^fenit.'il anomalies of, 23S trealnient of, 2:VS cysts of. 241 (li'Velopiiient of, '.VM'i eczema of, 2:i!( einphysi'ina of, 2.>(i ervsi|M'las of, 2:i!l furuncle of, 21(1 liiM[>es /osier of. 2:t!l injuries of, 2.")(> maliiriiani (jrowths of, 214 icilema of. 210 n'lative positions and sizes of, 232 syphilis of, 241 tumors of, 244 ulcers ot, 240 variolous eruption iifion, 240 Kyes, artilicial, 4!li I.,V\('1.\L hemiatrophy, proffrcssivo, rela- tion of. to diseases of the eye, (mO iiiTM'. relation of paialysis of the ocular lir.anch of. to diseases of the eye, (i.">2 I'actilioiis myopia. S4 rliit and the position of the lacultative hy|K'ropiu, !Mi Tar point in hy|)eropia. UO in myopia, HO direct determination of. 124 Farlow's opi'ration for forward prolonga- tion of septum, 7t>2 punch forceps, O'.ts larsitthtedness, 7li Fa.scicular keratitis, 2!tS I'avus, relation of, to disiases iil the i-ye, 030 I'iliia^ arcuata-, 20.-> normal adult, cardinal noints of, til I iliioansioma of nose, pathnlocy of. 722 ciir\alures of, (iM of throat, palholoiry of. 722 indices of, 1)3 I'iliroina of conjuiietiv.a. 201 evel.all. :!2 pupil. 20 tension. 3I> 1\- inuismitted li>;ht, 40 foreimi liodies in, inunafiement of, 401. 4(i:< ireniTal development of, 331 liori/ontal section oi. in orliit, MS liype|opi<', 7ii lymph p;i~sap's of. 311 31.') myopic, 7ti. Ml iMitntion of. 3t.~) the reduced. 01 the selieni.'Hie, 113 shade. (i.'>!i s|)cculuni. .")0t> teehniijUe of pathological and liac- teriiiloirical examinations of. litio Eyehiill, .aliophy of. 370 eenlic 111 rotaiion of. 14."i iiisirumem lor measurinc, titi7 mm ions of, i 1.') deraii>;eininls of, 14."i penelraliiij; woutiiI of the, 1 reat- ment of, .[OS |K)sition of lest, 1 17 pr-jKiiali-.i: "!'. Int pallloiu;;:r:;i and haclerioloyieal examination, titi" primary position of, 1 l.'i Eyeh.dls. .associated nioM'iiients, 152 i^\*e-i;rinind, icinial. 17 of external ear. 10S3 inininasal. SS5 of l;iiyii\, 001 of nasopliarvnx. 1032 d'anniisis of. 1033 histoloitic.d pathology of, 10.32 pro>;ni>~is of. 1033 -ymptoms of. 1033 trcatmeiil of, 1033 cold wile sii.iic ill. 1031 ek'etrolv:-is in. 1034 evulsion of. 1035 external o|Kralioii for. 1035 Halvanociutery in, 1034 of no-e, patholo^v of, 720 |-a(n!lare,- SS7 of throat, pathology of, 720 I'ii'ld of fixalion. 151 liinocular. limits o(, l.")(j monoculai, 151 /.v/>/;.v. 121 a I ii'Irl oi' fJNaliiiii, iiiiiiiiM'iiliir, limits nl', 151) mriisiirciiit'iil of. Iiy im'':iiis (it the |M'riiii('lrr, l.Vi FilaiiifiiliMis krralitis, UtMi Filaria sniieninis liotiiiiiis in tlic vitrrmis, 3H« Fissure, orliilal. iiilfridr, 1!I2 su|X'ri(ir. l'J2 l)alp<'l)nil, l!ta Fistula of oiiriifa, iiO'. of lacrvinal jrliuiil. L'17 lacniiialis, 22S Fixation fornps. 'rOCt foiiit, nK'thixl of ili'ti'iiMiniiisx, 12 interval, 'M> Foci, ronjupato, 57 rolati\c po-iitions of, 57 Focu-. real, 57 priiuipal, 57 virtual, .57 Follicular conjuixtivitis, 202 Forcipn bodies in aiccssory >iiiusrs, Osl in external car, l()il2 in nose, S7I rcninval of, 75(1 in plmrvn\, lOKi symptoms of, lOlti t'realllieiit of, lOlll removal of, (M5 in throat, N71 in tonsils, HNKt Fornix conjunct ivic, 2.5H Forstcr's ])lioloinetcr, .'{5 Fossa patellaris of the crvst.iUinc lens, 47t) Fox's fixation forceps, 412 FVacturc of nose, 10,5() Iri'atiucnt of, 10,")('> Friinkel's nasiil s|)Oculuin, ~IU Frcnular keratitis, 2il,S Frpuiienthal's electric \ilinitor, 7,">5 Fricke's nietljoil of blepliaroplasty, 215 Frog, entire embryo of a, Xi\ Frontal sinus, ",)2() chronic mucocele of, 210 development of, !»27 ivory exostosis of, 202 opciatioii on, (Mil exploration of frontonasal duct, 'M» progress of, !Mj,5 Kuhnt's operation, Utitl sinuses, relation of diseases of, to liiseases of the eye, ,")94 suppuration, i)72 di.'iRnosis of, 072 treatment of. !t72 indications for, !)72 Frost-bile of auricle, 10S5 Fulniinating glaucoma, .512 I'vindus refjev. 42 variations in color of, 37 \ Fungus-poisonini;, relation of, to di9ea.se.s of the v, ('07 Fir '• keratitis, :^(I7 I Obi , geiienil, .5>M) relation Furuncle of eyelid, 210 relation of, to iliseases of i he eye, tiSO Fusion near point in divcigrnce, li52 /lAI/KtN whi.stle, 1177 '1 (Janglion cells of the rciina, mellioU of staining, ti7s (iangrenous pharyngitis <!auss, formula of, tU (ieronloxon, ;{17 (ilanders, 7(Mi (jhinduK'ir enlargement, of, to dist>ases of I hi' e\( (Hands, Meibomian, 2,'{2 ocular, development of, ,33ti of Zeiss, 2:{l . (ilassblowers, fre(|ueiicy of cataract in. 487 Glasses, adjustment of, l:i(i allaly^^is of, 13H difliciilties encountered in wearing, 1,'il rules for the prescription of. 131 Ulaucom.'i, ,'ibsolute. ophthalmoscopic ap- [learance of the optic disk in, .537 .s<>ction of the optic n. rve head in. .537 a'^iile. clinical application of treat- ment in, .5().5 congestive, ,542 age as a factor in causal ion of, ,540 changes in the conjunctiva in, 528 chronic deformity of lens in a cata- ract from, .503 non-congeslive, 51 1 congenital, ,5,53 cupping of the optic disk as a result of glaucoma, .53s following extraction fulminating. ,542 hereditv as a factor in causation of, 510 " loss of sleep as a factor in lau.sation of, 541 primary, changes in the antcric" chamber in. .5.40 in the aqueous humor, .533 in the choroid, ,532 in th<' ciliary body, ."i,32 in the cornea, .520 in the crystalline lens, ,533 in the ir> ", .531 in the optic nerve. .537 in the retina. .533 in the sclerotic. .528 in the vit:.>ous humor, ,533 clinical ty])e.s of, .542 diagnosis of, ,545 predisposing conditions acc<immodalivi ,541 ace. 540 constitutional condi- tions, .541 depressing emotions, .541 of cal.aract, 521 540 effort. 1-214 IM'KX. Ill mnnnia. pr'in.ii \ , [MtM!i>|M)^iiiir iiiiili- ll:i\ li Ml. ili:nriMi>i- snl I'llol Iniilioii. .") II lipty Ih •.10 liM'.'il iiijiirii'^, .">ll I(is>* (iT xli'i'p. r»4l u|M'niliiill 1111 lilir ivr, i>l, 7!t.s liriitfiiiisj^^ 111, SOI ^MMptciIlls 1,1, HINl lic:iliii«Mi( (if. ,S()L> lliaiiii);. siilijiciivi' ■.(■M>;iliiiii>i iil, ll(»:t •.11 li-iiiiK 111', I ITii Hilniliciltz* thnirv amiiiiiiKMlatiiin, i 111 llii II- iiiri-hanisni iit ■.1(1 Ml llirnilii|li.t, .•)S(I »iii:illiii~' 111 (Diiiia. lliiiiialKipir iiii|iillaiv iiiaitiiiM •<i(tii, :U •>11 llM' 111 Mi\l Iriar trratiiiriil iil. .•.."ili Hiiiiiaiii.|.sia. Icrt-Milcil, Mi' .11 lli'iiiil'iirial liy|)iilrii|.li\ , ri'lalii.li iil', to 111, .■. 10 -<iiiinlai\ . varii Iil" »iliiplr\, riiiKTliliir riiiil r.irt inn i.l tirlds i.r \ isiiiii in. ">;|." Hi ili.s .'IM'S 111 ihr cvi'. (m(I •.:«'. (;ii ■^Illl.llUtl', ."> axin'.-i nas.al "^imm-uIiiiii. 7 i:ts, IH'.t < iliiiina (.1 ri'ti (ilvco-iirir am illMip (Jiiitri'. I Ai.plillialinic. 2(l>». .'.S'.t I'liiiliidv 111. 2(l.s >yiiiptonis 111', 'J(KS liralini'iil nl. 20!» (iiiiiiii'iiiriis ( N'cisst'i), (U'Mcriplii Hi H iKirrliaKi'. aiiililyi.pia Innii, 'uS iiitii llir anirriiii' ih;uiil)<'r, 'Mi'2 111' DOM', fi'NI Iriiin pliarxiix. 1(11.". Ill' throat. (HHl into ll iiiorrha^rir hi- \ itf K, :ws itiiiitis. 427, 42H, 42'.) i'r|M's ronjuiictivH', 2t>l ii.iiia'. .'{lO tri'atiiiriit ol', :{ll) pliaryiiKis. (.ill (..'itliolo^iral si^iiilii-ai 111 tlw ryr, (i.S:{ iiottslcin's (iiri'ttr. I(»:»0 tier 111 lllsejl.'*4's Mlltt till iiriN, ri'latioii nl', to iliscascs of . (Kill (i iilil' pns liatti l.-.'.l zoster ol I'xttTiiiil oar, 1(W2 of IIOS)', lli:<toll.KV of, (.00 • Joiit of conjiinrtiva. 21.7 liiant'i Bii.irilril foicips. tllCi (iraniilar conjiinrtiviti'*. 2li2 oi.litlialiiio 2.l!t rrlation of. to ilisca-srs of thi- I'Vi'. i>:H) pliary licit i>. i I'tioli 'K.v ■liroiiir, 10111 111. 1(11(1 Hrtrrorliro of throat. Iiistiili.)jy of, lilKI :i4(i (iianiiloii (iravi" iiploins of, 1011 t'ri'atiiiciil of. 101 1 (lisras I'lat 111 riiiijiii,rli\a. 20S iflatioii iif. Ii ili thi' I liiiiiili ."..Mt ii'i'i'ii'-^ (.1,1 oiH'iatiiiii fur rir.atiii'ial en- Hrtrrntropia. 172 ti'opion. 'i.'.l ' ■ In'iii'^ piiwili r hliiwiT. 012 Inilirr's sp^ Hi'toroplioria. LIS ili'tiTiiiiiiation of. l»\- coiivfx sphcr- ical test. Itti" iiy par.alhix ti'st. HU iiiiac iiiiiM'iiii'iil in, llll nil (.'las< trs! in. KiO spasnioilir. ISl yiiiptoins of. Kil MTcisi' of thr \vi;ik I'VI' in, 1!M( nil 107 ilsi* of till' strri'i I'll riiiiii;'> niiiilitii'il lint/ •lltlirr iipil'.- linn fill* cnrrrrlion iif ptn^i-i. 2;l."l ( Irunwaliri Innip.. (•.".:{ H A.\]i'."i niaiinil. Id.". Hrnrtrlniip ariiliiial li'ich, ',iM. ;i.")7 Hippiis, ;io HirMhliirK'i pnpiUomrli'r. 20 sii|i'roscii[M'. It.;: Hnin's ili'Kini'ralion nf inula. 721 lii>tiil<nry of. 72.") II n-Hi'N. M Hnlninren's «nnl-te«t for (letectinii nf H;iniatnnia nf il\ ilia. OSS rnlnr lilinilne.ss, •>71 Ha'tnoiiliilia nl now. palholotrv nf, (iOO Hnmatropine-pnisiininc, relation nf, in rrlation of. Imlisi'ascsof tlic I'yi', .".S.". iliseases nf the eye. (>07 of ttirnal. pallinliiKy nf, (i<KI use of. as a nivilriatie. 1 12 Ha.ji'k'-' hook !nr npinini; -pliinoiil.-il Hniileolmii. 212 -inii<. 077 Mlltehillson teeth, itllt .'11 1 H.'irlinaiiii'- lar Iniirps. ll:i.">, 1112 H\';iliin' ileceneration. 72.". n.'i^al ^iHTiiIuni. 7^11 pathology of, 72.". iniijiiur fiinrp>. 1 1.".2 leaelinn tn stains. 72.". 'Harvi'stfi-' keratitis. " :{01 H\,ilitis. .'IS.") H.-fiii-r's valve 2 111 asten.iij, ;is."i Hayes' knife i ille. .-,0(i piinetala. ;JS.". May lever. 70S suppurati\a. :iSt'. ilelinilinll nl, 70S treatnieiit of. :iKti iM)h:x. 121; Hv«liiiil .iiiiT^. |i<T»i«tfiit, .'{X'. •■aiiiii. :tu. ;{»■> li'«Mi (il crvstalliiir liii>, I7(i nirinl.niin- ..I \ ilinnis, (tluiicomit fol- l'i«]Mit .iiilirior syncchiir of, ■>48 Hyiiroi(|i|i,iln,, ri'lation of, ii>i i^-iist's of the lyi', lit 1 llyilriipliilialijiri-. :r.>I Hy<lroj)s iiiitri. !t7!l. tS,r Miuocrle.) iiiniiiiiiiititiiriii-, tl7'.) Mydri.rrhii'.i, nii^.il. KMl pniitniisi* iif, 10-12 -viiiptDiiiM i)f, |(»42 irtiiliiMiil .II. I(M2 Hyiisry,(liiiii.-|K)isiillili>r, irliiljoii 111, III ilisi'iiw-. of tlir CM', l'A)7 HyjMTiiiniii. tisit ' Hyponrstliisiii „( iiit(innl lar, 1102 of liirynx. KMti Iri'atiiiriil ii| of iiiiM', 1040 III pliarynx. I04:i iliitKiiosis III. itii>lii(ty of MlliplOlll'i of tri'jilmi'iit of Hy|icrr>opliori:i. 1.>S HypiTfxoplioriii, I. is FlyiMTkiiH'sis, Lis .\linlili.\'~ 1111I-I1-.1 IO)ii 1044 104;{ 1(H4 1041 ll\|HTplioria. ii)jlil. lor, 102 Hyniploiiis of, l(i!» K'xts for, 170 tri'atiiii'rit of, 170 llyiMTfropia, I7() HyjxTtropliir latarrh of iiiiiMlr rar, 1182 ciiiisaliim of, 11S2 rhroiiic. ll,S(i cioHtrii'inI or p<»i- latarrlial HtHge, 11 (HI <lia){no«is of. 1191 proKnoHi.s of, 1191 Kvniptoni.* of, ' 1190 trealmont of, 1191 ilajti' Hyprrmi'tnipia lorri'itioii of. Iiv a coiivi'x Irns, 4:< Hy|K lopia. 7ti. !H) ahsojuti'. '.Hi ardiniiiHMlaliiiM in, 'Xi amount of. 9li axial, 9.i I'orrcii ion of, 91 i-oiirsr of fiiiiTKi'iit ravs in, !K» riirvaliirr, O.i t'XiiTiial r\ iilrnrrs of, 97 fariiltativr. 90 far point in, !M» inili'X, 9.i lati'iil, 94 iiianilr<t. 94 hi'ar piiini in, 93 priMiiliinR glasws fur, l:<2 rrlativi'. !Mi >yiniitoiM»iif n'fracliM' .rrors in, 110 lolal. !M \arii'tit's of. 9.") \ isioii in. 90 Hyprriipir rvr. 70 HypiTo.-^inia, 10;W prosnosis of. lo;ls -yiiiploins of. I0;{,s In'atini-nt of. IO;{.S Hypinisplirisia. lO.'iS pioifniisis of. 10:{,S ^VHiplunisof. io;w Irratintiil of. llKis flypiTplioria. lis • ti-l* luiinai inn lo:{ imairr iiioMiiii'iit in. 100 Irfl. .Maililox's roil-iist for, 102 parallax irsl. of fiiKorjfe- int'iit of vt'»- sols with exudation, 11S6 (liagnoNia of, ll.SX prognosis of, 1187 tri'atincnt of, 118S stages of prolif- fration anil rontraction, 1188 prognosis of, 1189 svniptoius of, 1189 tri'atnii'iit ol 1190 palliologv of. 11N2 .subgloftii- iiiflanunation, 71."i HyiHTtropliy of pharviigeal tonsil. 1022 of tonsils, !)9ti etiology of, IKMi symptoms of, 990 trivitmont of, 997 local, 997 olMTalivi', 9!«) aftcr-ln'atmi'nt of, 1002 rolil wire .snare in, 1001 eleetric »iR' siian' in, 1001 emicleatioii in, 100:{ guillotine in. 999 of \entrieular region. 7l;{ Hyph.Tniia, XV). ,{02 Hypoesoplioria, l.iS image movement in, 100 Hypoexoplioria, 1.">S linage movement in. loti Hypokinesis, 10.V2 Hy(H)phoria, l.">N HyiMipynn. 297 I2i)> i\ith:\ Hv|>i>|ivi>ii krnitiii^'. 'W-i HysttTiii. rxlrrmr ciiiiniiliii- coiitriiriioii in, .'>7."> Hysli-ririil .•iinlilvnpin, ATI 1t;jirHY<»SIS. nlalicm »\. u< illsi>u«-. Ill IIk' I'M'. tilfO IlliiiniiKiiiiiii. iKc'iil, 2li (>lili<|ll>'. J)i llimitr. ii'liiml. liiriiliil |ir"jrcli(iii .•iiid nclitir.iliiPii 111, till liiinK*'^. tiirtiiMtioii «>1'. .">."i ililVii~iiiii. Ill :iiiirlrii|iia. 7". "H lllllKliUll. lllalillll III, to (IJM'IISIV Ol till' c'vc, <i,{l Intlox, iiiuivali'iil nlnntiv.-, iif crv-tiil- liiii' li'iis, an hyiMTcipia. '■•.■> llivopil. St. "*.', rclalnr irirartivc .Vi Inli"<li(>ii>' (li-.c-ii-..-. ffii'ctv 111', M|«iii 111'' ryi'. tHIN IliHamiii.iliiiii. 1 liniiiic nasal, witli li'ii- ili'iiiy 111 .ilidpliy, 71'i cirriiinscrilifil, nl ixliTiial aiiilitory iiirafJi. lOS'J iliacmws nl. IO.S',» ,iiul<mv ..I. 10S!» s\ iiipttiiiiMil, 1I>S'.< Iriatini'iil "I, lOW* ilitTiK''. ill' r\tiiiial aiiilitiirv inralus, llltNl ilidlosy (.1. Kf.Ml -vnipiiinisdl, HKtO irr.aliiii'iit 111', l')*" tiyiwrlriipliir siilijilottic, 7l."i ui' lynipliiiiil lissiir, ti!»:i line 111 iiiiiTii-iir(!aiiisins, ti'.l7 of inuriiii-i iiii'iiilininr^. I'l'.Kt (if nOM'. tl!MI, 70(i rlimnir. willi aimpliy, li'.M) with hyiMTtnipliy, ti',M) infi'i'liuiin, ti!l2 rliuloiiy of, Ii!t2 iiruriitic. O'.MI pillllnlilKV (if. 7;Mi iraiiMialic, ti!l2 cliiiliiirv 111. Ii".l2 vaiiftics (if', (iiM) parciicliynialdiis, 7(Mi pcrirlidiiilrial. "(Hi [M'ridstc.al, 7IMi siiliiniii'dils, ri!t."i patlidldcy (il, li'.l.'i siii>rrli(ial. 7(Mi mippiiiiilivr (if iniilillo pnr, 1100 inl rairanial /nniplira- tidiis ol I IIKI Inlliiin/a, VMi (■iinipliraliim- nf. ^07 iliamidsi-. ililTiTi'i.iial .if, .SII7 • ■li<ili.ir\ iif. MMi pailiiildiry df, ii"s. li'tii priicnd^is of, MIT nlaliiiii df. td diseases of llircyc, I'll!) «yiiipliiiiis iif, MMi Influcii/.a, Inalniriil nl, S07 Infrailuction. iiira!<iiiiiiiriil of. I.>1 Insanitv. rclaliim nl. In ili-cii'i'- nf the eyi', VilO Inli'rnal iiii", ili^ra^'s nl. IIHHI InliTslitial kiralilis, ;{1 1 liiKTvaKinal ^pacc, 'H'l liitrncruiiial coniplinitidii. nf inipycina, (MO Iiitrahiryncial iiiji'iliiiii-. Mill Intranasal ailiiidiiia, H. iliat!nd-<is df, SIM itiiiliiBV 111. HfKI palhiiloKV (if. S'.HI priitftio'-is of, S'll syinpldins of. S!tl trpatincnt of, W»l adhesions, 7.'>I ••I idiocy of. 7i")l syniptonis of 7.'»l tri'atmciit of, 7.")1 aneioina, .S.S.S oarcinoina. S!»2 (li.iKiiosi.s of. X!U I'nniis of. .s!»:l pallidloity of. S'M synipldiiis 111, .SilM callictcr syrinK*', 712 (ibroiiia, NS,j (liagnd-is of, .s,H7 fitioloiiv of. S,S."> pathology of. ss'i proiiiidsis of. NN7 syinptiiiiis df, SSli In'atiiicTit df, SS7 dslcdni.a. MM p.'ipilldiiia. Ns7 iliaciidsis df, .SSS lonns of, .S.S7 prognosis of, SHS ' sviiiplonis of, SS~ Ircatincnt nf, .SSS polypus. SSI sarcoma. Sliij iliatrnosis of, .S!!."! clidli-Ky (if. S!t.-) mil riisi'dpical apiwarancc of, S!l."i patlidloity of. Sill pmnndsis df. H!l,"i s\ MiptdlllS (if, .sit.") Uratmcnt of. S!Mi Intra-dPular tliiiil, composition of, .")2l tiiinor. u'laiicoma fdllowinu, .Wl Intiib.atiiin in (liplitliiria, s:{7 Intiimcsccnl catarac'. 49:i lodinp-piisoninir. nl ition of, to diseases of tlu^ eye. tiO.") Iridectdiny :!li."i. ;i('i7, liliU indicatidiis fur. :<li7 in treaiiiiciit of jilaucoma. .">.")l> Iriilectomydialysis in trealnicnl of Rlaii- idiiia. odii Irideraaiiia. lUS traumatica, iifil Iriilesis, ;170 iMii:.\ 1-217 Iruloi'lioiiiiilitl^ liilliiniiik' lAliiii'liiiii of cntHrnil, .">l!l Iriiloivilili-. iMriiiiiiiri liillnwiiiK, 4".K) lolliiu'iiii: lAlrartiiiM iil ciitiiriii't, .'>19 pcrliir.iiirnr injury, :!."i2 m'cdiiiliirv, U.V» sym|)nllirti(:i. H.'iti Iriilodinly^i-, :tiil. :<ii<) IriilndiiiirslH, JS Iriiloplciriii. :i:t n'flcx, :{2 iiiiiliiti'r.'il, :U Iriiliiloiny, ;{l>'.», ;{70 Iris, iiimtomy nf, Itjti, :{;t Bntcriiir MiiiMlihi liiwinir. "it" Ixmibe, ;).■>:<, .jlii rliaiiKci ill I 111', ill priiiiarv (rhmciiriin, .".ai c'linitiiiitir aMViiiiiiftry of, 27 c'liliiliiiin,'! of, iiiiii:i'iiittil. 'AH lllaiiconiM I'olldwiii);, 5.^i2 ■ ysis III', ;i.v.) fxiiilaiioii into till' stroma of, 3-19 faciiirs iiitliii'iicinii color of, ;i38 forci'ps, ,")0S foroJKii hodiis in, :t(ll funrtii)ii of, ii.'i hooks, :{()» liyjx'nrinia of, :MS inrt.iininatorv disfasts of. 34s iiiiirrv,itioti of, 2S iiivirsioii of, .'it'i2 liircralions of. liiil ini'laiioinata of, XV.) o[)i'ratioii.s upon, :i(«;{ pt'iietraliiii: woiincls of, .Stil piilialcl, JT ["ostcriorlaMTsol the, of an alliinotir liiiiiiaii I'yi', 337 syiic'i'hiii' of, following glau- I'oma, .VHi prolap.sc of, followini; oxtradioii of oataract. :,\'.l. .520 soi.o.sors, 412 tiaiiinalir cli.iMtfis in, 3112 tiiiiiiirs of, tHMiign, 339 trial nirnt of, 359 (liinioij. :i.-)9 tiialiifn.'inl, 3.'i9 Mvalniotit of, 3(iO v,iriatioii^ in mlor of. ,'?4r> Iritis. 349 course. 3.53 iliabrtiia, 3.">."> tn'tilMirnl of. 3.kS rtiolc-k'y of, 354 ^lonorriia'ira, 3.5,'> tri'aliui'iit of. 35S iiliopathira. 3.)5 primary. 3.")5 ill liiap.-iiiii !'i Vi r. it.Vi rliciimatira. 3.'>.> tri'atuiriit of. 3.">S "iTofiilosa. 3.")5 sciiiiiilarv 3.")'i Iritis, s)'! I III I. 3.'i3 tnaliiinit of. syinploiiis of. .3.">2 sypliililii-. 3.-i."i trcalnirnt nf. trauiiialir.i, 3."><i treatniiiil of. 3,")t> luliirriilosa, 3.">,"i in xariolii, 3.'>.5 3.">.s 3.'VN lACKSO.N'.s liiiioi'iilar iimiitiiififr, 20 «' Jacsolir-.VrIt o|H'ration in treatment of triiliia-sis, 249 J8rvi.s' nasal snare, 7tM f, glaiiiipiiia fol- Javal ami .S'liicitz's opiitlialmumeter, 114, 115 i/Ki{.\rK('r.\si.\, 319 I\ tn^atiiient of, 319 Keratitis arlmresi-ens, 307' lianilolrl, 3lli liullous, 31(1 patlioloKy of, 31 1 treatnicnt of, 311 lindritir, 3f)7, li30 ili'sieration, 307 syniptonis of, 30S treatment of, 308 eozeinalous, 297 complications of, 299 diagnosis of, 299 proKiiosi.s of, 299 Mvniploms of, 297 treatment of, 299 fa.soicular, 29H filanieiilous, ,3fH5 idiopathic, 30t> .symptoms of, 30»i traunialii', 3(Hi tn-alment of, .300 frenular, 298 furrow, 307 harvesters', ,301 hypopyon, 303 marginal, 300 diagnosis of. 302 duration and symploin> of 301 treatiniiit of, 302 mycotic, 307 neuroparalytic, 308 treat iiiiiit of, 309 oy.ster shockers', 30O, 304 parenchymatous, 311 .symptom.s of, 313 treatment of, 314 phlyctenular, 297 punct.ata su|)ertii'ialis, 310 ramiformis, tJ30 rililion. 310 sclerosing, 314 symptoms of, 315 (lealliient iii, 315 scrofulous, 297 .suppurative forms of, 297 trophic. 310 vascular, deep. 310 12 » 'Wm V Kfl itL' ;i^i ul;tl !i • ■', f;tUt» -irtt .i;. .1 |i.ir:il\ 'i», .-liiiliii;v . Ill - 1.. r. ,.f. ;ni. 1. . iirii-iil. iu.'.;i '.. ... .1. :iii, lli-'l'ii.r.-il iiii.hii'l. H!.-|;i KiTiii.' ,:;•■• : . '.117 vciiirii-i.-, jinil,i|i« iif ; Ki'r:ii. iiii». :tr 1. .ryniritii, ni.si.-. Mo ll 'ilicTOis III. 111 < ii MIhkmI, s| I s\ M|tlt.|ll4 *>t. _ •li;l(riliii.|i of, HI ll..;iHr.>lll .i! .ill liiiloitv I'l ">i ; Ki-1.|1..L-I..l 11.. :cM illiiil..i;s . ■ ^l."i l"llu.i.ii. :tLM i..({iiii.i« ..i , s|(i uil-.|. . .121 III). 1. nil- ..! .S|."| Kt'rrili 1.1, M<^ tilmi-iii ■'111 KirilniiM ;((.( '-'(, ,-,y\ 111 >l(i i ' .1. I T 1 ,(♦ tt.i ii, I M ttnt- il ':ifltOll|x ..1, N| i .1 1 111 Hit ■ t.'iintTi li\ , M ■ lIHtlt I.f, H|l. K riluHnilW '." "12. HI.H K- : lliisin. ■ ..UlUX ! luiiilini.s III, H2I KWi- ' '!|lllll : iciUu- ' ' 1-1 In iiiTirniili 712 M-f ;MllHii*ii:h «iirrTih . ,H2:i ill •]' tir r\ f. *>■ i-lii.li.i.". I.f, S21 Kllll(l|i |ii turn |. JIMi ■<yiii|.' Mi« 111, .S2I till :l,<i.| 11 lili/irnpl In-' 111 i>f. H24 u|H'rriiiii: r, *^**2 -Siitrv 712 .HIH Kiiigh''- 111- - ihaiK" uir- ' .,g\, s22 inoi ill, ..f. S2;l fc u-ll ' •.. <; i"li t .11. ■ S22 '111 !. ;ilH ) .es liM.-,: v2:< -Mil) ,1- III, V22 ( . ■.ir« ■ IV 20.' trcaii III 111. S2U |i:ii lioli.i;i. I i-liiiii^i"- ill, 7 1 :\\\ .'•MUV of. 1. .•!! |ii.iiriiii-i- . 1, .S21 -\ lll|ili.ti,- ..f, -Sl't .III. -J trrjitiri' t 1 ..1 , H2I ■ -Ullg p. ■!, liii-iiiorrli.-mi. ,1, sl:{ e):«u 2U |>lltliiili.i;\ of, M,i 1 ■.!■. .'17 .yii-i.i.iiii- iif, S|:i tl-.i...Mti,,ll . N In- Mil-Ill iif, ,sltl \tir|i:.ii..' • 1 liv[.iiirlin,ii-:i, x|:{ iiil.'i III . lii.liiuy 111, SI 1 :-,|>. 7 |i,-illiiiii...'\ .if, M 1 -ll|.| nil 1 of, -MII|.tllIM- III, SI l-|i. Jl- In .itiiiiiii ..1. .s|i- lllMli mill !i.'i-i.|)li,-ir\ ii;;ili- 7|ii ... Jl.'. P:i('I-m|i-i 1111,-1. S2.'> .-.Mill -'.ii i|i.-ti:ini-.is of. s2ti },ll Kltl-lii 1 1- '1 . lil.l.lL'.\ of, sj,-, Mo|..-> . («tl |.i.i(riiosi- III , s27 ni]. f, <K»I -yiiililoins 111'. S2.'i -.•:il|||.- . .1. Wi Ins'iliiH'iil of. K*27 iiBH- .iliii...;. 'ZVJ rli. iiiii.'itii-. S12 t- Ml 111 (if, X'lA rliol.iO of, SIJ ik. .. I' riin-r .-111.1 iii.-iis Ijiiok. r,.ili.in- ol. M2 >i 11 : iiiii'iil of. Slti -....■ll.'i. . 1 sii'i.-i .-iiiilii. SI2 . illiir (|i'M'i-i['i ion of, S12 \ . in'niiii.-iii 1.1, .Mil i..iiiii*.!i ' ii;iiti-iinficr, l.'i7 I.Jii-yiiiiiis.-ojM', liiiw to 1I-1-, 7;i7 ' irMii;.,il ,; n;{.> iii.-llio.|-i of illiiiHinaii.if.', 7:)^ ■ ll,-. >.:i:i I,.-ir\-iipts(-iin\ , 7.111 |..-.il,.i..j:. .1. ,s:i2 iii>Iniiii(-iii.. .-Hill mi-ll, I.I-, 7 '... ■^.-t)l|i-l;i- iif, s;l 1 i.-iryii\. a(lcii..iiia of. '.Mi;i --. i!ijti;':i:- -if. ■-:;>; an:r-41-.r -;,; of, iirir. trc!it!ii.-nl i.f. s:u ansioi. -1 of. !t(l2 ilaiiiri'i-^ fif Miiiii..\iii s;l."> i-ari ii! ;pKi of. 'MM Ii.-ii;lK-ii. Ill.'i2 .l.aiiiio.-ii- .1, ttO.^i liihiii-i-iil .-lii.lii.t.ir 10,-,:! .lilTi-i-.-rilial 'Ml.-. /.\/>/-.'.\ I ■_'!!» ^ir\ii\ larciiiiiiii nl , I'l ml- -j\ nl, '."'I |W iIm.I.. .1. '.Mil |iniuii(i-i- ..I. !HHi ^ V tti|il<'!tii ttl , *HI't In'OliiH-ril I. mHi t )i»*ri(lr<'tttH of, '«-J itl.lKIM'"i'< III. Kfi rtititoirv III. !«VJ ■^\ n.;iliiiii- ■■ 'HI. 'naMiii'iji 'Hi; ilMiriui.l, mill mn/ltcmi'iil m 1'' fVi-H III. TJJ. '« illirnijl.'i 111, 'Hll frticliiri- ol, 'Cli liv)xr;rsllir^i.i ■ , liili. iM'filmi-iii ' liit'i iiijii,!'-^ "I, '.M'l hpiiliiii of, -MU lupus i)f, SiWi ||iaKf.">i» 111, Hl(7 path<.lii!;v I.I. Ktiti >i>U.|lt(lllc- 'if. HiMi I n-iu nil-Ill 111. '^'i' tiuAi-nia .if. '-"il iii'iipl.tmii- , V.17 ■ liiitfn MMif, .si«( -itliTiiilial. >*'•'< '■I il .ixy of. .S<»S lildliillll. IMH p;illl..|otf\ of. .S!I.S oroiinosi.'* of. IKK) Mnptuni- I' iHSK) rratinini .u. !I0(( liiiiralcia HII7 h*'iiro?ii> ■ .illli iiioi 1017 papilliiiii I. -Vl" panrstlw -i;i ol. 1(U7 pftr.i'.vii- i.Sfc I.MiMiKiai l'aral)>i>. HC.2.> rplatum m li.si'aii- ol. to ili^i'ases of Ihr I'M-, .V,l.') ^itri'OMKt III , *M)S iliacnii-i'' "f. '•<«• I tiiiloiiv of. im^ IMiliolonv 'if. '«WI -iti-s of. IMIS >VI!ipt01ll^ ol. ^KHt rii'atiiii'iii III. 'Hli.t -pri*iii lit. in MiliilN. M)M» di.'imio-i- of. MM'.' .•l;iiliin\ of. Hint >x lliptollls of. Kll'.l Iri'atmi'iit 01. Kll'.l U. I'llilillKKIil 1017 (li:iiriio«i, of, KM.s el ..liiL'V of. HUT --\ iiii'tiiiH- "!. 1017 rn':iliiii'iil III. 101s pluiiiatiin , 111 111 ,strnii-i; nf Hti7 i-tiolocy of. HiiT pal Ii'iliijiy of. ,Mi7 -ivinploms of. SIVS Iii'.'itiiiiul of. 'Mi> l.iiryii\. ^1 pini - ol. nI^ >*i'riilnl;irv . SIS illai!!ii'-is of. sis pallii iii){y 111, sl». -MUpli.lll^ of. SIS Inaliiiiiiit III. ISliS ti'rliar\ . H.">1 |>!llllo|.i«V of, S.'ll ln:i'iiiint o|. s,"il lliyroiit tiiiiior of. !Mi;( traiiiiiati>iii ol , !ll!» ll-i-alllHllI nf. 'HO apparatii- 'or. '110 loial, <)I0 Hlij-ilii'^ia, i|| 1 inrilii'iiial. IIIO mi'thoiN of. (Ill) in'liiili/,i 1- anil aliiiiil/irK, 'III »urgir:il, 'iMO IIII<llKHii4. 'M ( tuiilTCUloHis of. 701. S.M rliiiiral iip|K;iraiiir of. 70'J iliairmi.i^is of. S.Vi patliiiloKV of, TOli. S.Vt pio^jnii^i- of. sni >>lllplo|ii~ ol. S."it .ippraranii's, XH't i'\pi rlnr.aliiin anil sorrotion s.-,l trialnii'Ml ol, s.")!» can'rry, siH iiili.'il.'ir\'imi'al injri iiiin.i. Sim ilinili:ilii.N. sill lor.ll, Mill -iiliMiii(oii< injcc'tioii^. HliU Ir.'icliriiiiiriiy. sill tumors 111. s'.i7 VlTtlKO of, IO.")I (•lioliii.'v of. lITil priiyno^i'* 111 . lll.">2 i\lliptii|H- 111, lll."i.' Ircatiiu'iil 111, 10.'i2 Wound.'* of, !I20 !.,<' Coiitr'i >r!ii'iiir tor ili'ti'cl ion of color liliniliii'.^>. r>7l I.cail-piiisoiiiiii;. I'liniiiir. nlaiion of. t > ilisiiasi's of thi' I'M-, IMI. IKI.'i I.i'ii- rapsuli . L'laiic<)tii;i folloiving .'inte- rior ^viii'cliiai of. .Vis (li'vrlopinrnt of. XV2 lihrcs, priniitivc, '.i'.V2 fi.i-al li'iic'li of a. (12 n 'rai-tioii. lill rardinal points in. Ii2 I.i'!:"s. i-l:i.^.>ificatiiin ol . lin !fiiiT;ttiiin I 'I. li- I7'^ ll'L'O i.\i>i:.\ l.iprosy 111 iliioai, S(i7 liailiiiliiiry ol". 704 Li'pti>iiii'riiMi:itis. aciiti'. in ini<lill<'-i'ai iiitlainiMiilioii, 1 1 1!) piinilciil, 1 Itl2 (liairiinsis ol. 1 !•>:( cliiilofiy (if, 1 Hi2 In niasl<>iilili~. II 111 )pmcnii>i< cii, 1 l(>;j svnipliitns ol'. 1 1(12 iriatincMl of. 1 'i'' s-'i IS, Il(i2 cli.'lKllosis of. I Itii syinpt<iiii> of. I lti2 trcalnniit of, 1 1(12 liilHTciilar, In inastoldllls. 1121 I.rptollirix mycosis. 70."> clinical apprarami' of, 70.'i niorhiil anatomy of, 70."> Leukaniiii, rdalloii of. to ilisoascs of ilic Mackcn/lc'> liull's-cvc Iimis ami nllcctor. l.upiis of lludal, (iin);i;osis ol, SCiO "liolocy of. .Stiti liislolonical patholony of, 702 syinptoiiis of, Hiill Irc-ilmciit of, .S()7 Lymph pa.s.saj;i's of eye, ',U-i. ',\\'> tissue, atiopliy of, 72.'> LyinplindciioMi.i of orbit. 201 Lymplianiticctasis, 2!H) treatment of, 2!)0 Lymphanttioin.i of orbit, 20-1 Lympliold tissue, intlammation <if, ii'Xi Lymplioiiia of orbit, 2lfl 1I(('IIV'S larvniieal porle laiistique, lU ini M( Hardy peiliniter U 1 McKay's ear forci'ps, IHl .Macewen's lnirrs, I !.")() eye, .'iM I.i'iikainir reiinliis. 427 Levis' wire loop, ")1 1 Liclien nilier, relation of. io dl~e,isr- of the eye, Ii:l0 Lid retractor. I tesm.irns'. 22 Liebreich baiidasje. modllied. li.'i'.l Linameiil, e\iirnal cl k, l,jO internal check. I • LlKamentimi |M>ctlnaUi-ii. XiS, ;(;{!• lyiffht pencil, .'il ra.\-. ol sen.s*', maniita' of testini;, .'i.> wavis, ."i;{ Lightning; Hash, amblyopia from. .■>7>* Linjniiil tonsil. lOO.'i i.sVc 'roMsil. Lin- Cual."! Lipoma of conjunctiva, 2!tl of larviiN. !H)2 nas.al,' .S!I2 patholoi."- of. 72t) of orbit. 201 of throat, p.iiholojiy of, 720 Li^hiasis conjmictlvilis. 2111 LonKsluhtediu'ss, 7li liOring's oplithalnioseopi'. Ml Loup, corneal. 2.") 11)7: cuttini! forceps, itl,") tonsilloiome, lOtK) ^^•^cula, ,")2 holes at the, AliS Intea, Cl.") symmi'tricil disease of, in young children, -i;il Miularosis, 210 Maddox iloubli' prism, use of. In detecting cvdophorla, 171 miihiple rods, ltd roil-test for esophoria, 1(12 ('■' . Aoplioria. 102 ior ii\|iei| lorla, UI2 for orthoplioria. 102 Malaria, rehilinn ol. todisi'asesof the eve. 017 Maltirial amblyopia. ."i77 .Mallorv's methods for ^tainiiiK neuroglia, 070 Mnrchl's method for >iaining sjx'cimcns of the optic nerve, li7S Massage, 7." 1 beiietits of, 7.V1 indications for, 7')1 inetho<ls of application, 7.5.") Ludwid's aiiKina. lOl.T. iSee I'lileitmon- Mastoid disinse, rekition of diseases of .ms I'haryncllls.) to ijiscax » ol the eve, .")9.") Luer'.s eye spiculum, 112 |Mrio»iitls, .icutc, 1110 Lujius. ervtheniatn^u-. oi eonjunciha. cansi's of. 1 1 Iti 202 of eMernal c.ir. 10N2 of larynx. Stifi diaRiiosis of. M07 palholocy of. KtiO symptoms of. .SOO treatment of, >«17 of liosi', .Mi.") diatmo-i- ol. SOO etiology of, SOO h|s|ol(ii;ieal patholoKy of. 702 ^vinploins of. .sot) ire.atincnt ol. Mi? of pharynx. .HOO ol throat, ,Sti.") patlmlojiv of, 1 147 irealinen't of. 1147 Mastoiditis. 1110, 1147 bruin ab.se<s.s in, 1 121 diainiosis of, 1 1 IS eburnation in. Ills etioloKv of. 1 1 Hi. 1147 pathology ol, 1 1 Iti prognosis In, I l.'iO purulent leptomininpills m, 1119 svmptoins and pathologv of, 1116, ■ 1147 irealinenl of, 11 IS operative, 1140 .•ifter-trealnieiil, 1 1.",!» " ' -"^ /v/>/;.v. 1221 1 Mastdiiliti^. iiilicri'iil:!!' |i'|iti>iii('iiiiii:iti-^ Molliisciini, simplex, 211 in. 1121 Monovular diplopia, lO.'l Mathi(>\iV idiisiUiitimic, tt'.t'.t Hold of fi.\ation, limits of, l.'iti Mn\itlimT's silicinc Inr ili'liclimi nl" llii- measurement of, by means atlVctcil imisclr- ill nciilnr paralysis. of the pi'rimeter,'l.")5 17S, 17!l squint, 172 Maxillary sinus, !lj:i MorKatsni, spheres of, tS<i rhrniiic suppuration ni, IM'J MortjaKniaii cataract. l!ll suppiirati'Mi. 'MI .\Iort<m".s ophthalmoscope, HO iliatiniisis (if. OT'J .Molais' (i|»rali(in for correction of ptosis, i trralincnt <.l, !»72 2-M) iniliialidiis Inr, '.>72 .Muc<i(rlc. 22:1, ",»7!» M<'aslf,~. rclatiim ii<i. In iliscasi's cil' ihe chronic, 210 (■>'•. Ill ;i tn'attnen' .. , 21 1 Mratus. middlr. pus in. !IS2 (•ourse of, 224 diatnosi- 111. 'J\2 in infants, ■220 ilitl'civiilial. !tS2 tn'atment of, 2'2(i Megulocorma, :i2l patholoRv of, OSO Mogalopsia, .'iSl sympt<inisof, 224, 070 Meibomian ttlamls, 2:t2 t'realMient of, 221, OSO Melanomata of iris. .'{.V.i Mucosa, tumors of. retention, 722 Menihrana pu|)illari< pir^iMiaus, 31(1 lym|ihatic, 7"22 Iri'alMiiiil of, .US vascular, 7'22 Ivinpaiii. wounds (if. 1()94 .Mucous dcKeneration. p.'itholojty of, 723 ctioloo '•! l(l!tl membranes, iiiHainmatiou of, t)03 synipli(ni~ cf. Kf.Mi Mules' o|n!ration lor ptosis, TM tri'atnicnt of. lO'.Mi vitreous spheres, 410 Meinliranc. Howiuan's, 2'.i."> introdacer for, 411 l)f>ccni*'rs, 21*."> Muller's fluid, composition of. 007 IM'rsistinir papillary, lU'i nuiscle, 232 Mpinl)ran<'Us ronjunitivilis. 277 Mumps, relation of, to di-eases of the eve, .Meningitis, ichilion <•!, {<• di-eascs df the (120 ''VI', (i;{7 .Musc;c volitantes, 1 10 .Monisms, convircinc Td Muscle, advancement of a, ISO, 1S7, 188 divcrttiiitf, 1)1 e.xleriial rectil-, iilt;iehment of, 148 Mereury-|«iisoninc. acuic. relation of, to origin of, 147 disca.si'xif till' eve. (j().") iiaialy-is of, 170 extra-ocular, insertion of the, 149 Meridiaiial alx'rralion, ((7 Mrtamorpliopsia. .VSt extrinsic, in locidization of cerebral -Metastatic puruliiit niininnili-. relation di.-eases. 1S2 of, 111 diseases (if the eye, l'i:i',l inferior obli(iue, or ,i:u' of, 14S Metlivl alciiliol, a- a (aiisc of lilindnoss, paralysis ol, ISl (KXi rectus, ori)tin of, MS Metre an>:le, l.")2 paralysis of, ISl Microphakia, 177 internal rectus, attachment '>{, 148 Mirropsia, ,"i.s| origin of, 1 17 Mierotoinc, knife f(ir. lUlli paralysis of, Isl inediuin lalioratiirv. tiii.") ocular, anatomv and phvsiolojiv of. Middle car. cat.'urh ol. atropine. 1 1'.l.'i 14.". ii\ pcrtidpliic. nstl development of, :i:ili clironic i.ascni.ii cnirorjremenl external. I4."> of. list; rectus, 147 deficient hlddil -uppiv to. I l>l!l extrinsic, 14.'> dise.-ise, eicalrieial -lane of, 11(10 innervation of. 145 proliferation .ami eoiitrac- inferior oliliipie. 1 is tioii In, 1 ISs rectus, : IS purulent itillannnalion nf. 1I(),S insullicii>ney of. l.")S Migraine, iiplitlialin<iple>:ii', ISO internal, 1 i.") scintillatitn: se(it(irn:( in, .'»70 rectus, 147 Militiin. relation of, to diseases oi the I've. intrinsic, 14.) IVM) nerve supply of, l.")l Mind lilindncss, 171 operations on ■■idvancement oi Mo!.- (if coiijnini ;•.,•!. 2."i!t ,1 mils, i.\ l.Sil tenolomy, 180 Mnlluseiiin contai;io-uni, 211 relation of, tn diseases of the para !y sis of, 170 ev. , (>;io diagifosis (if, 177 I.MH.X. Mll^clr. onilav, f>:il:i\\ -\ ITii r<l;itiuii> III ill)' ilouhlf im- :ij:rs ill. I7,s ~\ IllplcMIl- I.I, 17ii ■.ii|KTiiir .ili|ii|iic. 1 IS lrilll~. I IS i.iliilal, .•illiirliiiM'hl i.f. 1 Hi iiiiilalrnil |i:iiiil\-i~ cil, IT'.I |in"liiiini: iMtrnil i'\iiir~inii~. ti'>tiii!; riiiH-iiiHi^ 1.1, |."i!i \iilii:il .■MMir-ioii-, i.'-.|iiii; I'uMi- tii.ii- 111, l,')<l I'-fiim i.:il; 1' till , ,-il till' Mi'lir I'liiiil. I.V.I .«ii|)i'riiii-iil)ii.|iir. i.riiriii ..i, I is |i:il;lly.>i^ iil, ls() iri-liis, iiiiiriii 111. 1 IS p;ir:ily-i< nl. ISO tliyrii-.'ir>IiiMii.|i-i, |iMr:il\ -i< il, Kl.'il Mlisciil;ir .•i>lliiiin|ii,i. Km lll.n.«. iliL'ciiiT.'ilioii of, ill iniil.i. 7'2\ iiiilcil.-inii., l.'iS .\lii..iriilii> iili,iri~ llii.|,iiii, J:iJ .Myiii>i^. Kll,-) l'uiip.iili.~, 701 syiii|iliiiiis ul'. |i)l."i Iri'iiliiii'iit 111, 10l."i .\lyrnlir kiT,iiiii~. ;<07 .Mvilriasis. |i,ii;il\ li.-. :{;i -paslir. :fJ tr;iri.iii'm, .'V^ Aiyiiri:iIii->, u>i- i, ;i< a lacmr in tlir caii- s,'liiiii 111' srl;iii('iiin:i. .'ill U-^i' '. ill li'lllirlli;l|- r;ilar:li-l, ."lO.'l .Myl's n,i..,ij >pi'('iiliiiii. 7UI Iriiiar ami laiiiil.i. itlli Mvdiiia. 7li ..■nillllli.M|;lli..li ill. Sl.> )lllllliii|;ili\i', SI .lAial. S|, s,-i rliaiiKi--^ ill ill.' iliiir..i.| ill. :i7ti inlllpliralinlli ill, Sli .■III1II-, S7 IiiihIii,^ I'liaiiiri'^, S7 M-lirii-rliipriii(liti.i, pii~tri'iiii', S7 iiiiitri'iiiliil. ss lorrrdiiiii nl'. S| riiiirsi' 111 i.|iii.rir"iil i;i ~ in. SI ciirwiliiii' 111', prriiLiiiini, s,"> !|-aii..iiiil. SI i'\liTii.-il I'viijiiiri- .1'. slI lai-lilioii-, SI l.'ir iMiiiii ill, so iliriTi i|. liTiiiiiiatioii of, 121 iin' s(. s.-) II 1 •■ ... I ill, s-.> p ...r . . SS p-. , .. r ^rla,.,.- I,, I, lai pn of, s7 priiiti. <'\\r, ss si-hiHil. SS >\ iiiptoms of rvfrtf! \ ision ill. S>l Myopic I'M', 7li, SO .Myo«i.i, paral\ lie. ;tl. -i f, .'liolofis of. Myosis. spa~lir, ;>l, :{2 .M.vdtics, iisi' of, ill li'iiliriil,irraiai;n'l. ."lO.'i ill Inaliiiciil of ulaiiriiiiia. .")(i:{ .My.xuiliiua. nlalimi of, to ili^'a^-rs of till' I'yi', ."iSil Myxoma of ronjiinitiva, 2!»l <if l:inii\, !Kll of (iiiiii, Iil 1 1 of tliioal, p:itlio|..s.'\ of. 7l'(l >'.\lll'>, po>ii-rior. pl'i.,;i;iiii: of, 7l',l - I .\a-.,il liiiri'«. 7.'." ilipl.tlii'iia. siMI .iriiiiitioii oi, si,'!l .li;ii:iio-.i-:iiHlililT.'n'iitiali|ias- iio-i- of. s:io rtiolon\ of, .S2',) p:illiolo;;y of, S:{ll ~\ iiipioiii^ of, s:{0 tri'aliiii'iil of. s:t| I'lioiiili'oiii.'i, S!I2 iloinln' cup. 7)2 .'iio.''lo.-.i.<, .Sill i'\iisto,'.ii». .sm liyilriirrliii'.i, lOll pioL'llosis of, 1012 ~\ iiiploiii< of. 1012 . In'.'iliiii'iil of. HU2 liypi'iliiipliii's, 7li2 Iii'iitiiictil of. 7li."> iii^illlicii'iicy. hysterical, UMI lipoiii.-i, .S02 oiloiitoiii,-!. S!I2 p-ilypi, 7li:! trc'itnii'iii 111. 7li.'i IMilypiis with cthiiioiilitis. ssl. ss2 lii'phiin's. 7.")7 tiilii'rciilo>i-. S,')| p.'lllloloi:y of, ,s.52 -yiiiptoiM> of, S.V2 Ircaliiiciii of. s.VJ .\Hsopli;iryiii;i'.il cvsis, 722 NiisopharyiiKili^. acute. 1020 I'tiiiloL'y of, 1020 symptoiii> of, 1020 Ucalnii'iil of. 1020 atrophic. 1022 chiimic. 1021 iliiiKiioviv of. 1022 I'tioloKV of, il!2l syniptoiiis of, 1021 22 Iri'iitini'iit of, 1022 anil laiyiiiiiti.-, 710 Nasopharynx, .•m.-itonn oi. l(Ml,"i iliM-a'scN of, its.'), 1020 minor- of, 10:{2 lii'iiik'ti, lo:i2 lihroinata, 10:{2 liliii.iiiiicoiis polypi, 10H."> ni.-iliniiaiil, lo:f.') Nc'ir point fii-ion, l.')2 ill In [H'lopia, !i:i lO" iir iiMopia, S2 \car>iclili'iliics<, 70 Necrotic iliphthcria, ll'.tS p.'illioloifv of. (iOS iM>i:.\. I l-l-.i ■,\\i\ \< niatl |>:triit'( iii .">(Mi stniiitlit catanirl. .")()7 Neoplasms ul' larviiN. X'J7 .lianMiisi, ,,|. S(»<» am. iiiilial, S'.C.I ili(il(i;;y 111, S!tS path.ili'iiry II,, ,S!IN priii;nii~is ul, !I(K» patliiilii'-'\ III. NUN syiiiptiiMi- ui. S'Mt li-ral nt ul, !WIO III' Mosc, N77 nialiciiaiil. Vt2 NorvP, luurlli. parah ~is ni. IM). IMl .sixlli. paralysis ,, I, 1711. is:} sup'riiir larviicial. jiaralvsis ol'. 1054 third, paralysis ni, l\(l. 1S2 Nerves ol llie ilMiruiil, :{ti{ eiliary, M'.i efl'eet nt' ilisi'a^isDi, upmi 1 lie eye, i\'i\ Neiiralcia ol larynv. 1(117 tri^eiuinal, relation ol. to diseases of Iho eye. ('i."i2 N'>j(irulKia.s (if im^e. KlU N'pura.stlieiiia, rever-al of lii Id in, .")75 Neiiii'itdiuv, iiptieoiiliarv , oper.'itioii of, ll:i daiiyer- .iiid ail\antaf:es of. ll.-i Nciirilis, limit iple. rilalioimf, lo diseases of the eye. ImI optie, l."i(l spii"!.iiis. I.'il retrolmlliar, I.")!! Neiiroiilia of the optie nerve, iiielhod of .stiiinint. Ii7'.t Neuroparal\ tie keratitis. :{0S .Veurost's, aiiditorx, 11(12 of larynx. IIIMi motor. 1017 sensory, lOlii of nose, \(i:W of pliarviiv, lOl^i of thro.'it. KKtii Niehols' s|Kikeslia\e knife, 7-'>0 Ninlit lilindness, ,-)S(l \od:'.l point, .'lO Nod'.ile>. vocal. 7l."i liy|M»tlleses. 71.') .N'ose, ader.oeari-iMi)iit;i of, p.atholojiv of, 7!.S adenoma of, p.al liiilo);y of. 719 aiiasthesi.-i of, 1(1)0 anirioiiia of. pathology of, 721 applie.'iliiiii- Ml. 741 .'itropliN Hi -Meed. 7' eli. ,uy ii, 7|.S tn'aliiiini of, 71'.' eareiiiiinia ol, pathology of, 711^ ehoiidroiiia ol . H!)2 paihohnjy of, 721 evKt-c ti:', tiatlioln^jv of 722 ilerciriiiities of lO.V) artihi'ial siippori in, I0t'i2 appliaiiees iis<'d. l(Mi;{ le. deformities of, eoiieaM 1000 treatment ol diplit'ieri,! of, .S2!l (li.soa i-rtieal, 1000 f, hislolo(rv of, (is'.- ji.illioloiry of, OV dl.sliirlnnee-. of seeretioii of 1041 doiiehi s and sprays of. 7;iO epithelioma of. patholotry ol, 71.*^ e\;imiii.alioiis of, methods of, 727 tiliroaiii^iiiiiia of, patlioioity ol , 722 iibroina of, patholoey of, 720 foreiiin liodii- in. 7.'>0. S7 J diai.'iiosi> of. 7.">0, S74 reinii\al in. 7;- I. .S74 ^\ nipt mils of. 7.'>0 treatnienl of, 7.')0 fniclllre of, Iiecleiled, UHil liialnieiil of. 1001 lii'morrha^es of. O'.H) hyiienesthesia of. 10 Ml svmptoms of, 10,0 ireiitnu lit of, Kill iiiHamiiialions of. (iOO, 70<i patholnsy of, 70(i lepros\- of, .S07 p.itholotfy of. 704 lipoma of. S!)2 palholoty of. 720 lupus of. Nti."> histoloiiieal patliiiloty of. 702 neop' isms nf, s77 IiialiKiiaiit. >>02 neuralgias of, 1011 neuroses of, 10:fO odontoma of, S02 osteoma of, sol patholotfv of, 721 papilloma of, hislolouy of, 71'.i para'sthesia of, 1041 |M)ly^ius of. S77. .olnlion of diseases of. t.> diseases of the eye, MKi sjire<iina of, patholoiry ol. 710 scurvy of, tiSH) spurs of, 7.")0 diagnosis of, 7.">li patholoiiy of, 7.'i(i Ireatiiient of. 7."iii syphilis of. Sir, patholot;ieal aiiaiomy of, 70.S .secondary, S17 U'rtiarv, S4!) tilberculosi.sof, patliolo>rv ;it. 0Utt,700 tumors of. ,S77. S91 lieniBll. 710 malitiiiaiit. 71 S. S02 n'tetitioii. 722 N(ives-(i«iild apparatus ^ii ti.- itiiiei.i of exophori.i. iti."! Nuelpar cataract. 103 Niitriti!in, (iisturliances m. 7ls, 723 Nyc'ftiopi:.. ;;S(! N'ystagiiii^ I'vS aeiiuired. l^'.i coii(feiiii;i! !ss If A. li'lM iM>i:.\. t kCULAl; l)allott«>mi'nl, ISl (IphllialiiKxIvnaiiiiiiiirti'r, l."i7 ■oiijmuti\a. L'.".S Opiitlialmimialiuia, a7!> iiuijiclcs, iiisutlicifiicv ot, 1,'>S Ophthaliiioiiicln-. .laval and .Scliinlz'a, -i(rn» and svinptotns atlcniliiifj dis- 114. 11.') i-a.HCH III' ihr lirain. 111.') ()phtlialni(iplii;i,i. ixlrrnal, IW) ti'iiNinii. nicrrasid. I'lTrcts (if, (in llie inlcrnal. a:t. Isii ritriictiircs (it the cyi' and pniErcssix c, rclaliim (il, to discas.-:, of their rts|K(iivi' Innclinns, 52S tlic eye. 111.' luiiinal. ineclianisin for the total, Isi) niaintenance of. 524 Odontoma, n,i.-«il, S!t2 0'lJ«vei',s iiiliiliation tnlies, 83.S (JOdeiiia, cardiac. li!M) of evdids. 211) icnal, (i!K) Olfactory cleft, pus in, !>S2 di'iKiiosi.s of, <».S2 dilTcn'iilial, !tS2 Opacities m im-dia, diacnosis of, y,i parallactic displaceiiient of, 43 Optic disk. 4.S I IphthalrnoplcjiJc niiiiraiiie, Ixd ()phtlialn'.osco|ie, :{7 description of. ;i.s .stationary. 40 Ophthalmoscopic evaniination, indirect, 45 Ophthalmoscopy, application of, to deter- mination of refr.iclion, llfi Opium-ixiisoninc, acute, relation of, to diseases df the eve, fitMi OperatiiiR-mask for practising on ani- mals' eye>. (>(i;t Operation of depression in treatment of cataract. AtMi Karlow's. for forward proloiinatioii of .septum, "•'>2 the pin. 7iil teclmi(|lie of, 7I>1 of solution ill treatment of cataract, 507 Operation- on the eve, after-treatment of. (ill I anasthesia in. ueneral. (i5!) local. til'iO infiltration, fiOl illumination of, (ili.'{ position of oiicnitor in, titi2 of patient in. (ilil preparation of dressiiitis for, 058 of instruments. Ii."i5 of patient. ii.'i:{ of region of operation, 1154 of ,'*ponges. *i,"i7 of surgeon and .a.s.-^istants, ti55 of sutures and ligatures, ()57 lii if pcrformaiic(^ of, lifvl on tnn-ils, ii((!l Ophthalmia. 25'.» catarrhal. 2tiO chronic, 2S1 Kg.vptiaii. 2112. 2s5 niililarv . 2112 ucon.itorum, 27:t cause III. 27,'{ cjiinplicatioiis of, 274 diagnosis of, 27 1 iMllmd of iiilcclion, 271 pathology of, 275 prophylaxis of. 271 iiiidos:i. 2.Mi sympathetic, '.i'.m i-!i.-.|.-.gv of, ;i<to palhologv of, ;{!>:{ proph\la\is of, :i!l4 -\ uiptonis of. .'Jil2 cupping of. as a n suit of gluu- com.i. 'I'.iS opiil halinoscopic apjiearance of, in alisohitc glaucoma. 537 foramen, licj ner\e aiiaiomy, 110 atrophy (if. IliO, 4(12 changes in. in primary glau- coma. 5.37 coloboma of sheath of. 450 eongrnit;il iM'culiarities nf. l.'iO developni'iit of. 331 fihrts, opai|ue, 420 glaucomatous excavation of. 539 head of, 49 injuries to, 105 nuliations. 441 section of, 440 in alisohitc glaucoma. .537 sheaths of, 441 retained. 420 tumors of, 201, 401 symptoms of, 201 treatment of, 205 neuriti.s, 450 spurious. 454 papilla, 4S -stalk, 334 tra(;ts, developiri' lit of, 334 vesicle.a, primary, 470 Optical sy,stems, compound, 03 Opticociliar\ neiir rtomv, operation of, 413 danger- and .idvanlagcs of, 115 < iplic-, ili-linition of, .53 physiologic'il. .53 Ora serr.it.a, 331 Orbicularis muscle, 232 pupillary reaction, 35 Orbit, analomv of. 1112 eelhililis of, 104 ctioiogv of. itit symptoms of. 104 treatment of. 105 cvi.sceration of, 207 i\iii:.\. 1 -iU ") Orbit, rxfiilinilioti i>f, 207 foHMtfn l.inlii's ill, trcutiuoiit <if, 190 iiijurii-N ol. Irr.'itinciit nl', l<)f» iiistcitis of, l!t.') ulitilciisy III, 195 syiiiplDins of, 19(1 tn'iitmi'iit of, 197 I«Tiostitis of, 19.5 itioloitv of. 19,") --yrnploms of, 1911 Iri'Mlinriil of, 197 3;iicorii;i of. 202, 2(W tumors of, 2112 t-\|)lonitory incision to detor- ininc naluri' of, 203 Kronlrin's ostcopl.astic rr'scition in (li.'ijtnosis of. 204 >yni|>tonis of, 202 Mili<;il MTtioM tliioiiKli the, 149 Orf)itul nnisilis, ati;i(liniiMit of, 14(i tissu.->, ilcvilopincnt of, 'SMi tinnoi-i. aiii'Mi'i'-ni hv iinastonii>si.'<, 201 ancioni;!. 201 I'lioncli'oina. 20 1 rysK. 208 I'nceplialocolo. 20<) inilionilmnia, 20} lipoma. 20 1 lynipliailinorna. 201 l\ Miplianaioma. 204 lympliom.i. 204 myxonja. 201 osteoma. 20.) sircoma. 200 tumor of the optic none 204 v.-uicosc veins. 201 Oroiiliarynv, iliscasi's of. 98.") tumors of. 1017 Ortlioforni in tn'almcnl of inlicnMilo-i- of larynx. S(i(p Orthopliori.'i, l.")S • lotermin.-ilion of, livcon\r\ -plicrical test. l().'i Mnddox's roil-tesi for, lti2 Os.seons growth of conjiini'tiva, 2.")9, 291 Os.siciili<toiri\. 1141 |if)sI-o|KTalivc care of. 1144 (Ksihcation of ilic clioroid. 3S0 Osteitis of c>rbit. 19.") Osteoma of nose, p.'itliolc>t;\ oi 7;il intran.isal, 891 of orhil. 2tl.") treatment of. 2011 Otliaiiifitonia, I OS.") elioloiry ol. 10s.-, symptoms oi, Hi8() tn-atment of. 108t> Otii' cen4>ellar aliscess. 117:) difiereiitial di.'ienosjs of 1174 symptoms of, 117;i iicalnMiil iii, 1174 eerc4.ral alisc'ss. 111)9 diaRiiosi.s of, 1171 eliolo){y of, 11(19 (.•tic ccrobrrtl absci'ss, prognosis of, 1171 svmploms of, 11(19 I'reiitment of, 1171 Otitis medi.i piinilenla. (.Sec Inftairmui- tion of the Middit- Kar, Purulent.) acuta. 1127 <liagnosis of, 1129 paracentesis in, 1 131 prognosis of, 1129 symptoms of, 1127 treatment of, 1129 ilironica, 11.33 diagnosis of, 1134 prognosis of, 1134 removal of larger os- sicles, operation for, 1140 after-treatment of, 1144 -yinptoms of, 1133 treatment of, 1135 ttlomycosis, 1091 fungi causing, lOttl diagnosis of, 1(K)1 treatment of, 1092 O.xaluri.a, relation of. to diseases of the eye, (iOl "(Jvster shuckers' keratitis," 300, 304 IJACHYDEHMI.V of vocal co.ds, 713 I I'aehynieningilis externa with extra- ilural or epidural abscess, 1160 prognosis of. 11(11 symptoms of, 1 101 treatment of, 11(11 in middle-<>ar inflammation, 1119 relation of, to diseases of the eye, 639 I'agenstecher's o|)eralion lor correction of ptosis. 23(1 I'alate, cleft. KMio etiology of. 10(1.", symptoms of, 10(1(1 treatment of, KMKl o|)oralivc. 10(19 soft, 989 adenoma of, 989 angioma of, 989 benign growths of, 989 carcinoma of, 989 malformalioiiK of, 98.") congenital, 985 inaiignant growths of, 989 papilloma of, 9,S9 sarcoma of, 990 W'.undsof, 1008 l'alpi4)ral lonjunctiva, 25S fissure, 193 Ptiiias' operatifni for correction of ptosis, 23(1 probe for I'xploring the frontonasal duct. 9(13 l'ana.s-.-Mielleiio|)iMiilion for trichia.sis, 2.'>3 i'anmis. 309 cjiriiosus. 309 cra.s.sus, 30'.» \-i2i; iMii:.\. Ill|nl( . :i(Ht *y .1. ;)ii',t I'i illr:i ITlillir. :i:VI, iU.'i l'rll;ij:rM r1:il loll 111. Id (Iw ii'iiiii-. :iiK) tirati!ii'il III. :tl(l VilM' iilaris :«H» vyr. Ii:t 'iMiipliijrii JUS Hiiiioniiiia .'i'-ilirii<i|ii:i, Kit) I'anzcr'i -iiisMir^. '.•.").") I'apillilis. »,-)! I'apillHMia 111 r.iniiirlr. '2'.>J 111 iiii;jiiiiili\a. '_".•! inlranasil. ss7 111 larynx. S!t7 111 IHiv. Ilislulncy 111, 7hi miiii\ai lit. "M't uf thnial. liisli>loi;y ul, 71!t I.I' iiMil.-i. !IMI I'ar.Jiiiliiiilal IriKis, m l'ariirriiti'>i-.iil' aiili riiir rliaiiilirr In Ircal- lilrlil III tilauriiTiia. lt<V.i l'ar.iiii-i> 111 iiiliTiial i-ar. 1101 I'araildxiral |Mipill:.i'v irarlioii. 35 I'ara-stlii-ia nl lai\ m\. 1017 111 nii-r. Mill ■ 111 pli.iryn.\. 101 ( piiiHii<isi>. loll Miiipliini^ 111. 101 1 rarakihfsii. Lis l'aral!a\ ti-l. 111:! I'araly-is m al..liiit.iii nl innU, 1051 auitans. n-latiuti nl. to iliM'ti-i^'.-i ^il" the I've. (il2 liilatrral ;iililiiiliir. 105:i 111' ci'iitral aluliiftiii^. 1051 riin.iiis.ili'. 1^1 n! i-niniT^i'nri'. iNl III rvtiTiial irrlii>. 17'.1 III' I'liurlli iirrvf. ISO. ls:i tinirtiiinal. nl inli-inal rar I 101 111 inlrniir iililii|nr. Isl rciiii>, IM 111" till' iiisanr. rrlatinn ii!. 'n ilist'asi's 111 till' I'Vi'. lilO ul inti'inal rcrtiis, Isl 111 li'valm ,'ihr, 1011 111 iinilar iini'^rlr.^. 17li 1.1 pliai-vnx. 1015 ri'inrii'nl l.irviiKi'al. 105:t 111 .-i\tli ni'i-vi'. I7!». ls:( lit' Tiuirt'riiii' lar\nj;i'al ni-r\i*, 1051 iililii|U<'. I'SII ri'ilii-. ISO til' tliiril iiii'M'. ISO, 1S2 111 lliyrii-arMi'iiiiiili'i iiiiiM'li's. lO.Vl iinilalrial aliiliirtiii'. 105:i 1.1 mhilal niiiM-li'^-. 17!t I'.'inilytii' inMlti,'i>i-i. Xi myo.'^i.s, .'{1. ;i2 I'ari'nchyinatiiiis krr.'iliiU, :!ll infl,'ininiatiiin<. 7IMi I'arin.'iinr.s runjiiiu'lu iii.-. 2t>7 I'ariisniia. KKill I'liiiliiirv 111. lino Iri'.'itnii'iit 111. 1040 Parry's ili-^i-aw, 20S I'ar.s riliari" rrtina'. IWl. iWS niilii'.i nliriM'. liiil. :i:ri aii-M' (>r. 'JliS I'laliiiii III. Ill iM'f< Ot till tin' t'j-c, 7(H) ti:{0 tn'alniriil nl. L'OS Prriclininlrial intlaniinalinii'^, t^ I'l'rirlliinillit is nl >i'pluni. litMi li\ |in|ila>tir. 70tl I'lrii'lininiila! spaii' :UI. :U5 I'rrinii-ti'r, nii'asur"nii'nt nl iiiniux'niBr lii'lil 111 li\alinn In ini'iiiis of, 155 III M|iiiiil witli, 17:5 l'<'rin«ti':il ii|l|anini.'iliiiii>. "IKi lVrio.ll it is, aciitr ina-tniil. 1141) laiiM's nl, mtl p;itliiilni;y nl, 1 1 17 lii'atinrnt of. 11 17 111 orliit. 105 111' >iptiini, 700 IN'ri.Tiipir lri'.M''i, 01 IVritonsillar al>sri"<s, !)<<;{ I'tinlncy of, !Ht:{ s,\ini>lnius iif, WA I'rtalincnt ol, 0!»l IVrriuN .'irtiliiial rvi'>. 1(7 I'etit, ranal of. 17li I'etvnsal sintl.sc-, inlii'tivi' tlironil'osi!* of, 1100 i'liarv iitii'.'il alisd's-^. (i07 artiTi"'..*, KHIS annnialirs in ilistriliution of, KNIS tonsil, 1022 I'liarviiKitis, arilti', UHfS .linlocy of, 1»H)S, KMMI plilcKnioiiiiiis, 10l:( svniptnnis of, 1013 tn'aliiH'iit of, 1013 sviiiptonis of, l(K)y In-alniput of, KXK) atrophic, 1012 symptoms of 1012 ticatmi'iit of 1012 rhronic. tOlO granular. 1010 I'tioloiiy of, 1010 symptoms of, 1011 trr.afmrnt of, 1011 simpli', 1010 I'tiulocy of, 1010 svmptnms of, 1010 tri'.'itmi'iit of, 1010 Kanfrrciions, l()l;j granular, 1010 IMiarvngofcli', KHIS symptoms nf. KHts I'liaryntiosrnpy, 735 ti'rliiiiiiiii' of rv.'imiti.'ttion in. 73.% riiHiynx. aiiastlii'sia of, 1043 t'liolojty of, 1043 synipioms of. 1043 tri-atiiii'iit of. 1013 IM'UX. 1 227 I'liHi'Viix. I'l loiiijir - Mini iii.'illi>irii.'iiiuii^ I'llociirpiiK'-iMiiMiiiiiii,'. ii l.il mii nl'. I<> di of. I(HI7 fiis<'~ III tlif r\r. (HIS <li|)lilli<Tia I , ,s:tl iliHjrnii^i^ III. s:;2 (lilTiTcnii.'il, s:t:{ |i,-illiiiliit;y III, M{l tlc.itnirilt 111. Mil liiM-Mst'.-, 1)1'. iims riiii'iui' limlii'^ in. Kllti ^\iii|ili.iii- 111. lOHi lli'MIMli'llt Ml'. IDHi li>'!iiiiri'li;ik;r Iniin. !lll.*i li'Tpis 1)1. km;! -viii|)t(iiii« 111. ioi;{ IllMlllll'lll 111. idl 1 li\ |Hr:i>lliisia nl. lon (li:ii;iiiisi-i III. Kill (Miiiludv I.I. Kli:( <yiii|ili)iii^ ill, K»l I tri'iitiiii'iil 111. MII lupus dl', M^i M iiipliiin.-. Ill, "■•ill iii,'ilfiiriii:itiiins nl. KHIT imitiir .li>(Mili:iiiii'~ nl. Kll.'i MiMiiiisi-s ill. Kli:t I •ira'.Klhrsia nl, 1(114 pronniisi>i nl. Kll I syiiiplii|ii-< 111 . Kill paraly>ls <il, K)l"i para.sitic disi-isi- nl. Kll I nivcn^i-;. Kll."» thVusli, Kll I n-latinli n(' (li.s4Misr?i nl", in ilisrast'.s (*!" the lyi-, .">!):{ »|iasin nf, KM.") stoIKi.si.s nl, KKIS t<'rti;iiy .syphilis nl . S,")!! iliauiin-i- 4, S.')<l (lilT. iilial, .S.".(l palllnlni;. 111'. s.'>0 sviiiplnins nl, S.-iO trr.Mlmriit nl, .H,">(l lllhl'l-rulnsl- nl', .S,'>2 <iiaUMnsis nl", S"j2 (liliVrciitial. S.Vi patholngy (if, S.VJ pmillinsis nl, Hi)2 syinptnins nf, ,S,")2 wiiunds nl, KHIS I'liillips' plinliiplinii', 7;{(l Phli'gmniiniis pliaryiijjilis, anili', KM i syiiiptiiiMs nl, |in:< tiTatiiiriil III, 10l:{ Plilydena pallida, 2t)l Phlyctenular cniijiuu-tiv iiis, 27!* " keratitis, 2'.t7 Phosplmturia. n'lalinn m. i the eve, tiOl I'in n|H'i'alinii, 7(il I'iiiKueiula, 2S.S I'iiik-iVf, 2(iS I'lacidn's <lisk, 2r) appliratinii nf, in drti riiiiiuii)! cnriif.d (urvature, 1 H I'laiie iiiirrnr, ux' nf, in -kiascnpv, 121 I'laiin-rniii'.'iM' liiisi-, (il -riiiiMA liii>i'~, I'll I'lexu.s annularis, 2!Mi I'liia seniilunaris, -'.'iS riu'Uinninicie innjum I i\ itis. 2(i(l I'neiininni.i. relalinii •!{. In diseases nf the eye, .'>'.).', I'nlliiiriii, :{IS Polilzer's liajr. llSd s|HMiiluiii. Kl77 Pnlypi nf iniijuiiiti\a. 2'.II eysis in, 722 filirnniiienus. nf nasnpliarvnx, IdH.') I'lilypnid i-ysts, SMI syliiptnliis nf, SSd treatment nf, SSI Polyps 111 inrds. 7H Polypus. Iileediiij.'. of septum, 88H intranasal. .SSI iia.s;il. with sinusitis, S.S2 iliai:iiiisis of, SS.'{ prnjinnsis nf, S,s:l tre.'itinent nf, ,SS| nl nnsr (ledematnus), S77 elinliiKy nf, S77, S,S(I luiernseopie ap|)earanee nf, 880 pathnlojry of, S77 retronasal, SSI palholn^v and ilinieal liislolnnv of, 714 Poiiierov head-liand and minor, 729 '• Pop-eye," ,S!» Pori'iieephalus, relation of, to disiases of the eye. (145 Posterinr ehamlier. 340 e\u<latioii into, in cvelitis, :{.-.2 in iritis, :j,-,(| .syiieehia', .'{."lO Postnasal grnwlhs, 102:t iliatrnosis nf, 1027 etinlngy nf, l(l2:t proKnnsis nf, |(|2S .symptoms of, 1023 (iratmenl of, 102,H PruK'.s asiiKinalie letters, 12."i iseases ,,\ i'li'.sbyopia, (ill " Pressiin' points," 231 Plio.sphorus-pnisnninn. lelal ion nf. In dis- Prince's a<h ancenieiit fnneps, IS" ea.ses nl the eye. tHI.". Principal focus, .17 Phthiriasis eilioruiii. 212 point. .5!) fpl.'itinii 1.:. ■•• di-f:i-<-snf the i-.r, ti;-;o Pri.'^ni. lictcniiiiiat i.Ul OI tliC ,ixi.s of Phthi.sis liiilbi, 3.54, 37<» 1 10 essential. 37'.» ilisplaceiiienl produced liv. 140 Pigment, ihornid.d, fiinctinn nf, til) Prisms, aclinn nf. upon retinal im.i({e.s retina!, fuiiclion nf. (Hi l.",:i 1 'i'iM l\ll^:.\. IVi-irn- ill tri'atriiciii Hi iliMi-tfiiit ^^tr!lllis- riini.li'iit iilitis m.'ili.i. ilirniiip, riiiioval mil-', IT.") of i's<i|>liiThi. ItiS of c'Miplmria. il>."> (if liy|"'r|>lii)ri:i. 170 Prismatir (ihirs oi' irv<t:tlliiir lens. 17.) Psou(loKlioiii:i (if the vilri'oiH. :{S7 P8oriii.Mis. n'l.ilioii iif. to (li<i";i->i's of lln' eyp, t't'M Pt<-"rvniiiiii. L'SS iliaHiiosis of. '.N!t n'ciirrrni'i's of. 2!K) liratini'iil of, 2S!I Ptoni:iini'-|M(isoniiii;. ri'latioii of, to ilis- eiis<s of till- t'vi', IKIS Ptosis, ISO, 2:u acquired, J:{."> ailiposa, 2:{,"> aloiiiia. 'J:t."> rorebral, 1S2 paralytic, 2H."i tli'atincMl of. 2;{,') WoltT'-i o|«'r;ilioii, i'M unilateral, is2 I'linita lacryiiLilia, 21 I atresia of, 21!l Puncliim |)roxiiiiuiii of converKenee, 1,)7 remoliini of coMvcrteiice, l.")7 Pupil, accoiniiiodalioii .iiid i-oiiver);enre reflex of, M .VrKvll-liolieitsMii, ;!2 associatcil iiaction of. :{1 cerehral cortev rellc\ of, :i 1 color of. 2'.l iiiiisi'iisiiO refli'x of, ,'{0 direct liu';i ntli'x of, :{() exclusion of, :{.V) indirect, n^flcx of, ;{0 occliisiiin of, H."i0 follnviiiv' i\irai'tioii of cataraet, .■i.'t n|>iTations lor ciilari;einent of, 3t)5 for ocelus'on of, ;!(l>t sli.iiie of. '.Jit variat'iMis in si/e of. 2!l Pupils, separation oi, iroin each other, 20 Pupillary im inhr.itie oersistins;, XVi, 346 n-aetl' M, oilii( iil.ir. :i,') pnaiioxical. :!."> Purpur.v, rtlalioii of. to .lisi'ases of the eye. 'mI Pniiileir. I' ptoinei,!n;rilis. lli)2 ^! rifio-i, ,>i. lltiii cliojosry of. 11112 proL'icisis and treatment of, lli;:{ symptoms of, 1 1(12 otitis media, acute, 1127 diasjno^is of, U2!l paracentesis in, 11:51 piiiixnosis of, 112(1 ->. iiijitoin:- of. U27 treatment of. 112!) 1 hronie, 1 13:! fliajriiosis of, 1131 [iroiriiosis of, ll:!l— !."> of large osui- cles, oix'ratioii for, lilt) after-lreatinciil of, II 1^ -viiiptoinH of, ii:t:{ Ireatmi'iit of, 11 :(.'>- Hi l'u~tulc. malignant, relation of, lodisi'ii>«'s of the eye. till I'ya'inia, relation of, to diw.ase.s of the eve, (ill Pya'mic retinitis, 130 <l riSlNK aniMv.ipia, Uil K .VCK.MO.sk staphvloina, 317 Kadial fihres of" Muller, 334 Ue.il foeih ,"i7 Ued liliiidness, ,'(70 glass test ill lieterophoria, I'M) Hed-Kreen hlindness, ."i70 lietli'x anililyopia, .'>7',l eonsi'iisuai, of pupil, 30 corneal, ex,'iiiiination of the. 24 direct liilht, (vf pupil, :tO fuiiiius. 12 Haali's. :U indirect, of pupil, Mt. iridoplegia. ,32 unilateral, 32 nf pupil, ai'eomiiiod:ilioii and con- vergeiici-, 31 streak, .50 lief ract inn, ,')fi absolule, ill aslifiinatism, UK) I'ardiiial points, ,")'.l collective, ,Vs formation of iinaces liy, ,'i!> at curved surfaces, .Mi di.speisive. '>S deterniiii.it ion of, application of oph- thalmoscopy to, 1 II) conditions i^overning, 110 hy direct illumination, 117 liy the direct method, UH liy the indirect methoil, 117 errors of, as a factor in the causation of glaui'onia, ,')40 Rcneral rules for examining, with the triiil ease, 12t) lens. oO oardinjil points in. f>2 Nulljecti\e tests lor. 124 astigniatii- clock-face, 12,") direct delcrmination of the far pomi in invopia, 124 tesi-<ards. 12l> trial casi', 12l) Refract i\ I- condition, estimation of, hy riicans of test-icittT.-;. 7:i errors, liygienie treatment of, 141 (.liiective tests for. 111 subjective tests l"or, 1 1 1 symptom ■ of, IDS /\/»/..v. I T2U Itilrmlivi' iiri)i>. Miiiplnnis of, in :i^ii«- iiiiiii!<iii, IK) in liv|»'r<i|>iii. Ill) ill iiiMipia, l()l) u*' <>l cvcloplt'isics in (IcIiTiiiin- iiiK, il2 imlox. ri'liitivr, .j(i Hi'jfrrssivc (lisliirlmni-cH of niitiitii)ii. 723 Keik's foriniilin sicrilizor, ti.')7 RelapxiiiK lr\pr, nlatiiin of, to iliwaws of the oyi', (il7 Uespiratorv trncl, cITicIn of disiiisc* of, upon the vyr, VXi Kpiiiih. nniitoiiiv of, 117 atrophy of,' 422, l.<:l rhnnKCM in llir, in iiriinaiv Kliiucoiiia, coiiKcnituI piKnirnlat.'oii of, i:W cysticorciis of, i'.iX dftiicliiiicnt of, l:i."> Klaiiroiiia followini;. .'>.51 devclopiiiriif of, ;{;«. 3;u (list rihiit ion of vi'-si>l.s of, .'lO eflffot of liglit upon, JX? pmbolisiii of ii'Mlial artrrv of. 431 Klioma oi, 43.S. »;!!) rirxaeonal picmi'iil cells of, 341 injuripn of, 43X sclicini' of stiiKliirc of, 41^ tliromliosi.s of iintnil artery of, 433 Retinal asthenopia, 1(H) image, mental projection niul rectifi- cation of, (Ml pigment. Iiiiiclion of the, 00 veins, glaucoma following fhroinbo- sis of, ."),"i2 Retinitis, allmmiiiiiiic, 123, 425 ciniiiata. 431 degenerative, 424 dialietic, '20 hemorrhagii . 427. 42S, 429 inflaniinatory, 421 leukii'inic. 427 pigmentosji. 434 proliferans, 430 pva'inie, 1,30 striata, 4.30 svphilitic, 121 thromhotic, 427, I2S, 429 Iletrohnlbar neuritis, 4.50 Retrona-sal polyims, SS4 Retropharyngeal ahscess, 1017 iliagiiosis of, lOlS etiology of, 1017 svmptoms of, lOlS («>«••■ it of, lOlS Rhachitir te , 313 Rhachitis, n'lalion of, to diseases of the eye, r,H5 Rheiimalie laryngitis. S12 etiology of, S12 s\mptoni.5 of, St2-St0 treatment of, 816-SlS Rheumatism, relation of, to disease^ of eye, 012 Rhinitis, acute. 70S Rhiiiiti.>, acute, diagnosis of, 771 etiology of, 70H prognosis of. 771 syinptoiiis of. 770 tn'atment of. 771 alrophie. 710, 7S!) diagnosis of, 79.'i etiology of, 7!K) prognosis of, 79."i >ymptoms of. 792 ihronic, 774 di.ignosis of, 7S2 etiology of, 77."i prognosis of, 7H2 sjnipfoms of, 777 treatmi'Iit of. 7S2 dry anterior, 7IH filiriiious. 7H0 diagnosis of, 7H.S etiology of, 7S7 prognosis of. 7H.S s' inptonis of. 7SH trealmeni of. 7HH hyiMTtiophic, 774 diagnosis of. 7S2 etiology of, 77.") prognosis of, 7H2 symptoms of, 777 trcatnient of, 7S2 sicca anterior, 71>< simple and chronie, 774 diagnosis of, 782 etiology of, 77."i prognosis of. 7s2 symploms of. 777 treatment ol', 782 vasomotor. 091 pathology of, 091 Rhinoliths. K7.") diagnosis of. H75 pathology of. S7."i symptoms of. 87.") treatment of. 87.") Rhinorrhoa, SOI rerebro-spinal, 1042 diagnosis of. 1042 etiology of. 1042 symptoms of. KM2 treatment of. nil, 1043 diagnosis ot. 80") differential, .SO.") etiology of. ,S04 prognosis of. 80,5 symptoms of. 80,5 treatment of, 800 Rhinoscleroma, 70.5 histology of, 70.5 Rhinoscopy, anterior. 727 attitudes in. 730 instruments used in. 731 reflectors for. 728. 729 source ol light in, 727 technique in. "32, 733 r)osterior. 733 examination in. 733 ^quisites for. 733 i-.';;n /../'/•■.v Wiclni'- npii iiiiiii i.ir ci'tro,!!..!!. ■.'.Vi, .'.V. Hini.', ilii.n.i.iil. IS -ili-nil IN 111 Wnl.l. w 1, llKi.-. linn;"' *•>»' iii;t-k. ti'ts • l!i|ii ' r:il;ir:iii. IVI l{ii|r\ 'i riil.irv |iii-iM, llil l{ii|inirr 111 rlmniiil. H>«J ^AN li 'MN I't'l'-'lMN" i. ri'latiiiii ot, i' III ili>iaM'~ III till' ryr, (K)" StCl.iii' riHiMi^iin's lurri'ps. !•7^ SiijiiiH' li.i-.ll -nail', Till Surriniiii <>i rliiiinlil. :(>•<• III riinjiini'livM. Jll'J III ■•xtirii.il lar. KKi iiilraiia>al, Vi:» iliamiii>i> 111. "»!•-■> i'liiiliii;v III. sot -.li'tal iTl,i-i-. iM'.itliiilil I.I, :tJs nni:. IS ,-iliTiii-, Mr, ili-.|i, :i2i. MTiihiliiii". -i-' SiliTii-i'lioriiiililK |iii-iiiiiii. s7 Si liiii-kir.itii-iiilii. :iJ7 s\'ni|iliitiii 111. -127 Iri'atini'iit ul. Si' ^ilirii>i>. ililTii.-J' riTilir.il, rrlatinii ul. In ili-.i-;t>iH III llif rvi'. (ii:; iliTwiiiiiiatiil. nlatiiiii nl. to ili.sfa.si- lll tl vr. ti»J .Sill. rill ir. rliaiik'i- i" tl"'. m primary (tUtl- coiiia. vVJ'S .SiliTiitiiiiiv. iiiitrriiir. ill Irialmrnt of ulaiii'iiiiia. ."it'll jMistiTiiir. ill Ural Mil lit 111 ulaui'oiiiu, ■■'•'-' Srii|Milaiiiiiii', iiM' of. as a iiivilriatio, 112 mirii.siiipii- appiar.iiii-r m. s'.l.l Sfii|Milaiiiiiii'-piii-iiiiiii»t. ri'latloiiuf, to ilii»- p.llllnlilliy 111. S!ll priiuiiiisi- 111, yt.'i -yiMplnlll- 111. S!t."i trralini'tit ul. .H!ir. fii larvnx. IHls iliaminsis iii, '.HKI i-tiulucx 111. !KIS palliiiliitfv ul. IMMI sili-s 111. !H(S syinpliims ul'. '.Ml*.! tii'almriil 111'. '.'Oil 111 iia-iipliai\ hX. I():>."i ol tuisi'. palliiilni! 111. . I'' of orl'it. 2112. 211.. 'JIMi tifaiiiii'iit 111. '2117 of soil pal.ili'. '.«H( -\'fiiptiiin- 111 . II'HI trralllli'llt of. tl'.H) of tliroal. |ialliiiloirv of. 71(1 of Iiiii-il-. |IK):i iliairiiiisi- of, IIMM iliiil.ii:y ..I. HKll -VMipli'llll- I.I, IIMM tn'.'iiiui'iil i.i. lllii . of lIMll.l. 'I'HI s\Illp'iilll- III, IIIHI ll-i-.'llllii'lil of. !»!MI Si-arlati;ia. M'i.'il imi of. to ili-i'.'isi's of ll I'Vi', lilU Si'lili-ii'li's iiililiialioii alKi'-tlii'-la in opi nitioiis on I 111' I'M*, ''itil Si'lili'inni's I'.iiial. :i2.-i. Xi'>. :ii:!, :!ll, ;il.' " Si'liool invopi.'i," ss Si'lr.-a, :(2i .'inaloMi\ I.I. :t21 ili'Vilopiiinii of. :(:i."i foi'i'ii;ii lioiliis ill, :i:{l) injiirir- III. :{2!l laii'ialini; woiinil- ol. H'J'.I inpliiii' of. ;{:ti) -iiipii V ioiii.i "I, -V^^ svpliilis of. :i2S Iri'aliiii'iit of, :i2".t Scli'ral I'ltasia', ;J2S r,'llisi.. ol', :i2s I'asi's III till' r\ I', I*»<I7 St'oloii a, ll!l ri'nlral, in tii\ir amlilyopia, i\X iirKativi'. l.'ili (Kisitivr. 4.'it) si'iiitillatiin;, ."n!! Sooloinata, in ilissi'iiiinnli'tl choroiditi.s, It.S Seiirvv of llosr, liiMI of throat. li'HI Si'liorrliii'ii, rrlatioii ol, to ilisiasi's of tlic i-yi', 030 " .Siiond -ielit." I!'2 Si'ili'r's tuliiilar forrrps. '.117 .s,.|,i|i. I'.'itarait, |HS. isd, .|!M). lltl Sipiica'tiiia. rrlation of. to ilisfascs ol the i.yc.till Siptuni, blcriliiii: iiolvpiis of, SH8 ilLiUnosi'-, of, ,S',H) i'li..liii:\, of ss',t pallioloKy of, KV.I proirnosis of, MM) syiiiptoiiis of, H*M^ tri'atiiirni of. SiM) ill-, ..ill if. 7.'ili liiiiiliiiiiilrilis of. lilMi liy)M'rplastir. 7ll'.l IH-riosliiis ol. 7W |.ioliiiiKatiiiii of. forwaril, 7li'2 sytiiptoiiis of, 7li2 trralniiiit of, 7ti3 I'aiiow's o|)i'ratii.ii. 71.2 ^i rai^iili'iiiiifi of. 7.''i1l .Si'xii.n's fori'luii lioilv forri'p-, lltlU S'xnal oritaiis, I'tfi rl- 111 .lix'asi- ol. upon I hi' cvi', litM Shallow ti'.-l. 1211 Shui'li-v's powilir Mow. r. 1112 >iili'rosis, l(i:{ ■^;'-;;!<'n pli.-tliii:i<!'- -Iw-i'ii'iiHr., !!77 .■^iiimoiil sinus, infi'i'tivo iliii'iiilio-i- oi, lHi:t ilia^nosi- of. IIi'm proiriii.*i- of. 1 It'iti /.V/)/..\ iS.i\ >iKm..i.l Miiii-. MMipliMM- ..1. ll(i:t Sinn-"-. .|,lMn,,j.|.il. .Iiri.iii. Mipimr ition Inatm.iit .,1, M,Kr,-,lni-. lllMi in. .vii.,,i,,i.,. ,,| <tT.t filvpr sali^, |Hii>iiiiiiik: l.v. rihiiii t, td .lliifiiip-ii o' 'i; J di*x*., .,1 t|,r .vr. .Ml.-, ,l.-v,.|.,,,n,.Mi nl'. •rjS Slllgerf. ii.mI.^ S2, .Hii|.|Hii:ili,.i, ..I, !t:iO ■ li:itfiin-i»..l. SJs liiiilfri..l..Kv .,1. !i:i-J "•llnli.ny III. S2S llioluliv nl, H:|(l .iiiil parliMl.itni.i. iiiiiimil oC, iiiiirliiil aiml.Miiv Ml, it:t:t '"•''• '"" SiiiiHitis, (•.•il.irrliiil. cliniiiic,' 1.17!) (>V, i\in|iliiiii- ..I. S2S .Miiciicrlc.i Ir.'iilni.'iii ..I. S2S wrciiH, '.•7il. lS,r Mii<-<„tI.' 1 """"*•"■ ••" "-"HV. !t.s(l with im-.,\ |H.K|.u., H.S2 ili«'!iM.t III. <fJ2 Skia.Hc-opv. 120 .limTriili,ilili:iniiii-i-iil, ••S'i appriciition of, with tlif coriiaM- miirniH liniiiit ol. '.rj'.i plivsiiiliiity 111. !I2!» ^iippnr itiiiii ill. iiiinf, !»:<;{ .liiilmry III'. !i:»M lyniptiiiii.s (il. IKtl trciitiniMiI III. lUI siirKiiiil HiiatDiiiy nl, !t2:i tllMlllls 111. <IS(I ctliniiiiil. <ISI Iniiitiil, !IS1 iiiaxillarv. ilSI i>|ilii|ii>iil.i».Sl ini.riir, 120 with llic plaiir inirrdr. 121 fi'iitral ami [MTiphiTal nIiuiIhwi, 12.1 rhnrailiT of tlif ri'flrs, 122 iw II niiilirinatory ti'sf, 121 ilctcriiiinatlon iif a.itii{iiiatisin bv 1^2 of irri'Kiilar aitiKinatisin liv, 123 (IlKtancr at wliirli ti-st Is madi-, 122 f)i>iiit of ri'V<"r«>l, 120 li'stiiiK llu> n'r<iilt. 122 ll!<«- of cvclopIi'Kiis, 121 ivernoiiv, mliitiv.' ihniiiil.i.Ms of, ,skin, .lis<-a«'.-i of tlir. .HV.w of upon ■'*>** the o\v, 112!) etIunoiiUI, -itriTliiiim of. inal.n.'iit Skull, .Irfomiitics of, iilalion of, to di,- "',-'■' eases of the fvc, (ill fronfal, <>2t; Srnell, e.vn«li'Talioii of. 10;{H. (.sv, Hvi ehroiiic >inipiiiatioii in. )t.Vi osinia.) roiiiplirations of. IMiO loss of, KKJ.S. (.SV, \iiosniia ) .li;i(rn.,sis of, it.Vl |.erv.-i>ion of. I0,«». (.>>,■ rarosniia.i iinpiilatiiiM III niiilillr si'nsc oi. 10,'<7 lurliinaliil. !r>s ilist'urliniiii- of, 10:{s liy I'Mliision. il.V.I Sneezing, exiessivr. 101,! nasal e\-iiiiiinat ion, <J.J7 Snellen's Iran-parent tivt-li'tter- use of -mnihnc llie Irontal in ileteilii.n of Miiiiilaled aniiilvopia lyper- I lansillninin.-Ltioti li'.st, Snow lilinili !I.Vi olij.Tlioii> lo. !l.'',7 trealiMint ni. MliO exiernal nprr.Mlion. ■Itil inli'.'iiiasal. IHMI ral lii'liTizinjJ anil washing: out fniiilal -imis. ItfiO punrnire of I I on r of .-.SI spasm, laryntteal. in ailiilts. lOPl ili.illiiosis of, lopi iliiiloiiy of. 1(M!I syniptmns of, lOpi Irralmi'iii of. lot!) in rliildhooil, 1017 iliatinosis of. lfM8 etiology of. 1017 ■^yniptiinis of. I017 treal nl of. lOl.N phonatiirv. lOlil of phar\ii\. 101", Spasmodic entiopioii. 21!t heteiophoria. IS} -inn-, !MiO ili'Vi'lopinenl uf. !I27 ..•;!xi_llary, !tsi Sp,is.i,. l„.,-,.r.,pl,„ri:,. ls| tumors ot. !IM iiiv,lria-i>. .{2 petrosal, inlerliM' ilinunlio-i- of. nivo-is :il :{2 . :', Specillmn. eve. ,VXi siptnoid. n.teHivi. il,ron,l.i,-i- of, .s; ,„, Watson's ini-thml in tr..a.n„.n, '"'•>. . of trii iiiasis 2(s -pl.-Mioidal. H'iS >ph,.nii„|al sinus, !»2S :f!!".""' ';''i.'.s'""""' '"■ -'^ ifTeerion- of. trealinen, of, 2n .■tnalotny ol. l»2s anatoinv ol. !I2S ilininie siippnr.-iuon ni. !)7H deM'lop'm.'nt ol. !l2s i-van^ination of. 1174 77 if etioli iL'v III. !l7:f . iSf2 I.MthX ^|>ll^■|ll.i||lll 1.111 -. ullllioll 111 ilii«-|li>-< 1 111 ill-<'ii«i--. !■■ ill'' "•>'\ .VM >Iilii'ni.il iilitri iihin, •>.'> Splii'r(w\ liiiil ' III! !*pliiini«rch -1- iiiii'iiiir, -tTtl Spilllll inlil, I'lTl , •< of .1 -illll"^ 111. HI" llii' eve. iit,> Slr:»liisiiiii». ilmTH''iil. ninliii'ii' nl.lTft ihiiiiitiii', l.'iM (Kinks. il;j illt'Timl or niin'ruiiii ili.iL'ii'^'.ii "U 172 .' iiipliiii.- !■' I7'J I!"' .'itin'-iit ' i 17^t ^iri-iilli'iM i>|MT.iii(in Kir 'ii.liiii>i-. 'J.Vt II II- 1-^1. -'Tl* , iif iiiiH'rii-" III, mwiii till «ilrf|>liiiiiriii« pMiiJiiii-. .l.-irni)iion anil — li.iltiiiloKiciil Hiiiiiiliriiiiii- ill ili««a.-«'». of r\f, *mI Spli-nir hM-r. Iil.lliull III. !■■ ili-<'»W I III' l'\r. Ill I Spt.i\-. 7 111 liilllllll.r 111. 710 llllllluil-i "I rllMII-illll! III1-* I 111.. 111. 712 ^^|^rilll^ iiitiirrli, -'lil eSpiirs III' 111!'"'. 7'i'i il iiriiii"!' III. 7."i'i |i.'illiiiloi;\ III. 7,Vi Iri-iliiiiiii 111. 7'<i S)uiiii. 17'-' 11(111.1:1111. 172 ciin'.i'rji:*'. ' 172 t'Mi'rii.'il. 1 , ') iiii-M-uiiiiii'iil I'!. Hiili pt'riiiKti-i 17:! niiM>-niil:ii, 172 Staiiiiiirriii!;. IHI" iiii,lii«v III. lOHl Kviiiploiii- 111. HM(t. H).-.ll in-iiiiiii'iit 111. IM'iO S(nj)i'.|, lixutiiiii III'. ll"'> Staplivliiciiriic pyi)^rni-< aiin - li' - scniliun ••iml palliolucii'al sipiifioaiH •■ in li;-':ls<"H of til"' I'M-. 'iM Staph* I '1, ill" rnn •■ |Ui*nc«'> nf. itl*^ ((.-lliiii.ia, ;U!t priiiiai>. Ml rarrmiisi*, HI 7 of sill ra. :i2S Hi'riiiniarv. 1117 Ircalniini nl. HIS; StapliylotiiiiiN . :t70 Stcllaif piiiii 11 liirri'P'<, 7l'2 Sli-llwat'- ^iu" ill i-\i'pli'li:iliiiii' liiiii'' 20". I f^tchiifls lit lar\ ii\. Mi7 iliiilnyy iif, Mi7 patliiiliiuy iif, S(i7 syiiipliini- of, NlW Ircalinnil of, HIW ol phani \. KKIS StenH)sr(i|)i'. 190 Stcrmitatiiii'. HiCi ■Stevens' pi 'ronii-tiT. H'lO. li'il tnipiiii:' !• r. l."i'i .Stralii.'.imi'.. 172 altiTiialini: roiiM-i;" ni. 171 liiaiiiiosis ' 171 iX lUpIiiMlS III, 1 7 « tnaliii'iil of. 17.'i ili\<'rji»'nt. I7."i rtinlojiy of. 1 7."i syiiiptnniM III. 17i if I Iif •■>!■, liM Sirii".i*liiMii'^ Husk, *iii! -tvc. 21J .-tvl's. '2'2(l III Siiliiliiral al.M. ■ lliil symploiiis III I It'll tn'Btiiirnt ol. o|MraliM'. 11''2 Sulilivaiiilil liciiKirrliairr. i'W Siilimiiriiii" iiill.'iiiiiii.'iliiiii li'l'i patholoKy nl, li'l.'. Kiil.^tamia piopria. 2".t'i Slllrlls iiliTW. 21M Sulplieiiial-iKiisoiiiin:. ii-liiiioii "i lo 'lin- I'aM'.s of till' I'M'. ti<Ki Siippiiialiiiii ill Mrii's.«irv i:i\iiii'^. I'^o In .|iii'iii'y lit. ".«".. <.«ti. 9.17 -. iiipliiiii- 111. ''H7 "^ 111 aiilrriiH crimp of -imis<'s, coiii- hini'il. ".»72 itiafc[ini*is of. 97*2 ii'i'iiliiniit of. 972 iiiiliialions for, 972 rlii'oiiii', in arii-'-Miry -imis«"s, 93.'> ill splifiioiilal siinis, 97H iliairiio-is of. 9".'H itiiiloi.'\ of. 97;{ I'xaiiiiliatioii of. 97 1 laiiula fill' wasli- iii(! out splicii- iiidal sinus, 971 iiiitlioils of. 971 symptoms of, 97H tn'atnuiil of. 977 of sinii-i -. 9:«> Supr.ailuilioii. iiii'asiirciiiiiii ol. I.tI Siipra-orliilal iiotili, 192 Siiprarcnal i-vtract. ilss' ol, in ili-i';iscs of ilir niw an.! throat, 7 1."! .'^iipravairiii ' 'mi'I', iil.'i .".iirsuiiivrir M • . I.V2 Swrt't's ipji.-i.a'us for loi'ali/iii>r lorciffn ,„„, lidilios in till- ryi'. 40<i i| till', ill iH'tt'iotropia, Svrrilili-pliaron, '2."i.->. ■29:< tri'atmcnt of, 29;» Synipatliitir opiithalmia. S90 Synrliisis i-orpnris \ HS7 scintillaiis. ;i.s7 •Syneohia'. anterior, of in , ' ! tiu'inliranc of tlir \ili'i'oi. .aiH'Oiiia fol- lowiiii!. .'vlH of iris, ^laltroiiia ioitoMiii^. o4't of l«'ii> rapsuli', iilaiii'onia follow- ilifl. .-.4H IHislerior, .'t.">(l aiiiiiilar. .'{.''id i.mh \ ia;i .>Mi.'.|,,;. , |Mi«ii nor. Ill 111. uliiiii.iii.a fdl li'WiiiK, '>!<• Iiilal ixi-liTKM, .i.'i'J N.V|>hili«. c'liiiKi'iiiiiil. rflntmii .■! '„ clin- • aws (it till' 1M-. ()2ti of riitijiih(ti\ii. 'J>f.i 111 iv.|i,|,. 211 inlHiilcil (uTiii.iriiiii iMii«ir-i 111 ;ii;i 'II iMrViix.HlS •«"nitii|nry. SIS llilllflliwi. Ill, SIH |mlliii|iiu\ iif. HS •vmiitdiiK III, Ms irialiiiiiii I.I. siH liTiiarv, .Vil |>iitliiiliifi\ of, KTil tri'Ht Ill of. H.jl of IIOH.., HKi acc|iiirr(|, SI7 iiiiiUi'iiital, Mli rvitdiiloifinil .iiiatonn of, 7l);i -I Toiiilarv, HIT <lia({ii(i«i-i of. ms pallioloity of. HIT >viM|il<iiiis of, M7 'i-tiiarv, s|(t (liai-iiiiswof, H4!t pallioloKv of. SV.t •,vm|it(iiiH of, Ml» ri'almi-iil of, Sl<» "I |iharvii\, .S.V) tiTliarv, S.TO iliaRiiosis iti.i ililTiTonliai iliaKiiiisi. of, ,H,V> |iat!ioIo)ty of. S.lll <.viii|iioiii-iof. .S.'iO 'ri'iitmi'iil of, s.'iO rHlatioii III, loili-*ca>i'>of iliiMvr (121 "f "clcra. .■12s I'f throat. Mti ao<niir»'(|, S47 I'niigonital. HICi IHitholoifical aiiatoiiiv ol, 70;} SHiNiiidarv, K17 tcrtinrv, Hl!t ■ liaf;lI<|^^i^4 ol. si<) patlioloKV of. H^l!» i.vmptoiiis of. S49 treatiiii'iil of. H|9 >.vpliilitic I 'iiiriori'liiiitis, :i7t irilii. X',."i n-linilis. 121 >vriiif?omyclia, nlation ni. t,, ,|i.*.a.s<s of the «'ye, M.-f TABKS ilors.ilis, ii-lalion of. to <li»f'«..-s 1 of the cvr. in.") Iifiiia iiK'dioi'aiicllata in llif vitrpoiis, 'I'arsal nstlit'iiopla. KKt i-onjuiictiva. 2.W i'ijrsi. Zil Tarsiti.s sypliililiia. 211 I'arsorrliapliy. 2;12 IVnoiiilis. I!J7 I "lion's (•ap^■ll<■, 14!( 78 lt'lioii\ -|,a(i , :il|, ;tl.- IVtiof..|in, partial, in Inalni.-ni ul ,.n« plioriit. ItiH 111 tr ■itmi'iii of ivuplioria, llitt I I liviM'rplii.ria. 171 I'fUsioii, •, riiiiil miliar, iiiicliaiii^m ii.r ill! iiiainti i.aiiif ol. ."i2l o'cilar. I'fTi . I of iiicri'a«,| on ili. "Inn till of iln' .M. :,|„| tli<irn'>(»iiivi Inn. lions. r.2H met h. Ill of iiiilln(tiiiB,(|ii{i«i». I, •'Iti Trrtiary ■.^philisoi iki-k', H4!I ili,i)jii..-.in of. H4H p!illi.ilii)fy of. Ht!( •VI ipliillis of, S |i,| lri-:iliiiiiit ,if. Mil rent, iT(| (fli^>, I fit) I'liii-li, 177 Ii'^t-cards. lis.- 1,1. 1,1 ili'i. rniiniiiit rffra-f- li'in, I2ii li-st-litlirv. cstiiiialioi, ol n inin.KJn- live iHiui-r In iiiran of, 7a of n-fraclivi' rii.iiliilon In inean>i of. 7;i nii'itioii of iiiraiiMiii; .ii;.| aciiilv with, 72 TheobaUi < [>ni|)i s. 21!> I hoiiia^' iitoiiiiziiit! \a|ior'" r, !lll Thoni*m's iiii"i'!i,»iio,i ,,| HolniKifiiM wmil-tf-.! for ilctrciion ,,| clor hlind- nejw, ,i7J rhroBt_a(liii,ii.iniiiiiiiia o|'. |)at|„,lo(fy of. .uli'iioma of. pallu l.itsy of, 72* aiifcionia of, pailmlouv o|, 721 applicaiiiinsii,. 7U atrophy of, 7 1 II I'lnillonia •,!, patliolom- ol. Vl^ oliomlroina of, pathol.ijiv of. 721 • '.yulMof. palhi|.ic\ of, 722 diphtheria . s2l» di.-«'uws of . lii-t,,lo(jy of. lisd pailioloify of, livi i-Iiithelioma of. patlioloj[\ i, 71s '•''aiiiination of. iniiliod* .i, 727 Mliroanpioma of. |iai IioIokv of. 722 lilironia of. patholoav of,'72tl forfiitn liodii's in. ,H7i diauiioKi.s of, ,S7 1 removal of, S71 hfinorrliaKfi ol. IHK) inflaninmtioii.s ,ii. ntNl leprosy of. Nti7 pathology of. 7(M lipoma of. paihologv of 7211 lupus of. HliTf hiHtolnKical patholo^'v of. 702 invxoma of, patliolouy of. 720 papilloma of, liistolugv of, 71(i «arc!!!ii;i of ;-.ti)}»-.li-.g\' .,i. 71;) sourx y of. liiio ."yphiiis of. Klii patholoRical anatonn of. 70;i seeondarv, S4,s lertiarv,.S4<i l-2:;\ tM)h:X. Thnml. tiihonulosisof, patln>li>):vi>l', 099, -0() t>imors of. honign. "lit mnligiiant, 71 M rt'ti'iitinn. 722 Thromliiisis of caviTiioua smiis, 201 of cwitral artery of n-tiiia, 433 of ccrobral \ossrls, rolalioii of. to ilis- casi's of the i-ye, '"33 infi'etive, of cavi-riious sinus. IIGS ftioloKy of, litis syiuptoins of. lltiS I)roKnosis of, 1 11)8 of (lotrosal sinuses, lltil) i>f iijrtnoiil sinus, 1122, lll>3 iliagnosis of, lltiS propiiosis of, lllVi symptoms of, llf>3 iri-.ii •lint of, opera- tive, lltiti of retinal veins, (jlaucoina foUowinR, .•)52 Thrombotic retinitis. 127. 42S, 42!) Ihnish, 1014 symptoms of, lOM treatment of, 1014 Todd's "tucker," 18i» Tonttue depressors, 73."i Tonometers, 3(> 'I'onsillar abscess, !)il3 etiolopy of, !•!•.{ svmptoms of, '.IH3 treatment of. il!t| tuberrulosis. 700 ap(K'aranees of. 7(MI forms of. 700 Tonsilhtis. .icute latarrhal. !t!M) etioloKV .>f. IHlii svmptoms of, <H)0, 991 treatment of, 991 lacunar, 991 etioloisy of, 991 svmptoms of, 991 treatment of, 992 uheralive, 99,"> symptoms of, 99.") trealnient of, 995 Tonsillolitlis. UKW definition cf 1(KI3 symptoms of, UK);< treat meiit of. 1(K)3 'J'oiisils, larcitiom.'i of, l(Ht4 diagnosis of, 100.') patholoRy of. 1004 treatment of, 100.") evslsof, 722 liiseasi's of. 9!HI lorciirii boilies in, 1003 hv|)irlrophv of, 990 .tiolody of, •»!«; *\inpttin)s of, t)90 In'atment of, 997 local. 9'.»7 operative, 999 after-|re:itment, 1002 cold wire snare, 1001 Tonsils, hypertrophy of, treatment of, op<>rative, electric wire snare, 1001 eimcleation, 10().'t (Tuillotine, 999 lineual, UH)5 hypertrophy of, 10O."> location of, lOO.'i operations on, !M(9 sarcomata of, 1(K)3 diiiKuosis of, 1(X)4 etiology of. 1003 svmptoms of, 1004 treatment of, 1004 tumors of, 1003 benign. 1003 angioma, 1003 echinococi'us cysts, UK)3 fibrochondroma, 1003 fibroma, 1003 papilloma, 1003 m:dignant, l(K)3 carcinoin:-., 1(X)4 sarcoma, 1003 wounds of. lOOS Toric lenses, (10 "Touch test," 177 Toxalbumin-poisoning, relation of, to dis- eases of the eye, (i08 Trachea, relation of diseases of, to dis- eases of the eye, .WS thyroid tumor of, '.K)3 Tracheal injections, .*<(K) Trachoma, 2<')2 Traumatism of larynx, 919 Treatment of adenoid vegetations, 102,\ of adenoiiia papillare, SSS of albinism, 371 of anasthesia of pharynx. 1043 of anosmia, 1039 of anosphn-sia. 1039 of asthma. H09 of atrophic catarrh of middle ear, 1197 of benign Lunors of iris, 3.')9 of bleeding poivpns of sept'im. SK) of blepharitis, 242 of blephan)spasm, 234 of blooil-staining of cornea, 322 of carcinoma of larvnx, 90t) of nast)pharynx, 103.") o. tonsils. U)0') of cataract. .")03 complicated, .M)ti lenticular, .Wl tramuatic. ls;t zonular. .101 of iilhilitis of orbit, 19.') of cerebellar abs.X'ss, otic. 1171 • if cerebral abscn.ss, otii'. 1171 of cerebrii-s[)inal rhiTiorrhiea, 1043 of chalazion. 243 of chondroma of larynx, !K)3 of chorea of h.rvnx, 1(M9 of choroidcl ci>l"boma. .171 of choroiditis, ai ute exudative. 373 i\ni:x. 1 2:i.") Treatment of tlioruiilitin noiliwii, S28 mipptirativf, ;}7« of chronic 9upp\irntiim of frontal sinus, (HK) of circiinisi rilK^I inHaiiitnation nf auditory iiifatus, 1080 of roncavi- vertical dcforniitv of nose, 1000 of congenital aiionialies of tlie eye- lids, 2:i8 of conjuRnlc paralysis. 1.S2 of conjunctiviiis, ni'ute contaj?ious, 209 chronic, 2H.') diphtheritii , 277 follicular, 2(i2 gonorrho'iil, 272 ffranular, 20,5 acrvmal, 2(i0 lithiasia, 2U1 menihranous, 27S phlyctenular, 281 .simple, 2(iO subai'ute, 270 toxic, 281) vernal, 2t)2 of cyclitis 3.5ti of cyclr.piioria. 171 of dacryoaiicnitis, acute, 216 chronic, 210 of dacryocystitis, 228 of deaf nuit ism, 1107 of diffuse inllaniniation of auditory meatus, lOlM of diplit heria of nose, 834 of pharynx, 834 of disi'ases of uvula. 987 of eczema of external ear. 1081 of elonpition of uvula, 988 of emphysema of conjunctiva, 287 of cmpvema of anterior ethmoid cells, !«i8 of antrinn of Hijjhmore, 948 of entozoa in vitreous humor, 389 of epiphora. 221 of episcleritis, :l2."i liersisteiit, 320 of epistaxi>. 749 of esophoria, 107 of ethmoidal siippuraiion. 972 of Eustachian <atarrh, chronic, 1185 of exophoria, 10."> of exophthalmic goitre, 209 of fibroma of nasopharynx, 1033 of fistula of cornea. 3(N1 of foreign bodies in cornea. 322 ill external ear. 1093 in nose. 7.">0 in lubit. 199 of forward prolongation of si-ptuni, 702 of fraetun'S of mo.s(>, 1050 neplecled. liHil of frontiU sinus suppuratio.i, 972 of plauconia, primary, ."i.Vi of gout of ll oiijiiiiili.a, 2t)7 Treatmeiit of lia\ fever, 802 of hemorrhage into vitnuus humor, 388 of herpes cornea', 310 of pharvnx, 1014 of hvahtis. .iso hygienic, of ref>-active errors, 141 of hypera'Sthesia of larynx. ItHO of nose. 1041 of pharynx, 1044 of hyi«>rosniia, 1038 of hyiK'iosphresia, 103^ of hyperphoria, 170 of hypertro|)hy of tonsils, 997 of impacted cerumen, 1088 oi infective thrombosis of sigmoid sinus, II (iO of influenita, 807 of injuries of conjunctiva, 287 of orbit, 199 of intrana.sid adenoma. 891 adhesions. 751 fibrom.i. 887 Jiapilloma. 888 sarcoma. 896 of iritis, ,350 diabetica, 358 Konorrlueica, 358 rheumatica, 3.">8 syphilitii', 3.58 of kei7\lectasia. 319 of keratitis, bullous. 311 deej) vascular, 310 desiccation, 30S eczematous, 2it9 filamentous, .300 marKinal, 302 neuroparalytic, 309 parenchymatous. 314 selerosinft, 315 of keratoconus, 320 of lagophthalmos. 233 of laryngeal \erti(fo. 1052 of luryngitis, acute. 810 in childhood. 81t> clironic. 821 dry. 825 hyiMiKlottic. S23 hiemorrh.'iisica. 810 hypoulottica. MO pachydermia. 827 rheumatic, 816 sicca acuta. 810 of leplomeiiiiigitis. purulent, 1103 serous, 1102 of loss of vitreous humor, 3.S8 of lupus of larynx, 807 of iios*'. S07 of throat, ,S07 of lyinphaiiKiectasis. 290 of malittnanl tumors of irjn. 300 of mastoiditis, 1 148 of maxillary suppuration. 972 of mcmbianous u (jina. 990 of nuicfxi'le, 211. 224, 9SII in infant'^, 220 12.S« IM>KX. Tn-iitmcnt i<\ iiivi<'<is. lol."> of ii;i>al hviiio.Tliu'.i 1(H2 liyiMTllopiiir-i. 7t).") IMilyps. 7li."> with siiiiisili-i, SS) iif ii:iMi|)li,iryii(jili i, .•icuti', 10'2() chroiiii-. 11(22 i>i nciiativr |>rrssiii(' of tvmpiiniim, I lit!) Ill' iii'cipl!iMii> 111' Ijiryiix. '.KM) of M()s<'-I)l 1. 7l'.t of opa^iti('^ in vilri'oiis humor, 386 oiK'nitivi'. Ill ^uiMl'iral absci'ss. 111)2 of ophihahniu nt'onatoruni, 275 of ortha'inalon.i. lOSd of osteitis of orbit. 197 of iisti'i-ma of orbit. 206 of otitis ini'dia iiuiiilriita ai-.ita. 1129 I'liroiiica. Il^.'i af 111' lyrosis, 1()!»2 <ii [lachyiiiciiiiDsitis cxIiTiia. 1161 I f paiiims. ;1U( of pnrnsinia. I(I4(( of iM'tiiphiRus, 2t>.S of |H'riiistitis of orbii. 1(17 of poritonsillar aliM-rss. !)!)4 of pharyngitis, aiutc. 1009 acute phle^iuouiiiis. 101.3 ••itrophii', \U\2 rhroiiir trraiiular. 101 1 simple, 1010 of (Kilypoiil lysts. SHI of pseiidoiiiiiip. siti of pteryciuni, 2.H9 of ptosis. 2:i."> of puls;itiinr i\ii|ilii(ialiiios, 2IX) of n'troph.-iryiiseal al)scess. .,)ls of rhiiiilis. arule. 771 alropliii-. 79.") fibrinous. 7W hyixTtrophic. 7S2 simplex, 7.S2 of rhinolilhs, S7.t of rhinorrhu'a. SOii of rupture of ihoroiil. A-" of .sareotna oi larynx, ihiii of nas ipharvnx. lOli.") of iiriiit. 207 of soil p;llale. !I!HI of tonsils. llM),-> of u\ula, 9'.M) of sileral iilasia-, :V2S of silero-kerilo-iritis. :!27 of sp..,vni of larvnx in adults. 1019 ill ellililhnoil, lots oi spurs of nosi', 7.''!l) ot si.ainnierintr. lO.'iO ol st.iphyloina, .ils of stenosis of 1,-iryiix. MiN of strabismus, allenintiiu; lonver- (fenl. 17-") i|i\er({ent. 17.") internal eonvere 'lit, 17K ol striated opaiilies oi cornea, 316 "f siippuralioii. acute, of accessor)- -iniisi's. >>:» Tn^atiuenf of sup|iuratii)n in anterior ){rou|) ol sinuses, 972 chronic, in sphenoidal sinus. 977 of .symblepharoii. 293 of sympathetic ophthalmia, '.Wi of syphilis of larynx. S,")l secoinlary, H4H of nose, tertiary. HA'J of pharynx. H'A) of sclera, 329 of throat, tiTtiary. H49 of t'jrombosis of cavernous simis, 202 of thrush. 101.') of tonsillar abscess. 994 of tonsillitis, .•icule catarrhal, 991 lacunar, 992 ulcerative, 99.") of tonsilloliths. KNU of trichiasis. 24S of tuberculosis of nose. H.W of larynx. H.")9 of tumors of accessory sinuses. 9Sl of maxillary sinus. 9H1 of optic nerves. 20.") of uviilitis. 9.H7 of wounds of iiieiubrana tvnipani, 1096 Trial ease, use of. in determining n-frac- tion, 126 Frichiasis. treatment of, 24H Trochlciris palsy. ISO I'rophoneuroses, etTccI of, uixin the eve, (H9 r-'heriiing's theory ol the mechanism of .accommodation. OH I'ubercular disease of the middle ear, 1121 leptomeniiiKilis in mastoiditis, 1121 iiuningitis. relation of, to disi^asi's of the eye, (i.'V.I luberculosis. adenoid. 701 of eonjimctiv,!. •2.H2 of larynx. 701. s-,:i pathology of, 702 clinical apiH'arancc ol. 702 of nose. ,s.")l pathoIog\ of, ti99. 700 of pharynx. S.")2 relation of. to diwases of the eve, 628 tonsillar. 7(K) I'limores cavernosi of eyelids, 241 1 mors of ,aceessor\* sinuses. 9.S1 diairnosis of. OKI ireatneiit of, !)S1 benign, of eMi-rn.al car, lOsH of nose, 719 of palate, 9S9 of tliro.n, 719 of UMila, 9,S9 of ethmoid sinus, 9M of frontal ^iiius. 9H1 of internal ear. 1 104 of laruix. H97 adenoma. 9t)3 angioma. <H)2 cnreinonia. !K)1 ehondroniM 902 iM>h:\. li'M Tiliiiiir* 111 l.irviix, (■v^«l^^ of. !H11 Hbroiim. !K)l li|H>in!i, •NI2 myxoma. 901 pHpilloma, S!»7 ^aic'omn, DOS ll vroid, '.KM njitli)!imiit. of nos)', TIH of (hroiit. 71S of iiKixilltiry sinus, 9S1 iliaKiiosis of. UfSl treatment of. OHl of nasopliarynx, 10;t2 lieniKn. I0H2 tihroniata. KKi'J filironiui'oiis polypi. 104.5 nialiKiiant. IDH.'i of nose. .S77 ni:ili)rnant. S".(2 of oiopliaiytix. 1017 ri'teiitiofi. of nnicosa. 722 of nos<'. 722 of throiit, 722 of sphenoid sinus. '.tHl of tonsil. UKIS. Off Tonsil, Tnniors of,) Tunii'a vasenlo^a lentis. :W2 Tiirek's i inpiie depressor, 7Ho TvMipiinie nienilirane, inas.sape of, lisl Tyinpanoloiiiy. I'xploratory, 1V92 Tvinpaninn nepitive pressure in. lUI.S causation of. ll!tS diagnosis of. ll'.d* palliolojjy of, ll!»s [irognosis of. ll'.HI ^\'niptouis of, WM) treatment of, 1 l!HI varialionv in atinospherie press.itr in, 11(».S lausation of, 111)8 elianfces proc' lO'd liv, 119S diagnosis of, 110'' nepilive pressure, I l(»s patlmlogy of. 1 \**^ propn<»sis (tf, 1 109 svmptoins and signs of. 1199 tre.atnieiu of, ll91t Tvplioid fever, leLilion of, to diseases of the I've, tiHi Typhus fever, relation of. lo disi'uses of , ' till' I've, (il7 reeurn'iis. relation ol , lo diM-ax-^ t-i the eve, (517 ryr.ll'~ hlnnt hook, ,">1 1 II.Ml.ArKH AI. paralvH- ol lie- orhiial I' muscle-. 179 reflex iridoph-gia, :t2 I rami c ^iniaurosis, 424 amlilviipia, ,"i77 Urie-ai'id diathesis, relation of, to dis- ease« of the eyi', (iOl Urinai> ingans, ellects of iliseasi's of. upon the eye, .")9S I rliearia. relation of, lo di»eas<'s of the eye, tWl Ivca, anatomy and physi")logy of, H3t> nerves of. :{43 Uveal tract, development of. HH.'i I'veitis. anterior, ;{27 Ivtda, 9S9 ailenoma of, 9H9 aiifiioma of, 9S9 benign growths of, 9X9 degeneration of iniisculur fiUn's in, 724 diseases of, 9.S7 diagnosis of, 9X7 etiology of, 987 .symptoms of, 987 lr("Htment of, 987 ilongation of, 987 causes of, 987 symptoms of, 987 treatment of, 988 JKcinatoma of. 988 m.alfonttations of, 08.5 congenital, 985 Mialigiuiiit growths of, 9.S9 carcinoma of, 989 papilloma of, 989 sarcoma of, !*90 1 \ulitis, 987 iliagnosis of, 987 itiology of, 987 symptoms of, 987 tn'atinent of, 087 Y \rcr\AI'I(>N, n'lation of, to <lise:ises ' of the eye, lilt) Vaccinia of the evelid. 210 Valve, Hasner's, 210 \ an Ciieson's methoil tor preparing .■■<'c- tions of the eyehall, •)7<) \'an Milligen operation for trichiasis, 252 \'aricella, relation of, to diseases of the exe. 010 X'aricose veins in the orliit, 2(H Variola, relalion of. to di.seases of the lye. 01 J \'arioloiis eruptions n|M>ti the eyelid-. 210 \ ascular engorgi'ment, chronic, of niiildle ear. with exu- dation, IISO diagnosis of. 1 1.S8 etiology of. lIHIi prognosis ui. 1 IS7 symptoms ol.U.87 \ .i-oniotor catarrh ' .nVc Hay Kever.f rhinitis. 091 p.'ithology of, 091 \ ra-i \ s portable' sterilizer. 0.5(i Veniricle. laryngeal, prol.ipse of, 903 \ inlricular hyix'rtrophv. 713 Vernal conjunctivitis, 2t)l \ertigo, laryngeal. 1051 etiologv of, 1(1.51 prognosis of, 10.52 symptoms of, 1052 treatment of. 10.52 12»8 i.\jn:x. ^'irtual focus, /i" Vision in astifnn.-itism, 101 binocular, 74 cell?, 3.34 ilislurbaiii'cs of, witlioul apjiurent Ir'sion, M\S pliysiolopy of, 53 Visual acuity, 71 cxcccdiiii; the .•.taiidanl, 7.S method of mcii^uriiiE, with Icst- Itttors, 72 anulc, 71 field, cccTiitrio contrai-tioii of. in prav atrophv of optic nerve, 440" lionionyniuu.s (juadrant hemian- opsia. 447 normal. 44.5 .sen.sation, duration of the. 74 Vitreous humor, bloodvessel formation in, 3S7 clmnKes in the, in primary glau- coma. 'hi'A eholesterin crystals in, 3^7 eonpenital anomalies of, 3S.5 de(5en<'ralionK of, 3S7 detachment of, 3S7 development of. V.^? ento/oa in, 38S In-atmenl of. 3W.( exudation uito, in cyclitis, 3.52 fattv defeneration of, 387 fluidity of, 387 hcinorrhape into. .388 treatment of, 388 injuries of. 38" loss of. 387 tnatment of, 388 macroscopic anatomy. ,384 tnicro-Hcopic anatomy. 38,5 opacities in the, 3H.5 treatment of. 38t'i physioloEV of. 3.84 pseudofslioma of. .387 Vocal rords. carcinoma ))oly)xiides of, 905 pachvdcrmia of. 713 hi.stolo)tical pathologv of, 713 nodules, 71') Von Graefe's cvslotomc, .511 \'oii tiraefe's linear knife, 3t)4 sipn iti exophthalmic Roitre, 20!» W.VTSON o|K.-ration, 701 Weber's canaliculus knife, 222 Weeks' scarificator, 2t)0 Weigert's method for staining nerve sheaths, (177 Wernicke's sign, 34 Whistler's cutting dilator, 8t)9 White's jialate retractor, 734 Whooping-cough, relation of. to diseases of the eye. 020 Wilder's ojH'ratioii for correction of ptosis, 237 Wilkinson's disease, relation of, to dis- eases of the eye, (>42 Wolfe's method of blepharoplasty, 240 WollT's oi)eration for I'orrection of ptosis. 230 Wright's na.»jil snaii', 704 X-HAYt5, use of, in locating foreign bodies in the eye, 405 Xanthela.sma, 244 Xanthoma palpebrarum, 592 Xerophthalmia, 285 Xerosis bacillus, 684 epithelia'is, 278 cause of, 278 complications of, 279 description and svmptoms of. 278 diagnosis of, 279 pathology of, 279 treatment of, 279 infantilis, 278 triangularis, 27S \''ELLOW fever, relation of, to diseases of the e-o, 621 Young-Helniholtz theory of color \ ision, .570 of production of coloi-. 54 yEISS. glands of. 231 /j Ziegler's pri.sni-scale, 140 Z'nn, zonule of, 340. 470 Zonular cataract, 41K), ,504 Zonule of Zinn, 310, 170 f&f mm