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 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. 
 
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 ^\ M«QILL 
 
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 ] 903. 
 
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 LEA BROTHERS ± CO., 
 
 In the Office of the Librarian of Congre... All righU reserved. 
 
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 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, 
 
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 ti.,ii i.l lb.- -11, 1, ,1111. 1- 
 
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 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 
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 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-^ 
 
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 -'!" 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 
 
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 11-25 IIIIII.4 
 
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 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. 
 
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 il L.:n\ iKjm 
 
ATH XX\' 
 
 n 
 
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 ..\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. 
 
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 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