~~~~~~~4    ~~~~~~~~~~~~~~~~~~........
7........
FORBES UTMCO.SOST~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~t4....... 
The frndus of th  e e as seen with the ophthalmoscope.  After Von Jaege......,.f.rs.
published   in   185G.    The face   of the  optic  disc  should   be  wore  pinkish   in..........color
The  arteries  of the  retina  are  the  lighter, the  veins  the  darker  vessels...........




A TREATISE
ON
DISEASES OF THE EYE;
FOR THE USE OF
btutentO antb 0eneral practitioner.
TO WHICH IS ADDED
A SERIES OF TEST TYPES FOR DETERMINING THE
EXACT STATE OF VISION.
BY
HENRY C. ANGELL, M.D.,
PROFESSOR OF OPHTHALMOLOGY IN THE BOSTON UNIVERSITY
SCHOOL OF MEDICINE.
SEVENTH EDITION,
REWRITTEN AND ILLUSTRATED.
BOSTON:
OTIS CLAPP AND  SON.
1891.




Copyright, 1891,
BY HENRY C. ANGELL.
nANbersitgt   ress:
JOHN WILSON AKD SON, CAMBRIDGE.




PREFACE TO THE SEVENTH EDITION.
THE present edition is mostly re-written, and
is more fully illustrated  than  its predecessors.
It is also favored with  contributions from  my
friend Dr. F. Park Lewis, of Buffalo.  His articles are placed in brackets and marked by his
initials.
As in former issues, the aim has been to make
the book suitable for the use of physicians in
general practice.
BOSTON, April, 1891.








PREFACE TO THE SIXTH  EDITION.
THE sixth edition is remodelled and to a certain extent rewritten.  As heretofore it has not
been thought advisable to devote great space to the
indication for the use of internal remedies.  Such
indications can be found elsewhere, and their consideration might easily be made to double or
treble the size of the book.  The main purpose
of the work is to make the nature and diagnosis
of -ophthalmic affections comprehensible to the
non-specialist, and after this, to teach how to
avoid the bad, and how  to avail of the good,
in the topical, mechanical, and  surgical treatment of the various defects and diseases of the
eye.
BOSTON, January, 1882.




PREFACE TO THE THIRD EDITION.
AN attempt has been made in this edition to
bring the work up to date in ophthalmologic
science, without materially increasing its size.
Alterations or additions have been made in nearly every chapter, and a Glossary of scientific
terms has been placed before the Table of Contents, which may be of convenience to students
and others.
BOSTON, August, 1873.




PREFACE TO THE FIRST EDITION.
MY readers are requested to bear in mind that
this work is written, not for specialists, but for
homceopathic physicians in general practice, - for
those too busied with the whole to devote a great
amount of time to any one part of medicine and
surgery.  The endeavor has been to treat the
subjects embraced clearly and concisely, in the
hope of presenting a volume attractive enough,
and small enough, to induce the busiest to give it
some attention.
In the preparation of this work, I have had the
advantage of copious notes taken during a somewhat prolonged attendance at the European clinics; and I have availed myself without hesitation,
also, of the privilege of taking and appropriating
whatever I have found desirable in the standard
or periodical works devoted to ophthalmology.
BOSTON. March, 1870.








CONTENTS.
CHAPTER  T.
PAGE
BRIEF SKETCH OF THE RISE AND  PROGRESS OF OPHTHALMIC
SURGERY.................
CHAPTER  II.
ANATOMY AND PHYSIOLOGY.
The Eye, as a whole, best described by the use of Geographical
Terms.- The different Tissues of the Globe.- Ciliary Muscle.
- Optic Nerve. — Tenonian Capsule and Lymph Spaces. -
Tears and Secretion of Conjunctiva. - Physiology of Vision. -
Excitation of Nerves. - Act of Seeing. - Eye as an Optical
Instrument. - Irremediable Optical Defects......  5
CHAPTER  III.
EXAMINATION OF THE EYES.
Objective and Subjective Examination.- Implements and Instruments. - Bandaging the Eye..........   26
CHAPTER IV.
THE OPHTHALMOSCOPE.
The Principle of.- How to use it. - What to observe.- Lateral
Illuminationo - Difficulties of Diagnosis formerly. -  Importance of the Ophthalmoscope to the General Practitioner... 37




X..CONTENTS.
CHAPTER V.
REFRACTION, ACCOMMODATION, AND THEIR ANOMALIES.
PAGE
Myopia. - Hypermetropia. -  Accommodative Asthenopia. - Astigmatism. - Cylindrical Glasses. - Muscular Asthenopia. 
Presbyopia. - Prisms for testing the Equilibrium of the External
Muscles...                                                 49
CHAPTER  VI.
THE CONJUNCTIVA,
Passive Hyperemia of the Conjunctiva.-  Simple, Catarrhal,
Purulent, Egyptian, Congenital or Infantile, Prophylaxis in
Infantile, Gonorrhceal, Diphtheritic, Follicular, and Granular
Conjunctivitis. - Pannus. - Scrofulous Ophthalmia. - Phlyctenular and Exanthematous Conjunctivitis. -  Pterygium. -
Pinguecula. - Warts, Cysts, and Dermoid Tumors ai;d Hemorrhage of the Conjunctiva...........                       94
CHAPTER  VII.
THE CORNEA AND SCLERA.
Phlyctenular and other Forms of Keratitis: Ulcerations of the
Cornea. -  Staphyloma Anterior.- Conical Cornea. -  Arcus
Senilis.-  Opacities of the Cornea. -Episcleritis.- Staphyloma of the Sclerotic.............. 134
CHAPTER  VIII.
THE IRIS.
Hyperaemia of the Iris. - Simple, Rheumatic, Suppurative, and
Serous Iritis. -- Prolapse of the Iris. - Cyclitis. - Artificial
Pupil. -  Mydriasis. - Myosis. - Action of Atropine. - Action of Eserine, Pilocarpine, Duboisine, Gelsemine, Homatropine, and Cocaine. - Iridodonesis. - Cysts of the Iris... 155




xii                         CONTENTS.
CHAPTER  XIII.
THE CRYSTALLINE LENS.
PAGE
Cataract. - Complications with other Affections. - The Cause of
Cataract. -  Hard and Soft Cataracts. -  Nuclear, Striated,
Black, and Siliquose Cataract. - The Infantile, Lamellar, and
Cortical Varieties. - The Various Operations by Extraction,
Absorption, and Depression. -  Secondary Cataract. -  Capsular Cataract. -Dislocation of the Lens. - Traumatic Cataract.- Aphakia............ 235
CHAPTER XIV.
SPECTACLES - ARTIFICIAL EYES.
Cataract Glasses. - Pantoscopic, Prismatic, and Stenopaic Spectacles.- Eye Protectors.- Artificial Eyes. -  The Dioptric
System of Enumeration of Lenses........    257
CHAPTER XV.
THE MUSCLES OF THE EYE.
Paralysis of all the different Muscles of the Eyeball, and of the
Ciliary Muscle. -  Spasm  of Ciliary Muscle. -  Strabismus,
Convergent and Divergent. - Operations for the Division of
the Muscles....         263
CHAPTER XVI.
THE EYELIDS.
Blepharitis. -Acne Ciliaris. - Herpes Zoster Frontalis.- Ectropium.- Entropium. - Meibomian Cyst. - Other Tumors
— Hordeolum. - Epicanthus. - Lagophthalmos. - Blepharospasm. -  Ptosis...........    280




CONTENTS.                            xi
CHAPTER IX.
THE CHOROID AND VITREOUS.
PAGE
Hyperaemia of Choroid. - Simple, Disseminated, Syphilitic, and
Suppurative Choroiditis. - Hyalitis, Simple and Suppurative.
- Opacities of the Vitreous. - Muscee Volitantes. - Hemorrhage into the Vitreous.- Synchysis. - Sparkling Synchysis.
— Cysticerci of the Eye............    172
CHAPTER X.
GLAUCOMA.
Acute, Subacute, Chronic Inflammatory, Chronic Non-inflammatory, and Absolute  Glaucoma. -  Glaucoma  Fulminans. -
Iridectomy. - Sclerotomy. - Other Operations for Glaucoma. 181
CHAPTER  XI.
THE RETINA AND OPTIC NERVE.
Retinal Hyperemia. - Retinitis Serosa, Exudativa, Albuminurica Syphilitica, Apoplectica, and Pigmentosa.- Detachment
of Retina.- Glioma Retine. - Ischlemia Retine. - Paralysis
of Retina. -Embolism of the Central Artery of the Retina.
Neuro-Retinitis. - Atrophy of Nerve.......    199
CHAPTER  XII.
AMBLYOPIC AND OTHER AFFECTIONS.
Diagnosis of and Various Causes of Amblyopia.- Simulation of
Blindness. - Hemeralopia. - Color Blindness.-  Retinal Asthenopia.- Anaesthesia Retinae- Neuralgia Oculi.- Effects
of Electric Light.................   222




CONTENTS.                           xiii
CHAPTER  XVII.
THE LACHRYMAL APPARATUS.
PAGE
Epiphora and Stillicidium Lachrymarum. - Inflammation of Sac.
Blenorrhcea of Passage. - Stricture. - Dilatation of Sac. 
Fistula. - The Probe, the Style.   Stilling's Operation.  The
Lachrymal Gland..                                           289
CHAPTER  XVIII.
AFFECTIONS OF THE WHOLE EYE AND OF THE ORBIT.
Hydrophthalmia. -  Medullary  Cancer. - Grave's  Disease. -
Affections of the Orbit............   302
CHAPTER XIX.
INJURIES OF THE EYE.
The  Lids. -  The  Conjunctiva. -  Anchyloblepharon.   Symblepharon. - Foreign Bodies within the Globe. -  Use of the
Magnet. -- Injuries of the Cornea, the Iris, the Lens, the
Sclerotic. - Hemorrhage into the Anterior Chamber. -  Sympathetic Ophthalmia. - Sympathetic Irritation.- Removal of
the Eye. -  Division of the Optic and Ciliary Nerves. -
Exenteration................  305
CHAPTER XX.
THE EYE IN RELATION TO THE GENERAL SYSTEM.
In Diagnosis. - In regard to its own Integrity. - As a Possible
Cause of Functional Nervous Disease....... 322




xiv                       CONTENTS.
CHA.PTER  XXI.
PAGE
LIST OF A FEW INTERNAL REMEDIES, WITH THE OPHTHALMIC
AFFECTIONS, OR TIIE SUBJECTIVE AND OBJECTIVE SYMPTOMS
OF THE EYES, FOR WHICH THEY HAVE BEEN FOUND USEFUL IN THE PRACTICE OF THE WRITER.
External Remedies..........                                 330
CHAPTER  XXII.
TEST TYPES.
First Series. - Second Series. - Tests for Astigmatism... 338
INDEX.........    349




GLOSSARY.
REFRACTION.... The power of the eye to focus rays of light.
ACCOMMODATION... Power of the eye to adjust the vision for
different distances.
ASTIGMATISM.....  Irregular refraction, an optical defect.
HYPERMETROPIA.... Over-sight.  Deficient refraction.
MYOPIA......    Near-sight.  Excessive refraction.
PRESBYOPIA...           Old-sight.  Deficient accommodation.
OPTICAL DEFECT... Defective power of accommodation or refraction.1 Error of refraction.
AMETROPIA.....            The general term for an optical defect of
any kind, impairing vision.
ANISOMETROPIA... Unequal refractive power of the two eyes in
a person.
E.IMETROPIA..... Without error of refraction. An emmetropic eye is supposed to be optically perfect.
AMBLYOPIA.....   Impaired sight, not due to refractive errors
alone. Obscure diseases of the fundus.
OPTIC DIsc...... Optic nerve at its entrance of the eye as
seen with the ophthalmoscope.
STAPHLYOMA POSTICUM. Bulging of the coats of the eye posteriorly
around the optic disc.
FUNDUS......    Back part of the interior of the eye.
TENSION....... Hardness or softness of the eyeball.
1)IPLOPIA..... Double vision.
PHOTOPHOBIA...    Intolerance of light.
ASTHENOPIA...     Weakness of sight.
THE MEDIA.....  The transparent cornea, lens, aqueous and
vitreous humors.
1 Exceptionally, "optical defect" may mean defective sight from disease
of the transparent media, namely, corneal opacity, etc.








DISEASES OF THE EYE.
CHAPTER I.
BRIEF SKETCH OF THE RISE AND  PROGRESS OF
OPHTHALMIC SURGERY.
IT appears that the ancient Egyptians were the first
to divide the practice of medicine and surgery into distinct departments, and that in those days there were
practitioners who devoted themselves especially to the
study and treatment of diseases of the eye and ear.
Recently published translations from a work written a
thousand years before the time of Hippocrates show that
eye diseases were better known at that time than had
been supposed. That greater progress was not made in
medicine at that epoch is to be attributed to the primitive condition of anatomy and pathology, and to the fact
that whatever knowledge of this kind existed was regarded as the exclusive property of its possessor, to be
left like an heirloom to his family or his successor.
The Arabians, Greeks, and Romans possessed considerable information in regard to diseases of the eye; and
Celsus, in the first century, wrote accurately on diseases
of the eyelids, described pterygium, and an operation for
its removal not unlike that practised at the present day.
1




2              OPHTHALMIC SURGERY.
After this we hear little of affections of the eye, until
the beginning of the eighteenth century; and even as
late as this, oculists were but itinerant quacks and lecturers who trumpeted their fame at fairs, in front of the
booths in which they practised.  There were female
oculists also in those days. An author of that time
says, "About five years since, I saw a woman in Holborn, by King's Gate, that had a dissolution of vitreous
humor in the right eye, a narrowness of the inward
chamber and immobility of the pupil, and half was
dilated. The crystalline was opaque and shrunk in its
bigness, pressed against the pupil and was of whitishgray, by reason of the fibrous parts of its crooked and
contracted segments, so that she could not perceive any
light with that eye.  She asked me if I could do her
any good; I told her there was no hope, for she could
not see the least glimmering because her cataract was
accompanied with a gutta serena which was perfect.
She told me that Mrs. Jones, a famous woman for
couching of cataracts, would have couched her some
years before."  The same author writes of the "Cataplexia of the eye which Hippocrates speaks of," and
goes on in this remarkable way: "Some call this the
conick movement which is the parrexis or helcosis and
abruption precision, or ulceration and solution of the
continuity of the optic nerve, caused from a stroke,
wound, or fall of humors or apostimation."  He says
further that the " Syntosis of Galen or the syntomosis is
a collaption, compression, flabbiness of said nerve,
which is affected by dryness," and so on.  Some of the
remedies in use only one hundred and fifty years ago




ITS RISE AND PROGRESS.                3
are equally remarkable.  A  scarificator was made of
beards of barley tied into a little brush. Applications
in common use were vipers' fat, gall of the eel and pike,
a mixture of ants and honey, and applications of a less
delicate nature. As original and curious as any, was
the insertion in the eye of a living louse, of which it
was remarked, that "it tickleth and pricketh and rendereth the eye moist and rheumatic."
Towards the middle of the last century the attention
of the profession, especially in Germany, began to be
directed towards the study of ophthalmology, and this
awakened interest finally led, in 1773, to the foundation
at Vienna, in connection with the University, of a department of ophthalmology.  This school became famous for its successful and distinguished teachers, and
in this respect flourished without a rival for many years.
About the year 1840, Dieffenbach, of Berlin, first
practised his operation for strabismus, the success of
which gave an impulse to the study of the physiology
and pathology of the muscles of the eyeball.
We come now to the year 1851, the date of the discovery of the ophthalmoscope.  From the very earliest
times the luminosity of the eye, especially in the cat
and the dog, had been observed, and had been regarded
by the people with superstitious awe. In the year 1704,
Mery saw the retinal vessels in the eye of a cat under
water, but not until some years later was the cause of
this luminosity properly referred to light received into
the eye from without.  Cumming, in 1846, came very
near depriving Helmholtz of the honor of his great discovery; and Reute, who improved the ophthalmoscope




4              OPHTHALMIC SURGERY.
in 1852 and rendered it practical, may be fairly said to
divide the honor of its invention with Helmholtz.
Since the discovery of this instrument the progress of
ophthalmology in all its branches has been not only
rapid beyond precedent, but more rapid than the most
sanguine could have hoped for. It is impossible here
to more than allude to some of these great advances
and their results.  Recognition and accurate description of the different diseases of the optic nerve and
retina, and their frequent connection with affection of
the brain, heart, and kidney; diagnosis of diseases of the
choroid and vitreous; classification of opacities of the
lens giving rise to variety and improvement in operations for cataract; the operation of iridectomy, rendering glaucoma a curable disease; improved methods of
making artificial pupil; rational surgical treatment of
disorders of the lachrymal apparatus; demonstration
of the laws of refraction and accommodation of the eye,
which has been of incalculable value in the diagnosis
and treatment of a large class of cases due to imperfect
vision; the diagnosis and relief of astigmatism; the
treatment of asthenopia and insufficiency of the ocular
muscles; the progress in entoptics; the detection of.
cysticerci in the eye; the introduction of the use of
atropine, eserine, and especially cocaine; the less indiscriminate use of caustics, - these and many other
improvements in diagnosis and treatment, which I do
not mention even by name, were and are the results of
the marvellous impulse given to the study of disease of
the eye by the discovery of the ophthalmoscope.




CHAPTER  II.
ANATOMY AND PHYSIOLOGY.
ANATOMY.
IT is proposed in this chapter to give simply the essential points in the anatomy and physiology of the eye,
such as it would seem almost imperative that every student and practitioner should be familiar with.
GENERAL DESCRIPTION OF THE EYEBALL.
The spherical organ of vision, or globe of the eye,
resting upon a cushion of fat within the orbital cavity,
movable in all directions, directly communicating with
the brain through the optic nerve, is best described, as
a whole, by the use of geographical terms.  The eyeball is the globe; the anterior pole, the centre of the
cornea; the posterior pole, the centre of the fundus;
and an imaginary line, passing through the centre of
the globe, connecting the poles, is the axis. An imaginary plane, perpendicular to the axis dividing the
globe into a posterior and anterior hemisphere, is the
equator. The vertical meridian divides the globe into a
nasal and temporal hemisphere, and the horizontal meridian divides it into a superior and inferior hemisphere.
The main envelopes or coats of the globe are three:
the sclerotic and cornea, the choroid, and the retina.




6     ANATOMY AND PHYSIOLOGY OF THE EYE.
THE SCLEROTIC, OR SCLERA,
is the outer and protective coat, and, if we include the
cornea, may be said to completely cover the eyeball.
It is fibrous in structure, a firm, dense membrane, provided with lymph channels, bluish-white in youth, as
seen through the conjunctiva, and yellowish-white in
adult or old age.
Posteriorly, the sclerotic is partly merged in the
sheath of the optic nerve at its entrance into the eye,
but a fine tissue from  it and the choroid, interwoven
with the neurilemma of the optic nerve, passes across
the nerve entrance, being perforated like a sieve for
the passage of the optic nerve fibres.  This opening in
the sclera is two millimetres (a millimetre being one
twenty-fifth of an inch, or about half a line) in diameter, and the sieve-like membrane covering it is known
as the lamina cribrosa.  The sclera is rather more
than a millimetre in thickness posteriorly, but becomes
gradually thinner as it approaches the front of the eye,
until it receives the tendons of the four straight muscles
near the edge of the cornea.  Anteriorly, the fibres of
the sclera are merged in the cornea; and, near the periphery of the latter, it encloses a circular canal called
the canal of Schlemm, which gives passage to a plexus
of veins.  Posterior to this canal, in the trabecular tissue near the junction of the iris and the membrane of
Descemet are the lymph spaces of Fontana. The sclera
is not rich in blood-vessels, and probably has no supply
of nerves at all; but, near the optic nerve entrance,
and anteriorly, near the cornea, it is pierced by so




THE CORNEA.                       7
many nerves and vessels for the supply of other parts of
the eye, that its firmness in these places is considerably
lessened.
THE CORNEA,
which forms the transparent front of the globe, is
curved so as to form a segment of a smaller sphere than
the sclerotic. It is also a firm, dense membrane, and
of about the same thickness as the sclera, but thinner
~~~ c~~~~ —--— ~~~~~~~~~~~
of about the same thickness as the sclera, but thinner




8     ANATOMY AND PHYSIOLOGY OF THE EYE.
at the centre than at the periphery. It is divided into
five distinct layers. From the outside we have: —
1st. The epithelial layer.
2d. The elastic layer of Bowman or Reichart.
3d. The true cornea.
4th. The layer of Descemet.
5th. The internal epithelial layer.
The corneal substance is permeated by a system of
intersecting canals, through which it is nourished by
the lymph vessels at its margin. The layer of Descemet does not suppurate in keratitis.  See page 140.
In youth, the cornea is very, though not perfectly,
transparent, but in old age the marginal portion becomes more or less opaque from  fatty degeneration.
The circle of opacity thus formed is called arcus senilis.
The cornea contains no blood-vessels except near its
edge; when, therefore, they are seen upon it, disease is
present. It is largely supplied with nerves.
A convenient division of the cornea, for the purpose
of designating different portions of its surface, is by a
vertical and horizontal meridian, which gives us four
quadrants: an outer and inner superior, and an outer
and inner inferior.
THE CHOROID, OR UVEAL TRACT.
The second coat of the globe is a vascular and pigment tunic, covering the eye posteriorly, and extending
forward and forming a part of the ciliary body and
the iris. These tissues together form what is termed
the uveal tract.  Like the sclera, it is pierced posteriorly to admit the optic verve and the retinal vessels.




THE RETINA.                      9
Anteriorly, a short distance in front of the equator, it
is merged in a circle of plaits or folds, which, taken together, form the ciliary body. The choroid is divisible
into four layers: beginning at the pigment layer of
the retina, they are the vitreous, the capillary, the vascular, and the suprachoroidal layers.  These layers are
connected by cellular tissue more or less pigmented.
The pigment layer, formerly described as being the
inner choroidal layer, belongs to the retina. The chief
vessels of the choroid are the vena vorticosa, the trunks
of which pass out through the sclera in a very oblique
direction, posterior to the equator. See Fig. 3. The
choroid and inner surface of the sclera are connected
loosely by a delicate elastic web; and the space within
the meshes of this tissue, between the two coats, is
called the perichoroidal space.   The nerves of the
choroid are parts of the third, fifth, and sympathetic*
They are the long and short ciliary nerves, and both
pierce the sclera near the optic nerve entrance, passing
forward over the external surface of the choroid, forming at the ciliary region the ciliary plexus, which supplies the iris, ciliary muscle, cornea, and the ciliary
blood-vessels.  The blood supply is from  the long and
short ciliary arteries.
THE RETINA,
forming the third tissue of the  globe, may be regarded as an organized expansion of the optic nerve. It
is divided by recent authorities into ten layers; namely,
the internal limiting layer, the layer of nerve fibres, the
ganglionic, molecular, granular, inter-granular, exter



10    ANATOMY AND PHYSIOLOGY OF THE EYE.
nal granular, external limiting, layer of rods and cones,
and the pigment layer.  The three layers which I have
italicized-  the second, ninth, and tenth — are the
layers of practical importance.  The layer of nerve fibres is an expansion of the fibres of the optic nerve
over the retinal surface.  The radiation of fibres from
the optic disk is not symmetrical, but, like the vessels,
FIG. 4.
chiefly upward and downward in direction and tending
mostly towards the temporal portion, as shown in
Fig. 4, after De Wecker and Von Jaeger.  This layer is
thicker around the nerve entrance, and gradually thins
out as we approach the ora serrata.  It is the conducting layer, and the ninth -the layer of rods and cones
- is the percipient layer. The cones are directed towards the centre of the eye, the apex of each pointing
backward, and resting on the tenth, or pigment, layer.
This pigment layer - regarded formerly as a part of the




THE CILIARY MUSCLE.                 It
choroid — does not, like the nervous structure of the
retina, stop in front, at the ora serrata, but passes forward, covering the ciliary body and the posterior surface
of the iris. The macula lutea, situated at the posterior
pole of the globe, corresponding in size to the optic
disk, has in its centre a depression called the fovea centralis. The second, seventh, and ninth layers are found
well represented at this spot, but the other layers are,
to a great extent, wanting. The vessels of the retina,
emerging from the optic disk, like the nerve fibres, pass
chiefly upward and downward, curving towards the tenlporal side of the retina, dividing in an arborescent manner, avoiding always the macula lutea.
THE CILIARY MUSCLE.
A short distance in front of the equator, the choroid
is arranged in small plaits or folds around the lens;
and these ciliary processes, some seventy or eighty in
number, form  part of the ciliary body.  The latter is
made up chiefly of the ciliary muscle, covered by the
choroid and the pigment layer of the retina. The ciliary muscle, or muscle of accommodation, has two sets
of fibres.: the anterior, which are circular; and the posterior, which are meridional.
The radiating, or meridional, fibres have their origin
near the canal of Schlemm, and are lost in the choroid
and ciliary processes. The development of this muscle
differs greatly in different individuals, the myope having usually more meridional, and the hypermetrope
more circular, fibres. The ciliary body is one of the
chief secreting tissues of the eye.




12    ANATOMY AND PHYSIOLOGY OF THE EYE.
THE IRIS
may be considered as a continuation of the choroid.
It is the iridescent, exquisitely colored membrane, the
opening in which is called the pupil, that hangs as a
vertical screen in front of the lens.  It is attached at
its margin to the internal epithelial layer of the cornea
at its junction with the sclera by the ligamentum pectinatum.  The pupil is not exactly in the centre of the
iris, but slightly below, and towards the nasal side.
The iris is more muscular than the choroid. It has a
sphincter muscle for diminishing, and probably a dilator muscle for enlarging, the size of the pupil. Posteriorly, the surface of the iiis is covered by the pigment
layer of the retina. Anteriorly, it receives an epithelial covering from the inner layer of the cornea. The
iris is one of the extremely sensitive parts of the eye,
being richly supplied with nerves as well as with bloodvessels.
THE CRYSTALLINE LENS
is suspended from  the ciliary processes, directly behind the iris, and in contact with the pupillary margin.
Posteriorly, it rests against the vitreous body which is
hollowed out to receive it.  It is a transparent, bi-convex body, enclosed in a transparent capsule, about nine
millimetres in diameter, and three or four in thickness.
It is laminated in structure, and more convex posteriorly. The centre, or nucleus, is harder than the marginal or cortical portion. The lens becomes harder and
less elastic as life advances; and, by the same stages,




THE VITREOUS HUMOR.                  13
changes from a colorless substance in youth to a strawcolor, and finally, in old age, to a brownish-amber tint.
It also enlarges in size with advancing age, but if cataractous, becomes less in size and weight. For purposes
of description, it may have, like the globe, a posterior
and anterior pole, an equator, and, liketthe cornea, quadrants.  The capsule is spoken of as the posterior and
anterior capsule.  The lens has neither vessels nor
nerves.
THE ZONULE OF ZINN,
or suspensory ligament of the lens, is the medium by
which the ciliary muscle acts upon the lens or its capsule in accommodation.  It is a delicate, transparent
tissue from the hyaloid, or investing membrane of the
vitreous, which, in front, passes between the margin of
the lens and the ciliary body, and is inserted into the
anterior and posterior capsule, near the equator.  The
existence of circular fibres has recently been discovered
in this tissue.
THE VITREOUS HUMtOR (VITREOUS BODY)
occupies the entire posterior part of the globe between
the lens and the fundus enclosed in the delicate hyaloid
membrane.  It is a jelly-like body, nearly colorless,
and consists of about ninety-eight parts water.  It has
cells but neither vessels nor nerves.  The hyaloid canal, containing a watery fluid, passes from the posterior
capsule of the lens to the optic disk, directly through
the vitreous.




14    ANATOMY AND PHYSIOLOGY OF TIE EYE.
THE AQUEOUS HUMOR
occupies the portion of the eye in front of the lens
and posterior to the cornea called the anterior chamber.
It also fills the small space between the posterior surface of the iris towards its periphery and the lens called
the posterior aqueous chamber. It is nearly pure water,
and, when evacuated, rapidly re-secretes.
SECRETION OF THE INTRA-OCULAR FLUIDS.
The capillary layer of the uveal tract is supposed to
be the active agent in the secretion of these fluids
which pass outward to the suprachoroidal space and
also inward through the'retina into the vitreous, thence
through the lens to the Zonule of Zinn into the anterior
chamber, mixing with the fluid secreted by the ciliary
body and iris, and forming the aqueous humor.  The
exit is supposed to be chiefly through Fontana's spaces
and the canal of Schlemm.  From  these openings it
gradually passes through interfascicular lymph spaces in
the sclera to the space of Tenon and thence to the vaginal spaces of the optic nerve.
THE OPTIC NERVE
has its origin in two roots, chiefly from  the corpora
geniculata, but also from the thalmus opticus and the
corpora quadrigemina.  At the optic commissure, or
chiasma, there is a complicated intercrossing of the
nerve fibres, as explained on page 220.  The nerve
brings with it from the brain an inner sheath, or neurilemma, the delicate fibres of which enclose a capillary




THE CONJUNCTIVA.                   15
network of blood-vessels from the pia mater. A second
sheath, received after the nerve enters the orbit from
the dura mater, divides into two layers; one lining the
orbit, the other forming the external sheath of the nerve.
The intervaginal space is found between the two layers
of the sheaths of the optic nerve, and is continuous with
the arachnoid cavity.  There is also a supravaginal
space between the sheath of the nerve and the neurilemma, and a perineural space between the neurilemma
and the nerve itself.  These spaces connect with the
lymph spaces of the eye.  The entrance of the nerve
into the eye is about four millimetres distant from the
posterior pole of the globe, towards the nasal side,
and just below the horizontal meridian.  The orbital
portion of the nerve is rather more than one inch in
length.
THE CONJUNCTIVA,
covering the front of the eyeball, called the ocular
conjunctiva, extends back nearly to the equator, and is
there reflected on to the inner surface of the eyelids.
It is loosely attached to the sclera, except at the corneal margin, and is throughout very vascular. Towards
the inner canthus is a fold called the plica semilunaris,
a rudiment of a third eyelid; and still nearer the inner
angle is the caruncle.
The conjunctiva of the lids is called the palpebral,
and that of the edge of the lids, the tarsal conjunctiva.
The posterior portion of the conjunctival sac, where it
passes from the globe to the lids, is known as the retrotarsal fold, or cul de sac, or fornix.  The conjunctiva




16    ANATOMY AND PHYSIOLOGY OF THE EYE.
is a mucous membrane, vascular, transparent, and,
with the exception of the ocular portion, thickly studded
with papillae, which increase in size as we approach the
retro-tarsal fold.  Here are also the glands of Krause.
It is also richly furnished with blood-vessels and nerves,
the latter chiefly from the tri-facial, or fifth.
THE EYELIDS
have for their base  a thin  plate of cartilage (socalled, although it is not cartilage proper, but rather a
dense connective tissue), convex anteriorly, so as to fit
the globe.  Externally they are covered by the orbicularis muscle and integument, and internally by the
conjunctiva.  Beneath the external muscular covering
is a connective adipose tissue, in which, near the margin of the lid, are the follicles of the cilia, or eyelashes,
the sebaceous glands, and the glands of Henle. Within
the cilia are also the orifices of the Meibomian glands,
from which an oily matter exudes to present a barrier
against the overflow of tears.  The Meibomian glands
are plainly visible beneath the conjunctiva; and this
circumstance is often serviceable in diagnosis and treatment of disease of the conjunctiva.  (See page 101.)
The levator palpebrae superioris springing from  the
apex of the orbit is attached to the upper edge of the
tarsus, and is supplied by a branch of the third nerve.
THE LACHRYMAL PASSAGE.
On the margin of each lid, near its inner angle, is
situated the punctum lachrymalis, the delicate opening
into the canaliculus leading in a horizontal direction to




THE TENONIAN CAPSULE.                 17
the lachrymal sac.   The  canaliculi, which  usually
meet before reaching the lachrymal sac, are about six
millimetres long, and the sac which lies in the lachrymal groove, or canal, is about ten millimetres, and
its continuation, the nasal duct, is of the same length.
The size of these passages is further spoken of in Chapter XVII. Homers' muscle lies behind the lachrymal sac.
THE LACHRYMAL GLAND
is placed in the lachrymal fossa, near the outer angle of
the roof of the orbit.  It secretes the tears, which reach
the eyeball through six to twelve minute ducts opening
into the conjunctiva at its reflected portion lying underneath the gland.
The tears, however, as we find them in the conjunctival sac, are made up of the secretion of the lachrymal gland plus the secretion of the conjunctiva.  The
latter secretes a lachrymal fluid, or tears, as well as
mucus, so that the eye is still moistened, and the transparency of the cornea preserved, even if the lachrymal
gland be extirpated.
THE TENONIAN CAPSULE AND MUSCLES OF THE GLOBE.
The Tenonian capsule is a smooth, fibrous membrane
or texture, loosely embracing the globe, enveloping or
ensheathing the muscles, vessels, and nerves that pass
through it, having its origin in the sclera, in a circle
posterior to the equator, near the entrance of the ciliary nerves, so that, posterior to this, is a free space on
the sclerotica, in the centre of which is the entrance
of the optic nerve.  Anteriorly, this capsule loses itself
2




18    ANATOMY AND PHYSIOLOGY OF THE EYE.
in the conjunctiva near the cornea.  The four recti
muscles of the globe — the externus, internus, superior,
and inferior - have their origin at the apex of the orbit,
pass forward, and are inserted by tendons about eight
or nine millimetres in width into the sclera near the
cornea.  The line of insertion of the internal rectus is
about five millimetres from the corneal margin, but the
insertion of the other straight muscles is slightly further back.  Where these muscles pierce the Tenonian
capsule near their insertion, they receive a sheath from
it which is carried forward, tnd inserted with the tendon into the sclerotic. Between the layers of the Tenonian capsule is a lymph space in connection, as
proved by injections, with the perichoroidal lymph
space, and, as I have stated, with the intervaginal
spaces around the inner sheath of the optic nerve, and
thence with the arachnoid cavity of the brain.  The
superior oblique has its origin with the recti muscles,
runs forward through its pulley at the inner and superior angle of the orbit, and then passes under the superior rectus to its insertion in the posterior hemisphere,
near the upper edge of the external rectus. The inferior oblique has its origin at the inner angle of the orbit, near the opening for the nasal duct, and, passing
beneath the inferior rectus, is inserted into the posterior hemisphere, between this muscle and the rectus
externus.  The action of these muscles on the globe,
and the nerves with which they are connected, are
spoken of in Chapter XV.




THE EXCITATION OF NERVES.              19
PHYSIOLOGY OF VISION.
It has been already remarked that the retina is the
perceptive, or, more properly speaking, the receptive,
part of the visual organ, while the optic nerve completes the act of vision by carrying the retinal impression to the brain.  The cornea, lens, and humors, called
as a whole the refracting media, being transparent, permit the passage of the rays of light, and, having convex
surfaces, bring them to a focus upon the retina.  It is
obvious, therefore, that either a failure of the optic
nerve to convey impressions, or any disease of the retina
destroying its receptive function, must occasion blindness. A loss of transparency in the refracting media,
by preventing the rays of light from reaching the retina,
is also fatal to vision.
THE EXCITATION OF NERVES
is produced through mechanical, chemical, electric, or
thermometric changes.  The retinal nerves are excited
by rays of light, as the auditory nerves by waves of
sound, the nerves of the sense of touch by contact;
and, the result of this excitation being conveyed to the
brain, we have the perception of sight, hearing, or
touch. All nerves are apparently similar in structure;
all convey impressions, when excited, at the rate of
about one hundred feet per second towards either end
of their fibres, the nature of the sensations conveyed
depending not upon the nature of the agent employed,
but entirely upon the organ with which they are connected.  Motor nerves, when irritated, produce move



20    ANATOMY AND PHYSIOLOGY OF THE EYE.
ment, because  connected  with  muscles;  glandular
nerves, secretion, because connected with a gland; sensitive nerves, sensation, because belonging to organs of
sensation.  It follows, therefore, that any of the agents
of excitation mentioned, if they could be brought to
bear upon the nervous portion of the retina, might produce the subjective sensation of sight. Thus, pressure
of the side of the eyeball with the finger, or a weak electric current through the eye, gives an impression of light
to the eye, although no light is present.  So disease of
the eye or brain, or narcotic drugs, produce similar phenomena.  The retina and optic nerve being infinitely
more sensitive to rays of light than any other nervestructure of the body, and being in constant functional
activity from this excitation, we naturally connect the
sensation of light with the presence of light, even if no
light be present.
THE VISUAL PURPLE
is due to a red-purple color in the outer part of the
retina.  It cannot be seen with the ophthalmoscope.
On exposure of the eye to light, this color pales; but
darkness reproduces it. It is produced by a secretion of
the epithelial pigment cells of the retina; but as its increase or decrease does not correspond to the retinal current of liquid from the suprachoroid, it is not supposed
to be of direct importance to vision.
THE ACT OF SEEING,
when we take into account its complicated nature, is
accomplished in an extraordinarily short space of time.




BINOCULAR VISION.                 21
The luminous waves of light, moving with a velocity
of 200,000 miles per second, strike the retina, are translated into molecular vibrations of nervous matter, which
in turn are converted by the brain into a sensation of
vision. It has been estimated that the above changes,
constituting the act of seeing, require no more than the
four billionth part of a second for their performance.
Letters upon a printed page lighted by an electric spark
have been seen in forty-eight billionths of a second.
It is supposed that each rod and cone conveys its own
portion of the retinal picture to the brain, so that the
well-known fact that the picture as a whole, upon the
retina, is reversed or inverted, offers no bar to our comprehending the fact that the brain perceives the object
in its true position. This phenomenon would be inexplicable, if the retina as a whole were supposed to convey the picture.
BINOCULAR VISION.
It is also necessary in binocular vision that the image
of the object should be caught by nearly corresponding
points of the two retinae.
When the two eyes aredirected towards a distant object, their visual axes are practically parallel; but, if
we regard an object at a distance of eighteen inches, the
two axes converge at an angle of about eight degrees.
With each eye separately, therefore, we see near objects
from slightly different points of view.  If we regard the
frustum of a solid cone, we see more of the right side
of it with the right eye and more of the left side with
the left eye. The mental combination of the two differ



22    ANATOMY AND PHYSIOLOGY OF THE EYE.
ent perspective views gives us the idea of solidity, or a
third dimension, thickness.  Distance, which is the
equivalent of this third dimension, is also determined
by vision with both eyes. The difficulty of snuffing a
candle with one eye closed is well known.  We judge
of distance by the muscular sense of the effort that converges the optic axes, somewhat as we judge of the
weight of an object by the muscular effort required to
raise it.
THE EYE AS AN OPTICAL INSTRUMENT
is by no means so perfect as generally supposed.
Myopia, hypermetropia, and astigmatism  are optical
defects of a large minority of mankind, and are more or
less remediable by proper treatment. These are considered elsewhere; but there are certain defects common to all eyes which may be styled
IRREMEDIABLE OPTICAL DEFECTS.
These are given by Helmholtz, and are chiefly as
follows:a. Lack of perfect transparency in the cornea and
lens, and fluorescence of both. A strong light concentrated on the cornea and lens will show each to be less
clear than the aqueous between them. Fluorescence is
the property that some substances have of becoming
faintly luminous from blue or violet light. The bluish tint of a solution of quinine in water is an example of fluorescence. A blue light thrown into the eye
shows the same haziness in the cornea and lens, and the
phenomenon is supposed to be due to the presence of




IRREMEDIABLE OPTICAL DEFECTS.               23
quinine or some similar substance in these structures.
These parts of the eye are therefore inferior to the
clear and perfectly transparent lenses used by the optician in the manufacture of optical instruments.
b. Spherical aberration, due to lack of correspondence
of the axes of the cornea and lens, to the lack of symmetry in the former and the peculiar structure of the
latter.  This  constitutes  a slight astigmatism, the
nature of which is noticed elsewhere.
c. Achromatism  or chromatic  dispersion of rays.
The solar rays being made up of the different colors of
the spectrum and each color being refracted in a different degree by the same medium, they are not united by
it in a single focus. Look at a street lamp at a distance through a violet-colored glass.  This stops the intermediate green and yellow rays, and allows the first
and last rays, the violet or blue and the red, to pass
into the eye. The result is that the red is focussed, but
the violet and the blue are seen in a broad halo around
the red gas-light.  The reason this defect is not oftener
remarked is that the intermediate rays of the spectrum
being brighter, the less luminous red and blue are
scarcely noticed beside the intense images of the others.
Optical instruments are free from this defect.
d. Slight color-blindness is common to all eyes. The
eccentric portion of the retina does not perceive green
and red as soon as other colors.  If we test the field of
vision as described on page 37, we shall find that the
color of a red object is not recognizable as far away as
the outline of it.  The eye also fails to distinguish a
difference between a white produced by the union of




24    ANATOMY AND PHYSIOLOGY OF THE EYE.
scarlet and bluish-green light, and a white produced by
a yellowish-green and violet; yet the first comes out
black in a photograph, the latter very bright.
e. The distinct part of the field of vision is very
small; the entire field of vision of an optical instrument
is very limited in extent, but distinct in every part.
f. Muscae volitantes.  These are noticed elsewhere.
y. The blind spot in the retina, due to the space occupied by the entrance of the optic nerve.  Make a
small cross on a sheet of white paper, and three inches
at the right make a black dot.  Shut the left eye, and,
holding the paper at arm's length, fix the right eye on
the cross; on bringing the paper gradually nearer, it
will be found that at about eleven inches from the eye
the dot will not be seen. The blind spot is sufficiently
large to hide the face of a man at six or seven feet.
h. There are also gaps in the field of vision caused
by the blood-vessels of the retina.  These vessels running in front cast a shadow on the layer of rods and
cones which lies farther back. The splits in the visual
field may be recognized by looking at the sky through
a delicate pin-hole in a card, moving the latter from
side to side at the time.
i. The yellow spot, the most sensitive point of the
retina, is by virtue of its yellow tint unable to recognize
weak blue light. The smaller stars are seen better by
astronomers if they look slightly at one side rather
than directly towards them.
This formidable array of common optical defects is
unnoticed by us, chiefly because, having two eyes, one
makes up for the temporary visual disturbance in the




IRREMEDIABLE OPTICAL DEFECTS.              25
other; even with one eye, these defects are rarely noticed, owing to the great mobility of the eye and its
continuous change in direction, and to the fact that
the imperfections are mostly away from  the centre of
the field of vision. Habit, inattention, experience, the
power of accommodation, may also be given as reasons
why our natural visual defects are unobserved.  Nevertheless, these optical defects do exist in all eyes; and,
as Professor Helmholtz observes, if an optician offered
for sale an instrument with these defects, one would be
justified in refusing to buy it.




CHAPTER  III.
EXAMINATION OF TIIE EYES.
OBJECTIVE EXAMINATION.
AFTER a glance at the exterior aspect of the lids, their
margin, the cilia, the general appearance of the eyeball
as to position or prominence, we may turn our attention
to the different tunics of the globe which permit of examination from without.  For this purpose a good light
is necessary, and the best, generally speaking, is that
which falls obliquely on the eye of the patient from a
very near window.  A still stronger light may be had,
when necessary, by lateral illumination, as explained in
the chapter on the Ophthalmoscope.  If we suspect a
foreign body, if conjunctivitis with discharge be present,
if the lids seem  thickened, if any sensation is complained of beneath the upper lid, if there is enlargement
of the mucous papillae of the lower lid, the upper lid
should be reversed.  This proceeding requires but a
moment, can never do harm, and may often give us at
once the key to the difficulty.
To reverse the upper lid it is merely necessary to raise
it slightly with the thumb of the left hand, then seizing firmly the central cilia and edge of the tarsus between the forefinger and thumb of the right hand, the
lid is pulled slightly downward and away from  the




OBJECTIVE EXAMINATION.                27
eyeball, and while the patient is requested to look
downward, at this instant the lid is tilted over the point
of the left thumb, which is used as a fulcrum.  If necessary, a probe may be used as a fulcrum, placing it
half an inch above the margin of the lid and parallel
with it. The signification of the various kinds of redness of the eye is noticed under simple conjunctivitis.
The surface of the cornea should be carefully scrutinized for delicate opacity, ulceration, abrasion, or unevenness.
A few weeks since a young lady called for me to
aid her in the selection of suitable glasses.  She did
not see well at a distance.  There was no refractive
error; nor could I find any abnormal condition of
the eye whatever. I thought of old opacity of the cornea, but did not find it. After learning, however, that
in childhood she had suffered from  an affection which
was undoubtedly a purulent ophthalmia, I felt positive
that the cornea must be at fault. On taking her again
into a darkened room, and re-examining the surface of
the cornea by oblique illumination, and comparing her
eyes under the strong light with those of her companion, I discovered a delicate cloudiness in both corneae.
Without the aid of lateral illumination and the comparison with the perfect cornea of a normal eye, the
haziness might have escaped detection.
The size of the pupil, its form, its mobility, and the
color of the iris should be noticed. The mobility may
be tested by closing the eye and then raising the upper
lid gently with the thumb, observing the reduction in
the size of the pupil as the light strikes the eye, or by




28           EXAMINATION OF THE EYES.
shading the open eye with the hand, then removing the
hand quickly.  In either of these experiments the eye
not under examination must be closed, to avoid sympathetic influence between the two. If the pupil is sluggish in movement, or does not appear exactly circular,
if the iris is at all discolored, we should drop into the
eye a solution of atropine (one or two grains to the
ounce of water), in order to determine whether there is
adhesion between the posterior surface of the iris and
the anterior surface of the capsule of the lens.  If adhesions exist, the enlarged pupil will be irregular in form.
It is sometimes necessary to use a solution of atropine
stronger than this, of four or six grains to the ounce,
when the iris is diseased, in order to affect the size of
the pupil sufficiently. See article on Mydriasis. The
appearance of the surface of the iris may be abnormal
as to color, texture, plastic deposits, and condylomata.
The significance of these objective examinations and
their details will be found when we come to speak of
the diseases of the various structures of the eye.
Tension or hardness of the eyeball is to be noted in
order to determine the degree of intra-ocular pressure.
It is determined by gentle pressure through the closed
lids upon the eyeball with the tip of the forefinger. The
two eyes may be compared, or a sound eye with the diseased one, in order to fix the degree of hardness or softness with more accuracy. Signs to denote the amount
of intra-ocular pressure are sometimes used. Thus: T.
1, T. 2, T. 3, indicate first degree or slight, second degree or considerable, third degree or extreme tension
(hardness) of the ball; while Tn., T? indicate tension




SUBJECTIVE EXAMINATION.              29
normal, tension doubtful. The same letter and figures
preceded by the sign minus mean reduced tension or
softness of the globe.   Thus: T- 1, first degree of
reduced tension.
The mobility of the eye is to be tested by requesting
the patient to follow the finger, which is moved in various directions, in order to detect paralysis of any muscle.  And the strength of the external muscles may be
further tested, if desired, by prisms. See pages 85, 88.
SUBJECTIVE EXAMINATION.
The Pain.
The nature, seat, and severity of the pain complained
of by the patient are of importance as an aid to diagnosis
and afortiori to the selection of appropriate remedies.
A dull pain in and around the eyeball, with a sensation
of heat, the pain very much increased by using the
eye, points to asthenopia. Smarting and burning, or a
sensation as if sand were in the eye, indicate a conjunctivitis. Severe pain with photophobia and lachrymation denotes sensitiveness of the ciliary nerves, as in
deep-seated conjunctivitis, corneitis, iritis, or any inflammation affecting the ciliary region, at the junction
of the cornea and sclerotica.  Deep-seated pain in the
eye, or just above it, recurring periodically, accompanied by dimness of vision, is to be seriously regarded,
and is characteristic of beginning glaucoma.
The severity of the pain, however, is not alone a safe
criterion by which to judge the gravity or slightness of
an affection of the eye.  When present, it helps us to




30          EXAMINATION OF THE EYES.
determine the nature of the disease, but it may be absent sometimes in the most serious cases, such for
instance as glaucoma, amaurosis, or choroiditis.
Photophobia, with no pain, or appearances of inflammation externally, indicates hyperaesthesia retine - too
great a sensibility of the retina.  Retinitis, by itself, is
a rather rare disease, and would be characterized by a
want of sensibility and the necessity of a strong light
to see distinctly.
The State of the Vision.
The visual power of a diseased eye is an important
diagnostic point in the examination. This may be determined by the use of the test types annexed to this
volume.  If the patient reads No. 1 or 2 readily, and
also the letters of No. 12, 15, or 20, at twelve, fifteen,
or twenty feet respectively, with the naked eye or by
the help of suitable spectacles, his sight is perfect.
His visual power = 1.  Good sight for a few moments
followed by confusion of vision, suggests asthenopia.
Rapid diminution of vision as objects recede from the
eye, points to myopia. Lack of clearness in regarding
objects near and distant, indicates hypermetropia or
astigmatism.  Defective sight for near objects and normal vision for distance, is characteristic of presbyopia.
Cloudiness of sight, improved towards night and in dull
weather, suggests cataract.  If "spectacles never did
any good" we think of astigmatism; then amblyopia,
and serious internal disease of the eye will be thought
of if glasses have recently needed frequent changing,
or become unserviceable. If the patient cannot see the




SUBJECTIVE EXAMINATION.              31
largest sized letters, he may be able to count fingers
held quite near the eye. Failing in this he may distinguish between light and darkness.  Seat him before a
window, and then interpose between his eyes and the
light some dark object of sufficient size; or a still better test, because it admits of measurement, is to take the
patient into a room from which daylight is wholly excluded.  He may be able to point in the direction of the
lamplight, even if it is quite dim; or he may be able
to discern it only when it is very brilliant, or he may
not be able to see it at all.  If he cannot tell with certainty, whether we shade it from  him  or whether it
shines full in his face, there is no vision to be improved. In these experiments, if one eye alone is being tested, the other should be covered with a folded
handkerchief so as to exclude the light from  it.  A
healthy eye will distinguish light from darkness with
the lids firmly closed.
The Field of Vision.
The extent of the field of vision, about 900 outward,
55~ inward and downward, and 45~ upward, may be determined by directing the patient to look steadily at
one finger held before his eye at a distance of eighteen
or twenty inches. We then move our other hand about
at a distance of two feet below, above, and on each
side, from the finger towards which the patient is steadily to look, noting whether he sees the hand or can
count the fingers. The finger which we hold up is at
the centre of the visual field and it may be necessary to
bring the other hand very near to this before it can be




32          EXAMINATION OF THE EYES.
seen.  A few weeks since, I found the field of vision so
much narrowed in a case of retinitis pigmentosa that
the patient could not distinguish an object moving until
it came within an inch or an inch and a half of the
centre of the field, showing that only a part even of the
yellow spot itself retained its normal function. A normal eye will distinguish an object moving at a distance
of from two to three feet from the central point of vision.
The field of vision may be mapped out when great accuracy is desirable. Put the patient before a blackboard,
at the distance of fifteen inches; make a dot for him to
fix the eye on; then approach a piece of chalk in a long
black handle from different directions, recording always
the point where the chalk is first perceived by a dot;
afterwards unite these dots by a continuous line, and
the boundaries of the field of vision are sketched. There
is also an instrument for accurately measuring the field
of vision, called a Perimeter.
Di~plopia.
Double images occur in paralytic strabismus, and frequently after an operation for the cure of concomitant
strabismus; it also occurs sometimes in heterophoria.
See page 89.  Monocular diplopia is a result of irregular refraction from abnormal curvature of the cornea or
lens, of mal-position or dislocation of the lens, of inequalities of the corneal surface from old cicatrices, or
of bands of membrane stretched across the area of the
pupil. We may readily produce double images by holding a convex lens of medium strength partly before one
eye so that we may look through it and not through it
at the same time, at objects across the room.




IMPLEMENTS AND INSTRUMENTS.              33
IMPLEMENTS AND INSTRUMENTS.
Trial Glasses.
Complete sets of trial glasses, or spectacles, are necessary for those who propose to prescribe suitable
glasses for the various optical defects. The selection
of proper glasses for patients is a very important and
responsible duty, and should not be undertaken unless
the practitioner is disposed to give sufficient attention
to it to do it in a scientific manner.  Let the haphazard selection of glasses be left to the itinerant
vender and optician.  The proper glass having been
determined, its number and kind are to be written out
and presented by the patient to a respectable optician.
A complete outfit of trial glasses comprising the convex
and concave, spherical and cylindrical, the prismatic
and the colored, will amount to some two hundred, or
the equivalent of a hundred pairs of spectacles.  See
Fig. 5. To such as do not propose a more or less complete equipment for the above purpose, I would suggest
a few glasses merely as an aid in diagnosis.
Weak convex lenses, of thirty, forty, and fifty inches
focus, will help to determine a hypermetropia, or a
beginning presbyopia.  If the patient sees No. 20 at
twenty feet as well with as without, or better with
than without either of the glasses, he is hypermetropic.
In beginning presbyopia the same glasses should aid in
reading the No. 1 print. Ordinary concave glasses will
aid in the differential diagnosis of a slight myopia and
hypermetropia.  Through concaves of thirty or forty
inches focus, a myope should see distant objects more
3




34:i~SEXAMINATIO)N OF THE EYES.
clearly, and a hypermetrope  ess cless    arl.  The same
spherical convex or concave glasses will aid in determining an astigmatism, in connection with the Inetallic
plate and slit.  A slipl of colored glass will be useful in
_ _~._ G,TIEMANN & CO.
FIG. 5.
testing double images, and a few prisms are necessary
to measure the strength of the ocular muscles when this
is desired.
The ophlthalmoscope perhaps ought now to be considl



IMPLEMENTS AND INSTRUMENTS.               35
ered indispensable to the general practitioner.  Very
necessary also are a pair of silver lid-elevators (Fig. 6),
G. TIEMANN & CO
FIG. 6.
and for the extraction of foreign bodies embedded in
the cornea, a wire speculum, self-adjusting (Fig. 7), a
FIG. 7.
fine needle and a delicate spatula, spud or grooved
needle (Figs. 8, 9), and a pair of delicate forceps for
G.TIEMANN & CO
FIG. 8.
I                 G.TIEMANN & CO
FIG. 9.
steadying the eyeball are useful.  The Snellen eyelid
tourniquet is an almost indispensable aid in removing
cysts of the lids. Fig. 10, on the next page.




36          EXAMINATION OF THE EYES.
Bandaging the Eye.
The ordinary bandage may consist of a piece of linen
about ten inches long by two and a quarter inches in
width, with a piece of broad tape at either end to pass
around the head, and tie. A third tape may pass over
the top of the head to assist in holding the bandage in
place when necessary. Before applying, a bit of abGTIEMANN & CO.
FIG. 10.
sorbent cotton, anti-septic, medicated, or otherwise,
should be placed over the closed eye.
The compress bandage should be one and three-quarters yards in length and about one and a half inches in
width, and made of linen, or, still better, fine elastic
flannel. To apply it, commence above the affected eye,
pass it across the forehead to the opposite side, above
the ear, to the'back of the head, below the ear, then up
across the affected eye, and pin it securely to the first
portion upon the forehead.




CHAPTER  IV.
THE OPHTHALMOSCOPE.
IN order to see into the interior of an eye, it is necessary first of all that the interior should be lighted up.
The old notion that an eye under certain nervous conditions becomes luminous from within is not correct.  It
can be illuminated only by light from without. The
second condition necessary is, that, having thrown rays
of light into the eye under examination, we should place
our own eye in such a position relative to the one illuminated, as to catch the reflection of the rays of light
which we have thrown in.  These two conditions are
absolutely necessary, and any further ones merely add
to the convenience of examination or render our examination more accurate.  With a bit of common windowglass we can fulfil these two conditions.  Seat the patient in a darkened room with a lighted lamp by his
side, the flame about on a level with the eye to be examined.  This fragment of glass held in front of the
pupil, and quite near the eye under examination, throws
a sufficient light from the lamp directly into his eye.
This fulfils the first condition. The eye is illuminated.
Now put your own eye behind the glass directly opposite that of the patient, and it will catch the return rays
passing from his eye through the glass into yours, and




38             THE OPHTHALMOSCOPE.
you will see the entrance of the optic nerve, or optic disc
as it is termed, and the vessels of the retina passing
over and away from it.  (See plate opposite titlepage.)
The fragment of glass is in reality an ophthalmoscope,
all ophthlamoscopes are merely modifications of this, and
and do not differ from it in principle. It has been found
more convenient, however, to substitute a mirror for the
plane glass, with a small hole at its centre for the eye
of the observer.  The mirror may be plane, convex, or
concave.  A concave mirror reflects more light into the
eye, and hence renders the details of the fundus more
EMANN i CO.
FIG,. 11.
distinct.  To the same end also it has been found serviceable in practice to hold immediately before the observed eye, with the left hand, a convex glass of about
two inches focus.  This convex lens enlarges the field of
vision; and, although we get an inverted image, on the
whole it facilitates an examination so much as to render
its use almost indispensable in the examination of the
deeper structures of the eye.  There are some forty or
fifty different kinds of ophthalmoscopes in use.  The
one most common, and to be commended, is that of
Liebreich (Fig. 11), though oculists use the more costly
and complicated ones of Loring or Knapp.  It con



1'T1I IN E )ll'l'    A iOP A.SC()i'IE.         #39
is ts  of a..  meitatlia  I in'inor sli r itiv con.cave, about.     a
intch a(      i a tigh th int il diaonet r1, sett in a metalltt ic fltame,,
with  a handlcl. whichlt p)ust.hes. into.itse.lf Iso as to  be Iot
mtlor.e t:han  t:Wo itnches itn lenigt   whien  not: in  lse, andt
conve1t i:entlit fior. t.'ti pocket.   Inll th  cc'itt: o    thl e miii  ior
Fio. 12.
is an  apert're  one-eighlth o(f an  inch  ilt diametei',  ndnt
a;tttaclhetd  to th:te  l'frante of t1le n irtro(  is a hingted  Ib'racket
to hold a small convex or cooneave lens, t:o assist. the e(ve
t:f he'observter if netce(ssa',.'ie o'l j)ieet  1aiss o' c('011 vet x
lens is ralther I a: tr ihan th  in:e'a t i e'ioro':)l  of a(ht t two( ihlf..es
focus()., tand  a mav be: set also  in  a mietaltli fiErame witt aI




40             THE OPHTHALMOSCOPE.
short handle.  The more elaborate " refraction ophthalmoscope" is used by oculists generally, and  is
represented by Fig. 12 on the preceding page.  A very
interesting form of instrument is the binocular ophthalmoscope, so constructed that by means of prisms we
are enabled to use both eyes at once in an examination.
Through this we obtain a stereoscopic view of the fundus, all its parts being brought into relief. It is easier
with this instrument to determine the relative positions
of opacities in the vitreous humor, or extravasations in
the retina or choroid.  Attractive, however, as the binocular ophthalmoscope seems to be, I find that in practice I seldom use it. It is large, cumbersome, and heavy,
and requires more time for its proper use, and ordinarily,
therefore, its advantages do not in practice appear to be
of sufficient importance to compel its employment.
Another, the aut-ophthalmoscope, is so arranged that,
by an ingenious combination of mirrors, one may look
with his right eye directly into his left, or vice versa.
HOW TO USE THE OPHTHALMOSCOPE.
In the beginning, in order to learn to use the ophthalmoscope, it is best to examine a number of healthy eyes.
It is advisable also to dilate the pupil with a two per cent
solution of cocaine - which will so enlarge the field of
vision in a few moments as to make the examination more
interesting and instructive.  Cocaine is preferable to
atropine for this purpose as its effect on the pupil passes
away in a few hours.  It must be remembered that if
we use the convex object glass we get an indirect or inverted picture of the fundus, and without the interposi



HOW TO USE THE OPHTHALMOSCOPE.            41
tion of the object glass we get a direct or upright image.
Having seated our patient in a room from which daylight is completely excluded, with a good steady light at
his left side, we take up the mirror in the right hand,
put it close to our own eye and our eye to the aperture,
and on a line with the eye to be examined, and distant
from it perhaps eight to twelve inches.  Turning the
mirror slightly towards the lamp, we illuminate the eye
of the patient.  Already we have learned something,
because all eyes cannot be illuminated,- an opaque
lens, for instance, prevents it. Now, hold with the left
hand the convex object glass before the illuminated
eye, at the distance of an inch and a half or two inches,
directing the patient to look in the direction of our left
ear when we are to examine his left eye, and our right
ear when we direct our attention to his right eye, - in
other words, directing that the eye under examination
shall be turned slightly inward so as to bring the optic
nerve directly opposite or behind the pupil. To examine the region of the macula lutea the patient should
look straight forward, directly at the eyes of the observer.  It will be recognized as a spot slightly darker
in color, with no vessels running over it. Having illuminated the fundus of the eye with the mirror in the
right hand, we must be careful not to change its position while we are adjusting the convex glass held in the
left hand, otherwise we shall fail to see the interior of
the eye from lack of light.
If the patient is myopic we gain a more distinct view
by approaching our own eye a little, and if he is hypermetropic we see better by increasing, slightly, the




42              THE OPHTHALMOSCOPE.
distance between our eve and his.  If our own eye is
presbyopic or hypermetropic we may also find it advantageous to use in the hinged bracket behind the mirror
one of the little convex glasses of eight or ten inches
focus which belongs to the ophthalmoscope.  The convex glasses will also be found serviceable if the eye of
the patient is hypermetropic.
In the direct examination without the object glass in
the left hand, if we desire to examine the disc or findus, we must approach our eye very near to that of the
patient; but to simply test the'transparency of the
media, - the lens or humors, - we place our own eye at
a distance of fifteen or eighteen inches from  the eye
under observation.
The appearance of the fundus of the normal eye differs
considerably in different individuals.  The fundus of
the eve of a light-complexioned person is light-red,
while that of a dark-complexioned one is dark-red, owing to an albundance of pigment in the choroid, and in
the pigment layer of the retina.  In the former, we may
see many of the vessels of the choroid which give the
fundus a striated appearance.  In very dark eyes the
choroidal vessels are invisible.  See Frontispiece.
The disc or optic nerve entrance appears generally, to
me, of a slightly yellowish-grayish pink.  In dark eyes
more white and glistening, in light eyes more rosy in
color.  It is usually circular in form, but in astigmatism  often has the appearance of being oval when it
really is circular.l  Its edge is sharply defined, and
1 Suppose, for instance, a case of astigmatism where the cornea
is too convex in the vertical meridian. The optic disc appears oval




HOW  TO USE THE OPHTHALMOSCOPE.                    43
ncar it may be seen  occasionally  a slight crescentic
line of pigment.  The face of the disc is more pinkish
at its inner half, and where the retinal vessels emerge
from it.
The retinal vessels run principally upward and downward, an artery, known by its light color, and two veins
running  in  each  direction.   The  retina  itself, in  a
healthy state, is transparent, and cannot be seen.  Exceptionally in very dark eyes, it may be detected as a
gray film, in the immediate vicinity of the disc.  The
physiological excavation, not unfrequently noticed in the
healthy nerve disc, is spoken  of in  connection  with
pathological excavations in the remarks on atrophy of
the optic nerve.   Venous pulsation may sometimes be
observed in the healthy eve.  It is to be looked for in
that part of the retinal vein between the centre of the
nerve disc and its edges.  It may be produced by gentle pressure  on the ball of the  eye with  the finger.
Similar arterial pulsation indicates intra-ocular pressure, and is not found in the healthy eye.  The ophthalmoscopic appearance of the diseased eye is spoken
in a vertical direction if we make a direct examination. In indirect
examination it will appear oval in a horizontal direction. The reason
of this is plain. Our convex glass makes objects appear larger if
held near them, but if removed from the object beyond its focus
(about two inches) we have an image inverted and reduced in size.
Now, in a case like the above, the eye lends the greater refracting
power to the glass in a vertical direction, and the inverted and
reduced image will, of course, be reduced most in the direction of the
greatest refractive power. The convexity of the glass and the cornea combined being greater in the vertical line, the inverted ima'e
of the disc is reduced most in this direction. Hence it appears oval
horizontally.




44             THE OPHTHALMOSCOPE.
of in connection with the various affections which demand its aid for their diagnosis and intelligent treatment.  I may remark here, however, on the great
importance of what is termed lateral or oblique illumination in detecting diseases of the anterior part of
the eye. A good rule to follow in ophthalmoscopic examinations, - one that will save time, facilitate diagnosis, and prevent error, - is to always commence the
examination by
LATERAL ILLUMINATION.
Lateral Illumination of the eye is best conducted in a
darkened room, also.  The patient sits relatively to
the light, as in the ophthalmoscopic examination. The
convex object glass is to be held between his eye and the
light, the patient facing the observer, so that a strong
light is thrown obliquely on to the front of the eye illuminating the cornea and anterior chamber.  We may in
this way detect opacities of the lens, examine with the
greatest nicety the surface of the cornea and the texture
of the iris.  A second convex glass may also be used
at the same time to look through as a magnifying power,
if desirable.
DIFFICULTIES OF DIAGNOSIS IN DISEASES OF THE EYE,
FORMERLY.
Before the discovery of the ophthalmoscope, by Helmholtz, in 1851, very little, comparatively speaking, was
known concerning the internal diseases of the eye, and
the little knowledge which we possessed was very inexact. The history and progress of this kind of disease




IMPORTANCE OF, TO PRACTITIONER.            45
it was of course impossible to determine with any certainty.  Diseased eyeballs were rarely dissected after
death; and when this was done, it yielded but scanty
return for the labor. A comparison of the pathological
anatomy in such an instance, with the symptoms observed during life, in an organ of which nothing objective in regard to its deeper structures could be
previously determined, afforded little satisfaction, and
still less serviceable information.  We may say, therefore, that previous to the introduction of the ophthalmoscope, our entire knowledge, almost, of the diseases of
those parts of the eye posterior to the crystalline lens
was conjectural.  When the cornea and the iris and the
lens presented no appearances of lesion, and yet the
patient's visual power was impaired, we were disposed,
and it might be said perhaps that we were compelled,
nolens volens, to attribute the visual disturbance to some
affection of the optic nerve.  In the words of another,
when neither the patient nor the doctor could see anything, it was amaurosis! 1
IMPORTANCE OF THE OPHTHALMOSCOPE TO THE GENERAL
PRACTITIONER.
It is within a short time only that, in the treatment
of general nervous disorders, the attention of the profession has been called to the importance of knowing the
exact condition of what has been fitly termed the outpost of the central nervous system, - the nervous structure of the posterior portion of the eye, the condition of
1 Amaurosis sei jener Zustand wo der Kranke nichts sieht und
auch der Arzt nichts. - Walther.




46               THE OPHTHALMOSCOPE.
which gives, in many cases, a picture of the condition
of the brain itself. The ophthalmoscope is, therefore,
destined in the future to be of great service to physicians in the treatment of a large class of diseases of the
brain and nervous system.  Among disorders of this
kind which the general practitioner is called upon to
treat, and in  which the ophthalmoscope has already
proved serviceable are the following: meningitis, encephalitis, hydrocephalus, cerebral hemorrhage, tumors,
epilepsy, insanity, locomotor ataxy, nervous fevers, and
\velitis.
In the optic nerve disc, for instance, we may see congestion and effusion, inflammation of substance and
sheath, anemia, and atrophy.  An optic neuritis is connected with meningitis of the base of the brain, with a
tumor, with  large hemorrhage.  An atrophy  of the
nerve, which may be recognized as either progressive
or stationary, is accompanied by disease of the brain,
cerebellum, or spinal cord.  In lead poisoning there has
been noticed a change of color and transparency in the
optic nerve disc.  In the retina, we detect inflanmmations, fatty or fibrous exudations, and hemorrhages; in
the choroid, loss or disturbance of pigment, hemorrhages, and effusions; and in the blood-vessels of the
fundus generally are observed diminution in size, dilation, obliteration, tortuosities, pulsations, varicosities,
blood stases, displacement, effusion, and rupture.  In
albumlinuria or Bright's disease, one may watch the
changes that finally result in degeneration of the sulbstance of the retina, and defective nutrition of the optic
nerve.




IMPORTANCE OF, TO PRACTITIONER.            47
Chronic headache, especially when the location of the
pain is unusual or seems permanently fixed, and when
accompanied by vomiting, should be regarded with suspicion, and every means taken to determine the state of
the brain.   Severe headaches and bilious vomiting
have been known to herald final disease of the brain,
and amaurosis.  The ophthalmoscope will sometimes
be of value in enabling the practitioner to determine the
significance of these symptoms, whether they are to be
regarded as of cerebral or of gastric origin, or are due
merely to errors of refraction or muscular insufficiency.
In insanity, the ophthalmoscope has become an important agent in determining its course.  Of a large
number of patients submitted to examination, many
have been found to present affections of the optic nerve.
Dr. Allbutt, of the Leeds Infirmary, found that in fiftythree cases of that kind of insanity known as general
paralysis, forty-one had disease of the optic nerve.  The
affection begins as a pink suffusion of the disc, and
ends in white atrophy.  It resembles in appearance the
"red and white" softening of the bralin.  Of fifty-one
cases of mania, more than half showed symptoms of disease of the optic nerve, - a stasis followed by consecutive atrophy, or white or mixed  atrophy.   After a
paroxysm, there is a paralysis of the blood-vessels and
about the disc, causing hyperaemia.  In dementia and
in idiocy, and in insanity, from epilepsy, a large number of cases show disease of the optic nerve or retina.
Thus investigations in regard to the diseases involving the brain and nervous system are greatly aided by
ocular examination of the nervous and vascular tissues




48            THE OPHTHALMOSCOPE.
of the eye with the ophthalmoscope.  Here we see a
diseased nerve, and measure with our eye the progress
of the affection. It has been remarked with truth that
hereafter no record of a nervous affection can be considered complete unless it gives a faithful account of the
ophthalmoscopic appearance of the retina and optic
nerve.




CHAPTER  V.
REFRACTION, ACCOMMODATION, AND THEIR
ANOMALIES.
REFRACTION of the eye, or the refractive power of the
eye, is the phrase used to express its power of bringing
rays of light entering the pupil to a focus in the vicinity
of the retina.
Accommodation expresses the ability of the eye to increase or lessen its refractive power by means of the
ciliary muscle and iris.  Thus, in a state of rest, regarding a distant object, the emmetropic (normally
refractive) eye needs no exercise of its power of accommodation, because the cornea and lens are precisely
convex enough to bring parallel or distant rays of light
to a focus on the retina.  The latter is situated at a
distance of about one inch behind the cornea, and the
refractive power of the eye at rest is about equivalent
to a convex glass of one-inch focus.  But if we regard
an object near the eye, the rays fall no longer parallel
upon the cornea, but divergently, and of course a greater
focussing power is needed to bring them to a point at
the proper distance behind the lens.  A  refractive
power, the equivalent of a one-inch convex glass, is
insufficient, and the exercise of the power of accommodation becomes necessary.
4




50        REFRACTION AND ACCOMMODATION.
Accommodation of the Eye
is brought about by the contraction of the ciliary muscle, which causes, through the medium of the Zonule of
Zinn, an increased convexity of the crystalline lens,
mostly at its anterior surface, giving it a higher refractive power. This action relaxing the tension of the Zonule of Zinn, permits the lens through its own elasticity
to assume a, more convex form.  There are also the
associated movements; namely, the periphery of the iris
is drawn slightly backward, the pupil becomes smaller
and is moved forward, the anterior choroid is moved
forward, and there is a perceptible forward movement
of the whole eyeball.
CONVERGENCE,
so that the two eyes may be directed to the same point,
is also, in binocular vision, more or less inseparable
from  accommodation.
DISTINCTION  BETWEEN REFRACTION  AND ACCOMMODATION.
It is to be remarked that the power of accommodation
in the eye may be entirely suspended (for instance by
the instillation of atropine), and still the ref raction
remain sufficient for distant vision.  In presbyopia, the
accommodation is much lessened in power, so that the
near point for fine print may be as far as fifteen inches
or farther from  the eye, while the emmetropic eye is
able to see the same print distinctly at three inches.
The former, like the latter, has perfect refractive power
for distance.  In myopia, the antero-posterior diameter




MYOPIA.                       51
of the eyeball being lengthened, the refractive power is
too great for distant objects, -the power of accommodation may be unimpaired.  In the hypermetropic eye
the same diameter is too short; there is a lack of refractive power, - the rays of light reaching the retina
before being focussed, - while the accommodative power
may be good.
REFRACTION AND ITS ERRORS.
Considering rays of light from  distant objects, or
from objects distant more than six metres or eighteen
feet, as parallel rays, we may say, in general terms,
that in the 
Emmetropic eye, parallel rays are brought to a focus upon the retina.
Myopic   eye,   "'' "   "    " "  " before "  "
Hypermetropic eye,'   "'   "   " "  " behind "  "
Astigmatic eye,' irregularly focussed.
MYOPIA (NEAR-SIGHT).
The optical defect of the myopic eye is exactly the reverse of that of the hypermetropic, -that is, its refractive power being in excess, parallel rays of light are
brought to a focus before reaching the retina.  This is
due to the increased antero-posterior diameter of the
eye, the bulging of the globe being posterior, at the entrance of the optic nerve. The retina is thus pushed
too far back from the cornea and lens. This elongation
of the posterior pole of the eyeball can be seen by requesting the patient to look as far inward as possible;
we then notice also that the space in the orbit between
the outer canthus and the globe, observable in the em



5;'          IdFI.F' t iO  ('. t 1. )N  AND) ACCOMMOAT ('I'.)lf) ON,
ettl  oi:, )ic.  (nort ally rt erac\-t i v),  atId  Osi   (  iat ia  ll   it  the
),ePmI(tvIolp)i Cl (?Ve.  is c(iltm}etely filled I by tlte distendedi
Fit, 18,
i:o.(:'.  Xclxceoptioally, IfIy)oia  t iavy   e ihe  re  islt: oif too
g.rcat rcifractiol,  thtie axis of thle Iee not  c beig itmt st td..re    1 above  esents  c, lhe   x
F    1. 16.
Fig. -14 sllows tl.he f)orl   ot tin)  emmi(etrpie eCe, w\hie(.}!
(err.'es))ponds so pe'fect el  wi th its rettfra(ctio)l th)at; pratf l




TH-E CAUSE OF MYOPIA.                 53
rays of light from  A  are brought to a focus exactly
upon the surface of the retina.
In Fig. 15 we have the mnyopic eve again, but being
provided with a suitable concave glass, its refraction is
thereby so far diminished that the parallel rays of light
are properly focussed.
THE CAUSE OF MYOPIA.
Myopia is rarely congenital, often hereditary, and
perhaps often acquired.  It is possible that an hereditary predisposition to the affection may exist in those
cases where it is acquired, and in which no myopic
parentage can be traced.
Late researches tend to show that, among school children, the myopic eyes are recruited, as the process of
education goes on, mostly from  those of hypermetropic
refraction; that, in young children, this form  of optical defect is very common, but as time goes on and the
eye is used for near objects in study, and especially if
the child is not robust, the hypermetropic refraction
is lost and the eye becomes myopic.  This change to
myopia is all the more likely to occur if there is an astigmatism also. The astigmatic eye is usually weak and
irritable, especially if the astigmatism is myopic.  Such
eyes pass directly over from hypermetropia to myopia.
It is affirmed that an emmetropic eye will, in all probability, escape injury during the educational period; but
comparatively few eyes can be strictly classed as such.
Progressive, or acquired myopia in young people may
not be directly attributable, therefore, to the process of
education, although education undoubtedly encourages




54       REFRACTION AND ACCOMMODATION.
and hastens its development in all those children whose
eyes deviate from  the emmetropic standard.  Unfortunately, the greater number of eyes are found to be
hypermetropic, and these pass easily over into the myopic; it is nevertheless a fact that certain conditions
tend strongly to the production of myopia.  I have
known several students at different times in Vienna,
who informed me that when quite young they saw as
far as their fellows, but that after commencing their
studies, and pursuing them late at night in their homes
among the mountains, with no light but that of a miserable tallow  candle, and sometimes even less than
that,  a shred of cotton in a cup of oil, a light so dim
and flickering that the book must be held within a few
inches of the eye, or the head be bent over so as nearly
to touch the paper when writing,- after studying in
this way for a few years they became myopic.  We
know that myopia is more common among the educated
than the illiterate, and that it is usually progressive in
schools from the elementary grade upward.  Probably
this progress is somewhat in proportion to the general
health of the pupil.  But it must be said also that
the worst and most dangerous form of progressive myopia is oftenest met with among the illiterate. The
severest case 1 have ever seen was in a young uneducated Italian here in Boston. Such cases are inherited,
and are so progressive and destructive as to be called by
some writers " malignant myopia. "
Diagnosis. - The diagnosis of myopia is not difficult.
It must not be taken for granted, however, that because
a patient holds his book too near, or because he does




THE CAUSE OF MYOPIA.                55
not see well at a distance, he is therefore near-sighted.
Astigmatism, and especially hypermetropia, may equally
produce defective vision, characterized by such symptoms.  Still, no opacities of the cornea or lens being
present, if the indistinctness of vision increases very
rapidly as large letters are removed from the eye, we may
be tolerably certain of myopia. A better test is to hold
before the eyes weak concave glasses, say of thirty or
forty inches focus.  If the patient sees better, he is in a
great majority of instances near-sighted.  Occasionally,
however, persons of good accommodative power see more
distinctly, for the moment, through weak concave
glasses, though not myopic, and sometimes when a very
high degree of myopia is present, weak concaves are of
almost imperceptible benefit; therefore, to make our
diagnosis certain, it is better to ascertain beforehand
about the number of the glass required to correct the
nmopia.  This may be done by finding the farthest
point at which the patient can read the finest type,
such as Brillia.t and if this be at a distance of six, eight,
or ten inches from  the eye, we may place before
his eyes concave glasses of a corresponding number;
if his far point is eight inches, a concave glass of
eight inches focus will enable him to see well at a distance, and the existence of myopia is demonstrated
beyond a doubt.  Another ready and convenient proceeding for the diagnosis of either near-sight or oversight is mentioned under the head of Hypernetropia at
page 68.
Myopia is also diagnosed with the ophthalmoscope.
For this purpose we use the erect image (simply the




56       REFRACTION AND) ACCOMM( ))ATION.
mirror, without the convex object glass), and find that
we can see the optic nerve disc and retinal vessels,
when the pupil is large, distinctly at a short distance
from the eye.  On moving our head to either side, we
find the image moves in the opposite direction; we
obtain an inverted image of the fundus of the globe exactly the reverse of that obtained in the hypermetropic
eye under a similar examination.  We may also detect
a myopia or hypermetropia by the use of the ophthalmoscope with the object glass.  In myopia, if we increase the distance between the observed eye and the
glass, the optic disc appears larger; in hypermetropia
it appears smaller; in eininetropia its size remains unaffected by the movement.  A two per cent solution of
cocaine will enlarg(e the pupil somewhat and make
these examinations easier for the physician.  See page
334.
Pathology. - The pathological changes in severe cases
of myopia, and staphyloma posticum, and an accompanying choroiditis, consist chiefly in an atrophy of the choroid resulting from  the inflammation.  This occurring
principally around the nerve entrance, permitting the
white sclerotic to shine through, we have, as a result, a,
characteristic, large, irregularly outlined crescent. The
irregular deposit of pigment is owing to the same cause
as are also the exudations into the vitreous, and the
possible final separation of the retina to a greater or
less extent from  the choroid.  With the choroid the
retina suffers also, and finally becomes atrophied in the
region of the optic nerve and macula lutea.
In such cases there may be phosphenes, flashes of




Tim, CIAUSE OF MYOSIA. 0T
(:oloredI  light;,  sapet:tra, metamol1iploip)si' L     as well -as
ambyII    opia.
Bttlt ttthe albov;   tliseatsed tolldit:iots tar  found oniv it a
higih grdX.e of mlty:ia iti adults.  tMlost catse  of slight,t1d tnedi t un grades. of myop (  ia aret [t ee oT   serliis  athtotogi'Icatl cliiaet s   The'11  otrd liari sn al l   wilitish cresTei:t:f
s( often seen at the outer i    argi t of tlh optic disct, i(dte
1to tl:t ret-:ract1io0lt or lliiinningt of sot iet (01r all of thole chlol)progress,8 1t: t unletss t;ltIh  progress eontlitt.es }.beyonld adult
Pfm. i. e'                          Fio. 17.
a.e, it needI not occ asion alt    A. rescent  as large
ats tlat' oft: - i...t  after Von Jael, mi:ttt  t t be.c.t18iered  ratlher steriout.'lle  eyebll at  repl')Tresen!ted  i
Fig'. I1.7, from  Nettleship,. sI.,ho ws "gre at elongat1ion, and a
net.c'.e ss ra:i  1 vhi1lt g(trade of m yopia,
~'i'/1  UC~rrdtaecd (J W/Op)U -int st 5011111 l8 }:l (  tW meical,
The treatmen'  t o.f m /opia must some.time s be medical,
e      (s.pt'eI tilllv  in  the easet  of weakly c1hil dren', butt more
utsually opticat l and  hygienic.'WhTen tlhere is consideralle  miusc:ul' as t hlienoptia, if the eye is  irritable, the
eonjunetiva  injected,  th'. e   op)llth'almoseoope  slowing  a
lrvpl(erWmic(. coi(,lition of the ner've disc: with or' without
staph1)ylomla postieumn, tand the patienti cotmplalinls of pain




58       REFRACTION AND ACCOMMODATION.
around and sometimes in the eye, with feeling of tension and heaviness in the eyeball, the prescription of
glasses should be temporarily delayed until, by complete
rest of the eyes and proper remedial measures, the irritable state of the eye is removed. Gentle use of the eye
douche will be found grateful, also a lotion composed
of a drachm of spirits of ether nitrate to six or eight
ounces of pure water, to which may be added a few
drops of aromatic vinegar, the wash to be sponged over
the closed lids and about the eye several times a day
and allowed to evaporate.  For hyperlemia of the conjunctiva a collyrium  of ten grains of borax, or four
grains of boracic acid, to the ounce of water may be
used.  Often the application of very hot water for five
minutes over the closed lids, several times a day, will
prove grateful. In some cases it may be wise to paralyze
accommodation with atropine and allow complete rest to
the eyes for some weeks.  There may be indications for
general medical treatment, the general health of the patient being of very great importance in nearly all cases
of disease of the eye. Children with progressive myopia
are rarely healthy.  Rapid growth, muscular and nervous debility, frontal headache, coated tongue, capricious appetite, are often present.
Spectacles.    Generally speaking, no preliminary treatment is called for, and our first step is to select the appropriate glasses.  They are to be selected with the
greatest care.  If too weak, they are comparatively useless; if too strong, a positive injury.  The degree of
myopia is determined by the negative focus of the glass
which neutralizes it. If a patient reads No. 1 of the




THE CAUSE OF MYOPIA.                 59
test type at six or eight inches, his myopia is one sixth
or one eighth. A concave glass of six or eight inches
focus should, theoretically speaking, enable him to read
No. 20 at twenty feet, and to see well at a distance.
Practically, however, we find it necessary to prescribe
concave spectacles rather weaker than this.  If the myopia is one eighth, vision will be most perfect through
glasses of one ninth or one tenth; which of the two numbers will prove best is to be determined by trial.  The
reason of this non-correspondence of the number of glass
to the degree of myopia is this: the patient's far point
being eight inches, the visual axes were converged for
this distance, and with convergence of the eyes is associated accommlodation (an increased convexity of the
crystalline lens); in looking at a distance through the
i)rescribed glasses, the visual axes are of course parallel,
and there being no accommodative power (increased convexity of the crystalline lens) to overcome, the glasses
should be proportionally weaker.  The proper glass to
enable him to read music or small print at twenty-four
inches would be of about twelve inches focus. The formula would be: -   + -1 =-1-2.  The patient's power
of accommodation will influence greatly the choice of
spectacles. When little or no accommodative power exists, as is often the case in a high grade of myopia,
spectacles may be given which completely neutralize the
myopia and entirely supplant any little accommodative
power present.  When only a tolerable power of acconmmodation is found, it is advisable to prescribe glasses
which partially supplant it.  Thus if our patient has a
myopia of one eighth, and finds glasses of one ninth best,




60        REFRACTION AND ACCOMMODATIO(N.
if his power of accommodation be one twelfth, he will,
through these glasses, be obliged to use his whole power
of accommodation for reading at a distance of twelve
inches. This is not safe, lest symptoms of fatigue supervene, his eye become irritable, and his myopia be increased.  He should, therefore, be provided with weaker
spectacles for reading; concave glasses, for instance, of
sixteen or eighteen inches focus, by diminishing but little the convexity of his crystalline lens, enable him to
see easily at ten or twelve inches, and tolerably at a
short distance beyond.  He should therefore, like the
imyope without accommodation, provide himself with two
pairs of glasses, one for reading and one for distance.
If perfect or normal accommodation is present, as is
sometimes the case in the slighter forms of myopia in
young persons, a single pair of glasses which neutralize
the near-sight may be worn for both far and near vision.
As a rule, however, it is prudent to prescrii e for near
objects concave spectacles which only partially neutralize the myopia, and enable him  to read comfortably at
fourteen or sixteen inches.  Rules are often, however, of
little practical service.  The myopia must be corrected
by suitable glasses whether their strength correspond or
not to the apparent degree of near-sight.  Frequently
very strong glasses will be necessary for distant vision,
and the patient will find it convenient to carry eyeglasses to use temporarily before his spectacles.  These
eye-glasses must, of course, be concave and of just the
power to supplement the spectacles sufficiently to neutralize the myopia for distant vision.  When the myopia is slighter than one fourteenth or one thirteenth,




THE CAUSE OF MYOPIA.                 61
fine print being read easily at fourteen inches, spectacles
need not be prescribed, but simply the proper eye-glasses
for distant vision.
The chief danger in the selection of spectacles is that
of getting them too strong,  and so overtaxing the eyes
for near objects. De Wecker believes the great prevalence of myopia in Germany to be due partly to wearing
too strong glasses. I believe it may be due principally
to the peculiar text in which their books are mostly
printed.  The sharp and accurate vision necessary to
distinguish the letters requires the text to be brought
too near the eye, thus favoring the habit of short-sight.
Spectacles, therefore, should not be bought at random
of opticians or itinerant venders, but should be prescribed by a competent physician or oculist.  When
one eye is myopic and the other hypermetropic, the
more serviceable eye should alone be provided for. If
we prescribe a concave for one and a convex glass for
the other, the former diminishing and the latter magnifying objects, it will be difficult to fuse the different
sized images on the retina. Actual trial, however, is
the best method of determining these matters. The best
rules have their exceptions.  I have a patient whose
right eye is myopic and astigmatic, and whose left
eye is hypermetropic.  For the first he wears an eighteen-inch concave cylindrical, and for the second a sixteen-inch convex spherical glass, and with these reads
more comfortably with both eyes than with either eye
1 De Wecker's rule is very good in doubtful cases: " Eviter de
donner dans l'hypermetropie des verres trop faibles, et d'en prescrire
de trop forts dans la myopie."




62       REFRACTION AND ACCOMMODATION.
alone. In non-diseased eyes the phosphenes, spectra,'flashes of colored light, and like phenomena arise from
over-sensibility of the retina, and generally disappear
under treatment of the irritable condition of the eye. If
they do not, like muscae volitantes and scotoma, they
will be rendered less apparent and troublesome by the
use of colored glasses.
After prescribing with the greatest care the proper
glasses, it is necessary in the progressive myopia of
young people to enforce strict hygienic measures.  Our
patient should not work continuously at near objects, but
should rest a short time at intervals of a quarter or half
hour, and always whenever the eyes feel in the least fatigued.  He should never work or read with the head
bent forward, as this promotes intra-ocular congestion.
The light should fall upon his work from behind, so that
the eye may be protected from glare. Children's school
desks should, therefore, be made sufficiently high and
sufficiently sloping, and be placed, as regards light, to
fulfil these conditions.
In the myopia of children, enforced rest of the eyes
will often produce very great improvement in vision;
that is, the grade of the myopia is improved.  The inproved sight is apparently not wholly due to the removal of the slight tension of the ciliary muscle coimmon in these cases, as the paralyzation of the muscle by
atropine produces an effect considerably less than the
final effect of complete rest.  Nor is it due to the curative effect of rest on the amblyopia.  Often no amblyopia is present. I attribute the improvement to a
change in the shape of the globe due to an exclusive




THE CAUSE OF MYOPIA.                  63
use of the eye for distance.  See page 49, Accommodation of Eye. We should prescribe, in these cases, daily
use of the eyes for distant objects in the open air.
In very high degrees of myopia, such as one fourth,
one third, or one half, even if no amblyopia be present,
we cannot expect the patient to read large print through
his glasses at a point as distant as a normal eye would
do it.  The powerful concave glasses diminish the size
of the image too much.  Very strong concaves are also
inconvenient to the wearer, by compelling him to move
his head always in looking to the right or left.  His
glasses are so deeply hollowed that he must always look
through their centre, or they produce the effect of prisms
or decentred glasses.
Finally, it should be remarked, that in a certain
number of cases of accommodative asthenopia in slightly
myopic young people, it may be advantageous to prescribe convex glasses for near work.  Even in cases
where concave glasses are worn for distant vision, I
have found weak convex glasses necessary for the eyes
in reading.  Such cases are exceptional, but they occur.
The same is true also in myopic astigmatism of a low
grade.  We find that for reading, a weak convex cylindrical lens is best; while for distance, a concave cylindrical is required.  I may add here, that in high grades
of myopia there is frelquently an astigmatism  also, and
that what we at first take for an amblyopia may be
remedied, to a certain extent, by proper cylindrical
glasses.  Many nvmopes, therefore, when the myopia is
considerable, require a combination of cylindrical and
spherical concave glasses.  And not unfrequently there




64       IEFRACTION AND) ACCOMMODATION.
is insufficiency of the internal recti requiring the comb)ination of prisms, base in, also.
The power of convergence is not infrequently im —
paired in myopia.  This need not necessarily be due to
weakness of the internal recti muscles but rather to a
lack of ability in the muscles to work together so as to
converge the eyes for the proper distance to give easy
and distinct vision.  The recti interni may also be
weak.  See Muscular Asthenopia, page 84 et seq.
Finally it may be stated that recently, Fukala reports operations for discission of the lens in twentythree cases of very high grade of myopia with excellent
results.  Absorption of the lens made the refraction
emmetropic, hypermetropic, or less myopic, and greatly
lessened the amblyopia. In one case vision was raised
from one tenth to one half, in another from one twentyfifth to one half.1
HYPERMETROPIA AND ASTHENOPIA (ACCOMMIODATIVE).
Hypermetropia,
as we have already seen, is that condition of the eye
in which its antero-posterior diameter is too short in
comparison with the refractive power (convexity) of the
crystalline lens and cornea.  The rays of light consequently reach the retina before they are brought to a
focus, forming circles of diffusion, and vision is indistinct. A convex glass, or spectacles, by supplementing
the refractive power of the natural lens, enables the patient to focus the rays of light upon the retina, precisely
1 Ophthal. Review, vol. ix. p. 304.




I:tYPEl'iMEtA RIO.l'IO 1'A  ANI) ASTIIENO()IA.      6(5
as in presb)yopia.  In presbyIoptia, however, ralys of light
from   a  distance -that is, wllat are  termedp parallel
rays.   a.... re broughtt to a focut s o   the retina without the
use of accomtlnodat int. g  pol wer; ( wh i le, in  hyperlmetroplt ia,
the exercise of this lotler' is alwt-itays necessary,  even for
distant vision, and, in the higrher grades of the aItectiolt, ColV.X glasses atr  t lsto necessarty  fo'r all distatnes.
A. ltyperlt l   opict':   eye is generalIly  sma llelr in all its    i 
mnsi onls. ts t  tlhn  tle entelletrop'ie or nor ma 1ll  re{fract i
tand is usually cong ntit Ial ttand hereditary.   Ti'is fo:)m  of
ple:,rttinet rotl'pia.a is somne,11titmes c(:alled{ a!ial in distilcltion,
to a folrm  wht ici tt is (occ.asiontaliy II me~ i:ti      it th illt d,e to: ant
ilsl0tiicitent ratr  of rthe ref'ract:i e medi a. and called
cutrvatare il'yle'lmf  tropl:ia.' lThe t same.li is true of my:ptia
whlicth, usnuall    axial, maty  exce'    1t iolnt lly btItt  ctlurvattture
intopia: ctlt.1atsed ity exeessi ve:  ci(.trvature - of the refIt racttivt:.
ntmedti a.'it' 1.8,tt albove, is intlenled to repiretsent. n etl.vealt II of
the  tyliev me t:ropi c      formi  t he  para:llel I rays of li tlht frot
A. tare seen  to reach: l the retina befol:re tbein, lb'roIIuht to: foteus.  Sutch t      eNye mit tightl perhaps fot>tI. s parallel rays
by lte exercise of its  \owert olf acomt(.modation; butl if
the rattnte of,ac.coitmoda tiion weire litmlited, or the ograde
1)




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---— _' —--— 1   |      v   **rt  z
-5  z -rais — -i e.-'     _,                    R                                -;   _~~~~~~~~- 
t-   _                       _                                                                     -             - -
z:  >  e> age ad l......
t* _ ~~~ ~~ ~~ Ad ^ BOX +w ~~~- rfi




DIAGNOSIS OF HIYPERMETROPIA.             67
that a change to weaker glasses may after a time,
become expedient.
Hypermetropia is divided by Ionders into facultative,
relative, and absolute.
Facultative is the slightest form, where the patient
accommodates readily for all distances; presbyopia occurs rather early, and then asthenopic symptoms are
apt to occur; while, in
Relative hypermetropia, although the patient can accommodate so as to see well at all distances, yet this
is only accomplished through great efforts of accommodation, and by converging the optic axes strongly at
the same time.  Such persons are almost certain to
become asthenopic.
Absolute hypermetropia is a condition of the eye in
which the patient sees distinctly only by the aid of convex glasses. Without spectacles no effort of accommodation, however great, will suffice to focus rays of light
upon the retina.  A hypermetropic refraction is caused
in the emmetropic eye after the loss of the lens in extraction, and also in aged people from a high grade of
presbyopia.
DIAGNOSIS OF HYPERMETROPIA.
Let the patient look at No. 20 of the test type at
twenty feet, and if his vision is improved or not lessened by looking through convex glasses of thirty or
forty inches focus he is hypermetropic. These glasses
would not render the vision of an emmetropic eve more
acute.  But it may happen that, although slightly hypermetropic, he does not see as well through the convex




68        REFRACTION AND ACCOMMODATION.
glasses, or he may even see as well, through concave
glasses of thirty or forty inches negative focus, as in
myopia.  He is not myopic, however; but in looking
through the concave glasses he involuntarily exerts all
his power of accommodation; and when this power is
considerable, he overcomes, for the time being, his own
as well as the additional hypermetropia caused by the
concave glasses.  Slight tension of the ciliary muscle
might also cause an apparent myopia. Ordinarily, however, we find that a weak convex glass improves vision;
if it does not, we may try the effect of paralyzing the
accommodation by the instillation of atropine.  We
can then determine the whole extent of the hypermetropia, both latent and manifest.  If after an -hour or
two we try our convex glasses again, we may find that
whereas, previously, he could only see well through
convex thirty, he now sees best through convex twelve
or fifteen.  His manifest hypermetropia was only one
thirtieth; but his latent, being added, gives him really
a hypermetropia of one twelfth or one fifteenth.  The
hydrobromate of homatropine in one per cent solution
may be used in these cases generally, as its unpleasant effects on accommodation pass off in a day or two.
Another, and very simple test, for anomalous refraction, without the aid of glasses, is mentioned under
Amblyopia.
We may diagnose the affection also by means of the
ophthalmoscope, using the direct image. With this we
see the details of the fundus at a little distance, as in
myopia, only in this instance we get our image uninverted. A movement of the observer to the right or left




THE OPHTHALMOSCOPE IN MEASURING AMETROPIA. 69
will produce a similar movement in the image, and not
the reverse as in myopia. Approaching nearer, we find
the field of vision unusually large, and the optic disc
apparently small, but distinct, just the reverse of what
we notice in myopia.  In myopia, however, we may
render the fundus of the eye distinct by using a concave
lens in the hinged bracket behind the mirror, and in
hypermetropia we may make the fundus more distinct
by the same use of a convex lens. In this way, by the
direct or upright image, we may not only detect the existence of an optical defect, but determine its nature;
and the number of the lens plus or minus, our own eye
being emmetropic or made so by a proper glass, will give
us the measure of the manifest and sometimes the total
hypermetropia, or myopia.  The newest forms of the
ophthalmoscope have a large number of lenses so arranged as to be quickly available in diagnosing and
measuring ametropia. But the accurate use of
THE OPHTHALMOSCOPE IN MEASURING AN AMETROPIA
requires practice. The accommodation of the patient
must be relaxed, and if the dark room in which the examination is made be sufficiently spacious, or if, as in
my ophthalmoscopic room, a dark curtain be arranged
on the wall opposite the patient, this may be accomplished; otherwise atropine is necessary. The observer
must also relax his accommodation. Then, the convex
lens, beginning with the weakest that enables the observer to see the region of the macula lutea or some of
the retinal vessels running from the edge of the optic




70       REFRACTION AND ACCOMMODATION.
disc most distinctly, is supposed, if the defect is a hypermetropia, to give its measure.  In the same way,
using concave lenses, the degree of a myopia is determined.  The optic disc is not available when strict
accuracy is desired, as, not being at the fovea centralis,
it cannot be at the same distance from the centre of
the cornea.  In myopia it is sometimes anterior to the
macula.  As an aid in determining and confirming,
in connection with other tests, the existence of optical objects, the ophthalmoscope used in this way is
convenient.  This method of measuring optical defects is good practice for oculists, if for no other
reason than that it breaks into their routine habits of
diagnosis.
The shadow test will also aid in determining an error
of refraction. The light is thrown into the eye by the
usual concave ophthalmoscopic mirror from a distance
of about four feet. It should be shaded from the patient, and may be at the side or just over his head. The
room must be darkened so that no object in front of the
patient shall hinder the more or less. complete relaxation of accommodation.  We now notice, in moving or
rotating the mirror slowly on its horizontal axis, whether
the red reflex in the pupil moves with the mirror in the
same direction, if so we have a myopia. If it moves in
the opposite direction or against the mirror we have a
hypermetropia, a slight myopia, or emmetropia. By putting trial spectacles on the patient we may determine
approximately the degree of myopia or hypermetropia.
If myopia, the weakest concave lens before the eye that
reverses the movement of the reflex gives us the meas



THE OPHTHALMOSCOPE IN MEASURING AMETROPIA. 71
llre of the error of refraction and indicates the proper
glass for its correction.  Similarly, the weakest convex
lens which reverses the movement of the reflex gives
us nearly the amount of hypermetropia.  In the latter
test the convex glass indicated will be somewhat too
strong, and in all cases, nearly, a more correct estimate
of the degree of refractive error will be obtained by the
use of a iydriatic.  The direct method with the ophthalmoscope as given at page 69 is, I think, more certain and more practical.  I have assumed in the above,
that the observer uses the ordinary Liebreich concave
mirror.  If a plane mirror is used, the movements observed will be exactly the reverse; that is, in myopia
against the Inrror, in hypermetropia and emmetropia
with the mirror.  In slight myopia, - that is, of one
dioptric, or less, -the movement with either mirror
is as in emmetropia.
Spectacles for distance should not be prescribed for
hypermetropia, if the patient can see well and without
fatigue, as after being used for distant vision they become indispensable for all time; but for near vision,
they should be ordered the moment asthenopic symptoms appear.  In higher grades of the affection, where
vision for all distances is imperfect, glasses which correct the manifest hypermetropia may first be worn; and
later, when  the eyes become accustomed  to  these,
stronger ones may be prescribed, if necessary, so as to
correct more or less of the latent defect also.  Exceptionally, such patients require the stronger glasses from
the first and reject the weaker ones.




72       REFRACTION AND ACCOMMODATION.
ACCOMMODATIVE ASTHENOPIA
may be defined as a condition of the eye in which it
cannot be used continuously for near vision, even in the
best light, without pain and confusion of sight, although for the first moment the patient sees with ease
and distinctness. The eyes are sound in appearance, in
movement, in visual form, in convergence of visual
axes, but they rebel against all use, however moderate.
After the least service upon near objects, they feel fatigued, full, hot, and sometimes become quite painful, the pain extending to the head, or following the
branches of the fifth nerve.
It is not unusual for asthenopic eyes to show a slight
hyperemnia of the conjunctiva, and in the neurotic we
often notice an enlarged and rather sluggish pupil. The
dilated pupil is not due to local disease, but to reflex
disturbance of the ciliary nerves from irritation of the
sympathetic.  In these cases we find spinal irritation
or disturbance of the uterine or digestive functions.
The dilatation of the pupil is, when it exists, an additional hindrance to distinct vision for near objects, by
admitting too much light and too many lateral rays,
and by increasing the circles of diffusion.  As the rays
reach the retina before being focussed, the object is not
pictured upon the retina at a single point, but by a
number of conical pencils of rays in the form of circles
which, overlapping each other, render the image blurred.
Sometimes there is to be observed a hyperasmic condition of the optic nerve disc and retina similar to the
hyperaemic state of the conjunctiva.  In rare instances,




ACCOMMODATIVE ASTHENOPIA.              73
the optic nerve itself appears to be the principal seat of
the pain. I can recall instances where the least exercise
of the eye produced deep-seated pain of the globe.
Formerly, asthenopia was looked upon as a grave
affection, and as a probable precursor of amaurosis, or
some other disease fatal to sight. It is sometimes a
symptom of general debility, arising from exanthematous
or febrile affections, from overwork, mental troubles,
dissipations, abuse of the eyes, and like causes. All
these, however, only express the occasional, or exciting
cause.  The primary cause is usually to be sought in
a more or less faulty state of the refraction, the consequent fatigue of the ciliary muscle, and the resulting irritable condition of the eye. Some hypermetropic eyes
escape asthenopia for a time from having been originally endowed with a wide power of accommodation. A
youthful normal eye is sometimes able to read the finest type, No. 1, from three up to eighteen inches; while
another may be able to read it only from four up to
twelve inches, —the first showing an accommodative
power of considerably greater range than the second.
Moreover, according to Von Graefe, there is considerable difference exhibited by different individuals in the
impunity with which they may exert a great part of the
accommodative power at their disposal. Some persons,
for instance, are unable to use one half of this power
for any length of time without injury, while others use
more than three quarters without fatigue. In the first,
there appears to be a lack of energy in the ciliary muscle; while, in the second, it is unusually vigorous.
Hence it may follow that the more or less perfect opti



74       REFRACTION AND ACCOMMODATION.
cal construction shall in some instances give but an
imperfect indication of the serviceableness of an eye for
fine work.  The working power of the eyes may also
depend, to a certain extent, upon the equilibrium of the
external ocular muscles.  See page 84 et seq.
TREATMENT OF ACCOMMODATIVE ASTHENOPIA.
The first and most important indication in the treatment of accommodative asthenopia is to relieve the
painful and overworked ciliary muscle by supplementing the refractive power of the crystalline lens with
suitable convex glasses.
Sometimes, when the affection is of long standing,
and the whole eye seems to have been reduced to an extremely irritable and sensitive condition, we may have
considerable trouble in finding glasses that can be worn
with comfort; and yet, if the eyes are to be used at all,
the help of glasses is absolutely required. It may be
necessary in those cases to completely paralyze the accommodation for some weeks by the instillation of atropine, simply for the purpose of resting the eye.
For the selection of glasses, I generally determine
the amount of manifest hypermetropia, by permitting
the patient to look at No. 20 print at a distance of
twenty feet, or where an emmetropic eye would see it
with distinctness. Then I find the lowest convex glass
through which he can read the print, and this determines the degree of manifest hypermetropia.  Having
determined this point, I prescribe, if the hypermetropia
is thirty-six, a convex glass of thirty inches focus; if it
is fifty, glasses of about forty inches focus, and so onl.




TREATMENT OF ACCOMMODATIVE ASTHENOPIA. 75
De Wecker advises that the manifest and about one
fourth of the latent hypermetropia should be corrected
by the first glasses presented. In practice, however, it is
often necessary to begin with a weaker glass (D  - 0. 75
or + 48), and then change, after a few weeks, to those
of a greater refractive power, in order to complete the
cure.  But the strength of the convex glasses will depend greatly on the amount of latent hypermetropia, and
this is to be determined with the ophthalmoscope, or by
atropine and the test types.
We must remember that in myopia the convergence
is always in excess of accommodation, while in hypermetropia the accommodation is in excess of the convergence.  In neither optical defect do the ciliary and the
internal recti work together harmoniously; hence, probably, a great part of the discomfort.
Sometimes, in asthenopia due to facultative hypermetropia, the glasses, after having served to cure the
asthenopic symptoms, may be discarded.
The systematic use of the glasses after the Dyer
method is usually advisable. Thus, we take as a starting point for the exercise of the eyes in reading, that
period of time asserted by the patient to be the longest
that he can use his eyes without fatigue. It may be
one minute or less, or it may be five or ten minutes. He
is then instructed to put on his glasses and read the
given time through them  three times a day, adding one
minute to this time each day, until perhaps a half-hour
is reachedo  Then two minutes a day may be added;
and when the patient can read from one to two hours
at a sitting, without fatigue, the cure is complete. Reading by artificial light may finally be practised in the




76       REFRACTION AND ACCOMMODATION.
same way.  The reading matter should not be of too
absorbing a nature, and the patient should be made to
understand that the sole purpose of the reading is for
the hygienic exercise of the eyes.
If the asthenopia is clearly the result of general debility, due to diminished energy of the muscular system
generally, and the hypermetropia is slight, or wholly
wanting, it is possible that the restoration of vigorous
health through internal medication, generous as well as
prudent dietetic regulations, or change of air, with systematic exercise of the eyes in reading as just described,
may cure the asthenopia without the necessity of a resort to spectacles at all. I have found the Dyer method
alone - that is, without glasses - sufficient in a certain number of cases.
ASTIGMATISM.
This is an anomaly of refraction dependent generally
on a lack of symmetry in the different meridians of the
cornea. It was noticed by Young, in 1793, but first correctly explained by Donders, who published a work on the
subject in 1862. Previous to the researches of Donders,
there had been recorded less than a dozen cases for
seventy years; since his investigations, cases are recorded daily.  Astigmatism  is congenital, or may be
acquired from wounds or ulceration of the cornea. It
is divided into the regular and the irregular.
Regular Astigmatism
is called simple when one meridian of the cornea is
emmetropic and the opposite myopic or hypermetropic.
It is compound when both meridians are myopic or hy



DIAGNOSIS AND TREATMENT.               77
permetropic, but in different degrees, as if, for instance,
in the vertical meridian the cornea were sufficiently
convex to make a myopia of one eighth, while in the
horizontal line it might be only convex enough for a
myopia of one sixteenth.  In rare instances there is
mixed astigmatism, one meridian being myopic, the
other hypermetropic.
Irregular Al.ytii/mati~)m
is due to imperfections in the structure of, or to partial
dislocation of, the lens, or to its partial opacity. It is
found also in conical cornea, and results from ulcerations
of the cornea, and occasionally from  irregularity of its
surface after cataract operations. In these cases the meridians of greatest and least refraction are not at right
angles to each other, and this form of astigmatism is rarely
benefited by glasses. Lately, however, conical or cylindroconic glasses are said to have proved quite useful.
DIAGNOSIS AND TREATMENT.
To determine whether a patient is astigmatic, we have
only to place some well defined lines running in vertical, oblique, and horizontal directions before him at considerable distance, - perhaps thirty feet, - and then
gradually approach them so as to find if, at any distance, one set of lines appear clear and the other indistinct.  If such a point can be found he is astigmatic;
if not, we are obliged to refer his defective vision to
some other cause. See test type, page 348.
We must bear in mind that no eye is perfectly symmetrical in form, and so we may expect to find that vertical and horizontal lines will not be seen always with




78         CE'REFRACTION AND ACCOMMODATION.
equal distinctness;  but usually this asymmetry is so
slight that no annoyance in vision is occasioned.  It is
well to begin the test of imperfect vision through spherical glasses, and finding that these do not render vision
sufficiently acute, we may be quite sure that we have a
case of astigmatic refraction.
IHaving determined the existence of astigmatism, if
we permit the patient to hold a metallic disc before the
eye, in which there is a slit of about a line or rather
less in width, and rotate it until it comes opposite the
elmmetropic meridian of the cornea, so that rays of light
are received by the eye through this meridian alone, he
will see distinctly, reading No. 20  at twenty  feet.
This supploses a case of sim ple astinmati.sm, one meridian of the cornea being n(ormalll   refractive or eimmetrlopic.   To neutralize  this Castigmatismi  and  render
vision acute  we have   only to prescribe weak concave
or convex cylindrical glasses.
CYLINDRICAL GLASSES
are segments of a cylinder; whereas ordinary glasses
are segments of a sphere.  A  concave spherical glass,
for instance, increases in thickness from  the centre in
all directions.  A concave cylindrical glass, held with
its axis in a horizontal direction, is eqlually thin throughout in its horizontal plane, but in its vertical plane increases in thickness from  the centre like a. spherical
concave.  Those rays of light which strike a, cylindrical lens at right angles with the plane of its axis are
refracted, and those which strike in the plane of its axis
are not refracted at all.  Cylindrical glasses are, there



CYLINDRICAL. GLASSES.                  79
fore, unlike spherical, to be rotated before the eye until
the plane of their refraction comes opposite that plane
of the cornea which requires it.
In  compound astigmatism  we proceed  to determine
first, how much we can improve vision by the ordinary
glasses, convex or concave.  Suppose it a case of myopic astigmatism, and we find sight best through a
spherical concave glass of one twentieth.  We then
select a weak concave cylindrical glass, and placing
it before the other, allow the patient to look through
both, rotating the last until its axis is in the right
direction.  If it proves too weak we try others.  We
may determine also, in advance, the number of the cylindrical glass required, with tolerable exactness by noting the different strength of two glasses, through one
of which horizontal lines are best seen, and through
the other of which vertical ones are plainest. Take
the two letters on the next page made up of horizontal and vertical lines.  A. sees N  blackest, but with
convex No. 15 sees Z blackest.  With cylindrical convex No. 15 axis vertical, his astigmatism  will be corrected.  B. sees Z blackest through No. 60 concave,
and N  blackest through No. 20 concave.  Then -   10
60-   3O —-.   A  cylindrical -  30 glass with the axis
horizontal would neutralize his astigmatism.
1 A concave glass is designated by the sign —, and a convex by
the sign +; s. spherical; c. cylindrical;, combined with. Hence,
+ 1.5 s., +.75 c. axis vertical Left, means the prescription for
the left eye of a spherical convex lens of one dioptric and a half, in
combination with a convex cylindrical one of three quarters of a
dioptric. Or, under the old enumeration, a spherical No. 24 with
a cylindrical No. 48, the axis of the latter vertical.




C~tO AND ACCO.
wcow —--
-                     I




MIXED ASTIGMATISM.                  81
A color test is recommended by Green, of St. Louis.
Bright red and blue, or other shades of these colors,
rendered brilliant by transmitted light, as when hung
at a window, are most practical.  The colors are arranged in radiating lines.  I have mentioned also a
simple test for astigmatism under Amblyopia.
MIXED ASTIGMATISM.
This form may require by-cylindrical glasses for its
correction.  A  plano-cylindrical convex glass for the
hypermetropic meridian, and a plano-cylindrical concave glass for the myopic meridian of the cornea are to
be selected and put together, their axes at right angles,
then rotated before the eye until their best position is
found.  Or the defect may be remedied by a combined
spherical and cylindrical lens, as shown below.
A mixed astigmatism  may be quickly diagnosed by
the use of the stenopaic slit. Placing the slit before the
eye vertically, or in that direction in which by the aid
of spherical glasses the lines appear blackest, we determine the nature and extent of the optical defect in this
meridian of the cornea.  Let us suppose, for instance,
that we find a spherical convex glass of two dioptrics
(eighteen inches focus) gives the best vision in the
vertical meridian, and that a spherical concave of one
dioptric (thirty-six inches focus) is best for the horizontal meridian.  We may correct this defect in two
ways.  First, we select a cylindrical lens + 3 D, and
place it before the eye, its axis horizontal; this overcorrects the hypermetropic astigmatism  by one dioptric.  We then put with this lens a concave spherical
6




82        REFRACTION AND ACCOMMODATION.
of one dioptric. This corrects the myopic astigmatism,
and also reduces the convex cylindrical of three dioptrics to a lens of two dioptrics, just what the optical
defect demands.  Or, we may make use of a convex
cylindrical lens of two dioptrics, its axis horizontal,
combined with a concave cylindrical lens, its axis vertical. The latter course is the one that I generally
adopt.
Astigmatism  may also be diagnosed with the ophthalmoscope, as mentioned in the chapter preceding,
(
FIG. 20.                        FIG. 21.
The optic disc in astigmatism, seen  The same disc seen by the direct
by the indirect method (reversed  method (upright image). After Netimage).                           tieship.
the disc appearing oval instead of circular.  With the
upright image  it may be  approximately measured.
We find the lens which, placed behind the hole in
the mirror, gives us most distinctly a vessel running
in one direction, then replace this lens by one which
gives us the most distinct view of another vessel running in an opposite direction. The difference in the
power of these two lenses is the measure of the astig



MIXED ASTIGMATISM.                  83
matism.  Similarly by the shadow test (see page 70),
if we note the strength of the lens before the eye of
the patient that reverses the direction of the reflex or
shadow in one meridian, and then the lens required to
reverse the shadow in the meridian at right angles to
the first, the difference in strength of the two lenses
will give an approximate measurement of the degree of
astigmatism. The curve of the cornea sometimes changes
perceptibly from pressure of the lids and external muscles of the eye.  The degree of astigmatism  is also varied more or less at different times by the exercise of
the power of accommodation.
Astigmatism uncorrected by glasses may, of course,
give rise to accommodative or a mixed form of asthenopia.
It is indeed a very frequent cause of painful asthenopic symptoms, and in such instances requires the corrective glasses to be selected  with  great care and
accuracy.  Hypermetropia with astigmatism, in young
persons, is supposed to pass over frequently into myopia.
In view of this it may be said that astigmatism is,
in early life, a most serious optical defect, and that
its subjects, like those that are myopic, should be
carefully guarded during the educational period. The
later the earnest study from books begins, in the life
of children with these errors of refraction, the less
probability of harm  to the eyes.  If school life, or protracted reading, writing, and drawing, were never begun
before the age of eight or ten, weakness of vision would
notably decrease.  In the case of school-children, therefore, whenever there is a doubt in regard to the optical
condition of the eyes, it is the duty of the family physi



84       REFRACTION AND ACCOMMODATION.
cian to advise that they should be examined by a
competent ophthalmic surgeon.
MUSCULAR INSUFFICIENCY. LACK OF MUSCULAR EQUILIBRIUM. MUSCULAR ASTHENOPIA. DYNAMIC SQUINT.
This condition is due to weakness of an external ocular muscle, or to an increase of tension in the opposing
muscle; the result is a lack of muscular equilibrium
which sometimes gives rise to asthenopic symptoms and
especially to headaches. Exceptionally, a number or all
the ocular muscles appear to be weak. Errors of refraction, a neurotic temperament, or an exhausting occupation
or illness are apparently the cause of this condition.
[When all refractive errors have been corrected, and
even in cases in which the refraction has always been
normal, we occasionally meet with patients who still
find difficulty in using the eyes, and who complain of
soreness of the eyeballs, headache, and a strained, tired
feeling when the eyes are used for any length of time
at close work.  Frequently more pronounced nervous
symptoms are present, nausea, dizziness, insomnia,
pain in the spine, or general nervous exhaustion.
The tenotomy, especially of the upper or lower muscles, should never be attempted by one not skilled in
ophthalmic surgery, because of the danger, in such nice
re-adjustments, of over-correction.  Injudicious tenotonly in chorea and epilepsy has given warrant to the
severest criticism of conservative surgeons; but while
it is too early to determine the full value of this opera



MUSCULAR INSUFFICIENCY.                85
tion, it is beyond question that in certain nervous diseases, even chorea and epilepsy may be influenced by
imperfect co-ordination of the eye-muscles; and while
it has long been recognized that nervous diseases not infrequently affect the eyes, it is a fact, becoming daily
more emphasized, that we may trace the origin of many
baffling nervous derangements directly to eye-strain.
The nicest discrimination is necessary, therefore, in
these cases, in locating the exact relation of cause and
effect.
There can be no absolute standard of the strength of
the muscles of the eyes, as variations will depend upon
the age and general physical condition of the patient;
but it has been found that, as compared to its antagonist, each muscle must have a relative strength that
can vary only within narrow limits.  If, for example,
the internal rectus is able to overcome a prism of 40~,
the external rectus should overcome a prism of not less
than 6~.  The ratio is about 6 or 7 to 1.  If any one
of the external ocular muscles is disproportionately
weak, it may be impossible to use the eyes without
either local or general discomfort.
The method of testing the eyes in these conditions,
while simple, requires patience and care.  A candle
flame at a distance of twenty feet is the object usually chosen.  Now if a prism  of sufficient strength
were placed before the eye, double vision would be
produced. In testing the strength of any of the straight
muscles of the eye, prisms of increasing strength are
placed before the eye, the edge towards the muscle
whose strength is to be determined, and the strongest




86       REFRACTION AND ACCOMMODATION.
with which single vision can be retained will measure
the strength of the muscle.
In manifest weakness of one or more of the muscles,
the cause, if possible, must be found. It may be dependent upon general constitutional weakness, or may
follow any exhausting illness, but more commonly it is
the result of protracted eye-strain.
Treatment.
If muscular weakness is simply a reflex symptom
from ovarian, rectal, gastric, or spinal irritation, the
original disturbance must, of course, first be determined and corrected.  If, however, nothing points to
any such possible cause, or if, as sometimes happens,
the asthenopia persists after the possible cause has been
removed, the attention must then be directed to the
eyes.
It will frequently be found that the refraction is imperfect, and the adjustment of suitable glasses will often
strengthen the atonic muscle by removing the strain
upon which the weakness was dependent.
But in a certain proportion of cases, the insufficiency
of the muscle will be the only defect apparent, and our
efforts must then be directed towards a restoration of
the normal balance.  This may sometimes be done by a
system of ocular gymnastics.
Prisms which require some effort to overcome are
employed for a certain length of time daily, until the
weakened muscle gradually regains its strength.
A more satisfactory method will be found, however,
in the use of weak prisms placed to relieve the strained




MUSCULAR INSUFFICIENCY.              87
muscle and which may be worn continuously.  Noyes
has found in a large experience that many permanent
cures may be made in this way.
Having exhausted other methods of treatment, -operative interference may be considered, and the tendon of
the muscle which is disproportionately strong may be
partially or entirely divided.
Before determining upon this method of procedure,
the diagnosis must be verified by most careful tests.
Ordinarily, tests may be made as already described;
but before venturing upon a tenotomy the relative
strength of the muscles should be ascertained beyond
question, and an instrument of precision is valuable.
Stevens has devised such an instrument, which he
calls a phorometer.  It consists of an upright supporting a cross-bar; upon  the latter is a spirit-level,
which makes it possible to obtain a perfect horizontal.
In a sliding groove on the cross-bar are placed prisms
with the bases out, and of such strength that double
images are obtained.  If the head of the observer is
held erect, and the eyes are properly placed, these
double images should appear on the same plane.
If there is a difference in the height of the images,
it will indicate a difference in strength or position of
the corresponding vertical muscles, and the difference
may be measured by another prism held with the base
up or down until parallelism is restored.
In a like manner a lateral divergence is shown. A
prism is placed with the base up or down upon the phorometer, and when the muscles co-ordinate, the double
images will lie in the same vertical meridian.




88        REFRACTION AND ACCOMMODATION.
If one should deviate to one side or the other, the degree of prism  which will again bring it in line, will
indicate the proportion of cases of severe functional
nervous disease. A surgical restoration of correct muscular balance is followed by brilliant results. - F. P. L. ]
For testing the equilibrium of the external ocular
muscles I find the simple glass rod of Maddox useful and
sufficient in ordinary cases. The rod is to be one fourth
of an inch in diameter, and may be three or four inches
in length for convenience in handling.  Held vertically
before the pupil of the right eye, let us say, it changes
the form of the gas or candle flame, which is twenty
feet or more distant, into a fine horizontal line.  This
line should pass directly through the flame as seen with
the other eye at the same time.  If the line passes over
or below the flame, then the line of vision with the right
eye is below or above that of the left.  When the rod is
held horizontally before the eye, it changes the form of
the flame to a vertical line.  If this line is seen with the
right eye at the right of the flame, the line of vision
tends outward, there is weakness of the external rectus,
or what practically produces the same effect, too great
tension of the rectus internus.  If the fine line seen
with the right eye appears to the left, there is weakness
of the internus.  That is, if the line is seen at the
right with the right eye and at the left with the left
eye, there is weakness of the externus and too great
convergence.  The degree of a prism  put before the
naked eye, base out, that just brings the line into the
flame gives the amount of the over-convergence,    that




MUSCULAR INSUFFICIENCY.                 89
is, the measure of the weakness of the recti externi.
In case of too great divergence the lines being seen
at the left with the right eye, and at the right with
the left eye, the measure is made with a prism, base
in, similarly.
Adduction of the eye is found by placing prisms of
increasing strength, base out, before the naked eye; the
strongest through which the eyes fuse the two images of
a candle-flame at twenty feet, gives its measure. Abduction is found by prisms, base in, similarly.
The Stevens nomenclature for these muscular deviations is convenient, and is as follows:Orthophoria, the visual lines tend to parallelism.
Heterophoria, the visual lines do not tend to parallelism.
~ ( Esophoria, visual lines tend inward.
I  Exophoria, visual lines tend outward.
HYI erphoria, tending of the visual line
of either eye above its fellow.
Hence exophoria signifies insufficiency of the internal
recti, and esophoria of the external recti.  Hyperexophoria would signify a tending of the visual lines upward and outward, and hyperesophoria, a tending of the
lines upward and inward.
To restore parallelism of the visual lines in esophoria,
a prism with the base out is required; in exophoria, a
prism  with the base in.  Very often there is an error
of refraction to be corrected also, so that a convex lens in
esophoria is combined with the prism, and in exophoria,
a concave lens with the prism may also be necessary;
and in either case there may be astigmatism, so that




90       REFRACTION AND ACCOMMODATION.
sometimes one spectacle lens may be ground as a prism,
a cylinder, and a spherical lens, to meet the required
conditions.
I do not find the daily gymnastic exercise of the external ocular muscles with prisms, as recommended by
Stevens and others, to be of great benefit.  Some patients say that these exercises make the eyes feel better;
but I do not find that the weaker muscles are strengthened thereby.  The apparent increase of strength in the
internal recti is undoubtedly due to the knack that the
patient gets of using his accommodation.  Thus a patient of mine in a short time could overcome prisms of
80~, base out; but his exophoria of 1~ remained the
same as in the beginning when his adduction was only
24~.  Some patients do not acquire this knack readily,
and then there is no apparent increase of strength
in the internus.
Prisms to assist the weaker muscles may often bridge
over the unpleasant effects of muscular disarrangement
until improvement takes place and the eyes work well
without their aid. The asthenopia of a muscular insufficiency is often due to merely temporary lack of innervation in feeble or neurotic subjects.  The apparent
relative strength of the external ocular muscles in such
persons, as measured by prisms, is extremely variable.
Such a patient showed an exophoria of 16~, but after
four days only 10~. After wearing prisms of 30, base in,
for two weeks the exophoria measured 16~, then a week
later 8~; a week later it became an esophoria, and later
a slight exophoria. The prisms were discarded, a correction of a slight myopic astigmatism was made, the




MUSCULAR INSUFFICIENCY.               91
Dyer method of exercise of the eyes practised, and the
asthenopia and headaches steadily improved.
In most people, an apparent want of muscular equilibrium is without significance; and the same is true of
those showing a weak adduction or weak abduction.  A
medical friend shows an adduction of 10~, an abduction
of 7~; but he has never had an asthenopic symptom.
Another shows an esophoria of 1~, his adduction 7~,
his abduction is 9~; and these measurements were carefully made and repeated.  He should suffer from exophoria and suffer badly; he has never had anything
more than a slight accommodative asthenopia from
over-sight of one dioptric. A lawyer with adduction of
9~ and abduction of 8~ never had a symptom  of eye
ache, and rarely a headache in his life.
Instances like these are not rare.  The conditions as
stated above, and the varying and unstable tension or
weakness of these muscles are recognized by surgeons
generally; but the situation calls for great conservatism
in respect of operative interference. Tenotomy, or "button-holing," should be held in reserve for rare and exceptional cases.   Some of the more  distinguished
ophthalmic surgeons, indeed, strongly oppose these operations.  Thus Roosa says,1 in speaking of the prevailing treatment of muscular insufficiencies by many
surgeons, " As to tenotomies nowhere in surgery has a
more desolate field been left by operative procedure,
than that made by oculists and neuralogists with mistaken zeal in the cutting of muscles of the eye." He
says further, "I believe that none of these insufficiencies
1 Ophthalmic Review, vol. ix. p. 286.




92        REFRACTION AND ACCOMMODATION.
lead of themselves to asthenopia," of which he believes
refractive errors to be the cause, and that to the error
of refraction is due the insufficient muscular action.
"Those who have been examining the muscles so carefully have been considering effects, not causes."
PRESBYOPIA.
Far or old sight is a symptom of advancing years, and
is due to senile loss of elasticity in the lens. Distant
vision remains good, but no effort of the ciliary muscle
is sufficient to render the lens convex enough to bring
rays of light from near objects to a focus on the retina.
Hence the necessity for convex glasses.  It is not advisable to postpone the use of glasses as long as possible
at the expense of discomfort and fatigue of the eye.
The proper glasses for a presbyope are such as will enable him to read No. 1 at ten or twelve inches.  It is
convenient to have two pairs of spectacles, the stronger
one for evening use.  Rapidly increasing presbyopia is
to be viewed with suspicion, as it is often a precursor
of glaucoma.
SECOND-SIGHT,
popularly  so  called, occasionally  comes to  elderly
people who, after using glasses for years, find themselves able to dispense with their aid, and yet read
with tolerable comfort.  Such persons have unusually
small pupils, so that, practically speaking, only the
central rays of light are admitted to the eye, and no
focussing power is called for.




MYOPIA SENILIS.                 93
MIYOPIA SENILIS
may also occur, so that not only is the absence of
convex, but the substitution of concave, glasses an improvement to the vision.  Such instances are due to
commencing cataract, when, as sometimes happens, the
lens has become more convex from swelling, but still
retains its central transparency.  This condition is
often the explanation, also, of the "second-sight,"ordinary print, in such cases, being read more easily
without the usual convex glasses.




CHAPTER VI.
THE CONJUNCTIVA.
PASSIVE HYPERBEMIA OF THE CONJUNCTIVA.
HYPERAM1IA of the conjunctiva is of very common
occurrence, and is due to over-use or abuse of the eyes,
or to optical defects, as in asthenopia.  The appearance
of the eye is very similar to that observed in mild
conjunctivitis, but there is no discharge from the conjunctiva, and usually very little or no lachrymation,
and the smarting, itching, and heaviness of the lids
is markedly increased in the evening. Reading manuscript by strong artificial light, or by a too weak light,
and the hazardous practice of reading habitually in the
horse and steam  cars, and that worst and most dangerous of habits for the eyes, that of reading in bed
by artificial light, -often excite this congestion. This
state of the conjunctiva may be a reflex symptom of a
similar condition, or more, serious disease, of the internal structures of the eyes.  The use of the eyes for
reading increases the hyperamia and asthenopic symptoms, if such are present.
Treatment.
To cure this affection, it is of course necessary to
remove its cause.  Optical defects must be remedied by
appropriate glasses.  Injurious use of the eyes must be




CONJUNCTIVITIS.                 95
given up and overwork proscribed.  As palliatives, the
use of the eye douche, always with closed lids, is excellent, or bathing in tepid water, or vinegar and water,
a few  drops of tincture of hamamelis or tincture of
opium or of hydrastis in a cup of water, or a grain or
two of sulphate of zinc, or of acetate of lead, - any of
these, adhering of course to the one which seems most
grateful to the eye, may be used as a fomentation,
either warm or cold, to the lids several times a day. If
preferred by the patient, these lotions may be used to
saturate a bit of lint or linen which may be laid over
the lids for a quarter of an hour, three or four times a
day.  The solution need not enter the eye, but will, of
course, occasion no pain of consequence in case this
should happen.  Sometimes fomentations of very hot
water for five minutes, three or four times a day, suffice.
CONJUNCTIVITIS.
An inflammation of the conjunctiva is easy to diagnosticate, and yet a mistake is possible if one is not in
the habit of observing accurately the difference in the
appearance of a reddened eye in different kinds of inflammation.  For instance, in the simplest conjunctivitis, in place of the usually invisible vessels of the
conjunctiva, we have a network of bright red vessels
plainly seen to be superficial and movable by the touch
of the finger over the smooth surface of the sclerotica.
On the other hand, in a severer, deeper-seated conjunctivitis, like the scrofulous, or lymphatic, and the granular, we have, in addition to this vascular network, the
close parallel lines of immovable sub-conjunctival ves



96                THE CONJUNCTIVA.
sels running towards the edge of the cornea, in a state
of congestion. This condition gives a pinkish-red zone
around the cornea, often more clearly defined in iritis
and keratitis.  In scleritis, or episcleritis, there is
presented still another redness of a violet or purple
tinge.  It appears nearly always in rather large and
tolerably well-circumscribed patches, and is sometimes
mistaken by the general practitioner for phlyctenular
conjunctivitis, although the bright red color and papular appearance of the latter, and the peculiar color of
the deep-seated spots of the former, render the differential diagnosis easy in ordinary cases.
Simple Conjunctivitis.
Simple conjunctivitis differs in degree, rather than in
form, from the acute catarrhal.  It is generally the result of slight injury to the eye, contact of a foreign body,
exposure of the eyes to dust, smoke, cold winds, or
dampness, glare of light, impure air, or from  some
other local cause. The subjective symptoms are very
trivial usually. There may be some itching and sensation of heat in the lids, or a feeling as if there were sand
in the eye.  We ought to determine by ocular inspection, whenever our patient complains of a sensation as
if a foreign body were in the eye, or when a simple conjunctivitis does not yield readily to treatment, whether
there may not be some foreign substance lodged beneath
the upper lid. The immediate cure of a conjunctivitis
after three weeks of ineffectual treatment, by the simple eversion of the upper lid and the removal of a bit of
quartz, is mentioned in the chapter on Injuries of the Eye.




CONJUNCTIVITIS.                   97
Catarrhal Conjunctivitis.
The objective symptoms in catarrhal conjunctivitis
are more marked than in the simple form of the affection.  The congestion of the superficial vessels of the
conjunctiva is greater, and in elderly people chemosis
may be present. The edges of the lids appear swollen,
the palpebral conjunctiva is distended from serous infiltration, particularly at its reflected portion, its papilla
are enlarged, and its surface presents a velvety appearance. There is a secretion of clouded mucus, alternating
sometimes with a secretion muco-purulent in character.
This discharge is often abundant, but rarely as profuse
as in purulent conjunctivitis, and is more or less contagious.  Probably the contagiousness is in direct ratio
to the increased admixture of pus globules in the discharge.  A  healthy conjunctiva may be successfully
inoculated with the secretion of an acute catarrh.
The subjective symptoms are not very characteristic.
There is the complaint of not seeing well at a distance,
and the common symptom of a feeling at first of dryness, and as if sand or some foreign body were in the
eye, and there is a heavy uncomfortable feeling about
the lids which leads to a desire to rub them, and frequently a slight burning and smarting sensation.  There
is rarely severe pain,/ nor is the photophobia marked.
The above subjective symptoms vanish, to a great extent, as a case becomes chronic.  As to the treatment,
it should be simple in acute cases.  No doubt acute
catarrh of the conjunctiva, under proper hygienic conditions, and under circumstances controlling the causes
7




98                THE CONJUNCTIVA.
which have produced it, frequently disappears in the
course of a week or two without any treatment whatever. In other cases, however, it may be sufficiently
severe from the commencement to require treatment.
Treatment.
In the first or inflammatory stage the cold douche, or
cold compresses, will afford great relief. No irritating
collyria are permissible at this stage. Later, simple
collyria, such as a solution of five to ten grains of borax,
four grains of boracic acid, two grains of alum, or one
grain of sulphate of zinc, one grain of nitrate of silver,
each to the ounce of water, will often be found serviceable. A solution of bi-chloride of mercury 1:10000 may
sometimes be useful also.  If the affection prove very
obstinate, and the discharge assume a puriform character, the case should be treated as a purulent conjunctivitis.  A solution of nitrate of silver, of five grains to
the ounce of water, may be used, but not as a collyrium.
The lids, upper and lower, should be everted, and held
in this position with the left hand; the patient should
close the eye gently, this will bring the everted lids together and prevent contact with the cornea.  The conjunctiva thus exposed is painted by means of a camel's
hair pencil with this solution, which after a second or
two is washed off with tepid water from another pencil.
If the pain is afterwards severe, it will be relieved by
bathing the eyes in cold water, by cold compresses, and
frequently through simple contact of the eyes with the
cool out-door air.
The applications may be made daily or on every second




CONJUNCTIVITIS.                   99
day.  The good results that often follow this use of the
nitrate of silver are doubtless due to its germicidal
properties.  If active inflammatory symptoms are present, - that is, a very bright red, congested, and swollen
conjunctiva when the sub-conjunctival vessels are visibly involved, and when the ciliary nervous system  is
sensitive, as shown by pain and photophobia,- irritating
applications should not be made.  In all cases where
irritating collyria are used, it is advisable not to push
their employment too continuously, but rather alternate
them from time to time with the use of the cold compress. In chronic cases it is advisable to see that a collyrium which the patient takes home be not too strong.
It is necessary, also, to remember that in a conjunctivitis occurring in two individuals of different nervous
organization, where in each case it seems to be of the
same nature and to require the same remedy, one may
use a wash with great benefit which the other may be
quite unable to bear.  Whenever, therefore, there is
doubt about the strength of the solution it is advisable
to instruct the patient that if the pain after its use continues beyond a minute or two, it is too strong, and
should be diluted with an equal quantity of water.  It
is safer, also, to direct that the collyrium be used not
oftener than twice a day.  It has often been my experience, when called in consultation with physicians, to
find that in conjunctivitis, complicated and uncomplicated, collyria when used at all have been frequently
too strong, applied too often, and to eyes already too
sensitive and irritable.
We should bear in mind the contagiousness of some




100               THE CONJUNCTIVA.
catarrhs of the conjunctiva.  The patient should be
warned of this danger, so that he may not propagate the
disease. Frequently the affection assumes an epidemic
character, attacking whole families and neighborhoods.
In the chronic form of this affection the results of topical
application to the lids will not prove as satisfactory as in
the acute.  Improvements will be followed by relapses,
and many cases will prove extremely tedious in treatment.
If, however, the affection seems to be purely local and
confined to the eyes, our prognosis will be more favorable
than when it is merely a part of a catarrhal affection
of the air passages generally or of the lachrymal duct.
" Pink eye " is a form of epidemic catarrh seen mostly
in young people, which is quite contagious and is usually most prevalent in the spring months.  It derives
its popular name from the fact that the ocular conjunctiva is usually deeply congested, giving the eyeball a
noticeably pinkish-red hue.  It is best treated by cold
at the beginning and later by mild astringent washes.
Owing to the ciliary irritation, pain, and photophobia
irritating collyria are not well borne. A 1% solution of
boracic acid I have found useful, also nitrate of silver
1:500 and bi-chloride of mercury 1: 25000.  The disease, supposed to be caused by a small bacillus constantly found in the discharge, does not invade the
cornea and the prognosis is favorable.
HYGIENIC MEASURES.
In conjunctivitis of all kinds, attention should be given
to hygienic regulations.  Very sensitive eyes should
be protected against bright light during the day or




PURULENT CONJUNCTIVITIS.              101
night by plain blue or smoke-colored glasses, which will
afford also a measurable protection against wind and
dust.  Grayish-yellow glasses are lately recommended
as grateful to the eyes if photophobia be present. The
patient should use the eyes with moderation, especially
by artificial light, and should carefully avoid all places
where the air is necessarily impure, -such as crowded
rooms, like the theatre, lecture-room, ball-room, or
rooms where tobacco-smoke prevails.  He should be
counselled also to avail himself, as much as possible, of
the beneficial influence of a pure out-door air, and
should be advised that when necessary to use the eyes
in reading,, writing, or fine work, preference should be
given to the morning hours when the light is constantly
growing better.
PURULENT CONJUNCTIVITIS.
Purulent conjunctivitis, which is to be regarded only
as a severer and more dangerous form of the catarrhal, is
distinguished from the latter by the character and greater
abundance of the secretion, the greater swelling of the
lids in consequence of the serous infiltration being also
sub-conjunctival, the great injection of the sub-conjunctival vessels as well as the increased vascularity of the
conjunctiva proper, the chemosis so frequently present,
and by the increased size of the mucous papilla, often
termed granulations.  One of the most practical methods of determining at once whether you have a blenorrhcea or a simple catarrh to deal with, is, by the easy
proceeding so long taught in the clinics of Arlt, of
Vienna.  The upper lid is to be everted, and if the




102               THE CONJUNCTIVA.
conjunctiva is sufficiently transparent for us to see the
lines of the meibomian glands running towards the edge
of the tarsus, we have a catarrh; if the infiltration is
so great as to hide these glands, we have no longer a
catarrh but either a purulent, a granulated, a diphtheritic, or some graver form of ophthalmia. In purulent
conjunctivitis the cornea is apt to become involved, and
this form is generally more contagious,
The Treatment,
during the inflammatory stage in which there is often
considerable fever, must be purely antiphlogistic.  Icewater compresses should be perseveringly used, and
these with the perfect quiet of the patient, and the administration of aconite, suffice to control measurably
the acute symptoms.  I have never resorted to the use
of leeches, and I have often seen them used in these
cases when I thought them  unnecessary.  If but one
eye is attacked, the other should be bandaged as a precautionary measure, and in all cases of purulent ophthalmia  the  attendants should be warned that the
greatest cleanliness and attention to the contagious
character of the secretion is necessary for their own
safety. After the inflammatory symptoms are subdued,
as shown by the diminished swelling of the lids and
the pale-red and relaxed condition of the conjunctiva,
and the watery discharge become thicker and purulent,
anti-septic applications are indicated.  If the cornea is
involved, care must be taken. that a caustic application
does not come in contact with it, by painting it on
the everted lids and immediately washing it off as pre



INFANTILE OPHTHALMIA.              103
viously directed.  See Treatment of Gonorrhceal and
Infantile Ophthalmia.
Egyptian, or military, ophthalmia is a variety of purulent conjunctivitis often complicated by a follicular
granulation.  It was first recognized and named after
an unprecedentedly severe epidemic originating in the
troops of the English and French armies stationed in
Egypt.  It spread so fearfully that after the Napoleonic
wars, England alone had upward of five thousand blind
invalided soldiers to care for. It is doubtful whether
this form of the disease is more contagious than any
other.  Very likely any form of the affection getting
a foothold among masses of people crowded together —
as in armies, alnshouses, and charitable institutions -
would spread rapidly.  Uncleanliness and bad ventilation are attractive conditions for this disease.  The
contagion of a purulent ophthalmia, as is well known,
may engender a very light or a very severe form of the
affection, -a mere catarrh or a diphtheritis.  In the
beginning the disease is hardly contagious, but becomes
so as it progresses, and the discharge increases in quantity and consistency. The form of the disease produced
by contagion seems to depend on local or atmospheric
conditions as well as upon the constitution or age of the
person infected. See Treatment of Follicular and Granular Ophthalmia.
INFANTILE OPHTHALMIA.
Conjunctivitis in the New-born.
Ophthalmia neonatorum  is a purulent conjunctivitis which comes on a day or two after birth. Excep



104               THE CONJUNCTIVA.
tionally it may make its appearance not until the sixth
or seventh day after birth.  It begins by a redness and
swelling of the lids and a slight watery discharge which
sometimes increases with great rapidity a few hours
later. Its cause is generally to be sought in a gonorrhoeal or leucorrhceal discharge of the mother. In mild
cases where the discharge is whitish, not very abundant, and chiefly mucous in character, the free use of
cold compresses, a careful and frequent removal of the
secretion with a bit of absorbent cotton may suffice to
carry the ease through to a speedy and successful termination.  Such are mild cases.  In  other instances
the affection is severe, and requires prompt and energetic local treatment in order to insure favorable results.
The responsibility of the physician in a severe case of
ophthalmia neonatorum is very great. Intelligent treatment is surprisingly effective, but negligent or unskilful
treatment is often deplorable.  Our asylums for the
blind afford many mournful examples of the results of
neglect or bad treatment in this affection.
TREATMENT OF SEVERE CASES.
If the disease increases in severity in spite of our
treatment, we ought never to neglect to determine by
careful inspection whether the cornea be intact or not,
because upon this condition depends the treatment and
the nature of our prognosis.  It is not a very difficult
matter to obtain a view of the cornea even when the
lids are much swollen. The child is to be held by the
nurse, its head resting between the knees of the surgeon,
and in this position there is generally little difficulty in




TREATMENT OF SEVERE CASES.              105
forcing the lids apart. If the fingers alone are insufficient in consequence of the swollen condition of the
conjunctiva, an elevator may be used.  It is remarkable how neglectful many physicians are of this simple
procedure, but in no other way can a case be treated
intelligently.  After the inflammatory symptoms have
been reduced by the use of cold compresses, and the
discharge has become purulent, I use a collyrium  of
nitrate of silver, one grain to the ounce of water.  It is
quite mild, and I believe generally very effective.  It
is particularly indicated when the discharge is copious
and wholly purulent. This should be dropped into the
eye, after it has been carefully cleansed from the discharge, twice a day.  A change of collyria often hastens the cure; and one of the best substitutes for the
above is boracic acid, ten grains to the ounce of water.
It may be used five or six times a day, or one may use
a mild wash of bi-chloride of mercury 1:20000.  In a
few days, if the profuse discharge still continues, and
especially if the increased haze upon the surface of the
cornea indicates a complication in this direction, a
solution of five grains of the nitrate of silver to the
ounce should be painted with a brush upon the everted
lids and immediately washed off with tepid water or
neutralized by the application of a solution of common
salt and water.  No evil consequences whatever can
result from this proceeding, and not unfrequently the
beneficial results of it are seen after a single application.  It need not be often repeated.  Cold compresses
may be employed to lessen the irritation immediately
afterwards, and I prefer as internal remedies after aco



106                THE CONJUNCTIVA.
nite in the commencement, mercury when the discharge
is profuse, and the alternation of arsenicum  with this
remedy if the cornea is ulcerated.  It is advisable in
these cases, so long as the discharge is profuse, to direct that the discharge be carefully removed from the
eye every half hour with absorbent cotton, by day, and
every hour by night. I will give the outlines of a case
which occurred twenty years ago in illustration of this
treatment.
Mrs. G., of Boston, brought to me her babe, three weeks old.
It had been suffering from purulent conjunctivitis since two or
three days from its birth, and, up to the date of her visit, had
been steadily growing worse. The physician in attendance had
not attempted an examination of the cornea, but had advised
her to keep the eyes as free from the discharge as possible, to
apply cloths wet in cold water, and had administered small
powders internally.  The lids were somewhat reddened and
swollen in appearance, and considerably puffed up, from  the
quantity of pus beneath them. After the removal of the accumulated pus, which was accomplished by repeatedly separating
the edges of the lids, giving it exit, and wiping it gently away
with a soft sponge wet in tepid water, I was able, by means of
an elevator, to open the lids sufficiently to determine the condition of the cornea, and make a prognosis as well as diagnosis.
The cornea of the right eye was found hazy, and slightly opaque
at its upper and inner edge. In the left eye, the corneal opacity
was greater; and directly over the pupil was an ulcer which
had already broken through, and occasioned, as I afterwards
found, a deposit of matter upon the anterior surface of the capsule of the lens, and a slight adhesion of the free edge of the
iris. The mother was informed that the mischief done to the
left eye was irreparable; that perfect restoration of sight was
impossible; that the disease would probably progress no further,
and that vision, to a limited extent, would be preserved to this




TREATMENT OF SEVERE CASES.                  107
eye. As to the right eye, there was no question as to its perfect restoration. The lids were reversed and painted with a solution of nitrate of silver, ten grains to the ounce of water, which
was allowed to remain only a second or two, and immediately
washed away with tepid water.  The nitrate of silver was used
in an unusually strong solution, because it seemed necessary to
check at once, if possible, further progress of the disease.  I
have noticed that when a case is severe, the lids considerably
thickened, and the mucous papillae very much swollen and
prominent, it will bear, with good results and without marked
reaction, a much stronger solution of nitrate of silver than it
would be prudent to apply in a milder case. In this instance,
the mother informed me, on her second visit, that the night
after the application of the caustic was the best which the child
had passed since its birth.  There had been no reaction, and
consequently no application of cold to the lids had been necessary.  Under the circumstances, I concluded to touch the lids a
second time with the same solution.  This was done on the
second day; and again the child had a remarkably comfortable
night.  On the fifth day, the discharge, which had been very
profuse, was considerably lessened in quantity. The mother
herself could see a decided improvement, and began to have
great confidence in the treatment.  I now diluted the solution
with an equal part of water, making it five grains to the ounce;
and after a week, it was reduced still more, making it about
two grains to the ounce. I had taken the precaution, also, of
dropping into the left eye a solution of atropine, two grains to
the ounce, in order to draw away the edge of the iris as much
as possible from the corneal opening. The application of the
solution above described was made but six times, at intervals of
forty-eight hours, when, the discharge having almost entirely
ceased, I gave the mother simply a solution of sulphate of zinc,
one grain to the ounce of water, to be dropped daily into each
eye; and in two weeks from this time the child was well enough
to require no further treatment.




108                 THE CONJUNCTIVA.
THE PREVENTION OF INFANTILE OPHTHALMIA.
At the Lying-in Hospital at Leipsic the following prophylactic treatment is adopted.  The eyes of the infant are immediately washed out with water, a drop of a two per cent solution
of nitrate of silver is instilled, and the eyes are covered for
twenty-four hours with cool compresses moistened in a two
per cent solution of salicylic acid.  These measures were first
adopted for the infants of diseased mothers only, but subsequently extended to all others.  The result was, that for six
months, in two hundred infants so treated, not one case of ophthalmia occurred.  In one case where the application of the
nitrate of silver had been accidentally neglected, a slight case
of conjunctivitis appeared.
A simpler treatment is employed at Halle;  namely, for nine
months the eyes of the infants were washed out, as soon as the
head was born, with a one per cent solution of carbolic acid.
This treatment reduced the percentage of ophthalmia from 12.5
per cent to 3.6 per cent, and the disease when it did appear
assumed a milder form.
It would seem, in view of the above facts, that a grave responsibility for the condition of the eyes of the new-born rests
upon the obstetrician.  I recall last year an otherwise perfectly
healthy infant, sent to me by the family physician for treatment; the child was four weeks old, and both corner wholly
destroyed from purulent inflammation. Of course the child was
totally blind, and was to go through life totally blind.  Such
cases would be almost impossibre if a careful prophylactic treatment were generally observed.  It is entirely feasible for a
physician to carry out the treatment.
Undoubtedly nitrate of silver is the most available germicide
we have for the eye. A solution in water of 1: 100 - that is,
four to five grains to the ounce - destroys vitality in about twelve
seconds. Carbolic acid is too irritating for the eye, in any solution strong enough to be effectual, and the same may be said
of hi-chloride of mercury, 1: 1000 being required to destroy vi



CASE OF GONORRHIEAL OPHTHALMIA.               109
tality in forty-five seconds. To be effective the fluid should act
quickly because it becomes diluted almost at once by the secretions of the conjunctiva.. A 1 % solution of nitrate of silver is
therefore the preferable germicide to be used as a prophylaxis;
and the next best, but far less certain, and more irritating, are
carbolic acid I: 100 and bi-chloride of mercury 1: 5000. Boracic
acid prevents the development of germs but does not destroy
them. A  -o% nitrate of silver solution will produce a similar
effect.
GONORRH(EAL CONJUNCTIVITIS.
Gonorrhoeal conjunctivitis, so called, is a variety of this
affection associated with a similar discharge from the
urethra, due to sympathy or extension of the virus over
the system, or, as more frequently happens, to direct
contact of a urethral discharge with the eye.  In the
former case, the attack occurs simultaneously in both
eyes; in the latter, it commences in one eye first, generally the right, and in its severe form is one of the
most rapid and destructive diseases to which the eye is
subject.  In its mild form the disease resembles a light
purulent ophthalmia, and requires similar treatment.
In the contagious form, the inflammation is sometimes
exceedingly violent. I cannot describe the nature and
treatment of this disease better than by giving the main
details of a case of a severe type under my care many
years ago.
CASE OF GONORRHCEAL OPHTHALMIA.
G. L., a young man of seventeen, was brought me by his
father, Oct. 10, 1868, to be treated for an inflammation of the
eyes. The right eye was closed, the upper lid so largely swollen
that, at first glance, I thought of abscess.  On turning my atten



110                 THE CONJUNCTIVA.
tion for a moment to the other eye, the lids of which were but
little affected externally, I noticed considerable injection of the
vessels of the conjunctiva on either side of the cornea.  The
affection of the right eye had been noticed first two days previously; but the great swelling had not come on until this morning.  The pain was not very severe; the patient, pale and anxious-looking.  The lower lid was but slightly distended, and by
drawing it downward and away from the upper one which overlapped it, I could see a marked chemosis of the conjunctiva of
the globe.  There was no doubt about the diagnosis of the case.
As the father seemed nervous and apprehensive, however, I
concluded to say nothing about its peculiar nature for the moment, telling him simply that the affection was severe, that the
left eyelids, on the next day, would probably be very much in
the condition presented by those of the right eye to-day; that
the boy was not well enough to be out, and that he must be
treated in bed. Ice-water compresses to be applied to right
eye constantly, and to the left whenever the cold could be borne
or felt grateful. Aconite to be taken every hour.
The next morning the external appearance of both eves was
about the same, the upper lids of both being enormously distended.  The right was less sore to the touch, and I was enabled to determine the state of the globe more definitely. The
cornea was still intact, but considerably lessened in circumference through the overlapping of the conjunctiva, the chemosis
being very great. The conjunctiva bulbi was red and puffed,
looking "like a piece of raw meat."  Pulse, one hundred and
twenty.  Ice-water compresses to be continued night and day.
Aconite internally.  I now ascertained that the patient had
contracted a gonorrhcea three weeks previously. The discharge
from the urethra is still rather profuse.
Oct. 12.  Externally the swelling of the lids is somewhat
lessened, the appearance of the eyes the same. The discharge
is rather thin and flocculent, not such as could be desired. The
pain is not severe; pulse about the same; prognosis doubtful.
The same treatment to be continued. The sanious discharge




CASE OF GONORRHCEAL OPHTHALMIA.                 111
to be wiped out from beneath the upper lid with a camel's-hair
pencil moistened in warm water, and the edges of the lids to be
tenderly cleansed with a soft sponge and tepid water,
Oct. 13. Swelling of the lids much lessened externally. In
flammation is still too acute to admit of caustic application.
Appearance of the globe the same, the chemosis being considerable. Discharge still watery and slight. Used twice a day a
weak solution of carbolic acid in cleansing the inner surface of
upper lid. Attendants getting weary and worn in changing the
ice-water compresses night and day, I had two little ice-bags
constructed and connected by a bridge, like diminutive saddlebags, to be saddled across the nose, the little bags filled with
small bits of ice to rest one over each eye. The upper lid was
found still too tender to bear their weight, but a day later they
could be borne, and were afterwards used constantly, thereby
saving the nurses much labor. Aconite and mercury internally.
The discharge during the next few days became more copious
and pus-like, and the external lids became gradually less swollen
and red.
Oct. 15. Appearance of conjunctiva nearly the same; cornea
not fully transparent, that of the right eye quite hazy at its
upper third. Raised the upper lids and painted them with nitrate of silver, five grains to the ounce, immediately washing
it off with tepid water.
Oct. 16. Treatment continued.
Oct. 17. Considerable pain in the left knee, which I found
slightly swollen, and very sensitive to touch. A water compress was applied; pulse, which had fallen to one hundred, now
rose again to one hundred and twelve.  Aconite and macrotin
internally.
Oct. 18. Left knee-joint largely swollen, measuring, with the
leg extended, fourteen inches at its largest circumference; sensitive to pressure, and immovable; but less painful than yesterday.  Right knee painful, and beginning to swell.  Discharge
from urethra continues. Eyes much the same in appearance.
Cornea of right eye the worse of the two.  Prognosis, which




112                 THE CONJUNCTIVA.
had seemed for a few days more favorable, now again doubtful,
in consequence of this new inflammation of the knee-joints, which
bids fair to reduce the vitality of the patient as it has already
his courage, and renders the question as to the power of the
cornea to maintain the integrity of its tissues a doubtful one.
Treatment continued.
Oct. 22. Fever lessened, more appetite, knees less painful,
but largely swollen, and the right one immovable.  Eyes no
better; discharge quite copious. Treatment the same.
Oct. 23. Discovered, this morning, what I had been fearing
from the first, - namely, ulceration of the cornea. The chemosis
having in a measure subsided, the conjunctiva bulbi had receded
from the edge of the cornea, which it had previously overlapped,
and so uncovered in the right eye a crescent formed ulcer extending nearly around the upper half of its circumference. It
was deep, its edges sharp and clean, so that it was necessary to
look closely in a favorable light to see its whole extent. An
ulcer on the left cornea in nearly the same relative position, not
so great in extent, but still ugly and dangerous looking, was
discovered also.  Both ulcers looked, I thought, as though they
were growing larger, therefore without some change of treatment the right eye would certainly be lost, and perhaps the
left one too.  I therefore made an immediate change in treatment.  His pulse was one hundred, the tongue was nearly clean,
and he had expressed a strong desire for solid food. I determined, if possible in the present state of his digestive organs, to
gratify his wish to the fullest extent.  A rare beefsteak was prepared for him  at once, and he was to be fed similarly three
times a day. Beef-tea was also to be in readiness, so that if he
tired of steak it could be substituted for it. He was to have at
each meal all the rare beef he desired. I further substituted for
the solution of nitrate of silver, which I had been using, one of
fifteen grains to the ounce, applying it thoroughly to the reflected portion of the upper and lower lids, and immediately
washing it away with tepid water. It caused no pain whatever.
Mercury and macrotin were given internally.




CASE OF GONORRH(EAL OPHTHALMIA.                  113
Oct. 24. Ulcers look no better; knees improving slowly, and
can be drawn up or moved slightly without great pain, but are
still largely swollen.  Patient eats freely of the steak and
digests it without trouble; slept better than usual through the
night.  The discharge from  the eyes is rather less; continued
treatment; but before the cauterization I dropped a solution of
atropine into each eye to keep the iris rigid, and as much as
possible away from danger in case of rupture of the cornea from
the ulceration.  After the cauterization the eyes are bandaged
sufficiently tightly to prevent movement of the lids.  I find the
eyes bear this cauterization, repeated every twenty-four hours,
well, and it has already lessened the discharge.
Oct. 26. Ulceration appears slightly improved, especially il
the left eye, where the edges of the ulcer are slightly tinged
with yellow, and at the bottom a gelatinous look, as though the
reparative process were commencing.  Similar indications, but
less marked, are also to be seen in the more important ulcer of
the right cornea.  Patient complains of shortness of breath,
which I find is probably occasioned by overtaxing the digestive
organs, so I restrict the diet somewhat in quantity, and give nux
vomica and bryonia for twenty-four hours.  Other treatment
continued.
Oct. 28. Shortness of breath gone.  The eyes are decidedly
better.  The ulcers are slowly filling up.  Discharge from the
eyes less.  The cauterization now causes quite severe pain, so
that ice compresses have to be resorted to afterwards, for a half
hour before bandaging.  Internally mercury and macrotin.
Oct. 30. Eyes improving; knees improving also, but slowly.
The present solution of nitrate of silver being now too strong,
I reduce it one half, making about seven and a half grains to the
ounce, which is borne well. Discharge from the eyes much less;
from the urethra, also, somewhat less. Patient's appetite good,
and he is allowed to indulge it in nourishing food to the fullest extent.
Nov. 6. Improvement in all respects; he manages to walk
about the room  moderately.  Ulcer in the left cornea reduced
8




114                THE CONJUNCTIVA.
to a mere trace, that of the right surely but slowly filling up.
He can read coarse print.
Nov. 12. Acuteness of vision is nearly perfect, as the opacity,
left on the cornea from the ulceration and the reparative process, does not encroach at all on the pupil.
I may mention here that, some three months afterwards, this patient came again under treatment for rheumatic iritis,- a disease of the eye, which often follows
gonorrhceal rheumatism.  The affection of iris in this
instance was only of three weeks' duration.
Conjunctivitis diphtheritica is very rarely seen in this
country or in England. It is occasionally epidemic in
Berlin. It resembles the preceding in many respects,
but is usually more severe and dangerous.  The discharge is at first, yellow, thin, and flocculent, the
swollen lids rigid from deep-seated fibrinous effusion,
the pain and heat very great. In a few days the discharge assumes a purulent character, the lids become
less rigid, there may be fibrinous exudation from the
conjunctiva, the cornea is very apt to grow hazy and
ulceration or sloughing ensues.
The treatment indicated is that for purulent ophthalmia, except that much greater caution is necessary
in the use of caustic or irritating applications.
Membranous or croupous ophthalmia resembles the
diphtheritic, but is less severe, and there is less rigidity
of the lids. It is not often met with here. I have had
only two cases in twenty years.  The treatment is
similar to that for purulent ophthalmia.




CONJUNCTIVITIS FOLLICULOSA.           115
CONJUNCTIVITIS FOLLICULOSA
is seen first in the temporal portion of the conjunctiva of the lower lid in a number of slight, semi-transparent vesicles.  These are swollen lymph follicles,
and when numerous may extend to the upper lid, and
cover the entire palpebral conjunctiva, but more thickly
the reflected portions.  It is often found in connection
with granular or trachomatous affections, of which it is a
variety, or a milder phase, and like those is due often to
unfavorable hygienic surroundings. By itself, unmixed
with trachoma, follicular conjunctivitis does not result
in cicatricial or other structural change in the conjunctiva or pannus.  Uncomplicated cases are nearly always mild, and sometimes so mild as to occasion no
inconvenience even. when the swollen follicles are quite
numerous.   But this condition renders the mucous
membrane of the lids more susceptible to inflammations
of all kinds.  Usually the subjective symptoms are
those of a hyperamia; after use of the eyes there is
burning, congestion, a feeling as of sand between the
lids, and there may be a slight discharge which is
contagious.
Treatment.
The simple astringents mentioned for acute catarrhal
conjunctivitis will often prove efficacious; but, on the
whole, I have found a collyrium of boracic acid, of from
six to eight grains to the ounce of water, more generally
useful than any other.  Strong astringents or caustics
should never be used.  The affection is often obstinate,
recurring again and again; and when this occurs there




116               THE CONJUNCTIVA.
will generally be found some constitutional dyscrasia.
See Treatment of Scrofulous Ophthalmia.  In a case of
an adult that I have recently been treating, irritation,
lachrymation, and photophobia were the troublesome
symptoms.  Perfect rest in a dimly lighted room, and
the free use of a six grain solution of boracic acid, were
the measures that proved most grateful and beneficial.
The attack lasted four weeks.  He informed me that he
was always apprehensive of a recurrence of the disease,
as he had suffered from similar attacks, at intervals,
for a dozen years.  Sometimes they had been slighter,
and sometimes more severe than this.
ACUTE CONJUNCTIVITIS GRANULOSA (TRACHOMATOSA)
is characterized by pain in the eye, photophobia from
ciliary irritation, and particularly by the sensation as
of a foreign body beneath the lids.  If the latter be
everted there will be noticed in addition to the swollen
papillae, and intermingled with them, little gray points
which are true or follicular granulations.  After a
week or more, the conjunctiva becomes more swollen,
the discharge abundant and purulent, and at this stage
of the disease it is difficult to distinguish the affection
from a conjunctivitis purulentia.  This purulent stage
continues for some weeks, and may be treated as a conjunctivitis purulentia, exercising great care in regard
to the use of irritants.  So long as photophobia and
lachrymation are marked, no irritating collyria can be
used safely.  Later, with the exercise of this caution,
the affection may be treated like the chronic form mentioned on the next page.  The cause of this affection is,




CHRONIC CONJUNCTIVITIS GRANULOSA.    117
generally, defective hygienic conditions and contagion.
It spreads rapidly, like the military ophthahllia, among
masses of people.  Either from  neglect of all treatment, or from improper or imperfect treatment, or want
of persistence on the part of the patient, the disease is
very apt to become chronic.  The secretion diminishes
little by little, the general inflammatory state of the
conjunctiva disappears, and the disease concentrates
itself beneath the upper lid, and we have a
CHRONIC CONJUNCTIVITIS GRANULOSA,
and generally this is soon supplemented by an affection of the cornea, called pannus.
Trachomatous pannus is a vascular development
within the epithelial layer of the cornea. There is
sometimes an extension of the granulations from the
upper lid to the ocular conjunctiva, and thence to the
cornea, but a pannus may be caused by friction and pressure upon the cornea of the roughened surface of the
palpebral conjunctiva, and usually therefore, when we
see it, we know without further examination that we
have a granulation of the lid. The granulations, which
are often of a mixed form, papillary and follicular, are
on the inner surface of the upper lid, mostly upon the
reflected portion, and the pannus, of course, is generally found upon the corresponding upper half of the
cornea.  When later, it has extended downward and
encroached somewhat upon the pupil, so that vision
is impaired, the patient becomes alarmed, and seeks
the advice of the physician.   The indication in a
case of this kind is invariably to cure the granulated




118              THE CONJUNCTIVA.
lid. This being accomplished, the pannus disappears of
itself.
A further unfortunate condition, whether pannus be
present or not, is found in the structural changes in the
lids due to old granular affection.
These  are dryness, shrivelling,
and cicatricial contractions of the
conjunctiva.  This in turn may
lead to displacement of the cilia,
trichiasis, districhiasis, entropiFIG. 22.
on, or xerosis.  Fig. 22, from
Nettleship, shows a granular lid and the beginning of
structural change.
TREATMENT OF GRANULAR OPHTHALMIA.
The treatment of this class of cases is sometimes difficult and discouraging, owing to frequent relapses.  If,
as is frequently the case, the patient has suffered for
many months or years, has been previously treated unsuccessfully, is gloomy and despondent in anticipation
of coming blindness, he should be assured that his case
is not hopeless; and that, with the proper amount of
perseverance on his part, a permanent relief, with a
more or less complete restoration of vision, is almost
certain. A pannus - something growing gradually over
the sight of the eye, and threatening eventually to shut
out all vision - is usually a disease of fearful omen to
the patient. He comes to the surgeon, also, with fear
and trembling, from the idea that the growth upon the
cornea must be cut off. No doubt this view is sometimes imparted by the physician who confounds the




TREATMENT OF GRANULAR OPHTHALMIA.  119
growth with that of pterygium.  The patient then, in
the first place, should be rendered as cheerful and hopeful as possible.  Hygienic regulations, such as previously mentioned, should be strictly enforced, and
the general health, which in these cases is apt to be
deficient, must be restored.
As a local means of curing the granulated lid, I employ a smooth crystal of alum, a crystal of sulphate of
copper, and occasionally a crayon composed of one part
nitrate of silver to two parts nitrate of potash.  Pure
nitrate of silver in substance I never use.  A smooth
crystal of sulphate of copper is, perhaps, most serviceable when the eye is in condition to be benefited by irritating applications. The upper lid being reversed, it is
drawn lightly and quickly across that portion of the lid
seen to be thickened and granulated, and those portions
of the conjunctiva not involved are carefully avoided.
Considerable pain will ensue; and if the patient is
very sensitive, it is advisable to apply tepid water or
weak salt and water to the conjunctiva the instant after the touch with the caustic.  Otherwise, the patient
may, after the lapse of a few minutes, if the pain does
not cease of itself, bathe the eyes in cold water.  Immediately after this application the eye will present a
reddened and injected appearance, and should on no
account be used until this injection disappears, which
will be perhaps in an hour or more. There will also be
a feeling of irritation in and about the eye, and until
this artificial irritation has fully disappeared, no second
application of the crayon should be made.  Whether,
therefore, the process is to be repeated once in forty



120               THE CONJUNCTIVA.
eight, or seventy-two, hours, or not oftener than once a
week, must depend entirely upon the reaction caused
by it.  Meantime cold or hot water may be used freely;
vaseline, if the lids adhere together in the morning,
and the administration of constitutional remedies, when
necessary, continued. In sub-acute cases, where there
is considerable secretion, the application of a solution
of nitrate of silver in water, of the strength of five or ten
grains to the ounce, will be useful. It should be painted
upon the reversed upper lid, and after fifteen or twenty
seconds, neutralized by weak salt and water, from  a
second brush.  In many cases, and especially in such
as have been treated injudiciously or too heroically,
mild applications will prove more beneficial. Such, for
instance, are the aqua chlori, diluted with water onehalf or more, a solution of one to three grains of either
nitrate of silver, sulphate of copper, aluminate of copper,
alum, sulphate of zinc, to an ounce of water. In some
cases I have used an unguent of one grain of sulphate
of copper, or aluminate of copper, to the drachm of vaseline or lanoline.  A mild unguent of the same may be
made by adding three grains of tannin to the drachm.
It is prudent to begin with mild applications if there
is much ciliary irritation, and in many cases it will
*be necessary to feel our way along by frequent change
of remedy.  Sometimes the eye will bear no irritant
whatever.
Pressure is frequently a potent auxiliary in these
cases.  It can be accomplished by placing a dry compress of absorbent cotton over the gently closed lids,
so arranged that it shall be thickest at the angles




TREATMENT OF GRANULAR OPHTHALMIA.   121
and  diminished  gradually  towards the meridian, in
order that the pressure  exerted may be as uniform
as possible over the granulated  surface.  An elastic
band —flannel makes a good  one-  is then  passed
around the head, to hold the compress firmly in its
place, and may be drawn as tightly over the eye as can
be conveniently borne.  This bandage is to be worn
night and day, and the compress is to be readjusted
upon the eye as often as it becomes displaced. I will
relate a case or two in illustration  of this mode of
treatment.
Miss B., aged twenty-four, visited me first in April, 1865.
She complained of irritation and weakness in the left eye, and
had recently become much alarmed at the discovery that she
could scarcely see to read with it. I found a fully developed
pannus extending nearly to the centre of the pupil, well supplied
with vessels extending downward across the limbus cornea on
to its substance. The prognosis, as far as improvement of vision
in this eye was concerned, was favorable; complete restoration,
a sharp, distinct vision like that of the normal eye is very often
impossible. The faintest remnant of haziness of the cornea will
occasion indistinctness sufficient to annoy the patient. When
no cloudiness remains, and the cornea regains its transparency,
if there is the least irregularity of surface, minute depressions
or flattened facets, the rays of light will be abnormally bent in
passing through the cornea, and the image upon the retina will
be deformed and more or less indistinct.  If, therefore, a doubt
exists as to a complete restoration of the cornea it is unwise to
promise a perfect recovery of vision. The case of this patient
was a very old one.  In her early youth she remembered an
affection of her right eye, and the sight had never been as clear
as that of the left up to the present attack. On examining the
cornea of the right eye by lateral illumination, little irregular




122                 THE CONJUNCTIVA.
flattened facets were distinctly seen, which accounted for the lack
of sharpness of vision. The lid of the left eye was reversed,
and the cause of the growth upon the cornea was found il the
granulated state of the conjunctiva. The diseased surface was
lightly touched with a crystal of sulphate of copper, very cautiously at first, until the eye became somewhat accustomed to the
process.  Severe pain followed the operation for the first two
or three times, but this was effectually controlled by bathing
the eye in cold water and exposure to the open air. This eye
had suffered from an acute attack of inflammation, as she informed me, more than a year before, but had apparently fully
recovered after a few weeks. For a while it continued strong,
but gradually grew more and more irritable, until within a few
months she had scarcely been able to use it at all. She was
under my care nearly five months, and completely recovered.
This process of cauterization was repeated on an average about
once in three or four days.  Mercury was the remedy principally administered, although she had other remedies for disturbances in her general health during this period. Towards the
end of the treatment my attention was called to the benefit of
bandaging the eye in similar cases, and she employed this means
also with the effect, I think, of hastening the cure.  On visiting
me nearly two years later, while with the right eye she was unable to read No. 1 type, with the left eye, the one which had
been under treatment so long for'the pannus, she could read it
with ease.
Miss W. came to me first in May, 1867.  She also, like the
other, was suffering from pannus upon the left eye, and from
the same cause. Like the other, also, she had suffered years
previously from a probably similar affection in the other eye,
The right eye she affirmed had been cured by a doctor in Boston,
who had cut the cornea across its upper portion superficially,
and had also made longitudinal incisions upon the inner surface
of the upper lid. These incisions, she said, were painful, but
always afforded her relief, and eventually cured her eye. She
wished me to treat her left eye now in a similar manner. I




TREATMENT OF GRANULAR OPHTHALMIA.   123
declined her method, and touched the granulated lid lightly with
a bit of sulphate of copper, but it would not do. After a week
I gave up the attempt to touch the granulations at all. The eye
was rather the worse for the treatment. The ciliary system of
nerves was involved to such a degree that the irritation caused
profuse lachrymation and severe pain and photophobia.  I
therefore gave up temporarily the use of irritants of all kinds.
Water was used several times a day, and a compress and bandage, as previously described, was applied, to be worn always at
night, and, when convenient, during the day. After two or
three weeks there was much less congestion, and the pannus
had so far disappeared that the patient could read large print
with tolerable fluency. I now began brushing the granulations
beneath the lid with a weak solution of sulphate of zinc, which
I found could be borne every two or three days. The bandage
was continued with great benefit, and during the first part of
the treatment, while the eye was irritable, spigelia, and later,
mercury were administered internally.  After two months'
treatment no trace of the pannus was left, and vision was the
same in either eye.
Aqua chlori is recommended  for obstinate pannus
from granulated lids, and two to four parts of olive oil
to one of oil of turpentine also.  Inoculation of the eye
with pus to create an acute purulent inflammation has
been more or less successful in desperate cases in clearing up the cornea and restoring vision, and the same
may be said of jequirity, but both these measures are
heroic and not without danger.  Peritomy, an operation
in which the conjunctiva with its sub-tissues is excised
with forceps and scissors, around the edge of the cornea,
I have seen Mr. Bowman, of London, perform with good
results.  Favorable results, it is said, have also followed the operations of lengthening the palpebral fis



124               THE CONJUNCTIVA.
sure, so as to remove the pressure of the upper lid
upon the cornea.
The more experience one has in granular or trachomatous conditions of the conjunctiva, the more one is
inclined to prefer the milder to the so-called heroic
treatment.  Caustics and strong astringents are sometimes necessary, but their use should not be prolonged,
and they may often be dispensed with to the advantage
even of eyes that appear to tolerate them fairly. Thus,
I find myself of late years substituting a crayon of alum
in cases where formerly I should have used a crayon of
sulphate of copper, and I often use a three grain solution of nitrate of silver.
Naturally, much depends upon the fact as to whether
ciliary irritation  exists to any great extent.  If it
does, caustic or astringent applications are not borne
well, and may do harm  rather than good.  Pain, photophobia, and lachrymation indicate ciliary irritation,
and  when  considerable, contra-indicate astringents,
apart from other considerations.  In some of these cases
one should carefully regard the condition of the iris.
Atropine will sometimes be useful.
Recently, as an intercurrent application, I have found
boracic acid, four to six grains to the ounce of water,
serviceable.  In acute or sub-acute cases the boracic
acid, being a disinfectant as well as a very mild astringent, may be used freely several times a day.  When
used in a four grain solution in cases of even marked
ciliary irritation, it is usually borne well and is often
decidedly beneficial.




DIAGNOSIS.                   125
SCROFULOUS CONJUNCTIVITIS OR SCROFULOUS OPHTHALMIA
I place in this chapter, inasmuch as its primary seat
is usually the conjunctiva; the cornea, iris, and sclerotica becoming later involved.
DIAGNOSIS.
It is hardly necessary to dwell on the diagnosis.  The
mere circumstance that ciliary irritation and photophobia so affect the orbicularis that its spasmodic closure
nearly renders it impossible to see the eye at all, is of
itself an almost unerring indication of the nature of the
disease. It is necessary, however, to see the eyeball,
in order to determine its precise condition, and form a
correct prognosis.  A few whiffs of chloroform or ether
will sometimes quickly relax the orbicularis; but I
prefer a resort to the lid-elevators, to be used as mentioned in ophthalmia neonatorum.  Separating the lids
we shall find the palpebral conjunctiva red, swollen,
and velvety looking, the ocular conjunctiva injected, the
pinkish zone around the periphery of the cornea well
marked, the cornea probably dull, opaque, or ulcerated,
and the iris perhaps contracted. There is sometimes a
good deal of ciliary neuralgia present, and the dread of
light may be so intense that the child cannot be induced
to turn its face towards the most moderate light, even
with its eyes tightly closed.
Fortunately the disease is not always so severe as
this, and the photophobia much less intense.  In these
cases, by means of coaxing, and some little artifice to
excite their curiosity, we may, through the exercise of




126              THE CONJUNCTIVA.
considerable patience, arrive, with most children, at a
hasty view of the cornea sufficient for our purpose. Cocaine, if the case is docile enough to permit its use, will
make the examination easier.  Often the cornea will
be found nearly transparent, and the disease confined to
the conjunctiva and edges of the lids.  Generally, however, even if the cornea appears unaffected, the ocular
as well as palpebral conjunctiva is involved, and the
inflammation is so deep seated as to reach the vessels
beneath the conjunctiva, as shown by the pinkish zone
around the edge of the cornea.  The irritation of the
ciliary plexus of nerves is marked, the eye is exceedingly sensitive to all external influences, there is copious lachrymation, and any irritation is followed by
violent reaction.  In some chronic cases these symptoms are measurably lessened in severity, but after all
a leading characteristic of these cases is the ciliary irritation, and the consequent extreme sensitiveness of the
eye.  I dwell on this point because of its importance
in the treatment.
TREATMENT OF SCROFULOUS OPHTHALMIA.
The treatment of these cases must be largely constitutional.  The disease of the eye is but one of the manifestations of a disorder that pervades the entire system,
and topical means can at best be only palliative.
Soothing applications, however, like tepid water, milk
and water, quite warm or hot fomentations of water, or
warm water medicated with belladonna or chamomile
or poppy leaves, atropine, or cocaine will frequently
quiet a ciliary neuralgia or great restlessness, when




TREATMENT OF SCROFULOUS OPHTHALMIA.  127
simple internal remedies alone do not suffice. There
are, moreover, some phases of this disease, such for instance as when its chief seat appears to be the edges of
the lids, where a mild mercurial ointment, rubbed
gently between the cilia, - if necessary while the child
is asleep, - will produce sometimes marvellously favorable results. It should be continued a long time nevertheless, if we hope for permanent benefit, and mercury
may be given internally at the same time.
This is not the place, nor is it necessary, for me to
remark at length on the nature or pathology of what is
called scrofula and its appropriate treatment in general. In the management of these diseases of the eye,
hygienic and dietetic regulations are of the first importance. Fresh air, light, warm clothing, and good diet
are indispensable always. In regard to light, I do not
believe in keeping the patient in a dark room. If there
is no ulceration of the cornea, no special attention in a
hygienic way need be given in this affection to the patient's dread of light. The celebrated Professor Beer,
who formerly had charge of the department of the general hospital for diseases of the eye during many years,
in Vienna, used to take children affected with severe
photophobia and place them in a position so that the
sunlight might fall directly into the eye, and then force
the lids apart.  This appears like a very dangerous
proceeding, but I have the authority of the grandson of
the operator, the late Prof. Ed. von Jaeger, to the effect
that no unpleasant effects followed the treatment. A
rather heroic method, or one which mothers at least
would consider so, was practised by Professor Graefe,




128              THE CONJUNCTIVA.
in Berlin.  When the eyes were better and yet the photophobia did not yield, he dipped the child's head under
water, perhaps several times, thoroughly frightening it,
and usually with the result of overcoming the spasm of
the orbicularis. I have seen tartar emetic given to children, in London, for the purpose of making them  sick
and relaxing the orbicularis.  A 2% solution of cocaine
will often prove useful in such cases.
When there is an ulcer on the cornea or a vesicle
near its edge in the stage of excoriation, the photophobia may arise from the exposure of denuded nerve fibres;
and then the progress in reproducing an epithelial covering for the exposed nerves will be very much hastened
by bandaging the eye. The bandage will also serve the
purpose of preventing friction of the lids in winking,
lessen irritation and pain, and tend to prevent rupture
of the cornea if it happen to be the seat of a deep ulcer.
Children also have a disposition to constantly rub their
eyes,-a trifling circumstance enough, but one which
frequently has seemed to me a chief cause of the continuance of the inflammatory state, - and this the bandage of course completely remedies.   This bandage
should be changed several times a day, and the discharge washed from the eye, if discharge be present.
Sometimes great pain and restlessness will be promptly
relieved by dropping a 2% solution of cocaine into the
eye; and its quieting influence seems to expedite the
cure.  A weak solution of atropine will often prove useful also, when the cornea or iris is involved.  The atropine should never be dissolved in alcohol or alcohol and
water, because alcohol applied to the eye is an irritant,




PHLYCTENULAR CONJUNCTIVITIS.            129
and usually contra-indicated in cases where atropine is
likely to prove useful as a sedative.
It is almost, or quite, impossible to give even an outline of the treatment that may be required in scrofulous
ophthalmia, because, aside from the different tissues of
the eye which may be affected, the patient, so far as my
experience goes, almost invariably suffers from general
disturbance of the health.
PHLYCTENULAR CONJUNCTIVITIS,
or herpetic or pustular conjunctivitis, as it is frequently termed, may be considered as a phase of scrofulous ophthalmia.  It occurs usually in children, and
mostly in those of a so-called scrofulous diathesis, and
very rarely in children otherwise in good health. It is
characterized in its simple form by the appearance of a
reddened point upon an inflamed base of the conjunctiva, slightly raised, and situated usually either at the
limbus of the cornea, or upon the sclerotica near its
junction with the cornea. This red point usually terminates in a vesicle, which, changing into a slight excoriation or ulcer, gradually disappears, and leaves no
trace behind. There is generally some irritation of the
ciliary nerves, and, as a consequence of this, some photophobia and lachrymation. These symptoms being greatly
increased when the vesicle or vesicles happen to come
on the cornea or at its limnbus. If the vesicles are not
developed in too great numbers, and are not too near
the cornea, the disease is very slight, and requires very
little treatment. I was once consulted by an adult, in
a case of herpetic conjunctiva,whose physician had in9




130              THE CONJUNCTIVA.
formed him that he had probably a pterygium growing
over the sight of the eye, and it would have to be removed by an operation.  He was a sculptor, and I advised him to remain at home for a few days, so as to
avoid the dust of his studio, and he was soon cured
without further treatment.  Many cases, however, are
much severer than this and not as easily disposed of;
and in all, the tendency to recur again and again is
strongly marked.
Treatment.
The best remedy for this disease is the external application of powdered calomel.  The inspissations of the
powder should be made by taking up a minute quantity
of the fine powder on a camel's-hair pencil, then holding the pencil vertically before the affected eye, between
the forefinger and thumb of the right hand, having exposed the surface of the under lid with the left hand,
tap the handle of the brush rather smartly with the ring
finger of the right hand, at the same instant tossing the
brush slightly towards the lids, and some of the fine
dust will be projected directly into the eye.  This
manoeuvre is simple, but it requires a little practice
to do it neatly.  The calomel should be very fine, but
little should be taken up on the brush, and no lumps of
it thrown into the eye.  Neither should it be blown into
the eye through a tube; it is too coarse treatment for a
delicate eye, though convenient for the nose or ears.
The calomel seems to exercise a specific influence in
these cases, due to its germicidal properties. I formerly
thought the calomel simply an irritant used in this way,




PHLYCTENULAR CONJUNCTIVITIS.            131
but am now convinced to the contrary.  It does irritate,
and should therefore be used cautiously if the eye is very
sensitive and dreads the light. For the photophobia,
tartar emetic will often be serviceable.  Ciliary neuralgia may often be quieted by chamomilla, using at the
same time warm fomentations of chamomile water over
the closed lids.  Very severe pain may be quickly relieved by the instillation of a two per cent solution of
cocaine.  The general treatment will be that indicated
for scrofulous ophthalmia.  Norton advises sulphur internally as specially serviceable, and directed to the constitutional symptoms so often manifested by an eruption
similar to that of the conjunctiva, at the alt of the nose,
angles of the mouth, behind or in the ears, and about
other parts of the body.
Sometimes a herpetic point appears in the subconjunetival tissue, just at the edge of the cornea.  When this
is the case, and the sclera or the episcleral tissue is involved, the progress of the disease is tedious in the extreme.  I have had an example of this variety where
one vesicle remained imbedded beneath the conjunctiva
for more than three months.  It is difficult sometimes
in such instances to determine whether such a case
should be regarded as a conjunctivitis or an episcleritis.
See Phlyctenular Keratitis.
Exanthematous conjunctivitis, occurring during eruptive fevers, does not usually demand special treatment.
It is always present to a certain extent in measles,
scarlatina, and variola. Any discharge should be removed, and the eyes should be protected against bright
light. Bathing in tepid water, or milk and water, is




132               THE CONJUNCTIVA.
often grateful, and if the edges of the lids adhere, or
are tender or excoriated, the application of vaseline,
olive oil, or glycerine will be useful. If the discharge
continues, a collyrium of one or two grains of nitrate
of silver to the ounce of water may be used twice a
day.
Pterygium is a hypertrophied condition of the conjunctiva, usually of a triangular form, the apex towards
the cornea, the base at the semilunar fold. The growth
is tendinous, and supplied with vessels. When red and
irritable, rest of the eye, soothing applications like
warm water, and bandaging for a few days will greatly
relieve the condition.  If it is not particularly annoying, and does not increase rapidly so as to threaten impairment of vision, by encroaching on the pupillary area,
it is better not to disturb it, unless for cosmetic reasons
the patient desires its removal.  The operation is done
by seizing the growth with delicate forceps and dissecting it from  the cornea with a knife; then incise with
scissors the conjunctiva from the upper corneal margin
of the growth back to the centre of the base of the
pterygium, and make a similar incision from the lower
corneal margin of the growth and remove the lozengeshaped portion of conjunctiva between the incisions.
The conjunctiva above and below is then to be loosened
from the sclera and drawn over the raw surface and
stitched.  A variation in the operation is to dissect up
the growth, then double it inward upon itself and confine it by a deep suture. The operation for its removal
is not always permanently successful.  A less severe
form of the disease consisting merely of a slight hyper



PINGUECULA.                   133
trophy of the conjunctiva is readily and successfully removed with the forceps and scissors.
The cause of the disease is usually some injury of the
eye or exposure which irritates the conjunctiva, and it
sometimes results from a phlyctenular or other ophthalmia.  A warm climate predisposes to the affection.
HEMORRHAGE BENEATH THE CONJUNCTIVA
may be known by its bright red color, by its occurring
in circumscribed, well-defined spots, often extending up
to the edge of the cornea.  It may be due to a blow or
fall, but often no assignable cause can be found. When
it appears in feeble elderly subjects it may indicate a
weakness of the blood-vessels generally, and an attack
of apoplexy of the brain.  Usually it is far more alarming to the patient than hurtful; but in severe cases with
recurrence of the bleeding, rest and bandaging the eye
may be advisable.
PINGUECULA.
The little elevation of a yellowish color observed in
elderly people at the margin of the cornea, called pinguecula, is not annoying except from its conspicuousness.  If desired it may be seized with delicate forceps,
and snipped off with the scissors.
Warts of the conjunctiva may be treated in the same
way.
Cysts of the conjunctiva are to be treated similarly.
Dermoid tumors, generally seated at the corneal margin, are best dissected out with the knife, care being
taken not to go too deeply into the corneal and sclerotic
tissues.




CHAPTER VII.
THE CORNEA AND SCLERA.
FROM a clinical point of view keratitis may be divided
into two distinct forms, -namely, the suppurative and
the non-suppurative. The first involves loss of true corneal substance and more or less impairment of sight.
The second  may result, and  often  does result in
perfect restoration of the normal transparency of the
cornea.
PHLYCTENULAR KERATITIS.
The cornea is frequently the seat of excoriation or ulceration in the vesicular or phlyctenular variety of
scrofulous ophthalmia.   The objective symptoms are
those  of phlyctenular  conjunctivitis more  strongly
marked, with much greater ciliary irritation, congestion, and photophobia.
The vesicles, often situated at the corneal edge, are
small grayish points which usually rupture and leave
minute superficial ulcers.  The affection belongs essentially to the period of childhood.  A similar disease
appears as a
Fascicular keratitis in which vessels run near each
other in parallel lines over the corneal limbus on to the




PHLYCTENULAR KERATITIS.               135
cornea to supply material for the repair of the ravages
of the small corneal ulcer.  See Fig. 23, after Nettleship.
FIG. 23.
Superficial vascular keratitis is still another form of
scrofulous affection of the cornea, characterized by the
formation of a network of vessels over a circumscribed
portion of the cornea which, in the affected region, is
more or less infiltrated and roughened.  This condition
may be the result of repeated attacks of the phlyctenular
variety of keratitis.
Treatment.
The treatment of phlyctenular keratitis should, in
general, be that laid down for scrofulous ophthalmia on
page 126. Arsenic and mercury as internal remedies
are prescribed by me perhaps oftener than others; but
iron and good feeding are often necessary, and the best
possible hygienic conditions should be secured.
As for the external treatment, the ciliary irritation
is so great that considerable caution is necessary. Powdered calomel is not well borne. A half or quarter per
cent solution of atropine once a day is soothing, and a
two per cent solution of cocaine for pain and photophobia




136          THE CORNEA AND SCLERA.
three or four times a day may be used. A solution of
bi-chloride of mercury 1:10000 should be dropped in the
eye as an anti-septic; if it irritates it may be used directly after the cocaine. If it prove too irritating boracic acid, one per cent, may be substituted. As the
acute symptoms subside, one may use an unguent of four
to six grains of the yellow oxide of mercury to an ounce
of vaseline once or twice daily; but this often proves
too irritating, and hot water fomentations may be
equally serviceable. The water should be as hot as can
be borne, and the small compresses which are to be
placed over the closed lids should be changed every few
seconds. These fomentations should be kept up for five
to ten minutes three or four times a day, and as the
acute symptoms subside, from ten to twenty minutes at
one time.
In the beginning the eye should be bandaged for reasons given at page 128; but later, as the eye improves,
the bandage may be discarded as tending to keep up the
photophobia.
Vesicular, or herpetic, keratitis is rather rare.  Sometimes a cluster of minute vesicles filled with transparent
liquid are present on the cornea, and after catarrhal
affections similar herpetic eruptions appear about the
mouth and nose.  The treatment is that for phlyctenular keratitis.
Bulbous keratitis is caused usually by injury of the
cornea.  The epithelium  is raised and forms a rather
large fluctuating vesicle filled with a transparent, and
more rarely with a purulent, fluid. The detached epithelium should be removed under cocaine.  The disease




DENDRIFORM KERATITIS.               137
is liable to recur.  A somewhat similar condition is
found after old affections involving tension of the eyeball, but the disease is then due to cedema of the cornea
and is not amenable to treatment.
Dendriform keratitis is a very superficial ulceration
of the cornea extending across it in the form of a branch
or twig. It is best seen by lateral illumination. In a
recent case, that of a young man of twenty-three, otherwise perfectly healthy, there was a good deal of photophobia but not much pain.  Under cocaine I scraped
the ulceration gently at first, then applied a solution of
bi-chloride 1:5000 and bandaged the eye.  The pupil
was kept large by atropine, and he used a solution of
bi-chloride 1:10000 three times a day.  After three
weeks the bandage was left off.  He came to me on
April 21, and was last seen on May 24, when there
was no photophobia remaining, although traces of the
ulceration were still faintly visible.  Sight 20.
Vascular interstitial keratitis may be considered as a
severe, deeper-seated form of fascicular keratitis.  The
treatment should be similar, and in uncomplicated cases
the prognosis is favorable.
Non-vascular interstitial keratitis in which one or
more circumscribed infiltrations appear in the cornea
gradually growing more opaque, may supervene from a
vascular keratitis, or from some form of conjunctivitis,
or may be due to some unknown cause.  The prognosis
is good; but the progress towards health may be very
slow. Hot water compresses applied as directed at page
136, to be regulated as to frequency and time according to
the reaction produced.  It may be necessary to use the




138           THE CORNEA AND SCLERA.
hot water for a half hour three times a day. Atropine
may be used to keep the pupil dilated and avoid iritic
complication, and the general health should be guarded
by proper hygienic and remedial measures.
Diffuse interstitial keratitis is of inherited syphilitic
origin usually. It is sometimes possibly due to scrofulous diathesis, and a few observers believe that it may
follow acquired syphilis as a secondary manifestation.
It is often seen in children with the characteristic
notched teeth of inherited syphilis. See Fig. 26, p. 157.
A slight grayish opacity of the cornea is first noticed,
and this gradually increases in density until vision is
reduced to mere counting of fingers near the eye.  In
uncomplicated cases the prognosis is favorable. The
cornea usually becoming clear again after some time. I
have always used atropine in these cases, and given mercury and iodide of potash internally, but have never
been certain that the treatment influenced the course of
the disease, which is invariably slow. The past year I
used hot fomentations in the case of a boy of fourteen,
and the result leads me to think it possible that the application of heat may hasten the absorption of the infiltration.  L. R. came to me May 4.  V. R. saw fingers
near the eye. June 1. V. -2  0. July 5. -. Meantime
the left eye became similarly affected in June, and grew
gradually worse until July 5, when it began to improve. The boy was entirely recovered when I returned
from my summer vacation in September.  Here the disease was, in the right eye at least, of less than three
months' duration.
Keratitis punctata superficialis, as described by Fuchs,




SUPPURATIVE KERATITIS.               139
is a form  of keratitis following an acute catarrhal
conjunctivitis, and characterized by unusual ciliary
irritation, pain, and photophobia.  It is apt to recur,
and then little dots are observed about the centre of the
cornea, the marginal portion remaining clear.  The
dots are in the superficial layers of the true cornea beneath Bowman's membrane. The prognosis is good, but
the course of the disease is very slow.  It is most conmon to those between ten and twenty years of age.
The treatment would be similar to that of a severe
phlyctenular keratitis.
Deeper-seated affections of the cornea are keratitis
punctata, secondary to disease of deep-seated affections
of eye, see page 158.
Suppurative keratitis, which is sometimes met with
as a result of severe purulent ophthalmia or from chemical or mechanical injury to the eye, or from surgical
operations in the corneal tissue, is a grave form of the
disease leading to ulceration.  It is frequently accompanied by severe ciliary neuralgia.  The rose-colored
zone around the cornea, contraction of the pupil, and
sometimes chemosis are present.  We notice a gray
opacity, which changes afterwards to yellow as the tissues become broken down, and the end may be a perforation of the anterior chamber.  Or there may be extensive corneal abscess, perhaps interstitial infiltration
forming onyx. Or a hypopion may result from precipitation of pus to the bottom of the anterior chamber (hypopium keratitis). See Fig. 24, from Nettleship, on the
next page.  The matter may reach the anterior chamber from extension of the suppurative inflammation to




140           THE CORNEA AND SCLERA.
the iris without perforation, or more usually from bursting of the posterior layer of the cornea.  The elastic
layer of Descemet is not subject to the suppurative process. Suppurative corneitis is very readily produced by
injuries of the cornea in the aged
or weak, and is not unfrequently
met with as a sequence of typhus,
typhoid, cholera, or diabetes.
An indolent or non-inflammatory form  of corneitis, where the
FIG. 24,       absence of pain and irritation is
a characteristic feature, is of still
more dangerous nature.  In neuro-paralytic corneitis
the infiltration sometimes extends with great rapidity;
and necrosis not only of the whole cornea ensues, but
in rare instances the suppuration extends to the entire
globe.  All suppurative forms of keratitis, since the
loss of corneal substance is involved, leave permanent
opacities and more or less impairment of vision.  All
are probably due to infection; if not from  without,
then through the circulation from within, and this fact
should of course influence our local treatment.
TREATMENT OF CORNEITIS GENERALLY.
The treatment of corneitis occurring during the course
of the various ophthalmia has been sufficiently indicated. In the severe suppurative forms the eye should
in the first place be bandaged, and the flannel band
should be long enough to pass twice around the head,
so that considerable pressure may be exerted on the ball
of the eye. Pressure seems to have a controlling influ



SUPPURATING INTERSTITIAL KERATITIS.   141
ence in limiting the extent of the suppuration, and
every hair's-breadth of transparent cornea saved to the
patient multiplies infinitely his visual power in the end.
If the inflammatory symptoms are so marked as to indicate the cold compress, then the application of the
compress bandage may be alternated with the use of
cold water. It is hardly worth while to attempt to combine the cold and the compress at the same time.  One
or the other will be pretty sure to be inefficiently attended to.  In the non-inflammatory form of keratitis,
hot water fomentations of a temperature from ninety
to one hundred Fahrenheit are indicated, the object
being to create inflammatory reaction. The same treatment for the same object is serviceable in all forms of
corneal affections if the inflammatory appearance is lost
and resolution still doubtful.  These fomentations are
very potent agents for good, or, when indiscreetly
used, for evil, and their application should not therefore be intrusted to other than trustworthy attendants.
When a marked injection of the eye has been induced,
they should be temporarily discontinued.  Paracentesis
is sometimes resorted to as a relief from intra-ocular
pressure, to preserve the integrity of the cornea, and
sometimes for the evacuation of hypopion or interstitial matter.  Cocaine will often relieve pain.
Myotics must'be used with caution as tending to
ciliary irritation. Atropine is usually advisable.
SUPPURATING INTERSTITIAL KERATITIS.
This outline of a case of apparently total destruction
of the cornea from suppuration, as I at first considered




142            THE CORNEA AND SCLERA.
it, may be instructive as showing the value of paracentesis combined with the application of heat in certain
cases.
On June 7, 1879, Capt. B., aged sixty, master of a whaling
vessel, was brought directly from his ship to my office. IHe
had sailed some six weeks previously, with good sight, but off
the coast of South Carolina had been attacked with inflammation of the eyes, had gradually become blind, and was obliged
to bring his vessel back to port.  He was led to my house as a
blind man, but I found vision, left eye ten two-hundredths,
right eye entirely blind; he thought he could distinguish the
direction of a window in the sunlight, but failed to detect the
presence of a sheet of white paper moving before the affected
eye.
There was diffuse cloudiness of the whole cornea in the left
eye, but it was not sufficiently dense to completely hide the iris
and pupil.  The conjunctiva was moderately injected around
the corneal edge.  The right eye presented a very different aspect. There was deep, dark injection of the entire ocular conjunctiva with chemosis; the cornea was yellow and opaque; the
infiltration of pus between its layers was so marked a feature
that I looked for its disintegration very shortly. The patient
was assured that the left eye would probably be restored to fair
sight, but was told that the right was inevitably lost. I instilled
atropine into both, bandaged them, gave orders for a hot fomentation to each, of fifteen minutes three times a day. Gave him
quinine,?o- five grain doses, three times a day. The quinine was
suggested by his general health, which, although not specially
bad, was not up to his usual robust standard.
June 9.  Left eye better, cornea clearing a little.  The right
eve is not changed in appearance. He cannot see a white paper
moving before it.  Made a small opening into the anterior
chamber at the lower corneal margin with a Beer cataract-knife,
which I consider the best instrument for this purpose if used
cautiously.  There was a discharge of aqueous followed by




SUPPURATING INTERSTITIAL KERATITIS.    143
aqueous turbid from  pus, showing that hypopion probably
existed also, but undetected owing to the complete corneal
opacity.  Treatment continued.
June 11. Left, better.  Right can see a white paper before
the eye owing to a little clearing up of the cornea at its inferior
edge near the opening. Paracentesis again.
June 13.  Left, improving.  Right, about the same.  Paracentesis.
June 16.  Same.  But the chemosis, which had been lessening, is now more marked above the cornea, and there appears
to be a more dense infiltration of pus in that part of the cornea
near it.  Paracentesis.  Use the hot fomentations for fifteen
minutes only once a day.
June 18.  Right eye less chemosis.  Paracentesis.
June 20.  Right, again clearing up a little.  Paracentesis.
June 28.  Right, better.  Saw, near the eye, the large letter
C number 200.
June 30.  Right saw letters number 100 near the eye.
July 2. Improvement has ceased.  Fomentations twice a
day. Paracentesis.
July 5.  Right eye better again. Sees letters number 70.
July 10. Right sees letters numbered 30 near the eye.
July 14, 16.  Record is the same.  The patient left Boston
for his home a hundred miles away.  His left eye had so far
recovered that with D + 1.25 he could read print number 8
comfortably.
The distinction between a suppurative process in the
cornea and some forms of ulceration is by no means
clear, and the above case resembled somewhat the creeping ulceration of the cornea called the serpiginous ulcer.
In a case of this kind now I should make free use of a
wash of bi-chloride of mercury and probably use other
anti-septic measures.
Aconite, internally, is the remedy to  be employed




144           TIIE CORNEA AND SCLERA.
when the reaction is sufficient to warrant the application of cold to the eye, afterwards the remedies must be
chosen with reference to general condition of the patient, never neglecting the digestive functions and a
nutritious diet.  Pain is best controlled by cocaine
instillations and hot fomentations.  In cases due to
hereditary syphilis (diffuse corneitis) Norton advises
aurum internally.
ULCERATION OF THE CORNEA.
Corneal ulceration is nearly always an indication of
impaired health and weak vitality.  There is always
more or less congestion of the conjunctiva, and generally pain, lachrymation, and photophobia.
Strumous ulceration, not as the sequence of a vesicle,
deeper, and nearer the centre of the cornea, occurs in
scrofulous ophthalmia, beginning as an opaque speck.
The
Ulceration in ophthalmia neonatorum  is similar to
this in appearance. A grayish opacity, its centre nearly
transparent, the gray then giving place to a tinge of
yellow, and this, as resolution sets in, changed again to
gray.  A blood-vessel, or leach of vessels, may often be
seen to run from the sclerotic to the ulcer.
Transparent ulcer of the cornea is sometimes observed,
in which the vision of the patient, instead of being
clouded, suffers only from  the irregular refraction of
rays of light in passing through the uneven portion of
the cornea.  All objects appear distorted.  The above
are generally superficial ulcerations. Among the deepseated ulcerations, the




THE DANGER FROM ULCERATION.              145
Crescentic ulcer of the cornea, as described in the details of the case of gonorrhceal ophthalmia, is one of
the more common, while the
Sloughing ulcer, from suppurative corneitis in the
weak and ill-fed, and the analogous indolent ulcer seen
in the aged, frequently complicated by hypopium  and iritis,
called the creeping ulcer (ulcus
cornea serpens), probably of infectious origin, and sometimes
due to injury of the cornea, are
fortunately more rare in private         FIG 25
practice.   See Fig. 25, after
Nettleship. Both these forms are very dangerous. The
same may be said of a still more rare and fatal form,
the neuro-paralytic, due to paralysis of the fifth nerve.
THE DANGER.
The chief danger of ulceration lies in the tendency to
leave a more or less opaque scar or cicatrix in the corneal tissue, which, if it happen to be situated in or
near the centre of the pupillary area, renders vision
imperfect.  Another danger lies in the direction of a
perforation of the cornea, which may occasion a prolapse of the iris, resulting in adhesion between the iris
and cornea, displacing the pupil, or distorting it, and
perhaps engendering an iritis, or, if the perforation
happen to be small and central, causing a deposition of
matter on the surface of the lens capsule, or capsular
cataract.
10




146           THE CORNEA AND SCLERA.
TREATMENT OF CORNEAL ULCERATIONo
One of the most potent local measures for promoting
a speedy healing of a corneal ulcer is a protective bandage. It is just as essential that the exposed surface of
the cornea should be protected from the air, as that any
other portion of the body, under similar circumstances,
should be covered artificially.  The quicker a fresh
layer of epithelium  is formed to cover the denuded
nerve fibres, the sooner will the photophobia vanish.
Place a single thickness of fine muslin over the closed
eye, then fill the orbit, especially at the inner angle,
with fine charpie, or absorbent cotton, so that the band
of elastic flannel may press uniformly, but gently, upon
the whole eyeball, just sufficiently to prevent winking.
It has been found serviceable sometimes when an
ulcer threatens perforation to anticipate the rupture by
puncturing it with a fine needle.  The advantage of this
is that the opening made is very small and regular, the
aqueous humor flows off gently, and the iris, falling
against the opening, adheres over a very minute surface, and when the aqueous humor once more accumulates, it will be quite likely to be torn away uninjured,
and there will remain as a sequence of the disease but
a small corneal opacity.  Sometimes a perforation has
been prevented by a paracentesis of the cornea at its
edge, which relieves temporarily the intra-ocular pressure. In perforation it is of course advisable to prevent
the iris being involved, if possible, and to this end the
pupil should be kept widely dilated by atropine when
the ulcer is situated centrally. If the ulcer is towards




TREATMENT OF CORNEAL ULCERATION.    147
the margin of the cornea, eserine or pilocarpine may
be substituted, in order to contract the pupil as much
as possible, and draw its edge away from the seat of the
threatened breach; but eserine and pilocarpine are to
be used tentatively as they are often ill borne.
Pain and photophobia are to be relieved by removing
the bandage and using very hot water fomentations, or
by the instillation of a two or four per cent solution of
cocaine.  The diet, in cases of this kind, ought to be
as nutritious as the condition of the digestive organs
will permit.  Fresh meat should be prescribed, and the
child should be kept in the open air as much as possible.  No darkening of rooms should be permitted; on
the contrary the sun should be allowed free access to
the nursery, and welcomed as one of the best auxiliaries to the treatment.  The dread of light is of course
provided for by the bandage, which prevents access of all
light, as well as air, wind, dust, smoke, and all deleterious external influences. In some instances of chronic,
indolent ulcerations, heat, either dry or in the form of
hot fomentations, is found to hasten a cure admirably.
It is well to make the hot fomentations anti-septic by
the addition of the bi-chloride of mercury.  The examination of an ulcer on the cornea is much facilitated by
lateral illumination.  This gives us a correct idea of the
depth, extent, and progress of the ulcer.  When the
ulceration occurs in the course of a granular or purulent
ophthalmia, such applications as are necessary for the
cure of the diseased conjunctiva are to be made as previously directed, care being taken that no irritating
substance comes in contact with the cornea.




148           THE CORNEA AND SCLERA.
In certain indolent ulcerations a direct stimulating
or anti-septic or germicidal treatment has been found
useful in practical hands. The actual cautery or the
galvano-cautery is applied to the ulcer. Or the ulcer
is scraped and nitrate of silver applied.  Or the ulcer
is slit through its entire length with a Graefe cataract
knife (Saemisch operation), or an iridectomy is done.
But in spite of any and all treatment, deep-seated ulcerative processes in feeble constitutions often go on to fatal
results so far as sight is concerned.
The internal or general treatment in ulcerations of
the cornea must look to favorable hygienic conditions,
good feeding, and the constitutional dyscrasia. Mercury
and sulphide of calcium are accredited with a power of
limiting suppuration, and arsenic is of acknowledged
efficacy in debility and weakness.  Whatever our internal remedies may be, the promotion of the appetite,
digestion, and assimilation must not be lost sight of.
I have recently treated, in an adult, an ulcer of
the cornea, following an acute syphilitic affection of
the genitals.   The cure was speedy  and  complete
under biniodide of mercury internally, and the use
of the bandage and the instillation of atropine, as
auxiliaries.
STAPHYLOMA ANTERIOR.
Staphyloma of the cornea and iris sometimes occurs
as a sequel of perforation or sloughing of the cornea.
The iris falls against the opening, lymph is secreted and
a cicatricial tissue, something of the nature of opaque
cornea is formed.  Being weak and inelastic under




STAPHYLOMA ANTERIOR.                149
intra-ocular pressure, it bulges forward, and forms
a partial or total staphyloma of the cornea and iris.
The disease is to be treated surgically. The intra-ocular pressure is most certainly relieved by iridectomy
beneath that portion of the cornea which still retains
transparency, so that the operation may serve at once
the double purpose of improving sight and removing
pain and disease.  This presupposes the staphyloma to
be only partial.  When it is total, the bulging of the
eye is so considerable as to present an unsightly appearance; it is irritable, painful, and all sight inevitably
lost. In such cases the best thing to do, it has always
seemed to me, is to remove the eye.  Excision of the
staphyloma involves too great risks; but lately De
Wecker advises repeated punctures of the sclera in the
vicinity of the equator.
Conical cornea, a transparent bulging at the centre,
is most readily diagnosed by noting the difference in
the size of the image of the window on the two corneae,
or by viewing the eyes in profile. It may also be recognized by the ophthalmoscope.  By direct examination
we see a central red illuminated space, around this a
dark zone, and still outside of this a red ring of light.
The dark zone is occasioned by the complete reflection
and diffusion of the rays of light at the base of the central cone, where it joins the normal cornea through the
periphery of which the outer red ring of light is reflected.  One may also get an inverted image of the
fundus of the eye, as in myopia, in consequence of the
increased refractive power of the centre of the cornea.
The bulging is not due to intra-ocular pressure, for the




150          THE CORNEA AND SCLERA.
eyeball is softer rather than harder than in the normal
condition. It seems to be due rather to a thinning and
weakening of the corneal tissue.  The progress of the
disease is generally slow. The increased curvature of
the centre of the cornea renders the eye myopic, and
there is irregular astigmatism.  Concave, spherical, and
cylindrical lenses may afford measurable optical correction, and sometimes hyperbolic lenses are useful.
Surgical aid may be tried as a last resort and, when
there is opacity at the apex of cornea, there is less to
lose if an operation prove unsuccessful. Trephining,
or removing a portion of the corneal apex, and an iridectomy may be of more or less benefit.  Hirschberg
perforates the apex with the actual cautery, following
it later by an iridectomy.
Arcus senilis, a line of opacity extending partially or
entirely around the periphery of the cornea, caused by
fatty degeneration, requires no treatment, as it produces
no visual disturbance.
Opacities of the cornea, resulting from previous disease of its tissue when slight and recent or when dense,
the edges not sharply defined, and, in children, usually
disappear in course of time without treatment. After
all irritation of the eye has subsided it is possible that
the use of stimulating collyria may hasten this result.
A solution of two grains of sulphate of copper or zinc,
or five grains of alum each to the ounce of water may
be used once or twice daily. But I prefer usually the
stimulating effect of hot fomentations of water, used for
fifteen minutes or longer, night and morning. Whatever agent we may use to promote local reaction should




STAPHYLOMA ANTERIOR.               151
be changed from time to time as the eye becomes tolerant of it.  Internal treatment should look to the improvement of the general health, I think.  Calcaria,
cannabis, sulphur, and a multitude of other internal
remedies are accredited with having hastened the removal of these corneal opacities.
When an opacity is old, and has assumed a white,
pearly, glistening appearance, its margin well-defined,
and especially if in an adult, we shall fail in any attempt to remove it either by internal or external means.
We have then the resource of an artificial pupil, to be
made exactly behind such part of the cornea as retains
most of its normal transparency.
We may also resort to the operation of tattooing the
cornea.  The coloring matter, usually India ink, is
pricked into the cornea with a needle or delicate knife,
and not only hides the unsightly opacity, but may improve vision in some cases by lessening the diffusion of
light, just as the small aperture in stenopaic glasses,
and the pin-hole in a card, render vision more acute.
Nussbaum, of Munich, some years since, tried the
plan of removing the central'portion of an opaque cornea, and inserting a circular window of glass. It was
not successful; suppuration and expulsion of the glass
followed.  The operation of transplantation of cornea
has also failed.  It is always melancholy to be consulted by a patient, the interior of whose eyes is perfect,
and who could see, if only the foggy cornea could be
replaced by some transparent medium, and be obliged
to tell him that there is no hope left for sight.  It is
not unreasonable to believe, I think, that the future of




152           THE CORNEA AND SCLERA.
surgery will provide some remedy, more or less complete, for these unfortunates.
EPISCLERITIS.
Episcleritis begins in the form of a dusky-red circumscribed spot, beneath the conjunctiva in the episcleral
tissue or superficial tissue of the sclerotic, generally
near the edge of the cornea. As it progresses, the color
usually changes to a purplish hue, and there is more
or less bulging.  It causes a good deal of ciliary irritation and neuralgia, if it involves the edge of the cornea.
Otherwise, there is slight or no pain and little injection
of the conjunctiva. It is most common in adults, and
is then no doubt a rheumatic or gouty affection.  It is
of not unfrequent occurrence in the course of a scrofulous ophthalmia, and accompanied by a conjunctivitis
and some slight mucous discharge.  It must not in
these cases be confounded with a vesicular or phlyctenular ophthalmia.  No ulceration or excoriation ensues,
but the spot or nodule gradually pales away.
The immediate cause of the affection in adults is generally debility from overwork, or some depressing influence.  It is not difficult to relieve or cure, when the
patient can be thoroughly under control. Warm fomentations are always soothing, and atropine or cocaine,
when necessary, will quiet the ciliary neuralgia which
is apt to come on at night.  All use of the eyes is to
be prohibited, and a shade worn when in the open air.
Constitutional disturbances will generally indicate the
choice of internal remedies, otherwise I rely almost
wholly upon the protiodide of mercury, which has




SCLEROTICO-KERATITIS AND IRITIS.          153
seemed to be very serviceable.  An examination of the
urine will often suggest the internal treatment. Gentle massage, for a minute or two, through the closed
lids once or twice a day when the eye is not too sensitive is useful.
An unnatural bulging of the sclerotic often occurs as
the result of old choroiditis or irido-choroiditis. It is
not unusual in cases of glaucoma. It is situated commonly at the anterior part of the sclerotic behind the
ciliary region, and is called frequently anterior staphyloma in distinction to a posterior staphyloma of the
sclerotic seen in progressive myopia.  The disease is
not idiopathic, but supervenes upon inflammation of
some portions of the uveal tract, and presents no characteristic features except in the bulged and bluish appearance of the thinned sclerotic. The treatment will
be directed to the iris, choroid, or ciliary body.  If
there is increased tension of the eyeball, operative interference may be indicated.   Sclerotico-choroiditis
posterior is noticed under Myopia.
SCLEROTICO-KERATITIS AND IRITIS.
The bulging of the sclera anteriorly may also occur,
exceptionally, as a result of an inflammation in the
ciliary region which appears to include both cornea and
iris, as well as the sclera. The dusky purplish color,
already spoken of as characteristic of scleritis, may circumscribe the entire cornea, or not. There is generally
considerable pain and photophobia, and the affection is
persistent and often relapsing. The edge of the cornea
near that part of the ciliary region most affected be



154           THE CORNEA AND SCLERA.
comes cloudy or opaque. The treatment in these cases
must be similar to that already given for ordinary episcleritis, except that the use of atropine in the affected
eye is imperative on account of the iritis. The prognosis, on the whole, may be said to be favorable.




CHAPTER  VIII.
THE IRIS.
HYPERZEMIA OF THE IRIS
PRESENTS symptoms similar to those of simple iritis,
except that they are less marked, and the exudation is
absent.  It may be caused by over-exertion of the eyes
for near objects, and often indicates a congestion of the
deeper-seated structures of the eye.  It is frequently
noticed in scrofulous ophthalmia, and is not unfrequently one of the results of an injudicious use of caustics.  The treatment will depend upon its course, and
the nature of the associated affection.  Generally it
will require a treatment similar to that for iritis.
SIMPLE IRITIS, OR RHEUMATIC IRITIS.
The objective symptoms are injection of conjunctiva,
also sub-conjunctival injection, the rose-colored zone
around the cornea being well marked; generally there
is contraction of the pupil, and always sluggishness in
dilation and contraction, discoloration, - a blue iris becoming greenish, and a brown iris reddish-brown, - and
there may be observed frequently a plastic exudation at
the pupillary edge or on the surface of the iris. The
pupil is usually irregular in form, its lower edges adhering to the lens capsule behind it. In severe cases




156                   THE IRIS.
there is sometimes swelling of the lids, injection of the
conjunctiva, chemosis, and the posterior surface of the
cornea may be mottled by minute depositions of lymph.
The subjective symptoms are sometimes merely dimness
of vision and slight dread of light. At other times we
find them very severe; there is great pain in the eyeball, around the orbit, and in the temple, generally
worse at night, severe photophobia, and lachrymation.
Acute iritis is frequently accompanied by a diffuse retinitis, and sometimes by hyalitis. It is advisable, therefore, when the aqueous is sufficiently clear, to use the
ophthalmoscope to determine whether such complications exist.  Gonorrhoeal iritis, occurring during the
course of a gonorrhoea, is similar to the rheumatic, but,
unlike this variety, usually attacks both eyes at or
nearly at the same time.
SYPHILITIC IRITIS,
the symptoms of which correspond generally to those
above given, is a deep-seated form of inflammation, the
tissues of the iris becoming swollen and thickened. In
syphilitic iritis the exudation is usually copious, the
swollen tissues of the iris impede circulation, the vessels become congested, and tortuous veins appear on the
face of the iris.  Observation by lateral illumination
will be of help in noting the structural changes which
occur.  Little yellowish nodules may often be seen
about the edge of the pupil, the mischievous purpose of
which seems to be to stick the edge of the pupil firmly
to the capsule of the lens. The aqueous humor becomes
increased in bulk, and turbid from the admixture of pus




7
F2.    20.
This itltstration, from XNettlehlip, 8hows the apptearat.ac e  of the -lermaXlalent tseect
IT  IntstAlnees whore the enanel is  s'antim.g or ts  n:eriycrfct.   The uplper figure p}reselt-s
an ultinaily  a;.. exanmple.  Generally th.  defrectives enanrel   is ntoticed: only at the cedge
of thte tcisoars, a.s in-  tie'e:tmainintg  figures. tSuch teeth  are often  fountl  il dliftu.ao
keratfitis, Erous irltis, etc,




T1IiS  mItmS,
anld li.nmlph th rown out  by the iris.  The latter is somel
times compleltely covere( d by a thin veil of exudationt so
as to be, quite indistinct., andt the exutdatio on ay be so
extensive ast to settle at: the brottol of the anterior clhanber', Jtorntming a hypopiinm.  In ttis formnt of iritis lth(re
tare alsi frequently the tuhberculots nodules ont certain
porltions of the iris, reddish-yel ow\ in color, and wtli}ch
attt:ain often to c. ositderabl  size, and may even project
so far into ithe chamb.lt )er as to touch the posterior surface
of the cornea.. never saw these contdylotmatous nlodes
in a n onltl-syphlilit.ic case;  sucol inllst-ances ha.ve, ehowever,
}been. O   brvd    I  t ts81 tstal l  these  nodies d(etermine thel,natture of t(he case.  Still, in some instances, it is im1possible to r cognize a syphilit ic iritis )by the ilspection
of the eyve talone.
A 8 E RtOU  t I  I XTS
is a chronic affection  more coln)l mm lon  iln \womlen  tlhant
mcn, insiidious and less painfhil tlitln tthe plastic f,'ormts
of iriti  s..' cTh rc is increas(e  secretion of tlh a. iqucous
lthumor, Awhictl is turblid atnd de(.
/   14 ff             )sS~ts~s,.posits, small  secks of  lymph
9/1\ (                  Q> mt"pon tthe ptosteriort surfac:(tte of the
0'... ~:-.:..co(rnea; htence the affetction thas
been  called  kerattit;is -,.n.fetat:a.
It is'frequently associated with
Fjro, 27.
choroiditilt, a      cyclitis, a,and the
ptrognlos'is is not as favorable as ill moltst other ftorms
of ir itis.  Thcere is apt  to  hbe  a'n  increase  of tension, and tlherefor: e atropine may not always be used as
freely as would be desirable.  It is often, also, a cor



DIAGNOSIS OF IRITIS.              159
neo-iritis, and then the prognosis is less unfavorable.
See Fig. 27, from  Nettleship.
DIAGNOSIS OF IRITIS.
This is made comparatively easy by a careful observance of the objective symptoms already mentioned;
still, in certain cases, some of these are more or less
masked by the great injection of the conjunctiva, and
some may be absent.  Thus, the pinkish zone around
the edge of the cornea may be hidden from sight by the
vermilion redness of the congested conjunctiva.  In
such cases a general practitioner, I have observed, may
mistake the disease for a conjunctivitis, and this may
lead to the prescription of an astringent eye-wash, which
is always contra-indicated in an iritis, and always aggravates the severity of the affection.  Or it may lead
to the neglect of the use of atropine or some other mydriatic, a mistake too often deplored after an eye is lost.
But in these doubtful cases, if the physician will take
his patient near a window, and test the movement of the
pupils as directed at page 28, he will find a sluggish
movement of the iris, if iritis be present; but if the
movements of the pupil in contraction and expansion
are active and natural, he may be quite sure that he has
not an iritis. If in doubt still, he may drop a four-grain
solution of atropine into the eye and observe if the pupil
dilate evenly or irregularly. If the pupil is irregular in
form there are adhesions and iritis. When there are elements of uncertainty in the case, avoid all irritating applications, and then, at least, no harm will ensue. If it
is an iritis, it will develop unmistakably in a short time.




160                      TXI: E I;RIS.
fTHE CAUSE OF -It' nus
is frequen tly             r the exposure to changes of t Cemperature,
cold rain. Awi'l,   and like influences.'Th e sa-te (tcau.ses
\which t.end to develop a rheumattic atttack, often occasion it.'the pain often extends over the whole of one
sidef of tlb  headtd aCin:d facet, and the patient is apt to suffer
fromt  relatpses.  Jilt is frequently  of tlaumatic origin
(traumattic  iritis), and frtequently olf s:iphiltitic.  Most
tases of idiopathic iritis ill childreln are ptrobably of
syphtilitic origint, A. chrllntin c iritis, tholugh
not verv often seen apartl from  a choroi-:::.. ditis, may sutpervene upon an acute attack.,7The prognosis qf the disease when seen in
the beginn-ing8 fbefore... ext..tensive adh esions.
between the iris and cap:suloe of tle lens
have formed, is veryt favorable.  In unfa.,/;,    vortable cases the result may be motre or
ess extensive adhesion of iris to the anterior capsule of the lens.  When tlhe ad2- 8,s.  lhesion is complete 1around the edge of the
pupil, the usual channel of communicat:i o
between  the  posterior and  anterior chamlber of the
aqueous -is cut off and  the  iris bultges.  See Fig.
28.'Thl. e.Frenchl   call this condition  "Iris b:)oml:llnt
Without surgical interference stuch condition miglht end
in secondary glaucoma.  Partial adhesions are of less
import than was fornerly supposed.  I have under observation  a p)atient that:  was unintell itently treated
some t wenty  years ago;  adhesions nearly  complete;
pupil occluded by a membrane; there is no sigrht in




THE CAUSE OF IRITIS.               161
this eye, but it has never troubled her during all this
time, and the sight of the other eye is perfect.
The Treatment.
The treatment should, in the first place, look to the
prevention of these adhesions by the enlargement of
the pupil to the full extent by atropine.  This can
never be safely neglected.  For this purpose it should
be used of the strength of four grains to the ounce, and
be dropped into the eye at intervals of five minutes
three or four times, morning, noon, and night.  Less
frequent use than this will sometimes keep the iris
dilated to its maximum, but not always.  In mild cases
a drop or two once a day will often suffice.  Another
benefit of the use of atropine is that it gives the infamed muscular tissue of the iris perfect rest through
the complete paralyzation of the constrictor pupille.
When, as may sometimes be the case, the eye does
not bear the continued use of atropine well, an atropine
conjunctivitis, so called, being set up, an efficient substitute may be found in Duboisine.  Sometimes recent
adhesions have been broken up quickly by the alternate
use of a solution of atropine and calabar bean, thus producing extreme alternate dilation and contraction of the
pupil; but this should not be attempted if acute symptoms
are present, as the eserine would prove too irritating.
For internal medication I rely chiefly on aconite and
belladonna in the beginning; later, the cause, and the
condition of the patient must determine the treatment.
Pain must be relieved, and hot water fomentations supplemented by cocaine instillations will usually do this.
11




162                    THE IRIS.
Syphilitic cases will be benefited by mercury and such
other remedies as may be approved by the attending
physician.  Gouty and rheumatic patients must have
the constitutional remedies suited to such diatheses.
I have often given salicylate of soda in these cases,
and sometimes bryonia or colchicum; and I think the
hot fomentations several times a day after all pain is
gone are effectual in subduing the inflammation.  The
patient should be confined to the house and his room,
even if the attack be not severe.  The darkened room
will not be so necessary if atropine be used, still in all
cases it will be more agreeable to the patient to have
the bright yellow light moderated to a certain extent.
When necessary for the patient to go out, he should
wear a shade.  In chronic iritis, when adhesions are
left and irritation of the iris is kept up by them, a
strong mydriatic being of no avail in breaking them up,
the operation of Corelysis 1maxy be indicated.  After
ascertaining the exact position of the posterior synechiae by lateral illumination, a small incision is made
through the cornea with a needle, and a blunt hook -
called, from its form a spatula hook — is introduced,
and the adherent iris separated from  the lens.  The
great danger in this procedure, as indeed in all such
operations on the iris, lies in the difficulty of avoiding
the rupture or incision of the capsule of the lens.
The operation of Passavant, in which the iris is seized
by delicate forceps, and gently broken from its attachments, is preferred by some. Often an iridectomy will
prove  more  serviceable  than  either, especially  if
increased tension be present.




PROLAPSUS OF THE IRIS.              163
A chronic iritis, or irido-choroiditis, may sometimes
be mistaken, at first, for a glaucoma; the diagnosis is
corrected in such an event by testing the extent of the
field of vision. If glaucoma is present we shall generally find it limited. Choroido-iritis is an affection primarily of the choroid, the iris being involved secondarily.
The prognosis in the latter is more unfavorable; for
while in the former an obscurity of vision may be due
to a deposition of matter or pigment upon the capsule of
the lens, in the latter it is due to changes in the deeper
structures of the eye. The medical and hygienic treatment of these cases will be that of iritis and choroiditis.
PROLAPSUS OF THE IRIS
frequently occurs from perforation of the cornea from
ulceration or otherwise. If slight, we may succeed in
replacing it with a delicate probe, or, by enlarging the
pupil with atropine, it may be pulled away from the
gap. In any event the eye should be covered by a firm
compress bandage, to prevent increase of the protrusion.
If the prolapse is rather large and bulged outward
from the aqueous humor, it should be pricked with a
needle, causing it to shrink and dwindle away gradually.  It may sometimes be necessary, after pricking
it, to cut it off with scissors close to the cornea, to prevent its refilling.  It should never be touched with
caustic, according to the custom of some surgeons, as
it causes great irritation, and may set up an iritis,
and because under any circumstances it is quite an unnecessary risk to run.




164                    THE IRIS.
CYCLITIS.
Cvclitis, or irido-cyclitis, may arise from a severe
form  of iritis in which there is an irrepressible tendency to cell proliferation, so that the disease soon
reaches the ciliary bodies, or from injury of the eye.
The inflammation in the ciliary body, when not idiopathic, corresponds in character to the nature of the iritis from which it originates. It is recognized by the
tenderness of the eyeball to touch in the ciliary region,
and it is generally the occasion of a good deal of ciliary
neuralgia.  Its treatment in the main is that given for
iritis. It may arise also from the extension forward of
a choroiditis, and would then require the treatment
principally of a choroiditis.  It is always a serious
complication, and our prognosis should be guarded.  It
is noticed further under Sympathetic Ophthalmia.
ARTIFICIAL PUPIL.
The formation of an artificial pupil is indicated when
the natural one has become closed by disease, and also,
when, the pupil being normal or otherwise, the cornea
has become opaque to a certain extent, but
has still a transparent portion left.  Behind
this transparent bit of cornea exactly, the
new pupil must be made.  Or, if the cornea
be transparent over considerable of its surface, we enlarge or extend the natural pupil in a
direction which will render it most serviceable to the
patient. Other things being equal, the extension of a




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166                       ttl.1   IRS.
drawn tihough the wound, around   which a loopI of fine
silk has previously been placed.  7The portion of iris
drawn out is ligatured with the silk, and in the course
of a few  days sloughs off.  A  doublei iridodesisis  frequently performedl in opposite ditrections
\    whiclh gives a- narrow  slit for a, pupil like
tlat t olf ia cat   This is, the operation1 somletitmes do)ic for conical cornea.  When the
anterior cha.'lmber is vry naT trrow, thle'slender  cattaract t-kife otf (refe may be u1sed
inlstead of the lance-shaped keratolne, in
order to a void the risk otf   wounding the 
capsule of the lens.  The openilg is mad(te
alongltl  tihe ri-m of the anterior ch'lamber, as  I
inl the  flat  operation  for cataract, oMnly 
shorter,: Artifieial pupil by.inctsion simply, wifth 
a: broad needle,  such as K:nlt:app' s (ig. t32), 
tma.y  l'e prformed  ftor a  pupil centirely
closed,  when  tlher  is no lens, as after  I
cataract operation.  A.fter the punctureI,
ithet fibres ofr tthe iris, if it is tolerably 
healthy, w\ill retrtacit sufficiently to forlm a  I 
pupil; if not, a. bit; of tthe (ctt redge of tiher 3LV
1 ri-is my le: drtlawn out at  the smal at pert.1re
Fom. 32.       I.
in the]n. corna( and excised with the scissors.  A
much more ditlicult operation, thatt: of excisintt   a. trilangular piece of iris with delicate scissors(, is smtilmes
resorted to under simil ar  i rcumtsta ces.




MYDRIASIS.                   167
AFTER-TREATMENT IN THESE OPERATIONS
may be very simple.  A bit of linen is laid over the
closed lids, the orbit filled out with a little charpie,
or absorbent cotton, and a light bandage applied, and
for forty-eight hours aconite may be administered
hourly when the patient is awake.  It is rarely necessary to resort to the cold compress.
MYDRIASIS
signifies the condition of the pupil when abnormal
dilatation and more or less immobility are present.
It is a well-known symptom, when binocular, of grave
diseases of the brain. It is generally, however, of much
less serious import, and may follow a rheumatic attack
from exposure to cold or wet. It follows upon partial
or complete paralysis of the third nerve, and is often of
syphilitic origin.  A very common extra-ocular cause,
according to my experience, is irritation of the sympathetic, from disorder of the digestive organs, general
neurasthenia, spinal irritation, or, in children, helminthiasis.  Monocular, as well as binocular, it is often
owing to deep-seated diseases of the eye, which, by
diminishing the sensitiveness of the retina, impair the
reflex action upon the ciliary nerves which control the
pupil. It frequently follows injury of the eye.
Sometimes the cause cannot be discovered. I have
seen a case of dilatation of one pupil of five years
standing, in a woman of forty-five of apparently perfect
health, the eyes otherwise normal in  all respects.
The affection occasionally follows injury of the sphinc



168                    THE IRIS.
ter of the pupil from pressure of the lens in extraction.
A constant subjective symptom  is the impairment of
vision for near objects.
I cannot define any particular plan of treatment. It
must vary constantly according to the nature of the
exciting cause.  The affection is often a concomitant
of paralysis or disease of other parts of the eye, and
the treatment is spoken  of elsewhere.   Eserine  or
pilocarpine applied to the eye is generally of temporary benefit in restoring the size of the pupil, and
improving the vision for near objects; the same remedies are reported occasionally to have been of permanent benefit also.
ACTION OF ATROPINE AND DUBOISINE.
Atropine, to be used in the form of a solution of sulphate of atropile, which is exceedingly soluble in
water, acts on the iris probably by paralyzing the circular fibres.  The iris is extremely susceptible to its
influence, a solution in water of  I-o0-o  enlarging the
pupil, which it reaches by absorption through the cornea, with great certainty in the course of an hour or
two.  The disadvantage of a weak solution lies in its
feebleness in overcoming any adhesions between the
iris and capsule of the lens, and also in its uncertainty
of effect when the iris is diseased. For the enlargement of the pupil when the iris is healthy, a weak
solution, such as a grain to ten or twelve ounces, is
preferable, from the fact that its effect passes off in
the course of a day or two.  A  solution of a grain or
two to the ounce of water is often desirable on account




ACTION OF ATROPINE AND DUBOISINE.    169
of the promptness of its action, a half hour only being
required for its full effect. A solution of four grains
to the ounce will act still more promptly, and will also
paralyze the accommodation more or less completely;
the effect of such a solution on the pupil will not pass
wholly off for eight or ten days.  A  solution two or
three times this strength may be used in attempting to
break up old  adhesions between  the iris and  lens
capsule.  Very strong solutions, thirty to fifty grains,
are not to be commended, lest cerebral symptoms supervene.  A  long continued use of atropine renders the
eye intolerant of it, and in very rare instances it proves
too great an irritant to be used at all.  Homatropine
hydro-bromate acts similarly to atropine on the eye,
but more feebly, and its effects pass away in a day or
two.  It cannot be relied on to perfectly paralyze the
accommodation like atropine; still, used repeatedly,
in some cases it acts sufficiently forcibly, and is then
preferable to atropine as the eyes can be used so quickly
afterwards.
Gelsemine in the form  of a solution of the hvydrochlorate in water is less useful in ophthalmic practice.
Used in a solution of about four grains to the ounce
of water, it causes a maximum  dilatation of the pupil
in about an hour, or a little later.  For the purpose of
ophthalmoscopic  examination  this  alkaloid  is, like
homatropine, quite suitable, as its effects on the pupil
pass off in a day or two, while a mydriasis from  atropine may annoy a patient for a week or longer.  Gelsemium, used locally, also affects the ocular muscles.
Measured  by  prisms  the  internal  rectus  becomes




170                    THE IRIS.
stronger, the external weaker; the internal gaining
more than the external loses. Evidently the termination of the sixth nerve is specially affected. Given internally, it acts on this nerve, and in large doses also
upon the third nerve.  In poisonous doses externally
or internally, it paralyzes the ocular muscles.
Duboisine is, owing to its rapid action in enlarging
the pupil, often a convenient substitute for atropine.
Four grains to the ounce of water in solution will
enlarge the pupil ad maximum, in from  six to ten
minutes.  When atropine causes irritation, it is also
the best substitute, as its power over the pupil is more
than equally great. It also paralyzes the accommodation, like atropine, and its effects pass off more quickly.
COCAINE
also causes a temporary enlargement of the pupil,
and as it leaves the accommodation unaffected, acts
quickly, and as its effects on the pupil pass away
quickly, it is very suitable for dilating the pupil for
ophthalmoscopic examinations.  It contracts the superficial blood-vessels of the eye and causes a slight
retraction of the eyelids.
1MYOSIS,
signifying the abnormal contraction of the pupil, is
sometimes seen in iritis, and frequently in disease or
injury of the upper part of the spinal cord.  It has also
been observed in hyperaTsthesia of the retina, and in
persons who work at small objects, like watch-makers.
Idiopathic myosis is extremely rare.




MYOSIS.                     171
Eserine in the strength of one-eighth grain to one
grain to the ounce of water contracts the pupil, the
more quickly, the stronger the solution; but the strong
solution is quite irritating to the eye. It will overcome
the mydriasis of cocaine, but not of atropine. It causes
spasm  of accommodation and decreased tension of the
globe.
Pilocarptne acts on the eye in a manner similar to
that of eserine, and as it is less irritating, I use it
frequently in preference to the former.  It is inferior
in myotic power.
Miuscarine is reputed to cause an intense spasm  of
the ciliary muscle, and is also less irritating to the
conjunctiva than eserine.
Iridodonesis, tremulousness of the iris, is a certain
indication that the iris has lost the support of the lens,
as after extraction, in dislocation of the lens, or as in
hydrophthalmia, when the anterior chamber becomes
enlarged.
Cysts of the iris may be excised together with that
portion of the iris to which they are attached, by the
operation of iridectomy.
Irideremia, absence of the iris; coloboma, cleft iris;
corectopia, an eccentric position of the pupil; and polycoria, more than one pupil, -are congenital anomalies
rarely observed.




CHAPTER IX.
THE CHOROID AND VITREOUS.
HYPERBEMIA OF THE CHOROII)
is undoubtedli  of frequent occurrence, but is very
difficult to diagnose with the ophthalmoscope, as the
vessels of the choroid are, except in very light-complexioned persons, almost completely hidden by the pigment
layer of the retina.  Nor unless the iris and ciliary
bodies are also congested, does it seem possible to diagnose it without the ophthalmoscope.
CHOROIDITIS SIMPLEX, OR DISSEMINATE) CHOROIDITIS,
can hlardly  be diagnosed  with  certainty  without the
aid of the ophthalmoscope, as the otherwise noticeable
symptoms are common to other affections.  There is
usually some dilatation and sluggishness of the pupil,
some failure of sight, irregular obscuration of the field
of vision, so that perhaps but parts of objects are seen
at once, and usually little or no pain.  Sometimes the
external appearance of the eve is quite normal.  The
Ophthtalmoscopic signs are general cloudiness of the
choroid or vitreous, but oftener we see small yellowwhite patches of lymph, first at the periphery, aftervwards about the macula lutea and optic disc, and later,
if atrophy of the choroid occurs, the white sclerotic will




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174          THE ClHORO1) AND) VITREOUS.
Pt/he prognzosis must of course he gtuarded, owig to t the
tendency to complication tand atroplhy of the retina and
optic nerve.  Sometimes, howeve-r, the exudaltions are
absorbed, leaving  but faint traces of their existence
behind, and sight is tquite restored.
ia)rtal  chrooditis),  a steadily dtcreasing visua:l I owcr
in  idcerly people witih normal field of visioll points to
at circuntlsribed p)atch of choroidal' infilammation bleneathl
the macula lutea.  1The ophtlltalluoscope shows a yellowFi'. 36
ish, i: rregtularly  sha. ped spot with pigxntent:ed outlines,
and there is lno t-ttendellnc towards spreading. There is no
dangc r of total blindness. x Figs. 8*6 and 37.  Aetanorphopsiia, that is, distortion in the appearance of objects,
is observed, and of course ttere is a central scotoma.
See page 226.
Allied t t h is form  of choroiditis is the Am-etropit
rettz-ah/aroai{titi  described  by  (Gould.   It occurs in
A. of Oph,, vol. xix. No. 1,




(MCIIt(O )m.t.f'1  SIM1.|  IPLEXt.        17T5
younig  people, atrl id s  (ui  to:o  eve sta:iai  in  amnletro-'ii1a, ciefly ht permet iroei astigmatismt.'ihtA ItaLCula r
rgionll is slightly  pigmented.  TIhe'  lesion  is retinal.,
T1le treattititult is to cor'red  the aiitet ropia bIy prolfperi
@lasses,
t'ie     atte2menate at' Chorloiditis Simplext:
mustt II tbe gonv terined to tt great extent by the state: of our
patientls hicalth otherwise, tand the catuse of the disease.
Fita. 37.
T'Iisi is f(requentlv syphilis.  General ll  it will be found
that tie  liver, dtilstivt' otrganst, or the uterus aret    dtisordetred.   All these  cirllulltanees will inltlence  our
tr eatm eunt.   A t a ll e vents, the patilent should  abstaint
fl*1rom>  tlhe  utse o-f tthlet eyes in  readinl  or sewtig, and
guardl them  a(ainst bright light out of doors b  wea\            r
ing dairk     glasses. 
In old eases of irido-ehoroidithis fth  operation oft iri



176         THE CHOROID AND VITREOUS.
dectomy will frequently be indicated for the purpose
of breaking the adhesions between the lens capsule and
iris, as well as for the purpose perhaps of laying a
pupil before a transparent portion of the capsule. The
operation is, under these circumstances, beset with difficulties from  the narrowness of the anterior chamber
and the degenerated rotten condition of the iris.  If the
lens is wounded in the attempt, it must be extracted.
SUPPURATIVE CHOROIDITIS,
called also panophthalmitis, or ophthalmitis, is a very
grave disease and its course often rapid. The eyelids
are usually red, swollen, and  edematous, the chemosis
very great, so that the eye appears swollen.  The iris
is bulged forward, and discolored; the eyeball sensitive
to touch, the tension increased; and we notice, if the
pupil is sufficiently clear, a yellow reflex from  behind
the lens, due to a purulent infiltration of the vitreous.
Sometimes the pain in the eye and the region about it
is of the most intense nature, at other times less severe.
Sight is, of course, rapidly and greatly impaired, and
frequently all sensation of light disappears.
The causes are suppurative inflammation of the iris
and cornea in bad subjects, typhus, typhoid, py.emia,
injuries of eye, surgical operations, or sympathetic
ophthalmia.  Certain cases occurring with exhausting
diseases have recently been proved to be due to the
presence of streptococci in capillary vessels of the retina
(vide Ophthal. Review, Vol. IX., April, 1890).




OPHTHALMITIS.                 177
The Treatment of Ophthalmitis
in the commencement should consist of ice-water compresses and the internal use of aconite.  It may be
necessary afterwards, if hot fomentations and the administration of the indicated remedies do not relieve
the severe pain, to resort to the subcutaneous injection
of morphia in the temple, or the paracentesis of the
cornea. If the febrile symptoms will permit, the patient should be allowed a most nourishing diet, and
perhaps a tolerably free use of stimulants.  It is, of
course, often impossible to save the sight of the eye,
and indeed frequently any part of the eyeball, in these
cases, and sometimes life itself is endangered through
the extension of the disease to the meninges of the
brain.  When the disease is foreseen, and before the
suppuration has become general, enucleation of the ball
is probably the best course to pursue.  Recently the
operation has been frequently performed, under strict
anti-septic precautions during the suppurative stage,
and no harm  to the brain has ensued.  Noyes relates
a remarkable recovery under free incisions and antiseptic applications, after enucleation and threatening
meningitis. Diseases of Eye, page 501.
Metastatic choroiditis sometimes follows a meningitis
in young children, and leads to blindness and atrophy
of the globe.
Serous choroiditis is usually associated with a serous
iritis or irido-cyclitis, and would requile similar treatment.  See pages 158, 316
12




178          THE CHOROID AND VITREOUS.
Tubercular choroiditis, connected with a similar disease of the brain, is a very rare form  of disease.
Miliarv tuberculosis of the choroid associated with
similar infiltrations in other organs, is more frequently
seen.  The vision is generally normal.
Tumors, ossifications, carcinoma, and sarcoma are
met with in the choroid  occasionally, but they  are
comparatively rare.
HYALITIS,
or inflammation  of the vitreous humor, though usually an accompaniment of disease of other structures
of the eyeball, may possibly occur idiopathically.  In
simple hyalitis we notice, with the ophthalmoscope,
that the whole vitreous is clouded so that the details
of the fundus are indistinct, while floating about in it
are discovered  delicate  shreds of various sizes and
shapes.  Generally with this form of hyalitis there coexists a retinitis, choroiditis, or cyclitis.
A.supp',rative hyalitis supervenes upon suppurative
iritis or irido-choroiditis, and occurs after cataract operations and injuries of the eye, and is sometimes the
beginning of an ophthalmitis which destroys the entire globe.  The treatment of hyalitis must have reference to the primary seat of the disease, which is in
the choroid or retina.  I have never met with it in its
idiopathic form.  The prognosis is not good.
Opacities of the vitreous are frequently due to remains
of effusions of blood or lymph, degenerated, fatty, or pigmented cells, membranous debris of varied form  and
size.  These opacities may be seen best with the oph



OPACITIES OF THE VITREOUS.             179
thalmoscope in the upright image.  Let the patient
turn his eve in different directions in quick succession
and the opacities will be noticed moving slowly about
across the pupillary field. Such opacities must not be
confounded with the condition called muse volitantes,
usually a subjunctive symptom of less import.
Muscle volitantes are either transparent or opaque,
and are best seen by looking towards a white surface.
They are probably caused in most cases by over-use of
the eyes or by impaired general health, and consist of
the debris of cells, shreds of tissue or fibre floating
about in the vitreous, and slowly changing their position with every movement of the eye.  They appear
transparent and bead-like, or in other cases shred-like
or as dark, queer-shaped bodies.  Rest of the eyes
should be enjoined, the general health attended to, and,
if very troublesome, colored glasses may be worn which
will render them less apparent. They are more common
in myopic eyes.
The Treatment of Opacities of the Vitreous
must be directed to the removal of the cause, which
will generally be found to be an irido-choroiditis, or choroido-iritis, or some affection of the deeper structures
of the fundus.  Occasionally fixed opacities of the vitreous have been torn through with a fine needle, and the
visual powers of the patient improved by the operation.
Synchysis is the name for a fluid condition of the
vitreous, in which its gelatinous consistency is lost.
It is difficult to diagnose with certainty in all cases.
The free movement of opacities presupposes it, and




180         THE CHOROID AND VITREOUS.
when vitreous is lost from a wound or during an operation for cataract, we know that its loss is made good by
a fluid or serous substance.  Sparkling synchysis expresses a state of fluid vitreous holding crystals of
cholesterine, which present a very striking and characteristic appearance under the ophthalmoscope. Their
origin or mode of production is undetermined.
CYSTICERCI IN THE EYE.
Von Graefe had in eighty thousand patients eighty
cases of cysticerci in the vitreous or retina: three cases
in which it was in the anterior chamber; beneath the
conjunctiva, five; and in the lens and orbit, one each.
The result, when the cysticercus is deep seated, is the
loss of the eye from inflammation, and degeneration of
the choroid and vitreous.  Von Graefe occasionally
succeeded in saving the eye through the extraction of
the parasite, but the operation is very difficult when the
animal is seated behind the lens.  Alfred Graefe has
operated successfully in twenty cases out of forty-five.
The original seat of the cysticercus is usually beneath
the retina, where it may be seen with the ophthalmoscope as a grayish-blue vesicle, whence it emerges later
into the vitreous. The affection is rare in this country;
I have seen but one case in Boston.




CHAPTER X.
GLAUCOMA.
THIS is one of the most dangerous of all the diseases
to which the eye is subject, and, without timely surgical interference, generally terminates in blindness, and,
later, in complete degeneration of all the tissues of the
eye. It is not a new disease, but up to the time of the
invention of the ophthalmoscope it was not much understood.   No remedies, surgical or other, having
proved of much avail, it was quite natural that an almost uniformly fatal disease, of which very little in
regard to its nature was known, should receive less attention than others better understood, and which permitted of satisfactory alleviation or cure.  In 1854,
Ed. von Jaeger, soon followed by Von Graefe, gave
accurate descriptions of the morbid changes in the
fundus occurring in the course of the affection which
drew attention to the disease, the interest in which was
widely and quickly spread over Europe when Von Graefe,
in 1856, discovered a successful surgical remedy for it
in the operation of iridectomy.   Perhaps the most
convenient and practical way in considering the disease is, to divide it into three forms, -the acute, subacute, and chronic.




182                       G. At (JMA.
T' HI E    IitMO:  t O N' SYMPTT t: i'i X' 0 315 -'t() 3IS
of actite  gltaucottc:m    a Pre  uisually,   ftirst  i-t or(er, a   il(treased  tetion (hardness) of the eyeball.  This is ito
te dctclied(l b  thI lou}d   a tS.ur'eviontslyv (dcsert(iid.' lIt 
sltbjtetitvde.   sy')toni o) f   tlness aid  swelling, so oftel
felt in eonnjtltivitis, i tiriti,  or sclt.riteis, is not to be
mistiken tfo) illncreased tensionII of fle bal t whi     h indllicat;:et( es'11w   approach{)tlI  of atn  (acute tt attalck  of glaftucon)t.
With  this te-1:.sion.:  co(m.W  its  itst lre. tit l:ateR frutits,  pe
ri(odii: dimne i ss of visiol  stuclh a s onle 1may pfl'ro(uco by
prjessurt e of the finger ttupontl th:e ntormalt eye, lasting for'
a few  mometrnts 0or lours, and a rlapid development: of
iiany Il,'vioutslxy exist'ing presb'tyolia.  Thle pupfil is somewha}t, blut not; greatly, dilatedt; etand as a seiquel of thtis,
the pati ent noticet-s a h4 lo 01o rlainlbow ar.1ound the flanme
of,a crandleI. 1he ri ng  around the light is at its outter
side rled   its in:mer, } ttIish-gtreen.       iTh   mat   e m) or
1' less cilibarvy neutlralgliat over the eye, in. tthe forlehetad,
temple, and fatce; but in. Lmy cx pe riic:i'e,  ti s sy-lmpt(oln
at th is time is lnot commru.      T1  above:t lrt onitor
symnl)ptlom:s 1ar  those obstervabtle withoutl the use of t-he
opltthalm ntos(;f)ope:', and  may oc'. cur merely at intervals of
months; but, graduallg y'the intervals sh orten,   and only
weeks or dIavs: is tervene )bet.wetn tilhe reculrretnce olf the
synmptomst, and the next stage of t fhe (disease,   confirmed
glatucomt.,ti   mai t:t)e lo()oked for.
eI rc:'eaft:er, tho  tgh  t here are to be pelrhaps pe riodic
exatert)bationrs, ithere may  n1o.t be., )    in t:h   pmn]:l()itor-:y stage, any pe':tiect itermi s  sions..   The pa:tient   m ay
be 8suddenl v seized wifth  a terriile neu'algia ove'r the




Ti'J   Pit  MONI' t)iY SYMPT )M$               183.
eye, in the forihclead, templell,,  lace,  d(owl  tmhel side  of
th se nose,  with  severe  constitutional  S\'nptonls, }tigh
fever,  ailsea, aind even vomiting; s, that the: affiection
may  be  mtistatken for severe hiilious or ti)hoid fever.
In. one catse, I ftoutnd the disease h}ad Ibeen diatgnosed as
an. infitlann atit)o     a ffeetio) 0)f tie lra in.  An exa(ni na-:ion  of the  eye, ho.wevert, wvill torrtee  t}he d.tliagn.osi s.
l'Te lids will t  e ft oni:td pit tidy  nttd  sxvwfolle, ath.e (oinjlt.it:tiva itjetccid, tIlere is ehemnosiis,.1,0orce oP, less cl t   di ness
of thle aqueous liilltl'r, tist.eolorat ion (    of)   the iris whl'ii):ppe)ars  }tit':ged f(:,r-war'd ailn(.)ist: agtain(st tthe corne:?a, dilaitaltim  ) of the plp il, t:)an  dec{ided t.enlsion  of thOe evbt all.
Viton is  always  g'reatly  inpaired. /I hl:ave  never
known it- wltl       l ost: at: this stagc, al  though l   t:his lias
not  hilrtqi'f tei'ly  lappenlted..P atii.nts  will gent:rally
see a hanld held very near ihte I  eye, or be atitle  t:1) tdistIingulislt  tthe   lar1 fge gilt. lettetrs onl the  1bac:lk oft a book.'l'he]y  are  also disposed to( spe-ak of sudden flashes of
light btelfore the eyes, and p)terhaps o(i:t ter slct rt ral pthe. -
tnontena.  {Thest,   wit It sotunt  ph:otioplhoia:4 and lac1 hrytmaion), alnid  more or  (less a ti'steltsia. (of the cornea are
the  ltmar.kedt syilptomnls   t observ'ved  in  thle  tegintnirn:   (o-f
(1con1 irmI   d gI l a u1o.ma
As tle acute. at tah(ck ptasses a way, the sight will gfrow
tbctt cr, and perhapts very much b}elt: tr, }hut'the atppearat.e1t olf tie eye  with tta mll:odific hatioln'of' the severe in(:Iantlmait(ry  astpectI  remainis,    Ti4' a'I,(ttt:a:ks  r'ecur, the,
sig    ting lt   i  tla fr tet'.eacht in a.  worse condit-ion.'(lte:tensi.on ofT the  tvte increases, teli   iris shlriv'els, the a:nte.ri:o  chamnT:ril)' becomes still narirower,  t-li: stlb-cinjulictival veins appear l    urlbid td t ort uous, the ield of vision




184                      GIAUCOMA.
becomes greatly contracted, thl        senxsibility of lte cornea
diminished, the so-called  green reflex  is marked.  I
say so-called  green  reflex, because the reflex, to my
eye, is more slate-colored.  No doubt); it is sometimsl
giee-nishe, but if on1 looks for a decided  green  rcflex,
sullh as is frequently noticed  in the eye of a cat, hle
will b1   diisaptpointed.  The diminished  sensibiSlitv of
tile cornea(  may )be detcerined by toulchingt' it: with a
hbit of paper twisted to a   ointt.,
TIi1  0t) t)' i -TiALMOSCOP10  I(:W.? S~ YMPTOMS I'(  
in the premonitlor\' st:ag  are witoll absent,, or, at most,
frequncciitly of merely negative valIlc, from  cloud i ness
)of the ct'orneatt.  In the sta(g   of contir>t nled glauctatl
~:there icay.' be m  (ore or( less e(xcavat:ion of the optic distc,
dilati(a, iand tit rgefmscenct(t at a t(ort)'itsity vf t;the ret iltal
veins,  antdt vetnous puls atit n.  At a later stage of the
disease we imayt find tlie artt:eies thin atld pale(, arttrial
tpu'lsat iion, llhmorrthavge int(o a.d t'encral cloudiness ofi
the vii lre  ous,.  Thl la rge l e exca vat i(on of the optic nerve
ldiff ers lfromn t. e physiotlogical an d  a.al l     urot ic excava(tiollns, in size,  depthl, and in the ai}b rupt)t ess of its cttge,
in co)nseqt::ici tlte  tf v)twhich the ref tinal a vessels, in curlitng.t',over ttle tmagin   at  the:)order of  he l1 di sc,  are much
dtisplacted.   (ioiattare l'  igs. 88   and  39, on  the next
)pag,'(  he:althy opftic discs, with thlose of Figs,  40 and 41,.IFt'tiieueintly, however, the imttedia in glaucomna are so t.'rbid thflat nothing'whatever elcan I)e seen with the ophtht:almo()sope.  Fortu nately, whlen tlhis is tfhe case, the o;ther.
symlptomtt s are so ctha ractristic that no etrror in diagno".
sis need occur. The field of vision is usually contracted




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18~                        GLAUCOM A.
tag'e of tlie acute  formt  wlheI the exaeerbations lhavin
di lniish ed swomewlhat il iiltensit-i, the ilalammationt is
Fis. 40.
fixed and gradually l     rogressive, and the sight gradually  failing.
(.It oni f on-ifammat:(.r/ / /laucoma, asom.etit es c.alIled
glaucoma. simplex, is very ilnsildious in its courxse, and of
I(I   C III                 I.
FtI-. 41.
ralre: (.cc  l'rre'llt'e x'}:)1l':re'd1 to 10t:llerl' fom o: f the affietioll,
Itt has not; very  unfrelque.nt ly  haltppened  thatt pat-ients
Ihave been(.tii nitawarvIe of thll  existenl(e of this disease in
onle eye, the other  )("eilnlg well, until it a1ts tompi)letely




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188                     GLAUCOMA.,
lttaucomSfilmnanstttm s     l( is thel name formnerly given by
\Von Gmr ef: to a very 1rare form  of glaucoma:, the most
datngerous of all, il which the rdiesses progrcsses with
such fearful rapidity that the sight of a, p)reviously
sountd eCye mayC be wholly destroyed in a~ few hours, or
even, it is statCd, in half an hotur.
Absol-ute gltaulcoma, as tthe di tseiase is termed when all
perception of light has disap)pearctd, is frequently distinguisthed at at glance  by a pale-greenisl opacity of the
lens.  A.t this stage of the affection the patient may
suftter from  severe att:acks of ciliary neulrarlgia. Ltater,
the  iris  })comt:oes completely  atrophied,  tilhe  cornea
opaque tt and softe( ed, the choroid  and  retina  degencraite(i, antld ttthemor~lthagic efftsiont t:akes place within
t:he fllutdus, stalphv)lt oma of  it'he sclerotic, anld frequently
inlanmlatlion and att':rophy  iof the gl)obe:( follow.
THEX CA.Utl' OF (0.FGLAUC(OMAI.
is not yet:ftlly dlenost rated. l.There tis, first, anu affection of the iris,  cilia1ry bodytN, antd the clhoroid; tthen,
an increase of the. humort s of the ee, v an   ilnreas(e
tension  andt  xca( vat:i.(on of  the optic tlnerve; then, the
cornea, sleWrotic, tand  retina  become invol.ved.  The
space of Ponta. tna is obliteratetd and there are adthesions
between the perilphery of the iris and the corneta.  Comrn
pare Figs. 43, 44, aft:er Nettleship.  the fact that the
sclerotic in this disease is found rigid antld unyielding
is sutpplosed to be of importance; for the disease attacks
generally o        nly those of an age above thirty-flve or forty,
itn whom the sclerotic coat has already attained a tfirness and rigid ity unknown in youth.  An interesting




THtiE CAUSE OF GLAUCOMIA.                                    189
and perhaps rational theory is that which  attributes
the hyper-sccretion of the fluids of the eye to some abnormal irritation of the   ervces controlling these secreFi. 4,3..~etion through the ciliary regio n in a healthy human eye. Co, Cornea; Scl. Scle.
rotic; (1. At Cliary Muscle; C( P. two i lary proc<-cses one larger than the othet;.r,
Iris; t, tie nmarginal part of the erystallinte lenss, angle of anterior chamber; 4, mem*
brane of  et:scemnet, which tease.s (as sueh)  lwfo e re  aching the  angle ct. The doteted
line shows tVhe course probably taken by Ithid  from the auterior part of the vitre.
ots into tthe posterior aqueous clamhcr, whe r e i   i   a gmenited by aineous htinor
seAreted by the anterior imart of the euliry pr roce, the nce t hrough the pupilt (not shown)
into the anterior aquejous chamber t  tthe angle.tt. Suspensory ligament of leins not
shown. x 10.
ti.ms, this itrritationl  beini't'refltex  frotm    tie  sympnathetic...Thias hypot hesis mak              L( l. th t increase of fluids thfl         essenet
of the. disease, and  the lc(lMsequent  t:ensio    of t'he  globe
*::: - - 0 f...-. -...:.:..::.,,?,?o.1X.t.
F.m. 14.
Cii i   fa   r,:egion in a c ase of clhonic gilaucoma of thre ye ars' standing.  Notice the
ah.esion of irs intd cornlea at thte ang*tl  of the anterfor eitan er.'
the    caus           e      o f the ni a. ila atorv   syml}:)tois, l.The   iuterir'  tissues  of I1he, e             i become   i rr titate d  anlId   inflam  ed
from   thils  mee,   l              ical pr.esatlure,  and lfi ally  degenerate




1.) 90                               G(LA UCOl MA.
ftrorl.tis'ets     a d   lackl  t   oi. nutt;   t:iot n,    Nat.aut son  records
t; \g   t     i l -f3 tl t:E~ t   ut  ct 8t~f (A  i c  II C  o tI   8    I f  )N\ Tll II   S.l1i t  Cv t 1:t1 I 
tIwenty-eight cases of glaucoia   llowing senile cataract
ext m'rct ionl
r/eai tue.-  it..t is  dou:tli  lt   it' any    m asurt       s     ottit  r  ttha     slurgical are
of  Ip:o sitivc   v alu   c   inl  tihe tttI      tt itcitt  t    f   gla   co ailnt       but
whetn  wi.   re l. ct  theatlt      itt   a  g'reat  mlaj r ity  ofl ceases  thcre
ole.x i st e.lio.ls         c nstiit-utio  1al   iiist  tlances,.   sutch   ast
gtolt.  rIeoltt'ltI:nat:istt,    u ttlltiot         t' nal'or  (the. r  (t iscase'   of  ( til
dli.gevcst ive  orga t s,  lienIm rrlitioids,..........     and,  iln  femaltt es,  that
th.. afft-enct. io        15 apt tlo  occ rl'  at  thOt, pe.riotdi   of c1 essalt:i (.nt
t       mllettsl. r -ttai on,  it  sc(len.s a'l ostI il mt         oss.i ble  th.i  avoid
50 4\t41-:f..      iIttIa    1czlttti  lt  i.  (.)  "it fftrl-   X
ti'le clile ti  sio  tt I     {s-}i a t'   tiItthe  affectt iont    is   oiftlen    pri ttnait l
ext r a-cait: t I  a  ir         tlta sfrlt.  at  thie an {lit st    st tae, at t artefli, intellig enti, me:d ica   I I reatmln et, cmbliiintaed    v it   strict 
tyt ien ic   regC   lati t i      si, i  tl IIt hi l it roxVe ci lrativ t i   in   ce l s  rt in\t
cas es.       In  e t. imst 1ih ti tlt: > e   effec. ti t (if tied:t ii t i(t'  i t   it oweve, i  
wett    st:s        t t.tovirlt c   k   thl e   cir,   ei., sta c tc IIt tItat  aln t acuttec
attacklt     i   th: e Car tliest   stiage  naiax  re t:eate          y 1 itipass fl(t:  lteaving I-'tfi   sight t     ntlt l pair, t.'t'   N  dt     bit.)'    r  I   me{:t lll dies t mtl:
friove{  secrviieeafile  in   rcliie vilnt   or  si ot'enI ingti l'he  iuf.lrati)ot  of at  n  atttifackf       ttit  to  he  cit. rativ e, thex\y  mlst  prIeveit. t:It
its  re    rrt. ( t  (., Ic.I just  as  the  ofle t attio      ot1   i trid I    t (m       w   he'
st(icci ssf'ttl'{.l itprevets  i.ts   rec.rence.1't('.t   tn    er t. o    }ft'
ren.ldics'lis tl"e  t Iest poissibll ct han(ce  of  pr't vin'i.tg   of  pe} rln'anel-it'lenef it 1.:,   t:lti  slo, Iltt   {,'    t       t  mi   isi. t. ctre    a lst    du1 crini t
the:  pi   ioi t       (otf iit ttcrnissiotn,     W\\   (}lt c+ tt {V tI b    sureIt      that
i he  t''recatm:ien tt is  prox vintl   ofi' rtea l  service   wht en   we  tfi lI
t:hat   it'reduces   thie   lardness /:   ft?  q/oh. e.  ff                        atever
ill rweiduce t fll  tensio    of the                            I'I ii     a laia'     tiill




THE CAUSE OF GLAUCOMA.                191
cure or at least relieve it.  It is said that a number of
cases have been thus benefited, through relief of tension, by the use of eserine as a collyrium.  Eserine
should certainly be tried in the early stage of the disease, although I should myself never postpone an operation for this purpose, if it were clearly indicated. Some
surgeons prefer pilocarpine to eserine, in glaucoma.
The habits of our patients should be scrupulously
looked after.  Of course a moderate use only of the
eyes should be allowed, — bright lights and crowded
places are to be avoided; sunlight to be modified and
deprived of its piercing yellow rays by the use of colored glasses when in the open air, especially to be used
to protect the eyes from  the sunlight upon the snow,
white sand, or water.  In addition to this, all habits
which affect the general health unfavorably, — such as
the excessive use of tobacco, alcohol, or other stimulants, - all dissipations and exhaustive labor, mental or physical, should be strictly prohibited under
penalty of loss of sight.
The diet should be attended to, any idiosyncrasies of
the patient in this respect ferreted out, and indigestible articles forbidden.  The diet, however, should be
good and nutritious, and, particularly in elderly persons, the confirmed habit of indulgence in stimulants
like tobacco, alcohol, tea, and coffee should not be interfered with, unless it be necessary to substitute moderation for excess.
Internal medical treatment cannot be relied on exclusively in the treatment of glaucoma.  Doubtless it
may be of more or less service in many rheumatic or




192                     GOAtJCOMA.
arthritic patients and in cases complicated by hepatic,
hemorrhoidal, or uterine and other affections.  Such
complications will suggest the remedies better thanl
thev can  b:e suggested herle  in a general way  when
indicated by symptoms apparently only remotely conlected with the disease of the eye.
A serious obstacle to the success of any and all treatment lies in the fact  thpat patients rarely consult a. p)hysician until the dtisease is confirml ed, and too great tissuechanl,:,ges tha've occturledt.  Matny p)atients sent to mle are
suchl as have been tconmptletey Ib li nd for moInth, and sometimes years.  In c'ases of com.plete bli)tdness, an o)peratim  is isindicated simplyt for the relief of a tormelntlingl
nutralst ia overt the e.  No  restoration  of sight, is
possible.  (Only now and then dtoes a c:ase prtsentl itself
at thie moist favonrable time for, a: sulfccessflll operation.
If we -  inqui re into the cautset of the delay, we lind th"t:u
no attentlion what-ever was paid to t    e the (arly symiptoms;
t-}  attack         tlwas veg rl cd  ts ra  het.adach -te, 3rheumat:is
from  a ctold, a  ucral(gia in the head, or s0ome ailmentlt
not immcediately conncti ed with t he eves, and no advice
Ias sou"I'0htfl untiil?.... aft.er. the advent of a terrible aitack
of acutec intfammat iolt, or' tint il the siight wias found
p1)ter<a1t enti y   i mtpa i red, a ii(n spectacles of no s ervice.
It is very dili toult to Ir elieve th e svere cit   iary neuralgia'which occu ri     os to iof  t inlt ait    a tt acks, except bys
sural r:gical t e cii. c    Aa ieridectomy, and f1t     i requent:ly
a simple paracentesis of the ant('rior c.lhamber  wvill
oft:tn telievt\ the.pailn as if by magtict..i-visio n of thlt
ci iliary v musc:le will also reliceve the pain, atd,, li kei tle
others, atccomplishes its resul.t t Ib  removing the i tr*a



TH1E] CAUSE OF G.LAUC)OMA.                193
oculatr fpressur      At(ropine  can niever  be use.   d  withl
safety, and Cvcn cocaine l as been known to induce a
glaucomlatons attack.  Warml  fomentationtt         of simptl
water or warm  wateir medicated with clhamonmilla, or
op.imnu, Ilay  be otf 1some service.
sStturqieal Treatment..irigdecto-my/  iin the early stages of acute glaucomna is
frequently     a cure for it..  In the  later stages, it is
tnarly alwayst  a palliative, and sometimes a ctre.'ptt
ol:'(r(atdion is painful,  and usually\ perftormnled l dter the
influencet of a genelral anmesthetic'  or possibly it mal
b})i done  ttder cocaic,  i itt i   patient is not t iiid or
rest:less.  I.t is similartt   t.o ite opteration  for artificiial
ipupil alreadt   dtescribed at Ipag  1.(65, ex.ept thft wte en'tt:/r
the ctyeefrom the sclerotic nearf its jullltiol  with the cornea, a-nd  the optening  is as large as the
keratolne  or irideetomt  y lance wil.-l allow.'I'lh  larget opening, ).lan  the placingti    it in the
sclera  ar f     tt e r tl lrse oi f excisint    a
rio., 45.
large segment: of the  iris, and insuring; the
sectioln to reatch quite back to. to IfIhe cilitary border.  See.t:fig. 45,, afte:r bDre W:eeker.   lhis is sutttpposed to insure a mt1More ce..rt:ain  and peir' imanienI:t rel ]iet of the ilt
tr'a,-oceula r pres}sure1.     The iridecttonmy' shouild. be made
beneath tth  upper lid in order that, tfhe deformity in the
Fto. 46.
eye imay  be t()\-cverted, and the bent keratome (Flig. 46)
will be ntc tesss'ary for tihe ilncision(.  After tIthe operation,
13




194                      GLAUCOMNA.
the eye is simply bandaged, and the patient kept quiet
for a. few days  ltutil the corneat wound heals and the
artificially produccd irritation is gone.  Very rarely is
the reacttion sullieient to  call for the application of cold
tcompressesllW(.:1The administiration of acontite, for a day
or t:wo, lmay  te advisable after the operation.
WHEl lN T() 1 MAK   THE 1 xIDECTOM Y.
An inipolrtlat p)oint to:: be deterllrined is the length of
1:lne we mtay wait, in case our remedies fail of the desirted effect, }bef(    re tso.rtigr  to  an  opet ttionL.   T'lhe
Cready ianserl-,  and  the true answert, t:o a: questiot  of:
this kind is, thtl  s0ooner the ojpcrt'tif:,t: is  pe:for:it ed it,.
caset' yfla(ttco'   the blattet.  )*)etays, tare exceedintgly
1ldang'erouts.  Bu t tie  t:it  n tl  is n ot often w'illing; at the
very colmlnteeut  littent of the d'is:ease to subit  to an iri -
de..cto iov, levenl if we ha t pl- pe n to be to.rt: unate lenou-i gh to
be. cxsulted  tthus early.  As a rtulte  tlhen, hi  e may
sa:felv posti:pou}i,  thle o.perlt:int  so ltg' as t:he intermlnissions of1' eong(t'.l sstionl  p.,:and t llitndl(ness are c(omplete,. 1, anti l:, the inst il at ion of Cescr'i    may be  kept up.t
Whenlt1 t themt  is simply're-mis1si(nt inishtlad of itt:trmnission1 the ey' is in great datngtcr; 0and  if vision is contiit1nouslty imnpairmed,  antd especially if thfe ficld!qf visioen- is
eo tl tract.ed.  the ol).. ration  should be pol   i )St    td 1til    long t' 
than  is absoluttely  necessa'y.   We  must,  as be fore
ot)served{,  al:t.wa)ys b(e'.ar in mlind that.' with or witi:houtl.
meddical  treatmt m     hmlt  t ellt t{. subjective symnlpttomls are constantlty cltging, t tand tha.t   wi lc olur mett asurel s may tmr:be
palliative, t the  canno(tttt et-   cutt at;tive tilletss tlhey reduce
the abnormal  te.si'ilo (hatrdnlessl8) of the globe.   In the




WHEN TO MAKE'TE IRIDE1: TOaMY.               195
estimation of this tension we are tot be guided by our
sense of touchy, rather than by any sensations of the
patient.  B1oth 1lis eyes being  closed, we  )preSS very
gently Nwith the tip of our fitngers upon both eyeballs
eitlher sepa.ratelcy or together, dete:rmlini g  their cotm.pi arttivc hardness, and comparing them  in this rcespct,
if necessary, with our own.
The' prognosis,'whenl iridectonly is.performed in the
prelmolnitotry or the verty early stagpe of acute inflamimatory glauconla, is favorable.  In. order tha t.t th is success
should  bc nearly  certain, the platienlt should, beflore
o:.peratingt, be still a-ble to stc large tprint, and t h
tissue of  the iris be nearly ill i ts normal condition.
Still, suttcests ttmay crown anl opelrationl in acutt   glauc'oma wihen vision is'reduced to a. mere perception of
li ght.
tIt latert statges of:: acute gtlaucoma, if vision be not t:oo
mnituch. itmpaired, and the field of vision not mniuclh contracted, permanent tood tresults may be possile; but if
it' revelrse: t.s obtains, t  he visual field io  is na):rr(ow
sig}it very fmuch impattirted, at nd ttl he  exia:vation of the
optl i  ne'rve ctnsiderabtllc, the re(.uilt of the opetration,
though good, and. offering a. fair chance for the patient,
tmay not be permanent.
In subacute anld cihrotnic glatucot)ma we may ex!pect tot
pfrevent furtnher ltoss of visit(o  and ptrcsertve the eve  from
futu:re inroads  of the discase, provided  sight  is not
whollly gone andtt  (the fiteld. of visiton is not too much ntartrowtl(e.  In thse casese, indeed, visio)n somf:ti1es improves considerably;  1l(not rapidly always, tas alfte.r al.ope)ration  in aacute  glaucoma, ibut: aftert the latpsc of




11, 96                    ( GLAUCOAt.(.).:.
son xt: months).  In noni tftttmmat'oy glaucomat the progitosi s i ll:ot 8t favorable.   In tl is formll  of the disease
thle If  ot re receltly de vised opl,eratito  of sclerotomy, mentioi(ed fla rther ott, is pi'ef.eed  )Iv somei surgeo.nsi..nll absolute tt  ltua)loa,  wh1en all   pe rCeept)ion. of light is
tlgont    al operationl is onl  indicated to (cture pain, and
i'prevet the r(culrrenlIe oft tlh  inflamninatory attWacks.
Iti is not surprii silng w'hen wve consider that th  opera.ti.'.o of irideetomy-    o ffers a  hllalce, hlowever slight it:
mitay be, of restoring sight evenl ill otl and unfavorta;tble:.atses, that it shoitd often bte:pe-rformlctd againt all indicmations, "ald even ag'a ilnst all hope, and as a nat'ural
consiequence that it. should oftten  fail.    lThis occasions
disa)pp:)oinltment, and somnetimes distrust of the -value of
the operation    ne 1ra(lly,    It must not i)e forgotten,  how\.evert that there are p}retty detfinite itdicat-ionls fori  strgical i trc erence which cannot be i gnored, i     c    i f wte  xp ec t
01our p}rognoslis to )prove correctl,  and that it is rathter too
mnuch to expelct of atny ope.rationt thfat it shall prove 8suetessftul when not, indica ted.  f.t is not: al ir..d i t   of the
op.erati1on t: hat it is a sure cure tfo  glautitcol:.ta, but simnply thfat withn indicated it is ithe 1 most reliable cure for
glaucot ma known a:   the pr.csent t-li e, ant  that in a vatst
miajority of instances it shats t proved siuncessful.
The rationale  f iride'to-m# in this disease is not dceionstrated  as yet.   We know  that iridectoimy  at its
best peltrmanent 1l  reduces tension, )but hw it does thiis
is still a; question. f!xception.ally,        there  have  beten
noticcd  cases of glaut omatl.  without inclreased tensittn.
n suctt  instantces iidecttomy has proved.servicea t.ble also;
it would, therefore, appear that the operation hlas so$04e



(Eli  {t OJEtlATI ONS FO.)I:  CUt.ItEt (i)0  GA1:AU:COMA  19T
tltiers a. cutt ativ e effect not  cl:tu  to the removal of intraoulal' lpressrtc.ll                 Y.. LEROTOM 5 Y.
T'lle operatiotn of sel rotomy t'l i  filldt'ilg considerable
favor with imany ophthalltanic l urgeonS  as a substitutte ftor
iridectolmy.  llt does 1:1ot app})lea  to reduce tensioll so.
eftfettlually as i ridectlomv:l,   n o  is it so reliable fort. most:
formts tof (tlt.ncolm.  It is coinmentlllded  by sotme, lho)wovr., for ctlrltoi  glautotmit C   8stimlplex, inl whlich. idritec-.
tomnv is soi meCti. oles of lit(tle  servic11, a l. perh'laps
sbe adviscd  in c'ases of hemorra,'lra:ic glaucomal anltd'1in
those of a-lisolute g'laucolt(.la. wt lere, siglhtt being gonet,
an opeldrat ion for the r- lief of pt)ain is ill dicate:d.  T:he
operation is usually donee with the narrPow  ataract-knife,
1w1ictl is entered -1l|near' t'he corneal imar, gin of the sele.  r
as if to.11 makhe a  1s1all fi8 t, sonme two or trleer  milli-:metlr(es iln tlight. \When t he imtaginary ilap is a.bout two-t
itirtds fil liishled, and the aqueous has es ca ped,!the kn ife
is slo(wly wititdr8awl.  T'1he operation is dilicrilt., and
the.re is not tunlnliktel  to {b  a p'rolape ott f the iris, ill
whic]~h e(:.as e thte iris.is cu.t offI  and  the operlation r  esults
ini.. an  irideectomv.    i.Posterior seecrotom#  is  done  by
makingt   an  obtlitque  ilnisito   inl  t(he sle ratl from   the
equator of( tlhe evyeall e-xtenlding b)ackwtlard f'roml  six to
cihitt mril li.etres.
(IOTHlRIt O(PtFt'ATIO.f 3NS FOIlt TU'l:E CIf.JlX O(P (tLAJ. CI.OMA
a re those of divisio)n of the ciliary mluscle atitd I:aacettesis cornea..'The firs t ]has  lot proved  as p)ernmanent and certain in its resaults as would be desirable,




198                      G(.AUTCOMA.
tand the second requires a too frequent repetition to be
generally feasible.'ig'. 47 shows the form  of needle
Im. 47.
used  fort paraentlc sis.  l:3oth  of tlhese procced(utcs are
serviceable, as hats. been  statetd, inl  t lemporarily relieving
ciliary neural gia, and may somltimes   answer the pur)pos  of  relieving pain  in those told  ases of  glautcoma
where the sight is irrevocably lost, an.    d.nothing more
thal  relief frtom! intolerable sut eritng  is thopl e   for.
Itlte utste of atroplinle in the ciliary Ilcuralgia. of glatl —
coma, or for enlar:ggi    tihe pupil, is not permissible,
lest a fre.shl atttack  eI.) induced.  T''h o}peration folr. division1 of ciia:jtry muscle is described at page 8 19.
SECI('ONDARY O-I.,LA UCO M A.
(laucontma  sf.omet imes            uosupervet s upon injuries of the
eye, and more rarely  from  (deep-seated  d iscase of the
globe, stuch as choroiditis or irid. -choridiis, sympa -
-thetic o(p)phtltltmia, and  other affectio)I. It is to  be
treated, slurgtically,:lut the chllaces of sucless( ar  greatly
lessened, exc!pt in yourng'  p>eopl( c ant  iltn ctases whe\t.r
the e'xctitilng cause canll te removed.(1




_-  nCt g p*,~                A
o   Of,.! w "~~~~~~~~V
- 4:l                     Vtosi..,,. 
-4~ ~ ~~~~H -tn-                    -                                                                                                           - - z.  X _:FI
- _t Ii' ^eso                                                                                             - ~    i



200    Ti HE RIETINA AND OPTIC NERVE.
Iitlt  work t y arltttiicial la Iigt,t altlt   a  radtlical cltualtg
of occupat tion will tdo mucI to pro mote a cur.  Very
oft rt there wvill be found diorder of some of the  abl
domtina   organIts  1as a  a4lttieC.'fthe judicious trcat.mcntl:
tI t any disorder of the. gciteral svs temt l mayl  a afct a cure
o0  the eves.  Cto'tor Id I    lastes arU  adv lisitble  for' out-of —
dtoolr  tuse, if tihe pltot:oplhobt(i   is considrtwablo.  Wlhen
the afflection is severet  com:plete Irest: of the eyes s hould
be enjoined.
RVI4TI NITIS.
1n the serous ftrm  o r'etiuitis we nottice, with tite oph"thahnoscopec getnerallyv a veiled or0 hazy appearanc  of
the retina, less mtark.ed at theli  macalt a liutea wther  the
inormal  tlemblrant c is always of dimlnin isled thiclmknelss,
aidt llmoe decided aboutt thie (optic dis(c, whlichl is somewhat svwollen from  odm ttl  w      ia ts out     t is tlinl  rathe t ndisti nct,.'The arteries areic ntormlal,  but tlhe veins appet:a
dark and tortluos.
Externally, the eye looks well.   Perhaps the pupil
may ibe slightly dilated and sluggish; but, in m1y  exper.ience, thiis is not usually t.he case.  Nor atrc th cre any
of those symptomns ofi itrritatbility of the eye which.     a re
so often and erroneou sly slupptosed to exist: in retinitis,   "..
suchl  as phlotoptmlo)ia,   paitit. latchrymation, and the phtcin(t(me:nat: wh ich: tatccompat nyt retinal h vpe, r st chsia..i
causes ofl tItis affection do not differ nmaterlia lly firom1.
those mcnit ioned u ndcmr  lvperaemiia of the Reti n,  just
described,  andt the -i'catnmt ent must. be similar in clharactor,  ut of course more prolong'ed, aund  cannot, in
many  cases, tresult  as  successfi lly.   Our p1rotgtlosis
t    X k oss ea~~~~~ttt.Se }}l~~~~ttl~~~t ttl~~l(>"t/4  Sl1( 9tt}]~~~~~17(t}TI




T'liN IN n Ji'ri.s,.              2()01
shotld  bie 1moil  gluardedt; ifo.l  from  thle beghoinlllni   tihe
sig lt s is  mowrve    i  -mpai.ted.,   lThe  veil or (cloud  g{rows
thiickerl mldil frequen.tly the patient'l is ahlm.ost totally
tlidid.   UI'requentily,  if  the  4lisease  colltilmes  many
wtOekFS, atrophyot't    f  lthe retina may e.nsu', anli the sight
be jp.erman'ently destrtoyed(    Thlt  ev yes shoul d always be
protiectetd by, dalrk glasses,  and no tse of theml  whatever
for tlear objeclts 1be t)( pltlnitted,
i.  reti-nitis elxudaitw,(t, the't   dee "per-sfeated ort1 parenel./-"
mt.osos,/brt  fr1 q    tit itis,  thle ophthatllmt ostopwie appearactttecs,of the eye are nuhtllci it(ore sltriking.  The optic disc is 
io.dd'ttishl- grattv,  ats.od its (outline intitisnct and l. irregtla'r,
so dthat.it its allttost intpossible to 1find thte.' line of del-marc.ation  bet we en  it and  the retina..'he  ar tettris are.
Imore or. less diminiished inj si ze, iand the veins swollenl
and tortuos, a 1111d hil  dden  here anid there  n   xy  t e  It si. v
sexdat t}ionts tof a whitish  or gravyis]t:   eo.lol r  anid  blood
ext ravasat ionsl are seen in variouts,partt  s o)f the rettina.'lThe albove( is an opdhthal  -nmoseopit  ic tlt're of a pathtlog(i(ail coin(li:tion in wlhi't  tl  iite flan- tvatorv eovir i i(nito  of
the rt.eiti a has ptrodulcedti  hyIve:-trrop  xhysta sis, tprol i fl:erat:iont of ce(lls, ctollod or fiattly (deg((tenratt:ion, alt(. sc(.'ll(erosis 
of cot(rsct(. tthe olphthat1lm.) os l   wNill n Iot a tffords so cotm)p)let:c a pictIul.re as tt i(e aI.ove\ iIl t all ases oIf t( he kilnd,  butt
I hav:e obt(serv.e., on more than   (:n oc(asimo, lapt.(.eaancest:
al..Iostf e xacItly otrrespo( iiig t-on tho) s(   deseriled.   liv.en
in c(ases n.ea(tr.ly like. tlt. above, t'he blood st'asis is sonm)ietilimes re( iev(lved, thoe exdatl, ionas an1d ext-ra.'vasat. ions a)bsoi)r:edl, and  the ppatientt mtay rega ai     eoIn sideI..rable. vision to
ret(.ain i        tpe anently.  T'ilis, howelver., is )by n(o lmeans tlhe
tusual etourse.  It 1moreo frequ ent,.ly entlds in. at'.ro.plly'of the




202          TIle'  RETINA AND O0,If'C N^1EV.E.
retina and optic nerve.  Vision durintg the progress of
the aifect.ioln is often tolerable until the region of the
nmaculat luteca is inlvaded.  Aieropsia is often noticed,~....
thatt is, all objects appear sma-ller t         t han ty really are.
If you ask the patient to draw a given. circle, he invar tiably tdraws it smaller than the reality.  Thi t is the result of at de(ra:Itlngclxmelt in the position of the percipient
element: s of thel retilna.'When anl  exudattion sepa-rates
these elements so that there are fewer of lthem iln a given
space,  objects appear smaller; on the othelr land when
an  atrophy  leads to  greater approximation  of these
elements so that there is an increased nu.mber wit-hin a
giventl   area, we have  an enlarged image of objects or
macropsia.
The (,atuse^  and'Teatmentt.
The cause is f:requently a neglcted hyplcr.emic coldition  of tthe rttinatt ad  optic nerve, disease of the
heartt,   of Ithe  al)bdlominal  vi scera,  Ipr egnancy,  Bright's
disease, diabetes, sSyltilis, or cerebral afifections.  T'he
t:realtment shoul} d  be di r  ccted  to  the  rmoval of t he
cause, w}hen t:I}is cian bte ascertfai neit.   \' Whie  of syphilitic origint'   tlt  tr1'eatt:ment; will t.e more1 apt; to result
favorablvl thanl   i  cerIcebral or Bright1t' s dis;ease..erlcry sfhoutld,   I  tIl1in'k, te relicd ot  t tIll. t} to t et: the retin-ttal
indicati ils in t')is formi  if the affectJon, and*  arsom mit
and  zine for t l t}he      nphriti: ic variety, tisitng   suchl oit her
rem.:'edics te. lmpora l ril as the st:ate of t,(he patient's heatlth
or atny stpeiatl sympvltoims may reqtuilre.   See   ha   XX I.!'ygiemi elt   les shotl.d  receivet  tlhe greatest attent:ittl,
tandt thte eyes mt.tf rtatwat  be protectedf /' iom bright litiht,




BRIG:T'S DISEASE,                      203
by the ltec of colored spectacles.  With the  isest treatmecnt  iln  evcery  respect,  thel result  will often-. ) prove
ntlsatisfactory. 
XBIt1IHT'fS D)ISEAS8;,  OtR RETINITIS AIBUIUttNtIJtCA.'l'h    ot)htlialIoscopic  appearancc  of  the  eyes  in
tBriglht's (lisease dotes not diitflr  ery mfluCti  h'omt   that
ltready | described, except at a a later stage of the  afftec.
tion, when we slometils find aroiund the otptic disc a
broad,  whie  ring,  and  in  f te.region  of the macula
lIte:(sai aI mtll  hsteltated  whit:e  spots,  which  are  later
l'o. 48.,erg:t in  t:e geneal  x dationt.  Figt. 48, af(ter Vo
a.eger, c rpese nis  nea. i,y such a pic (tire as see n wit -1    the
) pht(ha: 1  tn oscp ( al( )
Thi  pathohgical /chiaqes ar  ri ncilealy tht  serouis
n filtf rat:i(. of)l ol nervte and  treti4na. -t.he f\attv de(ttcteral:ion maI-t1king the white patepcl-tcs, }Ipir-,itrp()lhi(ed and 1cleros(:d nerve fib'es, g:ivinlng rise s  t:o a str'ia ttted ap:tlpear.ance




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fSYPHIL)IT IC Rt f.INI.I.'205i
qltently thilatti failing sight, w\ith  the conse cient opltt'lt.m)oscopic sexamtiintion  lf thei ftunu  of thie eyxe,   as led
-to the detecttion  f ltise ase of thte kidney, c(ntfirined 1)n
later microscopical exannination of tI he urine.,  As a
rule, nej)bllritic retiniti  does not lead  tott. c )plete loss
of si'ght; but normal   vision,  ini  easttes olt:tan   setvent.ity,
is not altwayvs regained.  Tlhe amont of v'ision rettained
will ti-ally he:  detetrmilnd by tlhe exte(nt of disea"se of
thle nerv-tt   s truct:ttre o4f thle retinl.   1If' this has been
great, it may lead to at ropIhyv and b indnless.'The prog-'
Inosis is, o.f coutset, most fatorI(able ill albumllinu'ia1 after
fevers t o  in pr eg nane t.  The tr i'tcme nt.  as far as the
eye is conce'rned  will be merely hygi.e.nic, and itmedication must bIe directed to the curle of the primarmy se-at
of the disease,.......... tie kidney,
Y i I lITI(  t ETI N    OC 0tr Cr! Oit 1   ( I)O-.. t, I 0INI TIS,
dtloes (not pi.reselt so chlaraeteristi c a  pict ure  for tThe
oplhthaitlos:.ope, an)d th) e hist'ory oi   the ease with  the
1ttonstit   i uttioii  sytil ptlomns sometin' es tretlire to be conisulted before the diagnosis  is rendered ceirtain.  The
app'earan' e of tit futl(tdus  is st.riated, and  similIta  t'o
thatl in retdiitis albuminurii aitl i, buit not so well i mntked.
Thle stellated s)pots in lthe  1'1egio   of the ma-cu11a    lutetttl
appeat'  a{ndl  disappelar rapidly, and the vision ilmprtoves
and  r et roxgrades corr'esp)(ond igly.   li:Xtraasations  of
btlood are not usu'ally not iced.   T'/w pattl /oqical eha tnges
tare sei'01us infillft at:ion of thle retl' i   iniatflmn ation. at
dlegeneration of the choroid, Ilitit fortunately  lI'he nerveouos
struct4tlure of the retina is less apt:; to tibe impaired, and
t11ou  prognosis is; therefore favort'ble,  and espec ially so




206         TIIE RETINA  AND) OPIIC NERVt'.Y,
if th]c disease comes early untder ltreatmentnt. The disease is usually coincidentt with the const8itutional synlptomls of secondary syphilis, and the treat:lnent muust hb
directed to t-h  removal of the const-iltitution'at  alft'ction.
The retinitis pog'rsses  veCry slowly, and  the  )patient
is often troutbled by rela1pses.  Miterop)sia and  niarklledt
night blindness are observed,  and lait-er a. d ni. shed
field of vision.  The  clhoroid is uall isnvolved, and
the trea treat lt refcom- mended for (lhoroid iis wsill genetrally be applicable in this formn of retIinit is.
iN RETi INTIS A POP iLECTCA OR il HEMORI t[AG (CA
thleret is  great  tentd nct   to  extlt ravasat:ions of  1) lood
winich are somet:i4me:s so extensive as to Jide l)ar tiallyv
the  vessels  of the  retina, and  t:lhe  infiltrations at'
8slighter. and se'rolus ill character'.. Th'e siglht is not so
11mucht imlp'aired as tlle op)hthal'l oseo]:i(' a:t')p rant e ofl
the evye wtould indicate,  unless tthe helorrhagl     e is sitiuated about the yellow st'po.  The diseaset shows g.reatt.endeltcy to re lapses, 1and if                i     hemorr es recur oft en
and are at all extensive, our progno.sis is not so favorable as otherwise.  A.l.pplexy of the retilna  is  caused
by disturbances ol:l   t|he genel-ral circulat ion, frequent ly
tdue to tunlmtors within the orbit or cranium, or to thrtombosis of the centrtal artTer  of the retinat.  H.)Cpertrophy
of the left ventricle, or diesease of the aorttic valves, is
not unusual in t.such lesions.  It w;'ould bt e very difficultt
to state tihe prectise t reatment to ha t)e adopt)cd ti    these
cases.  Tlhe general htealth shoultd be   tde de  as perfelct
as possible, and the patient should, of course, be scrupulously correct and  regcular in  his lhab.its.  F'urther.




RETINPITS PIGMEtNT(OSA.                      207
than this, the general aspect of each case must determine thet course to be pursued  il reward to mediicine,
diet, changet  of ai,  climate, and  thle  likec.
1 1ETT1 N I'    PIGM'NTOSA, NIOGT BLIrN)N iNES   TW 1fIll  Itl.T BLIN)N E-SS,  NYCi1t.ALOPIA,
as  its  names  indicate, i.      s  anL  intlammatiol   of  the
retina  cl  ract ri ed  chiieft   by  great  pigment ationt.
The  ophtlhalttlnoscoie!  rXeveatIls  tihe  retinta  cvered  by
lahirge  line:.arl or  reticulated  irregular  platches of pigmeint, more at the peri.phery of the tun't           s wIhere. the.,
deposit (:cointlnces first.   iattetr, tlhere is pallo(r oft the
ol)tiic disc, diiniittttioun   tf. thte retinal vestsels, andt ftlrq.uent;ly  postetritor  poltar catairat:.    It  usualtl   a ft'ects
both  e~yes.
Tilh  stik styri  in   shmbjctive Symlptomi  ill thi  altfect.in  is
nigi'ht bliiidit ess.   This is thetf  restlt of a t torpid  cottnditioln  of  tthe  r(et ina, prod')ced
I)v  tlhe i ns'ltf'icien.4t  suppll)'ly  of
1\4 l'X(1  thllr'ot11tt 11th,111 rr1  ed
v e sseS   il         olLset-ItletwL}.)*
whsi- cht  the  retit.'a rqirt:   s a
b}rig lit  lig     rnghtt tio re tcciv( y l tile
inprev nssion' of oidets.  T'll. is
oiseat.s:, must  no(t-:-  }he cvon-              i 
fo-nded  witht   a         t i  ona l:ttl t   i  ree ot,ltoni  o te.ioi
disorder of 1 thet immnt.la called   h    i a e  ttti pigosa'flhe ltak part represents that part of
hemeratloi'ia, or nl ig.it blind-  til fiehld in the t-ight eye whicth he..t'
tltes', imn'etolled(t  mtiet  Aim- i:,nl st
lyvopia.   The field of visiont is oft(eii:  vervy 1nui.h.] dimitlishtd iln extent,  s(o tltat; WhiT le  ill   direct  lilne (:ll' may




208         T'l:l Im R'l:ET'INA AND) ()}rTC N010  VEI
st:ill read flite  )rint, all around  lmay be involved  in
darkness.  In such event; it may be ditficult for a patient.1  to find his  w'ay about'.  See Fig.  50f.  The diisease
is getiterally c on1geaitalt,  tor hred.titar,  and  sloonerf or
later leatds to   l induness.   l xc pt ionaltIlt, however, at
certain  par;  tt of the sight  is retai ned.  I have had
a tase olf this disease under observation  for t we.nty
vyear's.  The man reads coarse tvp, ats retadily as he did
twelve yeiarns ago.  A pplarently  the disease does not
pr'ogr'ess  tis intstttl'* it"e.'It often o        lus i'n m ariatges
of c{on.sanguinity  anid  with  d(teaf-t-ttutism.   Ft'teatmienti
can only oi e l pali ati ve, but th is imay posi' l y po  stpone
iblindness  for years.   Thle  patient':ls  general hedalth
should beL kept; in good condit ion, and  above. a1l,  the,,eves  should  be  spared  fatiiguing  ocenpations,  and
gularded from  bright  li]ghtt and:heat.  There is somtetilmes a,physiologic:al pigmentation of the retina Imank
ing an oplt-hah:tos)opi (i  }picture not ulnlike the disease
in que.stion.
D) ET'ACI MENT OF T i: XR li'TNA
is occasionSled  by serous1.     effusion:1betiween  it tand  the
c:'horoid.  I lt  oS tfreqt entl l   occutrs i  th t s ill   e lower ttalf
(of the fundils,  and commentces at t ei petriplhety.  With
the ophthalmosctopo we  1mu[st8 look for it first by di'eet
e:. tminattt io:.  The  light need  not  be  very  s(trog.
Not:ice that th e brighti red of the fundal ls is only seen
at the upper part of the pupil; all below  is dark; or
pe'rhaps y'ou catchl  tle  illuminate.d part of the pupil
only after directin[g the patient. to ttrn tllis eve in differentt directions.  T)o not, approacht the eye too nearly,




1)ETACHt M)4ENT OF TTIE REtITINA.          209
and you will see by carefully regarding the unilunmilmated  part- of the pupil, and apparently almost il
contact with)t it, at grayislh-blue cloud which undulates
with every movement of the eye.  Fig. 51., after Von
Jaeger, represents this condition as seen with the ophFxo. 61.                     FTw. 62
tha1moscope, and FiPig. 52, from Nettleship, shows a sectional view of it..  For lack of the siplle  precaution of
using the  qpright, itmage, and regtarding  thie eye from
the distance of twelve or fifteen inches at first, I hatve
known  aln  excellent ophtlalmoscopist to  overlook  a
la.rg'e detachment of the retina.  Once havting. made the
di0agnosis), we:may examine the detailss wtithl either the
direct or reversed image.  We fin d thed floating opacity
or retinal  cloud crossed by dark, shrivelled, crooked
vessels.  Slightt degrees of detachtmentt of the retina:
are mulch  more difficult to diagnose,..l'his is somletimes best accomplished by begpinninig  with a ret;inlal
vessel at the opt:ic disc, and following4 it; t:owardst the
tperiphery,  whre e e   nmay detect at chitange to at darker
color, and a tortuousntess i its coutrse; and we make
out at the same timte a slight fold in the retina.,
Vision  is,   as a matter of course, very much impaired.
14




210 )        THE H ETI.N   ANDtlt  (.r,'TiC  NEf iE.
Th'at t)orttion of th. re tilat  sep)artated ifrom  the ehor oid
by serous effusion  no  lonlger per.tiforms  its  functtionl;
but  the pairt which maintltaii      its elonneltioii with the,
thoroid:performits   its futtll:t:iot'  as usual.    ttln(e  it hap"i1)ens ttha.t lte tlp)te. r tpalrt of the i. eld of vision is entirely
obscuredt, or, if tih  detachment    t }appen to }ltave occurred
in tte upper part' of the lunduhs, i   the oburtm'it(y is.in the
lower p'art of the vis ual  field.   tl: paired vision is first
noti:ced!bt tle pati ett as a  4delicate cloud  with ilitstinlet wavy outl:tline, ati that point in the field of visio:nl
co rreslf:pondiilt  exacstly t    t the  situtlation of the effusion
beneatht tthe retina in tihe fundt1us..ilinlear tob:e(.cts apptear wa\t v anid brot ken, due, plrobablvy, to  the disttrbed
(collct-1t ion  f tth  retiintt at thte (edtge of tth  dehitaohmtt: ent.
lThere is oftt:enl xi iht blindn.ss and  sollmetiees  ta tendencv to cotnftus  te the colors!blue  tad green.
T}he cause of the diseaseit   is sonetiles di-iftcult to:
determine.  It is frequ(ent1 v o(0:1casioned  by ai  blow  on
t,:he eve.,  In a pattien t ot  mine, duringi tle p8ast year,
it could be t ra:cedtl directi (.v to a fall a  few  months )revtions.  It itav be due tto hem (lorrhage in disease of f.the
choroid or retina.  T'Ihet co(:mnmonoest cause is, perhfaps,
a shrlinking  of thet  vitrteotus, whil,   (rag'tging on the
rftinla, causes a riupt)irt', t  thelhus ptermit:ting  tlh flulid of
Ithe vit(reousiS to P)ass }:beind it.
flI ei p                                htro otils is  it nfavortablo,   as the separ.ation generall  gtoes on until the eve is rendereld blind. itorttunatelv it is, in a vast majority of instane:s, confined to
one eye.  Somet:imes, however,  the disease  ceases to
prolgress after reacting a certain  ponlt, and the sight
may ilmprovel  and if the detaelnment is not too exten



(:t rt()M.7A!tV X'IN AK   211,
sive, sighlt nma}y be wholly restoret(    througli the absorption of the exudation, andt reunion of the retina and
el1hroid.  Thle moedict'al treatment is to be directed to
the itmprovtem: nt of the general condition of the platiicent,
Surgical treatment has as yet beeln of no avail.,(I05IMA IIETI NAC.
is the name given rb  Virchow to a tumor originating
in the retina,  and occurringl.  mostly in young children,
ktnown gencrallv by tthe name o f ent celphtaloid disease
or fungus hamlatodcs.  In the comnumncecmenlt of the
affection,  thle ee apears l ealthly externlly, and thert
is no painl.'Thle pupil is, however, mlore 1or less dilated, and the sigltt of the eye is gone.  T'he disease
is diagnosed. with the ophthalmosopef at this stat;e; a
cirncIumsribed  l portion of the retina is to tt ledt, opaque
and  thickened  in applearltce.  Soon tlte growth protrudes as   a yellowish-white mass into' the vitreotus
humor,  and its vascultarl clha racter in al11 its d(e.tail is
)obse8rvable.'lRapidly now  thle growth  increases,  )usl hincg before it the lens and iris, augmentingl the intraocular pressure and pain, the cornea or anterior portion
of the selera bursts, and the tumor increases still more
raptidly.  It assumes latetr a dark hue from  exposurett   to
the at mosphere, exudes a sanitMs fluid wlhticlh becomes
incrusted on its surfatce, landt bleedts easily. 
%,7he progcosis is a ysaw\  gt rave, andt eslpecially so if tthe
disease is inl an a dvanced stage.  If tihe ipatie.nt is seen1
early, the  eye should he immeldiatelt   enucleatedt; as
cases a1re recorded  Nlwhere, aifter the lapse  of several
yearts, the diseaise htas not returlned.'The opti.c  nerve,




212         Ti1IE1 REITt'NA  ANDI]) OPTIIC N!1RVE.
in  perfolrinig fth   operation, should  be excised far
}::ack near the optic foramen, so as to inelttdu tlhe whole
of thes diseased  portion, if possible.   I\lven  after tlhe
tumor has burst -through th e eye,  an operattion will give
the only  chance of prolonging life, alnd will certainly
alleviate  a gttreat amot   t of suffering.'!,The  tu lor
breaks throught, and appears externally in from  one to
three years fronm  its commencement.
Thel cause of glioma is often very obscure,  It  occurs
most frequently in children from  two to ten years old.
It is sometilmes comtplicated with  cerebral disease, as
evidenced by headachte, drows ness, stupor, or paral.vtic
symllptom0s.  It is often hereditary.  I have seen  two
of four children of the same mother affectced by it.
IsXitehmia  retint-,  so catlled  is an extreimely anatnmic
condition of thte retina,  w1hich is nottably of rare occurrenee, land has been curedl by rei3moving the intraoctllar pressure by ptaract ntesis of the cornea or by
an iridectomyv.
C'omreplete paralift sis of thoe r'tita altnd total blindness
have been observed after blows,  and after a. stroke of
lightningl   The ophthanlmoscope does not always reveal
tle great change which one might expect to find under
sul1C:l Ch i t'Ureut  ta itces..Ejt0mbism tt     th e central artery qf the re'tin   is a  lrare
disease.  I have lhad but three cases in my own practice,.  T1he loss of sight is sudden l   andt almost totial.
Tlhe opthlltalmoscope shows at first, at hazy funduls especially at the macla1 lut:ea; but just at tthe centre of
this region a stall red spot is frequent ly seen; later
there is a p)ale optic disc, transparent howcver, and the




o01i K-.E NFThmITI.                21 3
vessels rnnting over it much        t attenated.',he arteries
of the retina:are very small, and partially bloodless,
so that att certaitn points of their course they may appear like white threads.  Te'l,  veins of the retinal present a somtewhlat like aspect, though less strongly lmariked.'%/tro'mbosis of the  te.ry tcates  si   ar a           lppea. ance
with  greater te nde(ny to hemorrhage*.  Th e disease is
solmetimet: s,  but not uniformlly, accompanied by v alvrn
Iat disease of the ileart.  Probably the class of remedies indi-cated int ca.rdiac aff'ct ionss mlligiht; frequently
ibe of serviceO in thlfis disetase.  A     fVew  eases of ctlure'
h)y massage have been reported, buIt the progntosis is
-1 f ltavorable),
OPTWIc-NICUIrITM. (PA  PILO-II~:..BTI NITIS),
Optie-neuroitis, or neut'o-retlt itisi is a condition in which
the optic nerve is thil primary seat of the inflammnation.
This affection is often connected with disease of the
brain.  Not unfrequently the ctause i s cerebral tumor,
Vision is generally grcatly impaired, andl, in a large
Inumber  of instafnces, atrophy of the retinsa and optic
nerve and blindness ensute,.1llis sad( terinilation,
however, is not always certain.  Even when the affection is cerebral in origin, the sight mlay rema1in uni:mpaired.  A  good prognostic symptomt   is afforded by
testing tile extent of the field of vision.  If this is
diminished in extent, we may expectit m       or less attophy of the nerve.  When the affection comes from  the
brain., there wilt usually be cerebral symptoms preceding, -- tt. such as headache, giddiness, vomiting, fatilro of
lmemory, loss of taste, hearing, smell, convulsive or




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210           TItE R' ET:INA  AND) OPTIC NERVE.
the foreheltad and tem)posra region, general neurasthenia- with perhap)S slight attacks of ivhysteria.  She was perfeetly v healthy lookij,^ but not veixy robtlst. iWhen she came to ime, vision was very
imperfect.
Jan. a, 1867, shte reads No. 8 print with  the right eye,
and only  No. 13 with the left.  There is hype raltia of the
optic disc* in both eyes, and in the left fundus, the disc and it~
ininlediate vicinity are slightly obscured by a. delicate reddishgray haze.  The pupils are abnormally dilated, but not mu1el
sluggishlness is observable in their response' to the action ofi
light.  Field of vision nearly tnormal in extent..Photophobia
not marked, and no pain in the eyes. Belladonna and mercury,
in alternation, were( prescribed.
Jan. 24,  Patient about the sate in gen teral health.  Sight
of right eye the same; of the left, a little worse.  Acuteness
of vision with the best eye about one eighth,.~.......... that is, print
that a normal eye could read at twenty-four feet she could only
read at three feet.  Partly owinig to her obstinate attacks of
congesti.ve headache, I prescribed cactus and sanguiaria i
alternation nighIt and morning.
Mtarch 6.  Her headaches are less frequent and violent, and
her sight in the right eye has improved.  Acuteness of vision
about one quarter.  The  left eye is no  worse; con tinued
medicine.
March 27.  Better, acuteness of  vision  three quarters.
Left eye better.
AMay  17.  She can read No. I test type with either eye.
General health very much improved.
The cause of the disease in this case was very obscure.  Her
eyesight now, after twenty-three years, remains good.
A. somewhat similar iinstiancl is the following: i    -
Miss A. G. S., Milton, Oct. 20, V. It. {   I,.:ir. Left fundus
hazy.  The blindness has been noticed for two weeks.  She is
otherwise healthy, but had been over-using her eyes. Has slight
headache.  No menstrual disturbance.  Slight tenderness over




OV(-N EI:I'VIS.                  217
the. low~er cenrvical vertebra, A Gave her i   lse millm  tincture
live diroj)s n1ightad mornint.
Nov. 9, 1.88?7  J)atient's ondition about the same.
Nov. 23.  Better, V.
Dee, lo.  Better, V.   1. Optic disc fanlltly visible.  Tye
more senstive to liflit~
)ee. 81.  Bet tor, V.   i
Jain. 9. Better, V'V.: J  optic disc toleral)ly clear in outline
but sghtl p  Th   dcidly more retillitis than papillitis.  A spot of tine pigmenfationt between the disc and maciula.
Mic ro psia'. Objecpts at, ten feet appe;ar one half their real size.
Feb. IT. V7.'V. 1,  Objects appear about two thirds their
ar. 8   V.      -i early.  Micropsia is passing away.
April 92L   V, samne, but eye can only be used for a short
tline.  Nobut the ire Opsit
June Io.  Eiye is get ting stronger but the fine pigmen tatiou
of the retina  reintins.
I could formi no idea of the cause of the discase in this case.
In most cases' of neuro-rtini    ho                the pognosis should be vcry guarded.  It will, be most favorable, of course, when the atffection  can  be  traced  to
disorder of the uterine or some other important function that admits of a cure, and also in cases that supervene on eonvalescence from  febrile disorders, especiially
if in these instances the ophthalmoscope does not show
great or dangerous change of appearance in the optic
nerve or retina.   Niuritis deseendens, as it is sometimes
called, when it arises from  mit a-cranial causes, generally  terminates sooner or later in total blindness.
Generally speaking, it has been noticed that when the
progress of the disease  and  loss of sight have been
rapid, the prognosis is more'favovable than when the




21$   ~~nTIlE I E'nx. NA ANI)  melT   NXEuVE.
rogres  ad  lss of siglt have  been  gradual.  In
til iion t.o the   l*edical ta            it tmst. of cou rse
vav            t ac   i  t. to  the  aus e, the  eneral health of th
patienst  and the exigencies of e ach  inditvi  al  ase.
Other things being  eqial, I should expect imercuriV
iodide of potash, aid pho s'tthrus to L  oftener useful
thtan.)eltlado)nna ctlninn, nux vo.1nica and gelseim.
Ctro.hat)ar.neuritis is a mider disease in  wch
hight or Ino change i  the optic   is  is observed; but
here Is at more or less tistin. ct c:ntral s o          such as
is observed in toxic ambl)vopia,. to wi    the aectio
bte~ars a st:.on;; resemblance.  The  rog     i i0     m
Ii volv hfavorab)le.  (See n;,)appA.) Arc ph   an., 1891.)
AT111(1O Y ()OF  I   O  O C PTIC         V,
A  mark.ed sym.ptomn  of this disease  notic.able a-t a
glance, is the ditlatted and slhuggish pupil, aand gener
a lIv, when the eye is quite blind, its almost complete
inmobility.  Exeeptionally, the pupil retains its aictilt, atnd, i  spiial 4a rasis,it It my e(vein  be eonti'atcted 4and unequal in the two eyes.
/he ophthadnoslso(fP  (tfppei(m cr5) othelit fhmuIIds are i
v'er  chaiact teristic.   lhe ierve d(is  is pale, fhromii the
at tenuat ion  or  disappeaoan    of the  small nutrient
vecs sels o)n its face; theIc is bluish or blnish-green discolorat ion, espeeial ly seen in spinal attrophy; the trails'
pareIIey  of the  disc is lost, but though opaque, its
otutliiiet is distinct (see  Iigs. 05,      41aftem De Weeker)
thlie retinal.vessels are generally diminished  In size,.
nottablv the aterides; and thtere is fretnentlv  an excava"
lion of the opt ic disc.'his excavation must he dis




ATRO:1ItUY  0()1' TI    OP'TI'C' NE  VE.            2.19
ingutished fronm  a vervy  slight di  physiological one whinch
iS cong'en litl illand ofte:n Se.e(n inl the1 no(.rmal eve, situated
ati  the cent, or a  little towards  the tMnlporal sidit  ofthe disc.  Ili tle- phtsiological excava-tion, of'   caue,
1one  of the synhpt(o.ns of att rop}iy above-n entionctd  ol,tain, tihe nIerve being  ill its normial con( ditiot.   lit the
atr:ophlic   xt avat iot   x whic  is i  sthallow,  its  edges  tare
gradna lv:   s loped,   quite tut1lik  thiu abru:ptptI maI rgit  of tolI e
fgl ateomiatotts 4xca\vat(iot i     ee   i s, 3i   and 41, tien e
the retinatl. vessel s, in passilt  into the  cavitt- tiro   the
t(C.  55. 5'mo. 50.
Atrophy of disc. from spinsl dis-    Simple atrophy of disc. T(he,ase.  The lamina erlbroa not        stippling of the lamina eribyosa
v-isible,                            is expcsiei.
Iornial sutrfac   of    e  li  disc,   o not)  appear und1111(er 1 ti 
ophthalm oscopie as  if displaced, as in  gla coma, I)1ut1
de41scrib, i1c  simply  af cirte.   Sonvet 1imes  il  the  plvysi(o
log;ical excavation tlis cirv'  mav also 1)b  albrIpt e)nough1
to giv- e   vessel t'le.apl:pet(arance of displacement.'The patient's sig Sht is        e o'   l es  inpair (ed, t(he field
of vision  contracted, and  ti:e ('olo  sense  is deficient.
In  secondairy ncrvc atrophy, already spoken. of.  as de
to creebal ot   r spinal disease,  ictinitis, et c., we s ometimes  find  the  affection  a  sequel of    emiamhopsia that




,20         TIlE RETINA ANDI OPIC )        NRVE,
is, a loss of half the visual    d        each eye.  The
aftfection  is  sometilmes  atsso)ated  with  homiplegia.
IU.sual l t(he loss is    lateral at the nasal half of one
eve and at the temporal half of'the other.  See Fig
FI. 57.
57.  Thlis eondititoni is the more favorable for recovery.
More rare is the loss of thile two temporal halves of
the  retina); the  loss  of the  two  nasal halves  is
exeeinl  rare a    lead  to complete atrophy of the
nerve   I once had a ease when the field of vision ws
waitii  in both ulpper halves.  It must be rememlbered
tliat the optic nerve fibres decussate at the optic" corn"
nissure, so that the right nerve passes partly to the
temporal or right side of the rethia of the riwht eye,
and to the nasal or right side of the retina of the left
eye, Iwhile tlie left optic nerve supplies the left half of
the two retimne hi at corresponding' niamier.  Now, if
the temporal side of each field of vision is limited, the
disease must be seated  at the commissure, and  this
augurs a bad termination.  Blindness often comes on
very rapidly.  But if the field of vision is contracted
equilaterally, total blindness is pretty certain not to
ensue, indeed rarely or never occurs, unless tlie disease




THE CAUSE O1 PRIMARY ATt OPH tlY.              221
extends afterwards to the com missHure, or somic nfw cerclral sv  )toms   aniLfest tihemselt ves
TIlE CAXU       OF tPRIMARY ATR}OPIHY
is sometimes obscure, but disease of the spine, notably locomotor ataxy, is not an   ncommn on cause.'[The
)rognosis is  bad.  In the secondtary form  the prognosis
is, as we have seen, somiewhat better.  Suddledn accession of blildnless s inot to be considered. an unfavolrab)le symptom, especially in  children,  It is favorable
if the (1 isease  remainail  stationary  for a considerable
tlime, and bad if it nmanifest a: slow, bu-t (cortraill progtess.  If the visual field is not contracted  after the
affec      tion has continued for some timeit i is a favorable
silgnl, as is likewise the fact of the line   of demarcation
etween tlhe good 1and bad of the fieltd being very d(isiinct.  Irregulatr contractionlls of the visual field occurring simnnltaneously, or in quick succession, in both eves
aIre tlllnfavortable. C(entra l scotmtma are unfavorable  if
the' visual field  is much icontracted, otherwise  not.)
\Vhen the field of vision be)yond tihe scotonma is inmpaired, it shows a lack of the power of t ransmission on
thle part of the retina, and progressive atrophy is to be
feared.  A.11 auxiliary or acco  pany ing symIptioms are
of great im)portance, because it is quite impossible to
decide from  the appearance of the optic nerve alone,
if in manV cases theli attrophy be prog'ressive or stattiona vry.
[Th.ie meditca treatimeint must; di ffter so muclth in d if Iferent
cases that I do not know  that I cant do more than refe.r
th' read(er to the indications and i'remarks in regard to
treattment made under( the ihead of Neuritis Optica.




('.I[t'A  l'E.1  X 1.
AMIL.YOPIC ANI) (THI E!. AF\i",CT[(ONS.
AMB i lYOP I) A.
Ti':s ternt, strictly speaking, is limnitted to thosl.e cases
of i mperfect vision in which the afTected  eve piresents
m.4 recognizabhde olbjcetive svniptolmns, with  or withlout
tle oplt hal inotscoie,1:(1 and 1il which the im1n1:ired vissiol
is not ldue to anonma lous refraction, as in hvperme itropi.a, mopiNa, an1d astivinatisis.
-hI a general way, the term  ainh.lyop:)ia is use.d to ex-.press innpaired sig'lt from  anly and every cause excelpt
t111at of opt:ical detect   Thu s w   Bsayv if we lind ithlat no
giasses imnprove tlhe. acnteness o(. vision, that the paltieunt
is a..nblyopi,.   m-Ieainio lhv the renmrk nothing morve
thefinite th.1an1 that the hlii.ndncss is not to he attri.bted
wholly to a!aorma:I refractive powver, and that somne
d isease of tli fhlnd us of the glohe is present.
DIA'G0'.NOSIS OF AM iBLYOPIA,
A. sim)ple, practical, and q41uite reliable miethiod of dia 1nosi,   atblyop)ia. as1 well as im tpairedl  vision generally, is by lthe simple device of permi.tt ingu tho l)atielt to
look thlronglt a largoC p1in-tole in a blackenetd caHrd.   1:
this' inproves nision, refracttion1 is faulty, and will  be
corrected by suitahble glasses.  If vision is noto'i impro.ved




I )AG NOSi. ilS      AMB: OPIA 51. t   0').  2,:
the lotss of visual j.,mer:\ u' stl et sot  lhtt    i is onlt  ofI tht'
inttitr structures of the e(ve, andt. aIt  ophthaltmto)seopito e.x
amnat tion will lie Ilecessarv.  O   (co urse nice-r metthods
thl.ant this to (idtetrmine.a' fiault  re.fraection,'whi(n th' e requisite con'ave and convex glasses at att hand, at re tliose
1mett'{1iolted inl the chaipter on Anomalies of Retract ion:
Ihut the req,uisite g        (lasses are ftreclui-eitly notl; at handtt   ilI
the  otl(ict.e of tle gentli(,tral  pr:acet iti  e'ltr, atlnd tlhe. a.bove,
test of (:,iralld.tlttelon will prove lvery  onvelu ielit.
Thttomsonl s'htws thow  thi tCest may lf' it;tl:md   to i dictate the] exact naItre o  a case of a    e  f an(:omalou's reftraction.
nll looking:ll  through l the pin-hole at a. gas-ligh':t at (t twelnt
feet diistanttce  if the evye is Iametrop.ie (of te fect:ive rc-:fractive 1powt-er), whenl tite ctardt is movted rapidily 1.eft.ore
the evye  the light will seem tin to dance.  If thIe eve is
emnletirotopic, tht  ligtlht-  will remlainl steady.    In test:tillg
fhet eve of at pa tilent int t!his way I f:ountld that the danllcing' of. tfl(e lilgt vwas removed Iy plermitting him.11 to look
throlugl'0   No. t1 6 conl.'cave gtsstes...    Iltho.sei at)ppI. red  to
render his eve Jem.met oic'p.  /'is eye was m yopic ~1.  In
aniothert instanceil     t'e tlithl danced  wthenl tt he cartd was
mtoved up. and dlown, but no t t tr;'    it iwas move:td hloriiztotall t r.. Thtis   itltti;ttdl atetirtopia t it inl tie vert':itcal
mtu.r-idia1n, and it: w\as tfoundl b ti tial  tha t  ia ctonicave c(yvl indrieal  glas s.s  No. 83(i, the axis horiz:)ontal   relmdied
the defect.  Thtlt  cate  as (s one of si inple asti igtllatisnl.
W it ti wo pin-holes, one eightRhi of tan i inch  a..  rtit, in the
card  an e nmt tetropic etye will see ol:ne  light, anl alttme-.
tfropi  eye, t wo.  tIn nmyop)ia, tthe  second imag e till be.at thle rilht, in hyplSer.t.i einetropia, at 1the- left.  Itn t  ( catse
of the mnyop.e  lustl mentioned, by covering onMe of I-the




224      XAMfBLYOPIC ANI) OFTHEJit AFFECTIO'NS,
pinl-tles with the red glass, he staw the rel ftame about
eight inlehs at the lright of the yellow, at a distance of
forty feet.  TJhroulgh his No. 16 concave glass tthe red
and yellow flames were one.  Inl the case of astigmatisnm. moentioned above, with  the  two holes he l(  one
atbove the other, at a distance of forty feet., h-e sawt the
red  flame ablout four inches above the yellow.  Hiis
cvyi ndrieal  glass nearly fused  the two  ilmages.  In
determining a hypermetroplia  by this method it will
frequently btie ntecessary to first paralysze te te acctrommodation with a solution of atropitnc.  An emmetropic   ye
may easily  bt ae me to test theo correctness of these
various methodl:s b)y placing before it at convex glass
which rendters it myopic, o  a concave glass when  it
becomes hypermetropic, or a cylindri al glass which
renders it astigmatic.
CAUSE ANI) TREATbMENT OFP A.MBIIYOPIA,
Temp orttarly congestion of the brain and nervous structure of tlhe eye may ble occasioned by suppression of exhalations from the skin through exposure to the cold or
wet, by suspension of the eatamt nia, anl by large doses
of quinine or oiler l'drug:s, the result of the congestion
beilng dimness or  ntire sllsplnsion of visionl.  T'le ievers(e of this, a dimintis-ihed supplyll    of pure bl)ood to tlth
lbrain and retinam, will also produtc  amtblyopia.  This
enfeebled condition:'01 l(ty  e (ttt. du-e to s(ev.ere illness,  excessiv er draint on t        t he system  t'hrough  elmottrrhage, utei:cine
discftargtes, gestationl, infanlt mlltrsingi, aind like dbtilit-:ttin-t cau.stls88s,
In sutch instances of impairedl vision we should not




CAIUS]E AND1 TREATMENT OFl AMBIAOLYOPI'A,    2
nD( fl c c; t  n I1 titlt    e moscoplic  examin at ion.    ur vl ogi -:
nIosits will b1e unce ltain u less we can first; establlish a
(.Iorrect di atnos111 isX0is  cam afis   bi al     dorn, liut  it
clan ofteln ibe dlon.   liTh't  fact t;  tht:the ophatllmoscoi c
cxaMit nation frcqcni:Nl yviclds lbtt negative results is of
it'slf a. fitavora.blet om(flt   for the pf.trognosis.   So(ettimes
the exZamnititition of the interior of the eye reveals c1noughl
to make thi  future of l  the patient extre mly doubttful
A, few  days siInce a ease of am1lIvyopiaN from  p'regnancy
at the. eiglth m.onthl.t  w-as sent to met, and otn e.xalinali on     I I f:und  on optic t  uri.tis wNIith consitdrable effusion
in  the retina.  T.,he prognosi  nds eeds to  le extremely
gttarded in sluch  instanl-ces.    l ess pitercept ibl  ch.tang:Ce
than this in the It  unldus of the fglo:obe are fol'ltowdi by
permanelnt iltmaiprimentt oif visiton.  A,. ntltl),ber otf cases
thavet  bee) n t publtislhed int  wh}ich the b'lilndness o.tf tpregnancy has termimnated unfavorably.
Wt e lt ave matny remedies suitable for conlgesti on of
the lnervous tWiic of tlthe ey e,   suchl  as cactus, lt  feIadonna, sanguinaria, plhosplhorus, glonoine, and ofthers.
[-o t     pedilnuyvia: are somett:ies strviteablte, alnd:thet jliciouls tlse of thte lTur{kisth.blth wif ill  c.t'itef  dtisordered
fluncti ons of the skint.  Th'lat the l(Tu' rklisth bat:h w\iil also
diminish { thet flow olf blood to to  he brain li:ls been plrovedt
bily optha lmloscopil c examiation made beforte ant aftcr
shoulxfd  e, Ipre'scribed.  Hellm.ienorrhagel  and  all unusual
15 




2(2       AM BILYOPIC AND) OTlhIERt  AFFECTIONS.
drains on the vitality of the patienlt must: be ct::ntrolled
before imlprovement, ae n b})  looked for.
Blood poisotw, y, fron dtrugs like lead, and narcotitcs
like alcohol tand tobacco, will produce amblyoi:      ia. Tota l IatSsititenlnce f'rol at lcohol t and tote)acco would seem  to
be the only courset for such as ca:nnot draw the lline  )e.tween a stimulatizng and  iarcotizic use of thelle substlanes.  1)rlug l)isolning  requires a  specifi  line  of
reatm nentt for each case; lead poisoning  is said, recently,  to be successslfly v treated by opiuml through t(he
hy)podermic injection of morphia.  Amlilyopl. ia nmay.L  be
th( dtirect result of bl.ood ptoistoning, but \evenll int blancthing and all'ppa.rentt,at:rophy  of the opltic nervel, a very
g1rav1   s'ymipt1o   indeed, there are i any  catwses  roe corded
i. which a more or less lpecrfect recovery of visioln is
known to have tatken place after the latpse of months or
Vyars of lOiinldness.  Quinilne  lindness,  as well is deafness, is quite common. lt often plcs  ofis    f.rafthr slttowly;and exceptionally 1  imp)ttairs the sifght plermanentl t.  Salicylic    i c   aci so  ad as als o ased ambyopia..J)Dettal net drati  sometimes in  ttnpatirs  vision,01  tl lhrou'}g
reflex  irritattion  fr)om  a  branch  of the  fifth  nerve.
itemov:<a  of the offlending  tooth genetraltly curlles.
Toblacco amilvyopia: is Ua form  of blindness now  well
reco'nized.'There is a central seotolma, a )blind( or p)artitally blinid region in that part: of the field, usuatlly,
which corresponids to the portion of the retina. be tw.eenI
the optic dtisc and the outcer margin of the  n acult      a.-.......theI papillo tmacular bundle of nerve fibres..:The scotoma is -more defective as to color than  form.'Thel
treatment. in such cases is, of course, to enforce entire




SIMUL ATION OF.  BLINI)NNSS.               227
absti nelce from  the use of tobacco, and t:l  ien to look
after ti'h general'   alhtLh.  Iloide of ptot'ash,   as well as
the hyplodt rmic injections  of st:itrchni:a. alret rerted s1rvicetable in nltearly all t  forml:s of toxict anblxop.ia.  5M. f
experie'nce leads mel to tbelieve that an.y relmedyv, ntit: of
itself ]turtf:tfl,   will, at first  improvllt: e a. lerve l.esion,
appatrenttt  tle;  latT  til  imlpro)vement ceases.  I suppose
such ilmlprovement is  tue to sutggestliol.
Tenlp' orarly anld inldeetd pe}:rsiste-nt, amtblyoplia is someti.nels duet to disorders of d i'estion from im paired futlncti:onal or olther disease of thle sto(:omntach or livert.  Th1tesC
affe:ctions caiusei, tlthro>gh  the m:edin of lthe symlpathetic nerve, somen disturbance in ti:e nervous structure
of thle eye wherebylx  vision  is itlpaired.   The same
eff(ect is} prodntlced on the sight, (cc(tasi;onally, from  nervous otr othiter apl)parent:ly slight affect iot.ts of the uterus.
Int factf, retlex disturilbance of visi:on may inl st801l(  instahn.cets tbe dfue to irritaItion. of any part' of the system,
inter-nal or external.  in such  tcreit, especially if the
oph.ithalmnoscopte shows no changes in the interior of the
eve sutfficientls   mar..ked to accout.t for the visual disturlbanlce, the treat mtenut must be directed ch icfly to tlhe
removatll   of thle exftra ocular lesion.
SIMULATION OF  i3lNI)N EPSS
in onle eye, by nervous or hysterical  persons, by conscripts or prisoners, is readily detected by holding the
finger or a ruler midwa y between the eyes and the lprint
while the patient reads*  If the patient sees with only
one eye, vision will be interrupte d, if with both, not   If
this i  noot wholly satisfactory, by moving thle ruler




228     IAM IBLEYOPIC AND OTHE:R AFt I'FC:ItION(:S.
slighltly frlom  siCde to Aid: s0 as to cover each eve in alternat ionl aty furtlher simtlation of bitlindess will ge.nt e  lly tIe d etcdetdi Thlt  dccet )tionl may also:) e show n by
mtans of a trisln,  base in ward or out ward, beIfore dlth
normal evye.  1i1 tlhere is a corr.ect:ive sq(uint or elilnge
in tih  d(ir(ect(ion o  tf he eyes. as tle prisml is remXoved,
linc:)lteu tar   i sion 1 proved,   or the base o)if t() he pris'm bleingt
tpluWartl o-)r diownwa.rd, if the pattiet stees double., tbinoclar
Avisit i  is eertait.  The stercoscope o1( may also be u1sed as
a test, as b)inoltlar Visio   is re(tisite iln order to a l'l)reciate its e:ffets,  Simnlation of hiindne:ss mi  hoe.th c/C,
may som(:ttetimes tbe  dletecteld by obse.'vitng; th]t e action,  ofl
t ligtlt ot   the sizep of thle plil.   Mobilitty  of the iiris
1(lunder ith.e stimt lust of lillht' is a tolerably surle indic'ation
of sihti in o(:ne or btf th (1 yevs.  Still, tShis tes; is not absolut)ely eone'lusi ve  and a bilateral simulattion of blindness maty   rtlove dil eultl to )detect.
HiEM  tALOP,(l    01  I)IOPAt'i' I 1C NIG H(1T BLINDNE O!SS,
is genterinally sconsidered a Ipurel  functtional disease of
the rettinal  in which no changit's are obtservat}ble vwiilt th:l e
opht:'ha'l hnosc.ope:..  It is an affectioln conin-led  in it's oriigin  almost. wihnlly to warmt) climates, amnd will be remllembl.ere:~d as onhe from  whlicl our soldiers'on dutl  in
ithe extreme  Southl  suffere(ld  considerablvly.  Sailors inI
tropicadl.re(,gions arto'  also frequent sf81f lrers.  T.he dist:iinguisiuiing chlar.acte.ristic  f theis    is, a torpor of
the retina., so that a: bright light is requir is nre   i red int order
to sitimulate it slnfciientily to receive (istinmt ilp)ress      -
sions of objects; hence by night the patient's sight is
unusualtly bad.  The  time of the day  lhas no  signili



COLOR  IBLIX)NESS.                   229
caniee, s:lnh as the namne of the ll ffTcction would indicate;
for by a tbright arti ietial lighlt, lte seels as well by   nigtt
atS if no attf:ltection of the eye w\ere'l: prest.
ItIe caitlme o-f the (liscese ise     exp)loslure t:o g'lare of light,
Iand i1mpove-t  rished condition of the blood.  lf):.t  tllhese
condit ion)s arte prelsent witll our solldilers and sailors in
watrm  latittdes. l     it is often mlet withl  iln.l onjuntion
with  Inaltaral"1  fevers, a(n  the i ll-ft.ed  andl t ill-tthoused
peasants in the south of lEuropel and i:n C(ental A. mniericat
artc 8subii(.ct to it.  Sailo'rs afflicted  with  s(ncurvy art
oft:en subject to it.'The ti'reatdment is veary suimple atd effii:cacious.  el'l tst,
protecttion of the (ees from I) ig'ht ligltht, su(ch coust:ittutional remedies as artre necessary for tihe'restorat:in o)f
the gteneral heallt, or change of climate, genrally cure
speedily.  In. t1aly, where tlhe aftf.f'eltion is qutite coinIIIo(   a poptlniar re'muedy aVmono'g the p:eople is fumhigation
with the vatlpor'froI   the liver of a sheep or orothe(r an imal.
(tQuagllio and lsot me  others lhave obsetrved s'vmptoms of
retinlit-is in the opht:hal)moscopie attppteatranet. ( of the fuld.st of the ever in this affeeti)on.  Nilht; blindtness is a
p'rominen. t  sy'nlptoma  also of the disease called r.etmitis
pigmen. tosal.  In tllis aff(ection( tihe fihaeld of vision:t econt'esI limited, a su syubjctiv\ mtom which' is )lot. o:ften
ob.served in idiopnthic   nigiht blindness.
is sometimest  cont enit(al.  In the..so  cases  there is uutiall am. ilnab)ilitr to distinguish the shalsdes of red. and
red fSrolm its complement ua ry color, green.  ( lree.n-red
blindnesis is also a symlptom  noticed in at ro.phy of the




280      AMB:I YO)'IC AN1) OTHIR:l AFIFECTI.ONS.
optic netrve.  At ckl.romatopsta, inability to dislingutish all
colorst, is usually tlie to disease  of tile optic nerve or
o)tic nerve aId retil a.  It has been noticed also as a
synlmptomi of m1iyehitis,
Y'/tc dia.tnosis by' the I folmllgrenl.method is simplet and
cal be carried out by any plhysician who wtill taket tlhe
t:.roluble to provide a pdlentiful collection of small skeins
of worsteds, abou0t one hundred  int nulner, of the
primlaii.ry coloirIl and their di.fferent; sitrhades A.  A stein of
light greentl,:for exams ple, is selected froml  the ma1.ss of
colors, and the pattient is asked to select other shades
tlat at'ppear to him  the mlost like it in color.  If lie
hesitates  alt l steleets fitallly grays, ineutral    tits, light
btrowns, etc.,,he is color blind for green.,   iven a light
tur.'ple or r:ose-colored sam: ple, if tte matches it  withl
light gf-reens, gnrays, and  light reds, lie is red.-lilnd.
tBlue-yeltlow blindness i.s very rare, a td congenittal total
t:(olor blindness is aslso rare.
IiYPE^ttsiSTiTflSIA rlfEIN.T;,> Oft REI*AL ASTIItTNOPIA
is tcaracterized by severe,tpotophotbia, laeh;t''mation,
alt:i  all  the symptoms of tan irritation of t1he ciliary
plexus Mof nerves.  Ihere are no ophtthalmli)soIt.tpi chaltges
ot:bservabl'e inl the fundus of t:ihe globo.  In cases twhlich
hIave come undelt r my care there t   hs 1been, ut i formly,
dilafattion of the pupil.  The siAght: is good in a diminiisheld lightl but the field of visi>on is usua lly sometwhat
contralcted.  It oeccurs mostly in young fema les it  dellicate health, of irritable nlerves,  hysterical, and suffering
from catametf nialt disorder.  lThe disc.aseS of the nerl:volls
structure of the  eye is but an indication of the state of




JIYPl;1tSTHESIIX A  tETINA;.,            231
the nervous systeml generally, adl the treatmenttl    murst
be directed to the removal of the constitutional syvmlpt oms.  I have found quite a variety of retedl ie    nceslle
sarv in dilerent  Icases, andt stomet:imes in the:tae ae Case,.
(Of course errors of refraction must be corrected by.)'10loper gtlasses, and. then theii  indicatiolns are to restore
thle tgeneral hetalttll hlth   such it reatmentlt; as may be neessarl.  If ltphto(phobitt bh  present  colored glasses shouldu
be worn in the open air, and it mayl be nlecssatiry to
moderate the light 1(to a fcertain extent iln-doors. I hlave
never. yvet found it nece:essiary to c.nfitn  pe}:)rsons f(or dtays
in compl et'lie darkltss, as las been I  ratised ad recomlniSended.  indeed, it; hats sieem.ed bett.er to clcourlt'age the
pati)et in atte mpti- ing t t o accustom   h t e'eyes gttradually
to the daylight, as te gelneral }taltIh is improved.  The
st:rontig lightt is u-tpleasant:rathler than injurious..
never hesitate to nse tih  op:hthalmttosope freely in these
cases, titrowingl  a stro'ng lig)hti dircctly into tthe eye.  No.)
seln.sitiveness whatever is not icd ti under til  examinnat:in after the fir st.few sconds,  andt I nevelr tard of
ay aftert ill  f               I:'ect ts.
Atft2:i'stlet.tsia  ti. ('n-c    is  ae ction  )lroduce  by exposure of thle  teye  to extrl    ly brighlt light flor a long
tilne.  iSnow tt  lint lSs'8' is a form of tthis disoxlrder, and it
is frequc: tly bl:rouliht: on tb  continued application of the
eyes ( nt.der st-Iront  artificial light'.  Thte,blinlldness takes
the form of a cloud before the eyes, antd may e) of only
short du ration, or m)ay contiinuet for weeks.  I was the
sutlject (of a( similar affection myself  ttduring. the pastl
suimmetr.  After gtazing out )upon the ocean fromn a pleastant w indotw fort an hour, on going downt on to the gpreen




823       AMBLYOIC AND OTIIlI AF'I:ECTON'S,
lawn\ l I ftoulnd that tihe grass atppl aredtt  o be veiled bI
tn exc(eedingly delicattt     le blt hazte. M,   friends declared
lhat no sntelt haze existed,  andl  at             afW  m I nuftes,'
rest,  I saw no tmove of it.  Many11  cases of thiis kinlld alre
lmorCe serious ttlttan  this-.'The symptoms wlhlen stevere
tare similatr to thlose mienltioned below  tunder the e't',.etfes
of electric light., and may require for paili atiotn at prt).lonu ed exc:lusio, of te eyes  fronl  light, soothitng apjtl icat ion:   t tho thI lidts  aln general   const itutional  t.reatment:;
bltt in tlhe end tihre is cotlplete recovery.
AFFECTI' ONS  f)''O'11i E EYEIfS  F EOM   SUE TO:'   T HEf 
BEIC('tlln  LI.,1G HIIT.
ii.'Exposu1re to elect'ric light nmayl be p1rod(ucttive of a severe
(aflfection,  btll is ordilnarily not very seritous in charac(. telr,
nlor of lontg durtation.  t'.ier  is Iachrymation:   ciliary
ir ritation l, i sligt  t swellng of the li ts alld of thlt ocu lati
conjunctiva, and  slight sensitiven:-ess of fthe retint  to
li ghtt.   tnhese, isturbanee s generally disappeal)nar in a f'ew
da ys.  In1 severer cases tiho re:ietina sullers more; there
is a: c0ntral scototna atd intense photophob'lt,   ia,     t og(ethecir
with  tle otherl synlptomst common  to tLh   less se'vere
formn.  Such attacks usually pass off iln a few days, but
octisiontally a lon, gr ti ne is lncessary for tlhet restortation of the nor-m. al functionls 3of the retina, as is shown
ty a  ase under my care laar-st ye ar.  A. wnoman of fifty,
of ie ur(,ltic tendency andt  iltmlired vitil it:aty, had CxtlpiosCd
her eyes for several evenings  to the. g'lare  o'f tan tare
lihit il tile street o)pp:site  her window.  I saw  her
three wee ks after til  expt)osurett    on A p\ril 8th1.  "here
Vwas severe Ihotophobia, rel ativ e centralt scotona, slig tt




H'YSTE1.1ICAL AMiBL:YOPIA.                 233
ovat l vcrticallv, and V. l. was {l2  I; I           1. J11    eild of
vision not  conitracted,.  (Ohthal nosotic s ign s wani;lg
tRest of  vets, colored glasses,  and care of gncrail haltht
by her p1ivsiciai,  were prese ribcd,
May 3.  Not much change.
Jtit 3.  B i ttr;  re ads with  2.50 D*
July 1   V. II  -;. U.1
Nov, 13.  tG(:eneral lhealth good. lPot:optlbia still, bult it is
now  quite sli  lt.  V  -1   but t site does not  t read No. 1:prit  quite as  rdily  as f  ore rily'In this instalnmee some seven months were required to restore
the sihtlit to its normalt   condition,'Th. irrit:ation of the electric li t1ht on the eve is du tI
to direct expos ire, and is produced by the ac tion of the
chemnical rays,    (Widmark, Oph.'leview, Vol. VIII.
p. 172.)
H YST'Tti(A, A MXBLYOPIi A.
T'Ilis dis order of s iight, so far as symiptomns are concerntdt, is ne arl  allied to a ns;tsl8si  and hvpcr;esthesia
of the rctintllla  and is seen in those sulttel, fron.  funct:ional or (ot}her( nlervous diSsease,.  Th181:rce mavt\, however,
he a mnllt11ittude of t:ler symlptioms i th:lan tthose me ntioncd
tnmder the above diseases.  Sludden andl co(i)plte blindness may occur, and as sitdldcnly disappear.  Or'there
mtay bc central scotolma, (or henianlfopsia; and  there
is sometimens a strongly abnormal color sense.
The trcatsment of fthese cases  is often tedious,  partly
from  the ftact that often no atdequate cause can be dis



2834     iAMBILYOPIC AND) OTHER AFFECiCTIONS.
covered to aecotunt for the condition, an:d partly flro
the fact that the nervous or miental state of the patient
Imakes any treatment precartious and depetndent,.  FiEvery
kind of treatmlentl is accredited with having ctlured tthse 
ea ses: ttrtgls tiv tlhe score, h ypnotism, faith cutll, mind
cref, tetallothel rapy, etc, MIy, limtit eed e lperience in the
treattment   of these cases is not cleatr enought to warrant
special advice.'The progno)sis is good.
NEIU-RALIX A OCUI.,
is usua.lly associatcd with,  or is mrcely a symptom  of, a
diselase of fthe eCe such as iritis, chtoroidiitis, glaucoma,
)t r   soot oither alefctioln, the treatmenltt of whvich hast
} lbeen atready indicated.  in hysteria, it is bitt a phase
of tmhe nenralgias conmmonn l in that disorder of the ncvous system,  aldt can only l)  cured by restoring, the
general ]health of the pat:iclnt.  It; llay'I  )   relieved by
sucl mcasnres s s are recotmmended for ci ia ry neuralgia.
I htav        e oil 0110 occasion0 caured such a ncurtalgtiat itn two orI
thrce  mi illtes by the  instillat ion of a drop of cocailln
into the affectedt  eve; atd   only one instillation was
neC@cessaryI!,




CIHIAPTEIIR  XI II
TI'lE CLIRYSTALLIXNE  1 LENS.
CATA IACT, 
(' xATAi CTr is an opacitxy of the lemns, its capsule, ot0
both litc   ad  tcapsule, ald may i teroflfo li  calle d le t'7ticuftar, caps'ulart,   otr tcap. ulo lenticulatr.
DIXAGNOSIS.
Thie,std^te scjpti', stl.    alt e (iiflCl: ss  of v. sion, in pro)portion   to  the ago or ldesity of the opacity, wthich
incr eases girad uall, exet. e it in trallmatic cata-ract lwhen
it lnatv labe sudden l,   1 and1l   in  c(ltVongeitatel eaittract.  The
patient; sces better generally in a dim  liglht; because,
tho pupl)  being larger, a pIotio l of tih lelns from  the'entret  towards lth  p}erilp)ery is ulnoverled, and  this
pn'art of tle lenis is tusualltt1y clearer  t      hian  thite cenettre.
Fl'or the same reason the instiillation of atlropine improves visison somewi hat.  XThe  tirst, symptolm  lsnial
ot-iced by bthe 1  latienlt w\ ith beginning cataracti  is, tlhat
distiant; objects appear slightly habzy, or as if suurrotuded
by a htalot.; aft'erwar'ds, as the ca taractt dtevelops, vision
for nealr objects is similarly ima)paired.
Oljecthire syi..pt.t' n -t,^   The pupilt is tgene(rally normal
in size antid moav'tement..he vacanti; look,  rollilng of
the eyes, and tendency to look upw ard of.anaurosis are




236              T'.HCnE CltYS'TA'AINE   LENS.
not present. Tihe I)atient is ilclinecd to look downward,
tand  is able usually to fix th leC   s on o              el: ts.  If the
fleet tion la(ts madte considerable pro''ress,  a gray ojpacity
is at once notice1d exactly fillinty  ting    t  are(a of the pupil,
Fmr. 68.
Nuclear cataract 1. —. Section of lens. 2 a Cataract as   seen with ophthalnlm o sopic
mirror. 8, Cataract as seen by lateral illtunination.
the  opacity  being  sharplly  limited  by  the  pupiltlattr
m.argin.   A.l,   corneal optacity tinay hlide:  a portion of the
iris,  but a lenttictlar opacity can (. only obscure the pupil.'the pl)pil shouldt   t b   enlarged with  atrolpine, tand  the
eve ex tamined b   oblique or lateral i tllluminati-t.
Ax't:?amitio n by la/ f al tt ailtmi:atlion         ) enat bles us to delterlline  the extent and  nat.ure ot the opacity, lwhether
co'mplete'   or ripet its color, its forlat ion),   wlcther  nuclear or striaited, and otlher details.:Direct ex:tamin ationt  witt the iophtbalmoscope is ch:i eflt.
serviceabtv)le in  detttctitng slig:t lf; and  tbeil.nilg    ot)aitv
of the lens, which would oth crwis  esae e sca    obsrvation.
lThe light. sfhould not be very strong, andt the eve of the
observer shotuld lbe twelve or  fifteen i. cells from  that of
the patient.'here    ay be a geneltra, but, ver  slighIt,
cloudiness  of the   ie ol   lens,  or the  nu.'cleus  a lone
may be  obsure (Fig.  i8,  after  Nettleship), or delicate stri u    matxy ( eb seen rtunning  from.t the  peripliery
towa rds the centre of the lens, as in  Pi.. 59 (Nettlesihip).  These opacities will appear  black  instead  of




)tIAGNOS:S OF(i  C        kATAR ACT.        237
gtraisl, ass  inI  the  lateral  examinmatiot.   Beginning
catatitir'at maylt:    b.t conlfoundlteld  with  8sepa ta ion  of thi
rttiinla, a fact wtAichl is not:iced under /te.'tinal i)iseases.
In ctases wthere -the catartact, is denAse or far adlvatncedi
FI(;. 59.
Reft rencs a in Fig, 58
the  othalmoscopie signs arc nega:ive,  as io  light
can  be throw'n  into the eve.
CoMpt', CAfl ON, \WTli  OT    IlXi: 01111  I:K 0)' THl: EY.,.he'lhl molst clonn'on I comti)licatf ions are'   -.-.he.results of irits,        Softenlini of the vit reous lunor,
(Choroilit is,                Sclerot ico-chlorodii is t posterior,
Separatitont of the retina,   Armbly'op.ia..
We may deterunid n.i   a compljiation or its albsece, 1)y
te.st i tig tthe patient's vistual power aftehr the ea.tarac is
ftllly.niatured.   lie mavy b)  a1ble to dist'intrgisl  niUltt
fromi  dat, or the lig'lt from at  window, attid to note a:
llhandl beftore his eves,  even a.t a dtistance of thlree f.t,. 
and stil  we s lould not 1be justil fied in pr1onomtctinit a  thlt
retina. sound bleyond a doubt)t:. To ren(:,der the abse'nce.  of
all comnpiicat;iois sure, the patient should h  he able to discern a dim n lii'ht; in a darke.ned room at a distance of ten
tofifteen feet,.T.her.   should be  ino c ont raction o f the
field of vision, as tested bv monving a ligohted cand le from
one part of the visual field to the other.  The patient'




238              THlE (CtYS'It iALLIN,'.LNS,
eyes should tbe fixed otn his finger at tlhe distance of a
foott duringll  tlis ts  est, and tile candle lt   lc    sluld    i thaded
while its position( is bein'lg chalngedt; the telnsion of the
evebatiI schouldt.: e n.ot:ic(d, atn  ilt in cases of tdout:, the
whole histor:)y of the failure of si iat investigmated thorough.illy.  fPain,  pthotophobia, flaslhs of lighltt, spectilra,
and like sympl)toms are to be regarded as Indicating n
favorable. comiplicat:ions.
Timr  CAUSE OF CATARIAC'
is )praobablly fali:ty nut:,ri tiion  of the le:ns.   itis may
occur in old al e, as in senile cataract; in dis;ease of the
kidiney, as in /diatbetic cataract; or itn aborm al c:hanget
in tlce deep structnure of the eye, as in secondaryt cataract.
There is also a congenital cataract, dating from  birthl
and a tt.ra tt atic eataract from  injutry,:leenectly, inves tigatitlons, by SchiOlen,  in regard to the
cause of senile cataract appear to show tiat the. opacity 
beg,'ins frequcentlyv in  those from  t.wenty to thirty years of
ge, and notably in hypernetropic and astigmlatic  eyes-,
in the form  of smlall white dots and streaks at the equator atnd in. the horizonPtal meridian of the lens, Later as
age comes on, tle opacities de4velop until the ianterior corl
tical atnd ituclear portions of the le:s become involved,
and then the failure of sioght is first tnoticed,  Anetropia, dleicient refractive powver or errors of refraction;,
may then be considered one of the primary causes of
senile ca.ta:ract:,   ()pacities of the len s fall, practically,
into twg-o great divisions, the hard and soft
Vide A. of Oph., vol xviii. No, 38




1^^           R            11    i;;' 1^1^ ivz. li    1^           1    I. 
^^            f  _ /  \ t oS   >-  c O - 94 w:v ^ ^  
^*~ ~ ~~ / O        O 4 4 O 5> ^. 6'* >'>' - W _
^^~~ ~     ~      ~~~~ w~  ^ +,,_ r,0 r;, 8o ^; >    >_t^ ^^ 
1            \/  e  I < o ^ F ^ _ * ^ - _ 4 l >> -^ i ^ _ 
<  w  b   Pss  O X _ F~  _ >~    -~  _-t -                -
^.    <#Q \X?"~,                       oO< o-^'^^   >_;>   ^ _ 
_' -   \4  G   ~ I ^ - ^ l"^  > i n r -' ^d - J:^; \          /        ^. 7 F r *:   ~L ""  ~^-   = r~::>,,^  ts,
C                                                             ".  -, "'V-    p- -s    o.,f;W - 
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1?'1  I I* SO_   l:  ~l,   li _  ^ll 3                   ^.




240  THE  CREYSTATIA S               NE'A;`LENS.
7he.iro/tress of htard  cataracets is verv var iabilel(, s8to
ti nes sl\ow  for a itne, and then raptt   idt.  They'ay, ind.eedtt  fort a tie l.not only ceatse to ptrogrlOtss,  Jbutt th1e (patient may,  tenlti)ora-ily, see  hletter.  It is  wiser t- n lot
to anlswer the invariable   uestion oi.f pat:ie ntts decidedly,
as to the t:imne  lwhent the catara::t will be tperfet   It: is
ve.ry c.r.tain tlhatl;t ti e o)rdintary se..ile.  it:t (c)ata t of one eve
will, sooner or  ( l ter, be f ollowed t)y the samc affection
in  the other.'iti tB OPERIA'T'ION 0' E;XTH'IICTION
is indicatte'd as soon as the eataraett    t  las  ipene.d.'Wte
Illtay  judtge of thEis l)y the app)earanlce of the opat.city
wh\ich is 1denser, deeperl in color, aild extenIds through
tlth  elltire le —ns, so tithatt thl shttadow  o:)df the iris at the
cireumtlferet  e of:the letns is8 sc trel  visible.  The visi
is also r(eductd  to th te  lmere tcountingt o{ finlt-ers.   Di taiion of the plpil wi tl  atropine l   iprtol:)ve   it less, as tlhe
p'eri'lpe   of t het lens  is ivolved in the  op)ac ity.   When
tle  cataraet niatres r ve ry slowly,  it has lbeeI     n recomlmende'(ld Iy  if)iorster t o hasten its d( \'velopl:lIentl  - t' ytl li
at preliilnl itnary  irtii1de:tomv and ru.l:)ingm the'orn:ea over
the pupil aid  lens capsule.'We may also operiate be1fore the catartaet is full y   ripe.'The disadv antiage of
t his is, th:at the tlrant sa. te It (l' orticat l lol't ion of  the ilenis,
hleiln  soft'er thant  the opaqtl    part, may'  s.ep'arate Ifromt
it, a ndt b:e left to a great:, extent: in thle eye, and tct afterwtards as a for0eign t)od(y, irritatingtlr the iris, and prodnelnigm distturbtance of v isionl.  Tt: is safer not to op.erate on
both tey'es at once,




TH1IE SMALI FLAP 0(1IATIO N.                     241.
THrtE PROGNOSIS,
The  p)rog:osis  in  extraction  is v'ry  favoi'able.   In
ulncomllticatteld cats    t here  afrct  probably not more tihanm
thllre or four per cent um  of ett'ire failures.
T.ie ope(rationls mostly ptra(ctised for  xt.rac:t ion  tar  tth
stmatl  fla.p, a nd  the pe.i'ereic.-ltte.r.'l.the  st rit poteripheric-l i near operatiion of (: rafe is losinllg grount d wtith
operatt):rs, f rom,' t1he dtanger of irido-evelitis, which mlay
follow it   meldiate:ly, or after the lapse of considerable
time.
Ti S 85. MALL.  FLAP OPE RATION,''}he patient bteilng  iln af rtcut lclbe.nt position, (an assistan:tt separatt.es thte lids, or th ey are  separa:ttd by a spe utlumn, the ('ope'rattor fixes the ee eye Ib pinchtingt  up a fold of
the conjulmet iva:r  wlith) a pair of smnlall forceps..lie then
lente.rs the corina, at its outer edge, eithcr at its upper..........           it......~.~.............v.........
Fio. 61.
('iraefe  cataract-knife.
or lower third,  withl a (- -ra.ef  cat:tract- tknitfe  (Fig. 61i.),
carri(es  it st:eadily  forwaird, cultt:ing  out either ab)ove
1'r  below,  and  makilng,  according   to  his  predeterminced  intention,    citlher     sluperior  or  inlferior l'ap,
I.::aq................ —::.:.:.-..................'.:
Fm. 02.
ceer tataraetuknife, frmerly utsed tfor imaking the flalp hi ex-t:actiton
Allowing the patient now a moment's respite, the eye
is again   opened, thle tneedle or cystotome  introdusced
16




B2! 2            TIi HIC CRY TA 1, N  L NS.
(Fig. 63), and the capsule of the lens thoroughly lacerated, This being aecomplished the opaque lens, with or
withont; the aid of gent::le pressure upon t     Ahe eye, emer.es
AN ltIlhout the aild.:)- of g-rentle procure1c upon tle eve,eergs
3fo. 64.
Daviel Cu ret to.
mains of the soft coriical substance of the lens are e'actuated -by (vent:vly apressing  h lie cornea fthrough the lid and
by rte aid of the cf te  uremtte or spa tula.  1 ig. (   a )t. lx
operators make an iideet:om   aftelr cmpleting the flap
antd before the evacuation of the lens; a few make a
preliminary iri:dect:omv about fou r weekis before operatilng for extraction.
Ei xvigenci(es urmaV, arise duiring' an operatfion like this to
modify it somewhat.  The corneal wound mav have been
made too small to adnmit of the pasSage of the lens.  If
SO, it mst be etllared  y cutting with curved       scttissors,
a p'ro'ceeding sometimes dific.ult, the cornea: Iinlg
directly uponll the iris, there b}ing,, no anterior chlamber
in conisequence of the escape of thle aqueous humoir.
The knife may have entered tfhe corneia t oo far from its
lilbus, too near its centre.  ]n this event, it is necessary to cut; out in the sclerotiea, and the wound will
lie towards the inner cantihus of the eye.  This may
render tedious manipulations necessary, a fter the open



PEmiPI IF: IC-LIJ NEAR  nX'riz ACTION.       243
ig:  onf th: e ca;tps I e, in  ord1er to force:lie  lens  inward to a poi nti   correspond ing to the openingll   of tlhe
wound.
tfr I:)-I~t t f f-ol.
Somnti tmes, after rui turing the c. apsule, instl ad of the
lens,  we have a gush of vitreouls llnuor firomn thl o   outih
ofi the wound.  In this cas e,  it is necessary to remove
the lens imme diatel v from n tle eve,  by Imeas of a
curette, or smnall spool.
beep-sated.'hemolrrhage may occ1ur1, especiallv if the'comiplication onf glattcona: existi andt in suchl evenlt tl he
p::r'ognosis is bad.  Ow()ing tv o sudden escape of the aqueous hIu.oll(., the: iris may be forced atgainst the kn life,
and wo tunded id,   in mak:in  th  corn eat l t( la. TIhis mart
render an iridcctomy necessar y   Tl  opraltion.:for exract nl.iont is done under cocaine.  The  instruotent s are
disinfcctdt,   atlnd the conuinctival sac thorougshlyv cle ans ed
with a solIt:iion of bi-chloride of mercury 1c   5000  before:lma:.ling t:hl ctoriiea.t in cisi on,
P -lRt I ri rIT.-  E.R N E  t  X:  X A CTIO() N,
Thi-ls operation, of'Von G(:ratefe, requ ires lthe recl-.'.'bent; position,  and the lids to he s'eparatetd b)y a stop-I:'
stpecutiumi.'he eyve, being lhe.ld iX  positit.on hr dJe'licate
forceps in the left hand  of -the operator, is en tere.    d
with the Craefe Xknife, the edge upward,    ii the scleroit ic, about half a lin f ct   m the corneal limb.us and near:t
its uppert'and outer port itn, so tlhat the anterior clhitm iter
will bt  openeid across its extremte upper n11arg4in.'Fi,
6(, from N'>ettcsl:sitp, slhows the varied cornical sections
in cataractf   operatiotls.  Th'lte knife, lbeilng enttered at. the
temporal side, is 1pusl'd downward aind inward until it:




244        T!        E CIYSTiAi      uN   LENS.
las  eterd at             eor ctber. th'o anterioc  th   extell nt of two'
or three lines,t wihe   the  titindle is depressted and the
pointt is caried horizontally f)orward towartds the nasal
tmarp:itti   of t:he cornetlct,  o as to  lttmerget o iit thle sclerotic
exact l  opipo(sit e it  ptlaco of ctrtr ance; the edge of the
iladte is then tturntted shtarplyt fotrwatrd, the knife pushed
horliontal 11  otnwatrd, and the sct'iont eomplleted  )y\ dratwing it backward ftromt  heel to poin  t l'tt e next step is to,  -
IFo. (G.
Line of incisions in extriac-ton ofnet:s. Old flap., f2. P'iplhel lainear. 3, Ul.ier
anid low\ir lshiot flap. D)otted cirelc showVs outline of lets.
lmak'e ant ilrideetomrv hyv seizilg the iris'whichl prI'esents
itself at t:he wotund, and snipptig it off.'1ThI  ea:tpsl:ett
is tlen licerated, 1a1, 1by genttIte   p'ressure 111ponl theo eve,.the  eatailraect is  foirctds   throughl   the  opl ing.   If, as
s::omn)eti:imes llhappl'ens, the len  is  Inot readily evacuated, it
shoutld lt)   drawn t: rom  the eye b:y a, s11mll slpoon-likei
tiract or or cureltte.  The oldt  process (17t30)) of svringin
oult te cortical remaitl   is again r1eviv\ted; but it is olne
ml:ore  manip:t ulationl of doubtful tnecessity, andl olne doul. tful Imanipulattti.on is undesirabloe.      t  It ymat I: o said, furtlter, tlatt  Nulel 1has fotun, by  Oexperimentt that pulre
water iltnct d ijectd  into the titerior clmn ilber causes a detaclnenti; of the endotthlium  of':)esceenlt's.membllrane,
in a half minute or letss,  (Arch. Ophtt., \'Vol. XI X
p  806.()




11 tCI.J NA.T1 ON 0)1 1)EIPl SSIO(N,          240
EXTRACTION OF TIlE LENS WVITI CAPSIlA.,%
An opening is lnadle in the  scleroticot or.the  corneoiera! junctionl, followed. b)y a11 iidectomy; a soo 
thten introduc(edd be)(hind the, leons a1d.Capsule.)  tiI and. )ot )h
are extraocted  t(roether.  It  is often  done for hyper1iaturte  ataraects.
ilI(CLNATION ()t l)EPIRESSION
for senile  ca taraoct,  b    justly  fallen  into  disreu)te,
and(t i  seldonl  practised.   T., eve i    s entered thronugh
the sclerotica, ab)out two litnes from  the c'orinea: at the
tem)por(al side, just be.1low the horizontal me)idian.  The
needle Jmnploycd is delicate-, flattened, an)d spear-shapled...:::::::::.:::.::::::::..: -.:; a.::...:;............................
Flo. 607.
towards its point, and double-ed(ed.'See   Fi,,t  67.   It
is carried forwa rd until its flat sturfa-e is directly beh-lund
the pupil, anid against th.c anterior capsuile..  Ti  lens
is then} pret',ssed geently } )ackward and d ownward out of
the field of vision.  Its effects T are, brlt li1an   t ti rst,.ut
not plermanent.  Now and  then there is an exceptionally successful result.  I saw, dutringl te h'semester of
t1803, in Vienna, a m1an whlo had reel intion p1rformed
for cataract in the year 1839, antd now, for the first tit ime,
was troubled l:by ildist.inlt  vision frlomn a shred of op)aq 11t
capsu le.
All  eatar'act operations are now done un111der cocaine.
A  4 %  so)lution is dropped into the eye twice or thrice




4:0t tii )        TI: iHE Ci l YS TAL. *,I..I  AiX:* N CS
at fitve-miute ilttcvals,} and strict anti-sepsis is otserved
as il other surgical operations.
A PTEI TRlE.ATME XI  NT I N EXT( ACTION.After tihe operation'  }both eves should be gent lv closed
arit  a sim t i    bandage ap t })I d  ats  dscribed i   chap l ter 
third under t    andaig,'. tche banldate and char)ie or
anti-septici ablsortlent cotton may be renew\ed every day,
thll. (tisct.hairge ttrenlytv  wtashed  away  with  tteiid  water.
At tentitliot s of tlis kind  re tder the patient lore t co.in-.f)ott.ab:   quiet, and less lt.ervous, and so facilitate Ihealiilt, anItd a f1ortulnate result.  Tie I    tient should kteep 
tis led about b  fou t rt v-eighttt hours, antl   then  if all goes,(well lie 1ltemay  lexch tiange it for the sofa.  lThe'   ttbandage.
may be comntinued for a we(ek, and then be replaced by
a brotad  shade,   andi  tlhe sooner aft:er  this the:patient
can gVt jnt.o  tihe open air the bet:te.  The  diet for
the first day or day antl a half may ensist of fariinaecoits articles andtl   beef-tea,  but after this, should bIl
generotuis, and nearly that to whlich he is. accu tt(iomed.
I genetral'(allyt a liister acolnite  for thirty-six hours or
mi  re after the op (eration.  If Ithere is mot pain o(i  especi"al disconiforti. t is  est not to examine t(:.he eye by open-, -
iln  thlte lids dturitng' the first five or six da.s.  If the ieve
is quite hot an(ld ptainful during t#.he first few thours after
t lie extractliol,   cotld compresses may be Iused..f.  (or t}he
lirtsto forty-cigt lhours if the lpxain is sevelre,  ad tlhe evelids swollen witth imuco-)urulent (lisfhatrge, we have al
dahnmgerous comlplicat ioin, suppuratioin I'f the cornea.  A.
comnttress bandage is to be applied (, amd  t         (ll  case trea:ted
as described undter   Suptpurative Cornrit is and Ophthatl-i




A.FT E  l TRUE ATMENT IN EXTiACT ION.'24: 7
miti s.  i'.his co(-iplicat ion avoided, we may  h.ave  an
acute iretis.  AtiAropile shlould be instilled t into the ee
at  ncrCe, of the stireitgth of four gr airts or more t  t:te
ounttee of water,  not only for the purpose of sCecuriln  im1mtobility t tho te iris, but to prevent, if potssible, closure o
the pupil.  Thle advelnt of acute iritis may be known by
pain, photophob1}: (ia, lachrytination, cheltmosis, (tiscolorattiont
of the iris, turbid laqueftous hum1X:lor, and contlracted pupil.
1The treat'tI(enmt of iriti has s been already given,.  Simtple
iritis,  of a serous cha ract:er, may conme on  later from'(.
irritation of the iris, and is less dangeroust  ttn tlthe
mntore rare acute  sctelppturative or trailt-ntic iritis above
timent iolned.   Prolsapse     the iris is liable to oc(urv soro0
ater extrat.ctionll in which case attopine and the:bandage
are to be imnnmediatety applied.  In case of corneal Jfist!a
from imp.'erlfect union of the lips of the (w  und, the edges
of the orifice tmay be toucht1ed catt tiously with a solt.tion
of ni ratofnitrat      silver which. may  effct thlte lCaling thlrough
the local infl:ammnination set tup by it.  If this fail, al iridectn:oy to relie ve intra-ocular  pre ssur e could be tried.
(fstoid c/if:tri:x, the namle given by Von (r-lfe to 
healing of the wound in the sclera or limbus cortnea?
t:ttroutghll the  intervent\ion  of cic.atricial tissue which
fintally becomes liniin and bulg'ing, is noticed oftenest asu
a s3(equel of irid|ectotImy for gglautcoma.  It may occur
also) iin gttlaucomattous eyes, after extract-ion.  We cannot
chltange tlhec nature of the cicatrix, but we mlay perhtaps
prevent, an increase of bulgitn,  sometrimes,  by orperating
to remove int ra-ocular pirecssurc.




248             TIlE CRYlSTALIAN.  LENS.
CAPSULAR OPACITIES AFTIER EXTRACTION,
After fullyt dilating  the pupil with  at ropine, the
wrinkled, setli-opaqueti   capsI)ul  wlnichl  some timles r clains int tle tpu)illary areat is to be torn open Iunder
cocaine with. lainle    dle wich is passed i    is p nto the eve
tlhrougl  the cornea.  See page250. It may he necessart
to use two needles,  one in each lthand, enitered at o))pposite sides of the corinea; their' poilts meeting inl the
ca)psulec ctan )he moved in oppo)site direct ions, wvhich renders the division  of it easier and more certain.  In
solnme instaitces, if the lmembrane is dense1 ( it.may he divided br a very narrowv knife whlich is madt  e to -elter tlhe
tiaterior chamtbet r at the outer or inn(-er edge( of the co-.
ilca; sometilmes it; may be advisable to a.ttemtttlt thle withdriawal of the tough capsule by mieans of lt>he tdelicate
canutlar l force)ps.  i t is a hazLrdous plroceedingl, andx   I
have often klnown it to fail.  None of these operations
should be unde t rtakel un uti    all irlrit iital t.y of the iris lis
p)tassed away, and after the operation, altrtopinet should: e),.
instilled, and the patient k;ept tfor ttwenty-fottr thouIrs ill
a. sub:dued light.  A. concentrated artificial light is very
ser  vieable in these delicate manwuvres.
SECONI)A RY CATARACT
is atn opacity of the    s occurring   in tihe comrse of
glaucoma an:d other deep-seated disetases of the eye.  \As
a  rule, nto operat iou for the retmoval: of the cat:a. iact is
indicated,  as tlte risk is veiry great:, without a prospect
of correspoinding benefit.  The operationt o)f 1mine, following tan iridecto' lyi for glaucolmal   published  iin the




SOFT CATAh:UAC-t.                   24 9
"New  lEnrgland Medical C(azette " for June, 1869, was
unusually successful, more so 0peCrhalps than could have
rea'onalt.)ly been  hopel d  for.  In'   tlhalt case, however,
there were pretty certa in indications thatt the ftundus of
the eye  tlhad been restored to a tolerably htaltht:   conditilon.  T'hie ptaticnti t c ould see a, lighted candtle in a datri   k
ene(l room!| at   (1 distance of fifteen  feet.  T' there was
evidelnce tha that tl glauconlma had l cettasd to progrecss, and
there wtas a clhnelt     t.hat whatevert  i nmplrovei^ nt of sight,
-milgt he g:aitnd bt  y the remnoval of the tiaqtcu  lens
would be permanent,
SOFT CATARIACT
occur8s in children  and  in subjecets under thirty-five
or fortrt yearsos of age.  Its color andi glenetral applttearance
have already bceen noticed.  One of the conmr::tone)st folrms
of thils lenItihculat  op:iacity is the.ttfantilt or conteritai
cataract.t /,     It is either congenital, or develops duringl
infancy. ""f.There( are two varicties: the lafmellar, called
by  ( eemant writers s/iei./,tstatar  is a central optacity
surroliuded I}) a more or less t'ransparent zone of lens
sutbstance, so flinat when the putpil is fully dilated,  the
sight is usually illmprov:ed to a( reCmark-able de(grt(e.  See
Fig'S. 68, on the next lpage.  It seemst to be connectled in
some mlanner w\ith infantile convulsions.  T}the p)rog.treyss of
the opacity is slow, sometimes almost impel:)rceptibly so.
(Chiltdren wit  th}is form of cataat are often thotuglt to
hte neatrt'-sighlted. thllt1s idt(ea maly be, corrc(cted 1ft   the test
mention(ed untder Amblolia, and t he cataract diagnosed
1)y ltatterl illlin'lattion  or tthe ophthalm(scopc.   t'he
otlher variety of optacity, the cortictal cataract, is much




'250              tTEB CRYSTALIANE iENS,
lmore rapid il its courtlse.  lThis op)-acity i's s8cet ill the form
of opaquet  sthi  rutnning fro lthe tircCttlunfrene  to the
celntre, tt e ie illsteices at filrst showingl tralnslarenlt lens,
whicth after a time beconies mottled,  hazy, and opaque.
3                         2! 
4
F>. G
ltefereces as Wfr.ore (Fig. 58) for l, 2, 8. In', the pupil is unditated, (After
Nettleship,)
When mature, the catariact is bluish-white, 1tnrcl dtense
at thlce cent:re, tle striae often >present-ingh   a pearly aspect.
In ilnfantile cataractt   n early Olperat-iolt is ilndicated in
order to prevent,  as far as possible, the ainblyopia retina, a which develops rapidly  in young eyes, when  tle
visual rays of ligaht are excluded  by  opacitics  in  the
t:ransparent media.
)OPmtEATIONS FOR. SOFT CATAR 1 ACT
i1ti, operattiotns for soft cataract atrc  tl hoso of desisci
sio'n, hnear e:l'.tr ction., t'- and st ion. D1 ei ssiot,, or 1solu:tion, consists  in  mi:ering  telc eve  tlhrough  th e cornea
with  a: fin  needle, ruptutring t         "he   capsulc of fthe  lens
centrally, and  lacerating  mor             e oor  l ess the  lens  1su
stancet,  permittint g its absorption by the aqueous humt or,




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52           1THE, CR(iYSTALLIN.E LExNS.
divin:- oaf the substane of the lens is mlore tharaugh
11an1d (?extende(d thlan ill tlhe ole advised for dise. ion and
rem   o fa the catartact b  absori ption.  Whent the l ens
matter las bccome soft(ened and sw ollen bv admixture
with lthe aqt(.eos humlor, the pupil being widoly dilated
bv at ro.pi ln, and the eye rendeored amIesthetic by a i:
saolution n lo.  co) ain..    the corinett is op..ened at its temporat
margin with a trl:ad needle in all oblique directi(on, A.
cur~ette is then introduced  the eve  being fixed in the.most  cnvlenienl t p(: osit ionl wit h th1e foreps), aind by gentle
pressur:e uponl thil   s  f te lips ofn the wond, the selli-tlui  lens
wNill flow gentlvy down th  ge groove tf the curette.:  and b
bronuigh t  o't att the small cort)eal aperture.  A ftertards
the silmnplie Ilandagce shaould be app)lied, and the padient
kept in bed fJor twent y-fouIl hours, the: pupil being dilted by atrpin   applied t   daily, ut1  i  all si gns of irit...is
lik\e the linear, is probably more easily e amplished
a few days after breakin I g  Ip the lens w ith the needle.
although either operation may fI low   iinmediately, if
neeessary.   iThe operation is like the last; described,
only in place of the ordinary Ncrette, is substituted a
tubulmair one, attaehed to a seeond tumlbet  ( If glass, and timis
to a metal svringfe from which the suction power i ohtained.,'Thel syringTe is conlstrncted so as to be worked
iby the right hand, which also guides the e(nrette, while
the lhft keeps the eye in position by the forceps.
Diabdtbc earaot, appearingin the course of a. diabetes, is generally soft, but harder in elderly persons.




' CASI.k ULAYt CATA IAC,  C253
It is to be reimnoved bv extract ion, if the health of the
patient is not too much impaired.  I have opera eld d0i
cessulir ill s Ch Cases, when the patient has had no
prospect of living, beyond a few mont}hs,
i catarac:'t is of'ire oet'    urct ie e.   Ge eral- v the re
is a nucleus l oreS orl less ftirm.    Suetion, or linear 
tractio,  is the( suitable operation for it.  I  appearace, it  is mtilky-white, lihomogteneous, and  without
opaleseeint striipes.
MED)ICAL. TRirATMENT OF CATAIRACT',
ataract{ is mknown to be a result of e'rgotisin.  It   as
also been produced in frogs by radministeringx su^ar in
lar    l quanltities, or by i     i     t unde.r the skin
rid S oft sodium-t  and alcohol have producede   simlar
reslo  ts.  In 0our school, cures, or beneficial results, are
reported to have fo1vled the use of cannabis coniuin,
phjospliorus, and many other remedies int ernallr.
There are reports also of cures~ by galvanisin  elect'ieity, anid massage of the eve.  But senile cataract is
culrable in one way onlyv; namely, by the removal of the
Opaqutiie lens fromn the visual field  through a surgical
operation.  (See cause of senile cataract, pages 238, 240),
CAPSULAR CATRAA.CT.
Ante(crior'sap's'u tar cataract or 0anteri or polar cata rae,
is usually situated centrally, and is caused originally
by an inflammation of the iris or' cornea.  In  young
children the anterior chamber is verr shallow, and in
the new-born it scarcely exists at all, the comnea and
lens being  nearly in contact, so that an  opihthalmia




254             TIHE CRYSTALINE LENS.
would he likely to extendt to the cap, o  i pu
leave some deposit upon its anterior surface.  Tis condition sometiles gives rise to a form of cataract called
pyramidal: it: projects into the pup1, but is within
the capsule of the lens.  An art icial pupil is    all
indicated in this form of opacity.  In capshiventic
cataact, both capsuio and  lens are extracted either
separately or together.
DIISLOCATION OF Tit LENS
may be spontaneous, the result of a blow on the eve
or head, or it may be) congenital and  hereditar.  It
is either partial or complete.  The lens mav be thrown
backwward into the vitreous humor, forward through the
pupil into the anterior chamber, or by a rupture of the
sclerotic it mar be forced beneath the conjunctivaha.I
the latter case, and also when dislocated into the anterior chamber, it should be extracted.  If lying in the
vitreous it may be permitte d to remain, if its presence
occasions no  irtation,  if otherwise, it  should  be
extracted.
iDlAON)5JOSi.
There is generally pail, photophoina, lachrvmation,
tremulousness of the iris, and the signs of absence of
the lens behind the pupil, mentioned under Aphakia.
Lyintg in the aniterior ciauber, the lens mnay be plainly
seen and recognized.  Not long since, however, a case
was sent me which had been called an opacity of the
cornea.  It was in ai eye otherwise diseased, and the
dislocation  was occasioned  by a blow  on  the  head.




TiAU MATIC CATARACT.                    255
UlJiler the colijulnctiva, the d.islplaced lens mnay be seen
a  it parent swe.lling.  In pa rtial dislocations there will boh)e monocular diplopia. or pol)opia.
Lateral ilium atiOt wAill etilnable us to deterl'mine the
namount, of (dis}platcemnenlt.  Direct exami'nation with the
ophthalmoscope is still better.  We may thell see the
free edge olf the leans as a dark creseentic line 1across
lthe red pupil.  Partii~al dispilacimelnt often causes great.
irritaition  and nmay lead. to glaucomatous it'flamniation;
in tsuclh cases the len-'s'is to be extracted.  Someltimlles
the great irritat~ion experienced at first miav be lessened
bh  the instillation of cocaine, atropine, by warm soothling" foment at ions of belladonna, ehamomilla, opium, and
the internal administration of indicated remedies.  in
congenital 1or other cases', where the dislocation aljppea rs
fixed, an operation for artiticial pupil is indicated,
TRAiUMATIC CATARACT.
The opacit' in the lens generally commences within
twxxentvyfoonr bours after the injury to the capsunle.  -It is
at first confined to the locality of the wound, but soon.
involves the cutire lens, spreading more rapidly, the
younger the subject.  There may be considerable pain
and irritation mrcsulting from  the wound in the cornea,
or laceration of the iris, or simply from  the pressuriie of
the swollen  lens upon  the iris.  Traumatic cataract
may occur from  a blow, which, without the rupture of
the external tunics of the eye, may nevertheless rend
tlih capsule of the lens.  The puplil should be kept dilated, and the treatment be, siimilar to that mentioned
in dislocation of the lens.  After the irritation has sub



27546            TH1'1Il E C  MRYSTALLINE.1I ENS,
sided1 if the absorptioll of the len s is found  to bo
on, there s8hlouldl b!le no surgical interference; but if the
pain    l continues,   t       ension of t    lobe tis increased  the
pinkish  zone around the l)order is marked, and traw
matic glaucomna is feared, the les should be extracted.
APHAKIA,
1or abseIWin of the crystalline Iles, occurs after extracti on, from  conmplete dislocation, aInd after ahsorption of the lens.  It may eb recogunized when the histonr
of the case is not known, by the blackness of the pupil,
di minishied size of the anterior chamber, awl tromulousness of the iris in case the latter lias lost the support of
the capsule also.  TPhe refraction of the eye is, of course,
much  changed.  An emimetropic eye becomes hypermet ropi c, a hypermetropie eve more hypermitropic, a
myopic eye less myo}ic, and the power of accommodation is gone.  T1hle spectacles suited to this condition of
the eye are spoken of in the next chapter.




SPEC,(T AC.LE,/ i]aS  ~..1 A   (TIFICIA  ES.Y E. ]Y.
SPEC('TACLES.
THE otdill:na.y l,.Isses fo sjl, sectales, in opt idef..a t,
are covivex or eoa ve,. p/eerilt  except: i n asti iiga i ia'ewhen  hev ar'e  c/el'!ri! or a co,' nationmt) ot   h
spj heoi al and cyvlinadrical,  in nuisntlar  isuthc ieneiCs
ey aIrc i'Tisms, eitheir alone or iI nComlbinatio:   wvith thi
othlers.  The nature and use of tlhese'glasses have alreadv wbeen,s'ticientilv expldailned.
power of the eve is lost, and therefore two 1pa10   ot spectaele   iisi  he nIecessa rv, onw for rending', of albout 1two and
one-half inches torus, and the otler tour and one-half
inche:s focus for d(ista1nce. Thltese  nuiner    ill varv
oinewhat accordin gt to the retractive sate of the eve
before operating whether emnet ropic, myopic, ort hperctropic.  It. is (advised bv sonc surgeons th3at thTIe.lasssES
1s1(1hould 1 ehi  1)-1 1s'tm' Id la circl',ed b 1}     black'ri::   of ebo: i   V}
or shell a quarter of an IIin    in width.  Large glhsses
admit too IIIuch li t into the eye, and enuse a dazzling
se(sation.  Somnetnies a combination of cylin.ndrieal with
17




258         SPECTACILES  AT.        CIA. BY S.T
tlh  spherical glasses is required lit order to afford suiweient ac'tteness of vision  for the patient to read   ith
comfort.
Cataract glasses should not Ae worn for some weeks aft
ter the operation; while.much irritation remais it is better not to attempt the use of the eves for near objects.
PANTOSCOPIC  LA
verres dti doul. e    er, are sometes called    n in
glasses from the fact that he wore such. The upper aid
lower half of each glass have different foci.  If a inyope
becomes presbyopic, the upper half of Inis glasses would
bel conca-ve for distance, and the lower half convex, to
neutralize his presbyopia in reading.
PRiISMATIC AND DECTIKIE) CLASSES,
Prismatic glasses are useful in aiding or exercising
certain muscles of the eve, as explained under Muscular
insulfhciencies and thlie article on Stab is)us.  Decentred
lenses are so constructed that the weaurer looks through
an eccentric part instead of the centre.  A convex lens,
for instance, may he so arranged that its centre lies a
little to the inner side of the visual axis, in consequence
of which a slight effect of a priismn is produced.
EYA'  PRtOThCTORiS.
Eye protectors made of eurved glass are the best.
Goggles with l  ive, silk, or glass sides keep the eye,
as a general rule, too (lose and warm.  For photophobin, simnple colored spectacles of plain glass are suf.lcient, and may be d(arker or lighter in shade, according
to the amount of protection required.




ARTIFICIAL EYES.                    259
Strong plate-glass speetacles are worn by those finding it necessary to protect the eyes against chips and
partieles of stone or steel.  It is proposed to make them
of curved mica.  Such spectacles would be cliheap, durable, not likely to break, and very light.
STENOPAIC SPECTACLES,
comp)osed of mnetallic plates with small' central apertures, are useful in opacities or cloudiness of the corliea.  They exclude the peripheral, and permit onlly the
central rays of light to enter fthe eye' acuteness of vision for ne(ar objects is increased, but fltheyv are not se..
viceable for more disttant views, as they limit the field
of vision too much.
ARTIFICIAL EYES.
After enueleation or excision of the eyeball, or after
excision of a sttaphyloma.   t            of the cornea, or ill case of a
shlrunken globe froml any operative interference or disease, Ithe deformity may be almost completely removed
)by wea ring a suitable artificial eye.  1.t should not be
wtor  steadily for a month or six weeks after the removal of tthe eyeball, lest irritation and intfltammatiiol
of the conjunctiivat% ensue.  To ilsert it, lthe upper lid is
to )be raised, the upper border of the artificial eye introdtcced beneath it, and the lid allowed to fall; then tlte
loweri lid is to be depressed and gently pulled forward,
when the artificial eye will slip into place.  To remove
it, depress the lower lid, and with a hook or bodkin
force its lower edge forward, and it will fal'out.  It
should be caught o(il something soft or yieldig so as not




:1" ^    "^   ^ ^          ^   ~~-^    %      ^     -.-.          -* y;   
-                              X S 1*,_                             4; - r
\\|': -                 -        jog_ o;,...       -.                   Ax        -Z:




DIOPTR IC  SYSTREIM ^I    NUM/vtRATION {    () t LI NSES.:261.
Numbenrs in           Focal distance.     (TCorrei>Soul:in ol
d iolp —Itricrsi' Paris inches.            numbers (ntcarly).
1I.......    ^.".,... 
s.,....,9'.)..
120....,...
will bhe noticed th/at the tnumber of the leu Ts inl the
new svstem  d oe s not corresponl1d, as in tle. old systelm, to
its focal lensth; hbut in order t.o find the focal lenlgth, we
of 9 inches; or, if we  all the metre 410  inctes (a metre
is 89.T EtInuglsh  inches), a lens of 4 diotptrics is one5 iot:10 Eglish  inehes focal length,.
To te~st tlhe, visual power, under t:his systems, we 1tt:place
before the patijent at a distance of six met res    ( about
Itwenty feet~letters of the sie of those numbered c 0 in
the second series of test type annexed to this volume.
If lie distinguishes these letters easily at six metres' his
vis in, is S  or one.  11 he can 0l1   see larger letters
iperihaps  those  numbered  TO, a   six  metires  dist ace,
his V.,'very nearly, the sevenity feet beia g about
In1 a case of amnetropia, take a convex lens of one dioptric (1)  I 1      If distat vision is impiroved oP iim -
paired by it, there is a mnanmifest Ivpcrmetrop fa of 0.,
dioptrTic.  1f, in anuot her case, vision is most inmproved
by 1) ~a4, there is a myopia of four diopt rirs.




262          SPECTACtES  A. TI1T HO!AL EYES.
To tcst the range or power of accommlodation.  in the
elmmettropic eye, the nearest point at which vision is
most distinct for small objects (the fimest type) gives
the mcasure of the accommodative l)ower.  For exampie, suppose this point; to be one linth of a metre from
the eye, then fTour dioptrics would express the range of
accommodation, the far poin:lt being  infiniteit distance.
ThIle accommodative effort lirought i into service to see at
thllis distance equals the effect of a convex lens of four
dioptrics, if such a lens could be placed with in the eve,
The same method is available in a case of hiyperncmetropia or presbyopia, the optical defe.t being Ji rst corrected
by a proper lens.  I!n a case of myopia, say of three dioptricss, - that. is, the far' poinlt is twelve itches, and the
near loint at three ill nches,   thel ac onnodat..iv.  range
is then from three to t:twe lve dioptlrics  th:at is, it it equals
nilne diopt:rics. Practtically, lowever, in hy llpermetopia,
I prefer to test the range of accommodation by fitting
proper g'lasses for reading, ald thenlt n(oting the far and
near points  thus yesterday, (for a yvotng, mat of eitlteen years, with slight; manifest1 hype etropia, I 1resentedf ))..- for read ing.  With these glasses lie could
read No. I type at tlirteen. centi. metres and  t fortyselven c( nt:i:res (from five and on e-fourth intc ic1es iup to
eighteen and one-half inches), a. very good power of accomntmodat0ioni..ll the ease oft a, wom(an of sixty, both
iyvpermeti.rop tic and presbyopic, throug'h grlasses of three
dioptl)rics she could read the tfincst ty]pe froln twenity.4-tree
centim etres to fort(y-four ce'ttimetress; also a fair power
of accoummodation for her age.




CHI'I A.PTE    XIV.
THE MUSCLES OF THE EYE.
PARALYSI8,
"I!l nerves supplying the muscles of the eve are the
third  (oculo-1uoutoruis), fourth  (t rochlcar),  and  si xt.lt
(abdlicens).  The third supplies the internal, s5uperior,
iand inferior recti, the  inferior oblique, the l'vator palpeibr'superioris, thle constrictor pupill',) and. the ciliary
tmuscle,.
The fourtt. nerve supplies the superior obiltique, and
the sixth  t'he external rectus.
The rectus extermus moves the eve out.ward.
i;  iinterulls Imoves the eye inward,'* +' "    supirior mloves the eye upward and inward, and rolls (inelhesi the vertical meridian) tlhe. eye inward.
"       " inferior imoves the eye downward tand inward, and rolls
it outward.
superior oblique moves the eve downwardi and ouitwardand rolls
it inward.
"inferior oblique moves the eve upward. and outward, and rolls it
outward.
The third and sixth nerves are m(-)ore)  often affectit ted,
the fourth  vc rya rearly. ]    or c)onvei en)      in deserit ing
the diagn:)ostic symptoms, we will consider the paralytic
afetion as occurring in I: the le ft eye.




264:                  THEt t    I  U'SCIX S  (   OiF TiffOE  EY I'.
PA  tA XLYSIS'i'0  ll X tX  {.XT  lJ  NL iltCT(.{J;
()n mol(vingl  ai tlo (}-tject  t)f(t) e( tlt'e t(-y  fr'oit   rig'lt   to  left
(a lig'hted catndle is cont.venllint), fa convergc. —nt  squlint  is
nottticed.    TIe m ove(ment  of t he eve to  t he  lieft  is  slttg
gbisHtl.'Thcere is diploptia as tthe oj}eci(Vt is:tmove: d  int-o tlhe
left ha1lf::t of  the field  oi:  visio, thto  imittages beinl-lg loiit tolti'ym n(s  (noti  cro(ssed, the  tria'gt   belonlglitgi   to  ithe- rig-   t
('9   t.:fl'ft.  lef; tO; f thi   le ft  cve),
iara'tlle l,  of   thei    stt.ame   Iheig.h t,
I tit  distailct'. c    -et:w(.ni  the.t'm     iln -
_ rea  si   g  as ti he  object is lmoved
l arthler  to  the  left.'Ihe  position  of thie headt   is also  ( chatiact-erist ic,  the  patiecnt  carryin ig  it;
itiitned  sominevhaiin t to  lthe  lefti,  int
order to  avoid  tlihe  conifusion  of
sightt  atisit(g    f ]roli   the  double)
iintaers.   A. prisnmat:ic g"lass  nnmav
he NV. wo'n   I;t) corre ct  tlhe  di plo)pita,
-as slhown ini Fig. 69.:'m. iD..           A-i pr.ism      entIs   tile  rays   of
Tlhis igulr, frou  N ettieshl    i,       i             r i    is           t
hows how a pI I m  ta    m I  |       gu  t.OWIXiS ri  ts laSC..            pp
tiiplopia,  It (the right eye) is  ti      i          it   
rtei. ltowards eri'   stead oft ob (the                 ie "et  
objea:), andt two imavgezs lof ob are
_jO, miitwoi'e',ofro:  t             ardts   the   tenlple,   rays   of
seen.  It.he prism  p, before the  
right  pry  deili^eo  the raIs to   Ii:ht   art   I ten, t     iouit ward,   a nd!1 (the yellow spot), anud single
vKision:s thle                     1'. in thti  t lnllt age  is ir'ojectd isnward'I
thte right eve i: stUppo-ed to he,,,1,                 t.'
a-itfictrlu'                       I:rlto a s  that   oi the  otfher  evye.
ThIe piist nati    c glass sh ( Id I')e just s'ti'rotn   enough  to:       fu t se
the two i  ages.   If we wish  tto cxCtci'    thie       ftl.              iparaly z
rectu:  so as gi                 traduall o t'o s{:trenti}e:  it, we may prescrit  e
reetus so as                            i'ng  hen- to    str}}-t   j9     it, \~'t' nItty [It'f5i' i1CS,




PA.tHA'iiYSS  (.OF TitCl'; SU:PEI.It:IN 0IA.  2(6 
ia weaker lprismitiatic glass l I whiclti dtoes not qutite fuse, but
ai.)lr',i'O xiates very nearly the t: wot  ilnages.  Te e fort of
the eve to fultse th11  itlltgts will call the trecet:lus eXxttertus
into aettion to( a liltited ext:ent:, and as it Ogrows stirogcer
(we may weaken tnhe prismt s.
PARAlt.,YSI  OF TtIC INTENRNAl, t   IC[tltUS
is rarely.vmet: wit t as tan isolated a clecti n.'The t hi rd
ltneve supplying rralso t1  h   Sup'eritor and  it fetrior rectti,
the: inferior obllique  ant: d  otherls,  severl. lmuscles aret
simu itanteo nitsl   aftt'cft:te  The  sympttoms  two(tltt,  how\eve r, be the reverse of thtose, jst noti(':ed, and prismalttic
glasses  would  he  worn  with lthe   ase  i ward.  Tei..
)patient.l  would also incline his he. ad slightly tor tow'a:rds the
righit.  In
iA HA L.YSl S  OF T i /t   SI UPEI iOit    l i  CT I. tS,
th(e. eve will not; t lurn upward readily.  T..c.re  is also
a slight diverg)'ent squinti.   Tl.he( inferior oblique drawintt the( eve 1outward. crot'ssed dot0)ile imaltges will otcurtl
in the utppelr half ofti   t Ihe visual fieldt.  Thel imag(es ar(e
not p;arallel, d i verg   upward, and differ i  i  l     heig  t:.
PA I ALYSIS OF S   TS E (    INlEURIOit iHECtYIUTS
would. occasion sympto ms j1 st the re verse of the a ove.
i n1.
)PA I. A, YS,     O   TE I SU t'  IO   O BL.  I' QUE) ti
the deviation  of the visual ax is is very stightt.  There
is a want of  mobility notict:ed  in  the attemplt to turn:.
the tev( d(ttIownward and! itward.   Iolmt: onymous, or cor-tresplondiing  d(oublei nmages are seen  in the lowerr half
| t  i~s}t~ll01 il brXi{}~l}  lit l 17~t4218   (li~    234>>^*8.  lll   t}l{} | ltrtll   1}*_   | 




2t(G             TiiE IMU t'SCAS OF1 TlH   EY E,
(of the  field  of visi:on.'Ile  left limag   (that of the
aftected  eve) tappears lower than  the other.  The imatges will hbe obliql1ti, (:onive1rgi' g towar.ds tlhe top..Thelc
patient lwibll he a 1tnnoye   in descending stkairs, whIich aptpearl dolic:te  and itrretgular in outlin ll.  H ol  will be arpt
to tu:rnt his head do'wnward and to the right,  so as to
lbrinlg  objecdts  into  thle upper and  left portion  of the
field of visioln, avoidinlg the (liplopia,   P'aralysis of tit
inferior oblique alonte almlost never occurs
PA  AIi YSit   Oft T.f1E- THI. t) NElXRVFI
Int. a  lhe co n')lcete, afficctinlg all the muscles suplplied by
it, or it maly be pa -1rtial, affect:ing  01onl   one  or n1more
of the nnittlsc.cs..11n  om.'ple.t:t aralvsis, say of (the left
eye, tlhere is fitrst ptosis.  Otn:rais ing lthe ut t lter lid  woe
filnd telt  eve'tstrict.ed it  its mlovteents in the upwarttd,
tdownwal d, andll  inlward  directiols.'Tle'rctu:ts extciritIs, )e}ing su}pplied  Iby the sixth. ntervet,   is utatffeettd,
anl  the  (t'e ey   ca   cot( tsquc ntly itmoe oult\att'd.   It; can
1also miove to a ce'tat i  ext:ent dowinwi' ard and  outward,
tlhrou( gh  tihe stl.pe tio''l' ('t)bliiqute, wt'I-ich. is stt'li(t 1ic   tt: l-cI
fo ti t.'t:Ei  t e.i'vc..'1rognftosis (tand  ireattmentt.
\'Wh'lethet a curtc  f pa'ralysis of t:hel i muscles of tlhe eye
can he progi)osi('d, defpentIds chiefly uf    m'n.  t  -he case of fthe.
afftctio,;   or. wht) twlet hic lesi.on  bie pIe'i tphe tc.al  or c)ntr'al,.  If syp7 h ilitic, ta nott tIotun uo(.mnot  cattsea, the p'rotgtlosis  is gener:i.t'tally  fa.vot.ablce, tht(e lcs sion   bein g tusuat ll
petriphleral.    If o.f'rheIuitt    ati'(  trigi, t}che  pr'ogno:sis  is
highltv favorablte'tlht    l    l.    lien due to i int:t': racramial causes(t, o)




XPARALYSIS OF THiE TH1111R1) NERVE,           267
sev.erle injury, fte prognosis is, of course, often infavorable.  Thle more acute the case,  generally speaiking,
thle better are the chainces for a cure.  In syphilitic cases,
I believe  iodide of potatsh, after Imrctt u, t:o be the best
remedy.  In rhel uatic ctases,  wlhere tihe sealt of the disease is probably the sheath of tite nerve, my experience
hlas beenl excellent wiith bryonia, gelsemiturm, lmerculry.
Local treatment should  not be  ineglected.   Passive
lttovtlnemTlts of th  eye vshould be made by seizing the
c.onjiunctival  with  the forceps and  rota;ttinlt  it sever1al
times in 1successi ( lon towards the a:ffected muscle.'T.lhis
can1 b       e done  aily under cocaine.  The patient. sthould
also 3exerteise the eye by efforts to roll it towards the
weancketCed tt.mulscle.'ThLe chlatltces o~f culre ae mlttcht incretascedI if the paralysis is partial Ilandt only one nerve
talte (. cteid, thle genralt nel\rvlous svsttem  beilng in good condition.  in case of ptaralytsis of the sixth} nerve (externalt
irctois), tlie condit ion of the abdomtinal  viscera should
receive more than ordinary attention,  as tlis nerve seems
to be partl'tictarlty influenced by reflex action fromi the
synmipatbtict.  W\hen otltcr means fail, patrlysis of the
c uila.t     muscles front perih'lewral'or Oxtratrainial catuses
matt  sometimes be cured by electricity, Faradi zationt
doesc not appear to be as eletiacious as the primt ary
gtal vani  currentl
Painl int tithe head, dizzilnss, loss of intelle:(ctual power,
lunsteady imov'emn. lt ts, a nd great; dific(lIte y in fusing thet'
doublle images by prisms, tal indicate a cere bral (caltse.
A\lmont^ the cerebral lesions.mavy:e me: ntionedt ttubercutar deposits, hydrocephalus, Cflusionls ot b)l(o:od, allecurisims, softcting (rillf   the b1ra in, and Itumors. tstti ts




268'IIIlt: MUSCLES  0ti-' THIE It  Yx i.
pit^rio sit is, es tos is,  and ttt the                        o /aise s'     of
the  braI in sitmt   ti t t es  oc a ion  tl h    paralysis.   HSim i  ai   r
orti:ail ttl.'e.tiols 1 n         Ist cV a118   caut  it 
It1 c(hltdretl, ofteite 1.1 th1an  in  a(dutlts, aI local pa al. y sis
1ayt t be thllie 1'l t11: t of somt n8 ervos iriitat'ion ini a.  dist8ailt
i)al'H'. IDentitio l is o'ft e:n the.exe itin   c aus 1i    a1td  it n si'li
i sta (-.es5 tl1e i)r gtl  sis is n' l. Vi   ltw    s f!'ttOav''orat ble.
is relieved.\   ty:i )  ta.dag:i  l one (: ye  or i vy th e   s e of spect  X.lat' ter l. w  otielr  r edia11 11easi uret 1s fatil, tor  oatl t
p: ar i ialltv c.oipI('le1't  t:    tie (rel,  tie' ati ( in al di t'irection  of
the eye antd thet.. resultilg   diptli ltia  may  sot         m'i1ttimes I(t'tremtedie d  Iy  an  o )pera tio)t 4 (1 to  rest ore  thie  ei tiuilii trii 
of the  11n l.a cles.   TI is w(o)uld  consist i.' Io ta)ly t   o I    a tte
not.      ofs  thie  opjo ipsipug,  1n1 1     al1    d lva ncneentien   of' th1
wedake:e-t, t.   siletc.   T'l'.,  d(esct'riti' on (i of. )t. pera'tins:on
thie  ntust(le's of tlh   eveh )all is,iv ven   uIett r I( 1 l tlh'artii le
ve're lt:ve rils anld t debilit:atit.g' dtise(ases like dii phthe t  ia.  I(t
mav ble    tI:produ c''Id tempo101l)rarily 1    v   1 dropptliiig, a  mtydryat:ic,
like  at:opiue,   into  the eye.   The latiel  t sees  well at
ta  distaltnc,  lu(t: its 1:it:,  aIftle( t   read' tie  tprin t.   Nelal
obj(ficts apll:)ear' i 1(1istinct.   Suitaile convex  glasses will
restore netar  visi(on.
Perfect rest. of then  eves and ft''eqnent 1.adlthing  iun cold




8THA'itMl U IS  U                  269
watelr should be enjoiined.  Th'e bdiet: iln theCe eases ouight:
to be gelerous altd Ilitiut 1  anad hvytieiiie:;  eoditioiis.
slhA1ld(  he madb e  ad s  a fvorable  as possibde,  lienItedies
tadapted to the ilpovcerished eondition of the patient s
svstom Inmay be useitd, bliut  ime alonel will also (ctr1  the
a freet oim.,
TiNSIOlN O)i T'lE  ILLIA Y MiUS CI.T
is iiet with  in  hIvIper.retiro(j i a as well  as 11 in lyVopia.
Itt o(easi ons  niyo )pic refraction of the eye, so that tlhe
patt'ient sees better iln  the  d(istalnce  through  conlteaveC
glhasses.  1.-y t' ral vzin'   the  eiliar'V  musele  holi\ev,'er,
we linid tl0at tIhe eye is really lpv ilernmietro:pic'; the 1tenlsion.ppe'ars to b.e the mresult: of overworkin ng' tIhe oilia ry muscle in aco.oimodatig, or 1'ma' he due to great exIposure:
of tlhe eves to brighilt  litiht.  B!est alone or rest-a nd
at: ropine instillation are the remed ies; late. r, 1the: faultxl
rebtf1action shoutld bre c'orected by pr'opt:'e  glasses..i'nstt;us, or involuttntary oseillati on ol  tleI  e yeb iall,
is owiniig to spqasmodici twvitelit:ng' of the nmuseles w! v   ich
conttrol  hlie trlobe.    It is most frequ'(IentiI see   in eongenital cataract in eh ildren, but n0may 1)c4  brougtiht oim b1)
~an.y a.f[fectioU  of the eye wvhich c0aus.s idlisti tneiess ofi
vision,. It s  eure  can  only lbe  effeet ed  by  restor'ingmt
autieII(ss( of vis1ion to the diseased eve.
sTi A uIs Itus (CONCOMITANT STA!I i3M S).
lyx this termn is mea.nt a manifest deviation of the opti:: axes;   latent or ('dynamici squint is notieed el.sewl.here,
When the eye is turned inxtward it is t:ermeld eo.vergoent
s'tiabtismus; if outward,  dive'erqet s'tral mis  us.  If eonlined
to one eve. it is ca'lled:mnot'uh/r; if the squint alternates




270'HtIE M3USCLES OF THE EYE,
between  the two eyes, it is bintocltt           or alternatiqj
strabism tus.  Il the latter case, tihe a(cutelness of visionl
in the ttwo eyes being about the same, the patient fixes
somctimnes  one e.ye sometimles the other;  on the object,
the squinting eye being the olne not il use for the time
}being.:tIn inonoel')t lar strabismius the sight; of the squinting eye is alhnost invariably impaired, and no attempt
is matde by the patient to use it.
IInt treatmentl it is practical to divide strabismius also
into th  per iodi and the e   t cof/tlirmt:cd, although tthe pathology of the two is usually identtical, and  lthe first is but
the p;recursor of the second.  Occasionally, however,
we meet; w\ith a- periodi(c squint, estecially in children,
whe\re ttm affect1ion may be tr t::td t: l s tome nervous irrtitation in a distant  part, or to the ce(trebral itlritatiot
ft1trom  dlentitiont.  No doubt that a S(lqint of 0  tis kindl
arises often fro)m pa(rtial pitaralysis of one or more of the
ocuilar mus.cless, andt is  therefore not 1pro pe)rl( y spoken of
under the head  of tConcomitant; Str ablisus.  In  the
latter t'here is a tel:nsion os r ant   increased  energy  or(
shl()rteling l f a misc l lec, but.l the eyebal ll catn   e m soved,
although  these ml(otions mttay be.) somewha(t restricted,
outward or inward. at  will, and in this it ( differs from
partalytic stTabismus.
"Th/e catuse of  trabisnmus are errors of refraction, uniscular insuflicienc:ies, tiamb)lyopia, or anty ctonditionl tentding to inequalities of vision in the two eyes.
CION'VxtIEG }NT STRtABISMUS
is usually associated with hypermetropt)ia.   onllers blelieved tthis to be the ease in sevenlty-seven per cent, and




CON()N VItECRUG llENIT S S t.UA H::iSM tS. T, 27 1
I)o Weeker in eiglttv per cent,.It will be r emenic'eiered
thatt in tho hvt)Cern l topic eye tle a ntero-iposterior diamneter is too shlort, alldl that paral'lel trays of lighlt reach
fle: retina before bleing focussed1, and visiton i  therefore
inllistinctet  thlat: thle rfcetfltacivye powerl ol  such eyses re't
(f uir cs to be aidedt bv ctnvex glasses in otrdr to prevent
over-exertion in alcc tonf odatitng or accommodative asthc-'n(opia.  I  rtegardtin'  near ohje;' ts, still,greater exert'iolns
to") atccolmlodateo art'e necessaryt  a! tlt ((co)lsenltlaneous withIt
accomntt01dation-  comes the conlverg'ttenc   of the  visual.
axets in ord.er t:o fix both ecys on the same Ineat    r t   ntl.
Convergence,   however,  il s tch eyes is gr eater thatt
itnd er similtar circltmstanc(s i(t wouldtl   e, inl normall v
refractive (enllm et:roptic) eves.  A  habit of tiurIilag the
et.ycs inwa  iw s forlied, whltich results first'i  in a  l). priodic
thean  inl: a   lpermanentltt squinti. Tl he c( on.vergtent e   ei ig
too great:, the child finlds it easier to see, if he t atrnll  one
eye slightly outward or fixes with  one eyve  the  lfelow
ye, foill owinglt  the llmovementl t rolll s still fa rthler inwardl
an.d thle h'abit of Squintilng' boegins.  aSucth squintt often.
makes its tsap:lpearan ce int childreln at the a ge of fourI
five, orh six,>'calxs, whl t.ey are learn ing't  i to retad  altt
is often  attributed  to:any cause  but; the  right tone,.
Solmeti:es it..s its appa.' c   is  toticed a few year(:s latter
when tlhe first.earest  stsud  is b. eg      if o  eve happels to b)e 1motref hyprmetrop.ic than t!      o tlerl thee tn.dency to sq:uint, is still strt'onger; for this eye m1ay t.hen
turn inwalrd without tle antlnoyaince which would ottherwise tbe occasioned bhy the producttion of distinct double
visionl.  The s:ame would be  true i  ifn  ivpermectropia
one eve should  be am:blyopic  or defective  in  visito




272'rII.    M  US'CL..EuS O8 ). TH.E ErYu,
fromi o((acity of atily kilt i, or if th-e rccditts  sextetus l  be
itt}stltal \ly weak..
t lrich,  Seggrer and o thers have       i sh(own tha t inl non- 
s('Ittllg  })rn'lett:ttrop)ic eye(:s  tlhe al:bdu:tion ic s stro:t)lger
thioKt' iin emme(ttor(lpic eves; Ihen('  the reasonable infer-'cie tlhat: in sqtoinitinlg t.ev:s ass:oiat(ed w\ith hylperm'net'ro
ptia. tile ab::duct ion is co.mtarativ ely weak.
)I.1ts1.:iNt SPTtA tT I BIJl wS S
is  vetry  apt, to 0  e  associated  wvith  ilyoplia.   iLarge
Stial:)Iylollta. p})sti'uni-tl'l o' pst(ostriorl' btullging of the glot)e,(
itci'nretases thei(   ttende(ltc.yv otf thte mvopic: e ye to t:ullrn ou)tward, 1a5 does als'o) tihe freqruent; weakness in the internal
ret-t ti miet  with  in liyop)ia    (.)t actt.ount of dtie telon-.(gated shape o.  the eyebtall it is dit.  icult to (.conv(xert(,e to
t'j t lhe..tar p)ointi fr tmyotl')i   isit)l.   T'ilherefore: o.e e   is
use:d tand tlhe. othe'r rolills outtward.  (One ee(). bt-:t>,lt,    ll iort:
mt lopic than  the (othrittl' i)ncretases the' t tledenlc  to divertge(.nt strl: txisus.  (':t, rtt r: it(.tet:.ts of sight in I'oth eyves,
vi ion  bteingl' altmost ablsent, are apt to)  produce sitgltt:.ivergen.t sqiuiint.'TO  DEI0EVTtMINE WIt1CQ11  E.YE I1  A IXFECT'ID),
Let the pati:.entl re'gard an obl.je(<t a t - w fel et feel rom  hlitt
thei)  c)over one eye with t he hand,  and note whletl: her itt: is
tnecessaryftl    forB the Un)\co(lredt(  eve to makeli  a lateral t  tlove-)
menttt ill ord erl to fix itself oni the object.   We ty  eacht
tey   in this way,   and t1he deviatting evye is the a:'ttectedt
one.'.hl is determilnes the pt,.mary deir     atwiotn.   T!'Ihe ste-.
o.ndar??    /deviatioan is the associat:ed mo nvtm: ent wthich the
Kinl. Moiu    iitteic', quoted by Nores, to. 1 7.




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274'TlE MUSCLES T   OF I'I FYE..Wv., while it is turned inward or outwar.d, and then
covering the sound t ey  permit the form-er to fix itself
o11 SOtllc conlvelnient object, when a second (  ma1.111 tk 1t beneatl
the cciti.rc of the pupil is agatin made.'Tle distance
bet.ween the two imarks gives the extent of the strab is
m nus.  Several inmstrum':tents are inA vogue also for the
imeasureimient of squint, but the above method is simlple
and generally sufficientlyv exaet.  See il"g   0
T.eatment.
T he tfrcatmoent, of course, will depend vei.y nmuch upoll
the cause, also utpo  the history, d1uration, the state of
vision, almou1nt of d(e.viation, peritodicity or permanency,
and wtiether monocular or bilnocular.   All these points
are first to be invest igated,
Wthen the. squint is recentt, and the result of nervous
disturbance from  asea.rides, dent.ition, whoopilng-cough,
gast:ric or othler visceral affetetion, the removal  of the
pri(mary  disease I by suit able general treatment, may restor the t eyves to their normal position.  I have knowin
squ iint to d isapp);tar spontaneous ly.
I will not enutmerate the many internal remcdies accredited with the cure of this deformity, but:.1 may say
that I onice. heard a. distinguished  1surgeon rCemark thalt
forty per cent of the cases  in youngI people get well by
proper hygienic treatm.ent and a correctionil of their optical defect by suitable g'lasses.  Not long ago a lady, upon
whose daughiter I had op)erateid for sttraisn1us, informed
me thlat: the reason she had not.. insisted on an earl. ier
operation in the case  of her dautghter was that she had
herself been "1cross-eyed" at tlle age of seventeen, but




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27T6           TH.E MUSCLES OF TmU  EYE.
slt   outwautard,  Tli  eve et  is turned outward tlhrough
tihe i voluntary effort; to fuse tlhe double images, care
bein$g1~ tlak(en thlat the plrisnm be of just sufficient: strengt-h
to n(eatly,  but lnot quite, accomplishl tlte fusion,  In
Iorder t-o  excrc(ise the internal rectus, the base of the
prism. should be directed outward.'lThese orthopa:edic'asurelS will generally be flounld more efficacious in
slitght paralytic than1 in conconmitantt squinLt   In the
latter, however, thevy may be used to ad(vantage,'when
nece ssat'y, with at ropine, in perfecti lg the lresult of an
operation, and especially in aiding to fuse the double
images, which solnltimes are very annllovint  aftr op
erat ions.  Bee   g 69 Ut) on page 264.  A naother method of
treat inent; fa-vorably mentionled for conyverget it stTabismus witi hytpermetropia, in chtildr en  is to paral ze the
ciliart  muscle with atropine,  so as to prevent all attellmpt  to accommodate, up to the time whenl suitable
glasses ean be worn.  Coimmenced early, during peri..
od ic squinat, this treatment has proved successful  in
some instances.
u.rgical  re.atrtient of,Strabismus.
When the case is of long' standing the operation of
tenotomy i isindicated, the object' being to divide thel
shortened lmuscle at its insert'ion inl the sclerotic, and
permit it to reattach itself farther back.'The operation which I usually performn, anfd which
I think most advisable, is that of Volt (ra-te.   The
eyelids lhaving been separated by a speculum or an as"sistantt, supposi ng it a case of convertgent st ral ismius,
the assistant turns the eve out.ward with a pair of for



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278       ~TiLE. MUSCLES OF TIlE EYE.
tmay be applied over the  losd lids,  an  a w  doses of
4l utiloe administered.  The divided  muscle will reunit
itself to the sclerotica within three or four day, and
whiie this process is bein, aecomltished  it is well to
batndagwe t]he sound eye/, so as to comptl a central position for tle otther, and inlure the  att ent of th  interinu  Ilhiild its lfo-rmer i f nsertion.  T.he dtail or ocaionat exercise of the squintilng eye, by baidaging the
ise o  tif; SqX {: t....
sounld one, for some weeks before the opeiratioIi for the
piiurpostO of restorinr aenCte(ness of vision, wen.'  tl t eve
1s amly lopiec, is e on n e tlda'l 1 e.
te sqin             considerable extent its  of  o eetter to
ofp)iate O'n both1 eves.  Fo-)r instalnce, i  the sterabisnf
is tlhr!e line..s iln extent., by one operation on the al'leeited
eve we may redutce it to one line1 then a sligter operation on the sound eve witll bring' the visual a-xes of both
piarallel.  It is best to wait soome weeks before openating
on the secondl evre ill order that. t11141 full etlect on the fi rst
may be determiniied.   ne operat 4)n will not usualiy reio'Wve( iorIe tlitant fr'l.om two to two ald al half lines of deviattioin.  The elltect 1is inerease      by a fre e sepa rat lioln   f
sni1.eonjune'tival t issue from  the mnusce! when  0peratin.
The effect is decreased by avoidinlg this.'1The. effect mayV
be lessened when, after an operati          -In, o  testintg the resuil t we find that. we have don1e to1  much. bly in isert in ig a
deep e4)njiiuictival suture, bringing the edlge of the wound,
antd with it the muscle, farther towards the cornea.  A
suture, carefully incluting the conjunetiva onIlv, may
be illnserted diagonalIly, to hlasten healing and })revenit
granu lati  s from spring ng np in the wound, without
lessening the effect.




SUi:1-RG}ICA L TI REATMINTET OF ST: A B1ISMUS,. 
Usuall tlie s6inkling in of the caruncle and the acomnpanving'  undue proninlllee in titt globe, fortIerl  notic<ed aftetr opiierations for st rabisnuis,  are to be avoided
~b  limitblig., the sepatration of the subconjunctival fascia
with  the  scissors (avoiding, also, all unnecessarily
large excursions with the hook), by conjunctival suture,
andl  above attll b  being careful to divide the tendon, of
thoe  musel  at.:  its insertion.  It is considered best h-v
m (ost o(perators not to attempllt too great an. effect upoln
)one eye,..but rather to divide the operation bet.ween bot
eyes; this avoids the disadvantage of setting back the
internus of one eve so far a; to prevent its turning inward freely, and thus disturbitng tho harmony of bi nocumar eonverg enlce in accommodatfion   as well as thle (oordiniate abalance betwe\en ti'e ocular muscles.
In rare instances, b)oth in paralyt'ic land. concomiitaInt;
squint, it becnmes necessary to adiva.nce the insert ion
of a muscle so as to  ~ive it greater power.  There are
imanay   e. methods of dointr ttis, each d if(ifili'ng motre or
less in detail fromit the other. PTor a. deseription of these
pl:erations I toll ot}li.ged( to referl the reader.. to the largerl
works on ()pht hi-,almology.  Thev are quite  dificult:, aInd
even in most explritneed Ihands less effect tiVe, someW
times, than their promise.  On the other hand, thei rIesult: is often surprisi'nuglvy satisfaetory.
Finally, I wouldd sav that T do not, as formerly, advise
an early operation in children.  T'.here may be exce;ptional cases wlien tlhis might be desirable, but in general we should wait until the patient is eightt or ten
years old before operating'




C(t1APL1I1t XVI.
THlE EYL'EYELID)S.
BLEPHAR ITIS   R POPlu I   IA[MI  TARSI 
Is a follicular inflainmattionl of the edges of the lids,
whbich. are red and swollen.  Excessive secretion from
the follicles of the cilia produces a   0mornllg agglutiation of the lids in the beginnil}ng, and later, in severe
cases, the secretion:)comtinug puruleint, there are pustules and superficial niceration, thle cilia fall out, the
tartsal border becomes tlickened and rounded, the lids
are crusted, the pun)ta lachrymahlia no longer catch the
tears, and the excoriation and irritation of the edge of
thle lids are kept up by their constant overflow.  The
cause of the affection in nmild cases may be over-.wse of
the eyes, especiallv  in an  unwholesome atm.osphere,
an(t such causes, generally, as tend to produce a lbypert'miat of the conjunctiva.  Quite frequently an error
of refraction is the primary cause of the trouble.  Severe cases occur mostly in ill-fed and ill-housed scrofulous subjects, and often as a sequence of ophthalmia
scrofulosa, or of exanthematous fever.
Tre atment.
In mild eases, rest of the eyes, avoidance of impure:,
atmos,0phere, the application to the edge of the tarsi at




BLEP TA'  LS.                     281.
nigit of vaseline or of aln unguent of one grain of white
prtecipitate to za drachmi of vasehire,  will suffice to cure.
The correction of refraction by proper glasses is sonmetimes all that is necessary.  In s evere eases, in had subjects, we must rely Chiefly elon the constitutional means
mentione(d under Conjunctivitis Scrofulosa.  The name
of Ithe unguent: recommendcd for these cases is legion,
but I find 0one better and simpler than the others, and
generallv ass effective as can be expected for an inflammnation which may be rega rded, often, as at local manifestation of a constitutional disease.  It is made of two
grains of the red oxidle of mercury to a (drachm  of vascline; a smallI portion is rubbed between the cilia: or
along the edge of the, tarsi at night.  Cleanliness must
be rbgidly insisted on; the  erusts mnust be soaked off
with tepid water, or milk and water, or warnm water to
which a little bicarbonate of soda has been added, every
morning, or no treatment will avail much,  F1or excoriated lids from overflow of the tears or eczema, a lotion of ten grains of borax to the ounce of water, to
which a few  drops of glycerine may be added, or a
solution of one grain of the acetate of lead to an ounce
of water, with the addition of a few drops of glycerine,
will be grateful to the exposed surface, and prove useful
at least as a. palliative.  Boracic aeid can be used similarly, and an unguent, two grains of the acid to a
drachin of vase:line, ma  be used on the edges of the
lids.  In siuch cases, slitting up the canaliculus, as directed in the next chapter, will often aid the tears hin
finding their proper clamniel,




282                    trIo  EY ELItS,
II}:tRPES ZOSTNtl FRONTALI,8.  (SEu OPtiTU AtMIC US.)
A. itlnber of ttffectiorls ol' the evoy  have beten observed
associa ted  wvith lterpes zoster frontal is; among  them
are co{Yjunclivitis, cornel itis uilccration of the cornea,
irtiris, paralysis of the thl irdt nerve, andl the ophthalt ic
br}anchl of tle fifth.  I  once hld a c ase of retinitis due.
to lthis a l fectiot.  It has been not iced thlat  lnless tlhe
vesit cles spread to the lnose, the eve usuall   es8ca)pes all
e.onpiieation in the disease; a(nd that: thle afleetion of
the eve is genuerally most severe when the vesicles extend downward to the tip of the nose.  The, t reatment
of the eve will b) mostly palliative, and Slh as, has
been giv n in this work in its proper plaee   The cure
will depend upon the removal of the hlerpes zoster. The
prognosis in such eases is good, excel)pt in old and feeble
1sub) jects.
MALPOSITION  OF Ti[m  IA )S.
J..'et(r>t  fm    W.versios on     thle iyelihls,
mary he caused bv the various opht-halmdiae, and by cicat rices. flron1t injlries.  A.rlt, of "Vienna, used to  advise u  in- these cases to bandage the e y, the indication
being} to shorten the lids and to protect the exp osed
mucous surfac8111   from  the air'hile piressure is to be
made by)  means of eharpie and tlhe bandag'e, not nl)on
the eveba ll but t  the angles of the lid, chiefly at the
inner angle, so as to increase the tension of the orbicularis,   After three or four days the improvement will
be decided, provided the bandage has been readjusted
whenever dis)placed.




MALJA()tOSIiOX  OF THtIlE LID S.             88
itn''Opiam:.t, in iver'io8  of th lAt, 
is (1tu  generally   to old purulent or gt'raulatltr op)hthtalmtia, in whichl h:t oth   o   frthe disease, and tihe prolmonged
Use of cttlst1ic(,  strulctitural  ha liaes of thle conijuncltiva.
htave\  rtesultedtt.   1t is somelittines tdue, il tihe lower t lid,
t::sp sodic a ftcect ionI.'l'i:hiria<is,  the tutnlilt     ilwtard of thle eyelashes, and the consequentlt: ititatiot  of
the  srfaItIc e of the cornea,  is a usual:  feature of thlis
atlect:ion..)histi.ltittsis.a   a double rtow  of ciliat inuore or
less regularly placed, results also from old ophthtalnie6.
The cilia tmay t:e cxt:rated in thlese( atse aes  wi lt  the  ilia
forceps.'he simple excision of a  fold (f the skiln betneatlh the lower lidt wilt soniettilcies iremove thle entropi um.n  In thfie tireatmente of ect:'rop.iuin and eutropiulm,
the pMalliative mc:tasut:res mentionled for o(phthalm i a tarsi
t landt thte ltmetdical and ]ygienic treattttlment  (reCo.-tme)ln(ed
for scroftllol!ts  1oph.ltallttita will always,e indic:tedt   In
severe etasets  urgi tiall. mNean'i   will be rctquitred also.t*  PtFor
the mntllt:ittude of op:tatio:s suited to the variotls:phases
of these atfeeti:on,   I am  rellet.tanttly obliged to refer the
read ler to the lmore comtprelhensive surgical wo rks.  Syphilitic and caneero.s iulcerat:ions of tlhe lid, tlhe latter beilng usually of the rtodent  or epithelial variety, require
thle same medical treatmenllt as if sitnated elsewhere.  I
lha\ve no lnew  experiences to offer.  A. case of rodent
cancer of the lid, now under my treatment fot  about
six wCeel, and of several years' standitng,i ii mprovinl' under arsenic  internally^, and  Simpson's  paste,
externally.




284                    THE E: YEiDJS,-S.
TUMORS OF T-Ili EYELrIDS.
Chftla.tziosz, or MJibtomiat:   (tS
is a morbid enlargement of a mieibomian gland,  gelecally isolated and ill tthe upper lid, but someltimes foulld
in the lowe.r  lid, and sometimes a number are noticed
in one lidt at the slame timle.  h'ley lare recognized at
first as sm1all hard promilencces which, as they  grl:ow
larger, gradually become softer.'Tlhe contents  are gelatilnous, or semi-fulid, occasional1ly nelarly fluid.  Exceptionallv they  are hard or cartilaginous.  Such tumors
are usually an indication of implaired health. Mothers
are frequently subject tothem  after conlltnemnt and
mirsilng
Tr'eatmenet.
These cysts not lunfrequently disap)pea r withoute treatment.  Sometimens the preseriptionl of glasses to corlrect
an optical error is all that is needed.  Occasionallytt
the application of an unguent of four grains of red oxide of mercury to an ounce of vaseline, applied to t he
tumor, n ighitt and mornin, with attention to the genleral condition and the exercise of patience  suffices to
cure.   Otherwise an  incision is to )be m:ade ill the
tumor inside or  outside  the  lid, and  the conttents
removed by a small. spoon or curette.  A four per cent
solution of cocaine is to be used, and miay be injected
into the tumor before incisingl if desired.  The Snellen
forceps or tourniquet  is useful to control the bleeding,
See Fig, 10 on page 86.




EPICANTHUS.                         285
f)TItItR TU(MOIiS'O THE UI)S
are  the  setbac.'tiou, o   dermoid, wt iclh  aptpear at the
upper and outter margitn otf thel orbit, butt soettilmes at
tle  lower andI  innert   ant  d  wheten  annoying  arI e  to   e
dissected outt; probably no medica(l ncmar     wi ll s1 iticeo
for their relloval.  Miiliul  or mollusomn, small white
tulmorl   arc to be prictkd or in.cisedlti    an  their contents
squceez(ed out.  o.i,.   antd atnteur t ism8 bs by anattsiotiosi   arie
to bhe t:reated as il otlr parts of the body.'. Waitrts -wmay
be ligattured, or snipped oil wtith the scissors.
HOR1 OttIoIUM5    R S TYE;
is (a small  boil at or neart the mal'rgint  of the lid.  It
is rarelt.c    necesstary  to tlatnce it.  At the eommcntlllee'nt,
if tle  fever and l   aiil are considcrable, told8i  cmnl'esses
and tacenite are indicatedt.   If dependent on general debilitty of thle tpatiient, t:he discase will lbe likly to rectur
ulless tilhe gettnet l  eailtht is restored, an1d often tA11t (l)Or
of refrtact'ion to which ite r ecurrence of the affection may
bo due, should be corlrected by glasses.  I.tbstt'ess of t/he lid
is gcerlital lyt  the result of  injurty.'tlhe treatmllent will
be prclcisely the sa me as for absess  in otltCr  t'pats of
the  lbody.   In case lantcinlug is n ecess(ary, tlhe itt:isiont
should be.ndett  iln at Ihorizoltta:l direction, so tlha.t the
cicatrix remainin lilt    wil: be  1unnotficed.
-1:EPICANT.    I US
is a  crescent-ic  fold  of skill  overlapping  the  i'nner
catthi of thO eyes, giving' thle face in this reg'ion an
Asiatic  tspect.  (lperations are underttaken  solely for




286                     Tif  E:YELU',I)S.
co.smetic considerations.  I  lt rememttber a  case of epicanlthmts at Sie.hel's C(flitni, iln Pari,  iln a girl six or sCvenl
years ol age.  Si.chel advised  )ichiing )up the skin at
tlie bridget c  of thle wnose wtith the finler's,   " ten or twentv
timnes a day for fi.ve lmitutes," T'le de:t formitv is  s congenital,  aind. decreases as the child growis  ol:lder.  1The
operlatl:ioltn  foJ{   it coltsitis in exc isitng  v-.rt:ical.  fold s of
skill il  the stpaces 1 betweeln the eyes antd lltittig tlvhe
edges of th!e wound with sutires.
PA t-A.lYSIS OF T'II:  OlII C UlA IHS lA OPt:t   ^AIMOS
p:revenlts  tom)plete closure of tihe lids.  A:fter a t:ime
tiell eve bt}ec.mtces itrrltablc from: c: nstant: expostur('e\; anchrypmati.:on,  conjunctivitis, corn:eitdis,  id(.  other cvils fo:llow.  fl:  tlhe c:ause of thoe diiscase. is:peripteral,  from
exposure to cold or dampness. ti   renmedies indicated
for'rlelt nat ic  af.ect:ions g(lnially will be indicated.
The eyt: should talways b(   e   silatt ld, or lightl y  covered.
For t:he t:rel:tcretttl ti when l ltle to  cent ral or  cerebral
causes, see:tceatie:nt t oft Para lysis of A uscl st     tof ij e E Lye
SPAS5M 0Ft 1'm'ult O  II( I:,cAta tX-S (i::t, XI''I i iA:OS)tPA M,
8is mtt lmost  frequentlyi t scrofulous ophtthalmia.   lt
is a spltsmi(odic closure of the lids, associated with affections of thit   eves where conlsiderable  ph:     otophobia  is
p'r.'esent    t is t is imet wi\thl in purtulent tiand granuliar ophthalnlias,;kerattits,  iritis  hypl:erasthesia. of Ith  retifna,
inl spratto'r(' it, l t:a  nera1 gias, an d i l cases of (:rf frf:cignt l bI(:odyt
in the cye.   With the remov al  of the above a ffection
the nature andtt    t reatmt t of  whlicth are spoken of elsewhlere,  tmhe sp.asm  of thef  orbictlaris t  ceases.




PIOSIS,                        2284
Somietilmcs the disposition to spl)asmodic closu.lre of the
lidt  becltctis tchtrofliet, antd l t:glltod pat a lld tient. t:treatment
is necessary  to  effet a.  c ue. Al cease of ri ln  of a year 
tand a talf stalf d t ingl du atpparietly to hyperthe'.t,.'tsia of
the retina, recovered tunderl th.e administ ratt iot) f niux
Vonrleait aand gclsetnilnml and the use of colored "'lasses.
lThe a(ffeci:tio, mav  be  due tfo  an cil   onr nod ati vc or
lmustelar asthcinopia, ttand rcqlis tr.atmlt      nt; as sech.
Occasionalvl,  in  severe  neuralgia,  when  the spasm
can be relieved by prelcssure over a t ranch, of th.e fifthl
InXrve, the branch  las been divided by  incisi.n, and
thle disease  cur(ed.  itc'tftt iation,: a stight  conlvu.lsive
twitchilng, or too frequnent wilnking or t     liink ing of the
lids,  is often  notficed  in  very  nervous or hvysterical
individutals.  It often acco(m pan ics other nervous d{"bility, is greatly  increased  by Imental agitation, is
somnetiltcs un:der collntrl lthrough lllj gret ef'fort  antd at
ot:ler itimes quite involtuntary.  It is oft.en incurtable
but ntavy somtcetimecs be removed. b1v improving  thle conditiont of tle lne rvAous svysteni of:.i   thle pa.tient.  It is occa.t
sionall v ailso'l an iindication of evy  strain.:f.romt m.uscular
or actcoinodati ve asthtenopi'ia.'  PTOSIS,
or drooping of the upplter lid, may bhc due to paralysis
of the third lerve, or of the branch which supplies the
levato.r muslsle.  In suc1 h instances tue treatmlenit should,
in tlhe main, be thlat laid down for par'alsis of the ocular mtusclese.  It is occasiontally an objective symptoim
of eye strain.'The diseasc  is sonletimiles contgenital, and sonuctuties




'288                  THim,:YELIDS.
the  reult of injury.  Ani operation may be performt ed
for its relief, but is not advisable unless  the ptosis is
nearly  or quite complete, and occasions great inconvenie nce.  Tie best op eration is that for the subcutaneous
contraction of the upper lid, A.  t'ransverse inc    isisi    is
made along the margin of the lid, about two) and a half
lines fromt its edge.  the lips of tthe -wound lbeing d rawn
apart, the inttpcegument is dissected fromn  the orbicularis
until the latlter is sufficiently exposed.  A  horizontal
strip of the muscle, three or four lines ill width-, is thenl
excised,  adl the wound clos d cl osd. sutures, which 
through the sl i   n   the sk  t   cut edges  of the or1bicularis.
(tass of partial ptosis in feeble pers'os from tumlef'ac
tionl of the lid due to effusion beneathl.  the skin are not
tulfretquent, antd tare to be relieved onlyl by sucht g'eneral
mteasures as thel impaired healtht demands.




TILE LACH)IRYMAIA  APPARATtS.
EPIPHIORA,
oi: thle  (ecessive secretion  of tearls,  is due to some
moechanical it-ritation of tIte eye li ke tlht of a foreignl
(body, anl inverted eyelatsl,  to a conljunltivitis or otlttalnit,.and to deept-seatedt illtanntit.on of the eve.  It is
freque(:nt I a reflex nervous sym3nptom  in ment al emotion
altd in va rious disorders of: the( gleneral. n' rvous svstlemn''le itrat:ment t lmunst,  of course, be directed to the rclmova1 of the irr.itation.  It is perhaps doubtful whether
hyp:er-seeretion of tears, itue to functional disorder of
the  laehrynal glaland, anl  independent otf affections
of the eye, ever exists.  lProfuse laclhrbvmlation is n:ot
a symlptomi of tlany of the recognized diseases of this
gland.
S'TIL,11itCltUM  LACHIIYMAIRUM,:or the ordinary "watery eye,"  is an elntirely different
affection,  and.  (may always be suspected when oine eye
alone is affected, and no immnedia te catuse of ilrritatlio
is present.  It larises fl'rom a.n obst.ruction  o th te flow of
tea:rs through the lachrymal passage.  FVinding no exit,
the tears collect along tlheI margil of tlt:h lower lid, and
inatlly drop slowly over its etdge upon) the clhek.  The
lid, after some time, becomes red and swollen front this
19




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ACUTtE INFILA. MMA.TION OF THfE LACIIRYMAL SAC.  Q91.
tand the abrupttt chanlge of lthe probe from t ite l horizontal
to the ver.ti cal )position,  tnecessary whent passiig it fromt
the lo)wer canaliculu,  is avoided.  Thle upperlt   canal is
readiy- slit with a delicate  probe-pointed  knife  like
Wbers. S.
In nraIr  instances the cat naiicaulus lma  be obtstru'eted
b'y at foreig'n  body, sueh  as an eyelash  or a Inlllte
chalky eon. tnertiontt    the relnoval of whcilc etffets a cture
of tIhe case.
ACUTE INFL AMMAT.ION OI' TIlE L.ACIHRlltIYAL  SAC
cot.es on rapidly, antd is often listakel   for erysipelas
of tile fe,.The region. aboutt the inner angle of the
eye is exquisitely sensitive to totou.c,  the lids are red
and   demnatous, anu d the in fiannation and pain over the
sac are intense until it burst's, w'hent  tomplettte r elief
ensues tl'11.   cause   of inlhtinmatii.on and suppuraft iont of
tifs kitl  is very likely( to be a  ptre.vious obstructtiont
to the flow  of tetars due to a eattarrh or blentorrelta.
HRetentiotn of lthe secret ionk in the sae gives r ise: to dilatation and thylpertrop:hy, and: f s  favors th  l format:io  olf a:bscess.  Jepetated suppuration leads to complete) ob)sttruetion:s of -the passage, to lachrymal l fisstula,tand to dist ase of
ithe laehlnrymal or superior maxillary bone.  N'asal  ptoly i
sometimes obstruc.t t:he lachrym-al passtage.    }te ttre atmlent of these diseases of the lachrtinal dutet and sac will
necsstnarily  be meealnical. as well as medical and topical.!r!eatment qf tAcute I./lanmmatio't qf the Sew.
Aconitef and belladonna, in this affection, will be requi red intertnatlly, with cold, or perhaps icc-wiater cot -




292           ~THE LXACIit{YMAL APPARATI'tS
tiresses externally.  By these iears tIlie formation of
abscess and btur sti  g of the sac, or the necessity of lancilng the sac, arlc frequcetly avertedt.  Another means o1
taverting pe)rforation is to slit the upp)ercanalicultel s, and
tpassingl down at narrow lkniife, incise tlhe neck of the sac,
which tmakes tt free openinlg upwa-rd fort1' the exit of pus.
If the dise ase plas  roglressed so far that suppllrattion is
inevit'able, it is better to lchange from  cold to wat-  applicatitons.  If the sac' is ver y mlucht swollen,  and tl(he
skin over it thas  beco)me thin, so th at; burstil ng  i ii uininclnt, it is advisable to t)o lay it open in a downward and
sliglhtly outward direction.  If left: to ind its owln tway
out, tte matter may escape at soe ulcerat      ated porttion of
the: sac, which }perfits it to flow bCene.atht the adj0oining
cellular tissue,  and  tulls create aidditional swellings
ttand finally filnd its way throug'h the skin at considelrable distanlce from its original seat.  Our object 8sould:be to )prevecnt comlpl:ications  of this kind, and  to give the
freest tand spc(diest t exit-  t the pus,   After open)infg, tle
Iilps of the w(tound should be kept lapatrt b)y a t- it, of lint
to pertmit of free disctarglc, and the swelling poultiede
if ttccessa ry.  After a few days, when the itllaminat ion
hlas subsided(,  the canali1'ultus should.be op(ened, and a
probe pIass ed into the sac to a. fford a free ent11trance and
exit fo:r the tears.  1The external  opening of the sac may
then be allowed to close.
If a considerable discharge of muco-purlulent matter
continuets, tthe sac andI duct may be s.8ringed out; with
cold watecr daily, or with som'e antoi-septic solution,.. ten
grainls of b}ortacic acid, or five grains of argent(ltum  nitricumn, each to an ounce o f water, I often use.  The solut



ACUTE IN XFA MMNAION OF THiE    AC I  YI  AI,  AC. 29
titlns are tlo he. employed daily, or every other day.'lo
syringe the sac tthotroughly, it is so0mietiit cs req:uisite to
patss a can tnulal (tqite into it, arttac:iltng the syritnge, like
tlhatl otf fi,   i,  tio   e mlolth of the canntula afterwardts
if neewessatry to thlie inlt rotduet ionl of tlhe {C'.annulla,  whicht
is I'erlthaps as lar'e as a number four to six of the B:8o'w-o
man pltroheJ,  the neckt of t   sac  t a  and tle intetrnall ) It'ebrudai fl ga:ncelt may be incised wi-th a probe-pointed k nife,.'1h0  select'tion of ilnternal  remedl ie s a\ lry much cntrolled by the general co:ndition of the patient and by
C TtEMAUUtt  & CO,.
Fie. 70.
the d.iathesis.  in serofuilos suILjects for instance, met rcur,, sulphide of ctalium, or iodide of potash s.emn to be
especially suitabte, and will be indicated stonetimes by
withi the disease in question have been sertvicr teal. lI
chtromnie eases, unless very mild, and of periodic.al. re —
currenee, when internal remed ie(s ar   e urative througph
the restoration of the general health, mechtanical tmeans
will be necessary as auxiliaries.




294           tHEt;   A   YX''l,''II't  tiMAL A PPAI.t IAT U'8.
D)Il.,ATA1TION OF TUillB  AC FR1O1()15 FISXA,'
F.ilinnt pressure upIon the sac will hlasten its reduction
to the nolt:rmal size and conditiot.'Tlhis clan be made
)y a thlick..contlmpress held in its p1lace hby a bandage.  In
clhronmic dilatation of  the sac,, where it is desired to a pply
the, pressure for a conlsidcrale period, it lits  Ibeen found
convcni t    nt to tue a slimaill spring truss, at taictettd t() a
tnarr1(w blland passing atround t1( head horizontallty just
tove  the ev'es, and kl)t iAn jld)ace by another hand rutnintg over the lheadi a at righ:t angles to it:
FISTULA OP fTHE SA( A,
Int old cases where the bursting of the sac has occutrrCed, tt     re1peatedly  occurred, a  fist:ul'oul  olpe.nitng
throttsgh  the skiln re is; and th   this chan neltt      the
tears flow over tt ctlhek.  It  theste:.scases an. exit ft(ort
the tears should hetl     mInade lbv dilat:iding tihe passage from
albove.'he fistuht will thten heal of itself o(r healingil
ma v')e 0t astene:.1td b}) toutt]ing' t}e edges otf (the ope)tnin('
with.    a crav(on of mild nitrate of silver, or s.ulphate of
ettopper.  In c'asets of ti ikind, d'isase of the bone is
stomtCim 1es present, and trlealtmentl, if undertaken at al,
is often uinsatisfaetory.
CH(t110(NIO  CATAIitR   Ott   BILENNOltRt[(!A OF T'! l! tACtlIYYM AL j
PASSAGE1T8,
l.maty result from  an  acute  ilftlama.lln:ltion  of the sac;
more freque ntItt   it is an extension of oa nasal catarrh, and
in DmV expst:>iene, it tappea rs some1timtes  to be an idiopathic disteae which comes on slowly and insidiouslv.




CI t lON IC C ATAIIIIH                29 I  5
A patient presents hlimself to be cluretd of "' waterintg
of an teve   He w:ill hardiv bc  able to inform  u.s accunately tof t:he tate of the commenceic  nt f }lis trouble.
It waIs first noticed  inl cold  weathert  and  (especially
whent out in l cold wintdts.  A fterwardts, it was tllnovi
iln-doors,  ocCasiSttonal    anld now the " watering " of the
eve is co(nti nlill(s.  We diagnose tle case at'once by.'puttimg   fi.inger over the laefhrvylmal sac andl  pressing'
gentilv upward, whelln a  mco-scrous discharge wells out
throughi thile puntctum. It.t naIy be possibl.e at tris stilag
ofI the tafi'ectiont to press t1le contents downwardt:1    t h rolugh
the tnse.    ltowever tins may be, if the patien::lt is willinL  to give   himself tlhe trouble to'press outt the contentls:of the sac sCeeral tif es a day, atvoid cold winds
over<-exertion of the eves,, and pay prop'(er attention to
the counition of Iis general h ealthI, t:he clhan.ces are
that lhe may go on for years, and lperhaps for a lifetime,
withoutl any increaset of tthec disordter,  In,  addition to
these hy gie ni c re la tions, mild c il l vri  of zi nc or al t ttum
dropp'ed   itt    e ti it  t  inlr corner of the eve will oft en
prove g,..reatv belefi cial   1. I have occasi(oalkly eIfected a
cure h   sy rin(ygint  the passage with inwild astringents
withoutt rcsortt t'o tlahe   robe.  F'urtxhemor, nwhent  the
gcineralt   healtth is at faulty one may sometilmes remove
the lachryltmal dis order by restoringl, the systenm  to a
healthy state,
Tr'eatment by Pirobint,
Patients  are frequt ntly imin patient luder tlth  above
treatmi ent, anid uItnwillil.rng generaltl  to follow suchl strict
hygienic rules;  they desir e a treatme.nt of somle deinite




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C11X:ONIC CA'TATRtHI.,                297
ingt the  probe  in a hoiontal direction, inclined slightly
upw\ard, at the sam  tlie i  stretching the ittcgtueint   s of
the lower lid outttward.  1-tavin lt reachedt the sac, as determined. by the firm   resistance of its inner wall to the end
of the lr, ad heob,  ad     the observation that the. inteCgrumtl nts
a t the inner angle of the eve do not aplpear to resist the
probe otr move forward with it, we turn the inst-rumentl
in a vertical  direction, and pass it do\wn into the sac.
To tilll( and ietert the lnasal duct, readil,  thle direction
of the probe wvill 1now  re1quirle to be sligrhtly changed,
so that its extrcnintv shall point a little outwardt alnd:
forwardt   atl, having  entered  the duct,  i  is to  be
pressed gently downward to the floor of the nose.  If
operCatinllg on the right  lachryal  passage, we may hold
the prtobe in the left hand, or stand behind the patient:anId use the right lhand
l}te probe maty remain from  t   t te     tw\\enty minuttes
nlesst irritation or pai  is8 felt, in which case it may be
better to leavxe it only fr-oml olne to five minutes.
24 stricture  may lbe s ituated at any point of the pass:age,  Its I most frequent seat is where the canalliculi
join thle sac, or below, where the latter is narrowedt
into the nasal duct.  It is to be overcome by firm, but
gradual and gentle pressure downward.  Frequently a
change from  a larger to a smaller probe will be snecessful, G1.enerally, howmever, -the larger one is to be
preferred if much. pressure is ltecessary, as less likely
to  lacerate the liining  membrane.  Tact,t  gentleness,
and sometimes a good deal of perseveraIce are requisite.  One may sometimLes try for two or thre ee weks,
at intervals of two or three days, before overcoming a




29f8          T'I i E T.AC1i I Y MAL, A)il:'lA AT AIUS,.
st:rict:re.    Whe.n w I  e find it impossitble  to enter the s.ac
from  the low1er canallticulr1   we mua  succedt,  perllaps,
from  thle upper, or it imav b.e n(cessa8ry to divide the
str'icturl,'beforet tlhe probet can be.troduttced,iT   with a
intrtrow:   histounr.  W\eberi' delicat   )o e-ointe   kt nife,
or the.'   narrow knife,  of Stilling are sait' abl le'b.   l'he cotit
(al probet of Weber (Flig. T8), wlhich increases rapidlyl
~? ~::,:GX?...............
in size f'rom  th:   point, mXnay sometli'nes be 11'ie d as ay
d.ilator to advant:agee, and the use of the knife tbs  dispentse. d   ith',   Occasio.:nall', the lini ng ofit  t:he sac is so
muchi thickened frotm  inftilammatiion atdt swelling, that
it st(eems imnipossi{ble to find tlhe entrance of the nasal du(ctet
frlom thlie sac. ti  such instances,  we may do bett'etc  to
r.'elinqlish all attempt.ts at probilng until t:iite and the
emt )loyment; of loc(al and Eonst it ltional remedies have
i'edt.uct..ed t:l.e inflamlmlationt so'ielwhati\   w\then tlhe lrobin'li.mav h  again attempted withl  beiter chances of snccess.
i   tnaving  once succeed.ed,  the operat ion sh}ould "be repeated on  every second  or thiird day,  syr'inging' also
with mild anti-septic solntions,  until thte flow  of tears
thl rough  the passage is mlunimpeded,'and  the secretion
becomes normal  in quanttity and appearante
TX't[ USE 0s O  TUE STYl.Ti.,
Attemp)ts  havee  ten made to.obviate the necessity for
repeated  proabilag, by the  use of styles.  Unlike  tthe
old-fasniotned oncs, these stSyles are intr odtuced  like the




GENERAL I 1    EMAh RKS.                2993
pt)obes, f1ro0  above, atl.d are to bo usedl for some lmoltlh)s
\\t When the dischat e  is nt g'reat thel y may  )e wo\ lt dtay
or weeks without chIang:ingl,  andt it is clai tlmed t-hat the
rritaititon set 1up) wvlen the st lte is firlst attemnptedtr   to be
tworn',  Soon1: passes off, ali  thle tptient filds it con
fortable.  lThey are matde of silvet r or leadf  of diffieren.lt
sizes, afd tl:may be fa ttenr.ed at tht e upper end so as t:o:be.
bent; over the lower lid like a hook.  The st yles atre of
wire ftroi  one twenty-fourth to one twelfth of an  inch
)'or   t'more in diametert  and tt, one and thlIree-farters if for
the lower, or two inchies in length if intended for the
ut ppe9r c anal ict lu ts,
MI x'ETiOD) 01F STIitXl:mNi,
Tihe( method: of Stilling plroposes to ttcure the disease
Ir.adically 1  by a single operat otiont.   l iest fit linds  the seat;
of th.e stri.ctut.ret b- probintl     andt then withdrawingtll  the
probe, intt'rodbucls a  smi        1 in. ar'row  knttife in  its place,
and irnc.ises the stricture in three or four different; direc(tiot..  Tlhis methodt wit}  probing  ort x th:)e w'tearintg of a
style afte:rwards is ia usual one at tIhe Moo:'l     ields I tspital, London.  IT t may  be a der dier retssort in obsti
nate cases, even if too'severe a procedure for ordilnary
practice.
O N ERAL.tEMAIIKS.
The m-ost frequent obsftacle to the permanent; cure of
catarrh or:blennorrhllealit is the thendency of the laclhr ymal
passage to close again  after it hiras been successftully
dilated.  1: believe tlhis tendency may be bes t overcome
by a modlerate and gentle dilation of the passages,  and,
when  possible, avoiding  all bruitsiing, lacerating,   and




8o00          TE LACHlI YMAI'      l APPARATUS'
even ctutting of.l the lining tmelmbal)u'tn, alnd tl-llhen by constituti:Moal and  local remedies endeavoringt to  resto( rvt
the diseased Inmucots surfacet to as lhealtlt   a condition
as possible.  Professor 2Arlt, of Vietnna,  rarely wvent
beyond the No. 41 Bowian tprobe, in size.  lie preferred
not to risk a ru)ptirt   of the epithelial lining of the passage, and relmarks that at its nasal portion its normal
eapacit:y is not mluch greater thanl    a No. 4 prot)be, and
tlat w where the caalnateuli join the sac the diameter is
less than that of No. 5,' The following  is his meafsurement on t.he cadavre of the sac and diuct,. AmilliXmetre
is equal to about one half of a line.....
TFtiL  SCAC.                 THE- NASA., )UCT,
Lengtlh, teln. W idth, four.  An-   Length, about ten. Width and
teroposterior  diameter, two      antero-posterliot r diameter, each
iXlllimetres.                     one and one-half to two andl
one-half millimetres.
in the zeal for dila-ting the duet as \widely as possible,
so as to prexvent its reelosure, the eatarrhal inflammation of the lining membrane and the diltattion of the tsac
tare over(looked.   I often succeed by using a. No. 2 probe
alone.  Here is a- case in point.
Mrs. 1,  Wetmouth, had suffered from blennorrhOcea of the
righlt lathrytmal:passage for thre(e years.  Matv 22. I slit the
lower canaliecuus, under cocaine, with scissors, but did not succeed in passing probe No, 2.  M:ay 24. Passed probe No. 2
after injecting cocaine into the pnssageM. Mtay 28, 30. Passed
probe No. 2 in th e samc  wayI. June 2, 4, 8. Syringed with
two per cent boraci cicad. June 10. Passed probe No. 2 aain.
June 14, 18. Syrillged with bi-chloride of mercury  1: 20000.
June 27, July 8, The eye is perfectly well,




TIlE  LACHItiYMAL GIANI).              801
Th'le permelability of th1e tear passage, altholugh a necessary stage in the progress of cure, does not always.com)plete it.' he abnormally dilated sact is to be rleduced Iby Iprssure, and the catarrh treated by lo cal and
constitutionotal relmeldies, otherwise the germs of flesll
itfltuamnationa s are left behind, and the old obstructioll
reapl)pears.
OTH I'R OPERATIVTE M EASUEJS,
"lThe operattion for obliteration (so called) of the laclhryvmal- sac by incision, and the applticat ion of caustics,
or the actual cautery, lhas fallen  tnearly  ilto disuse.
Thei sac is rarely obliterated by thle operatilon, and the
result: is generally nusatisfactory.  It mttay be dissected
out with the knife with better result it is said.
THE L.ACHRYMAT., GLAND,.
The lachrymal gland is subject, in rare instances, to
acute and chrolnic 1inttlllmatitons, hypert ropt)h, fistula,
and to cystic formiati ons.'Itle acute atd clhronic initlallnmatory affiections of this gland are atllnabtle to such
treatment  as would be suitab le for similar affections il
other partis of the body.  The disease of the gland is so
rare t'that dettails of symll.ptoms and treatme.nt may be left
for largerr treat ises.  In mitore tlhan one hundred thousand t casest of disease of the eye observed at the (Ohithaltnic Hospital in  Lolnldon, less thant twenty cases of
affecti8ons of this glatnd tare recorded.  It li-as been observed recently dturing an epidemic of nmumrps in three
or four cases.




CII APT ER X\   Il.
AF-ECTIO NS OF T IE  WHOLE  EYE  AND O]    TUI E
O(IBIT.
Ii Y l:)i() PJ  { Tt i A  i,5 I, T A.: A Kl A TO-()I;,O 1.1 US,
)Ut0'P1SXY of the cve (so called), a ffcets principally tlhe
antlcrior half of thle eye:ball.  Th  pelculitar stare w'hich
the p)rominllelnc  of the e'yes give:s tie  )pastient is very.striig.  The cornea) are increased in sti(e the anteior chelatlt)e rs i   ept    ad  i       rie)t, aarc t  re t mlonu us
for lack of sutpprt.  The pupi:     )tils are dihltted, tand so)mnw
times pear-shaped, and tltilmat ely vision is im)'ore or 1less
imp air tedt,  iThe selerottica grtows thin altnd bluisht a.s the.
disease'prog.'resses, 1and  all parts of the eve are finally
in. 1vollved.  The'lc prnogress of the affect ion is nsnall tv slow.
It: is prRohably incurable.   Reined ies like arsenic, mnerury,l aind t]hose suitiable f::r a-ffectioni)s of the corneait  g enera lly mavy  be presriibed,  in  the  hope, at leatst, of
retardill n   the progress8 of the ntfaladv. t   urgi ally  repeated parace(ntesis 0corneat  and i ridecttomt  y have been
productive of benefit,
EX`OPIHTXIf AI AMi  C (OIThtE  (RA V ESA   DISEASEX,
as far as  tprogressive  bulging  of the  globe  is concerned, re:selmbles dropsy. of the eye.  It is associated




.)tlSE'ASIES 0.F''TIT  OFB T l10IT.      803
with ihylpert:rophy of the thyroid  gland, palpitation of
tle heart., allnd subseq{unt dilata tion of its cavitices, antrinia, viscerl al dtcl raitglttccXints, andlt, il femalt(s, wittl antil.
(trtrhot a.   I'. h   diisease  iS talso accotmpan tied  by  great
tnervoIus excitemen t ttand somettiune  a caj(tl)rlicioull  temperl.
ts pro'ress is slow, and the prognot.sis is n.t as unf lrmly un fa.vt;ralbl as ill drol sy of tle eye.  The treattment cann.ot be laid dtown, on  accottunt of the a(lost
tnumbl)erless coim plicat tiolls whic(h the dise:ase may p-t'sent.   I     y  ropathic trecat ment is to be favorably mentioned as Ihaving 1be en serviceable in t:is affection  and
receCtly strophanlthus is reported as useful.
MI)ULLARIY.ANCER O0' TIE EYE
EDl)tJ  Cl  NN(1,t 1 (. 111  (  fttfE    lk G.fXj
lhas 1)1bee  spoken of unt1der teh nane na    of glioma retintw.
httlamfotie eaneer i is probal)    tc santlcE (tist:tse, witht the
add t iti> n oi more or lesos black pigmien:llt in its sstruc tireC,.areoma is a recurr'elnt growth, req(uiring~ similar treCatment to cancer, ttt exhibits less tendelanc  to s.condary
tdeposits.  Before brIeak-ing tllroutgh the anlterior tunllics
of the eye, it has been mistaken for gtlaucmna. ] it can
otl tI litt listlb  i /    tt  ) o           ~xllicte:: osco ics:xonly be disstinguishcd fron  cancer hby m icrscopic exatmiila'ttion,.  Oph/tlanllitis, or sulppn.ration of the whole
eye, is noticed iln the chapter on0 the Choroid.
DISE:ASES OF' Tl:HE ORBIT.
I have not the space tot speak in detail of diseases of
the orbi:,:and mulstl refer the reader to works on general
sltrgery.  As regarrds diagnosis, tumors of t-le orbit are
accompanlied by more or less prot xrlsion (:of the eye), and
rb dimninished Imobiltity  of the gloile, and soonel      r or
later there is impaired vision.  In inflammation   and




.804   A\FFlUCTIONS OF WHOLE EYEY 1 AND (Oi)rBIT,
atbseess of the cellular tissue, there will be added to these
symlptotlms pain in and aroundt the ball, and tenderness
xon presslure of the globe backwaXrd.  l'umlorl  will generally rjeuire to  be removed together withl the eyeball
antd inllamlmaltion and atbscess will delmand the same
gne.neracl t treatmlent as if loca:ted elsewhere.




CIFAPT'ItE:'   XIX,
INJ[OmRIES (OF  TUiB: ESYE.
TIt I1EN:XY: EYtI)S.
FI.B contlusions ani I.1d eclchv l oses of tih  ey elids we lhave
exccll.nt relmedics in arnicaa, latlnal-elis,  and calenIdula. I   lacerallted or incised wounds atre to be trcated as
tusual  in othet  parts of the bodyv, except that esipecial
(car'  should be takien in accuratClt'(t     ai)lox itilalt  the
edges of suchl wounds in the lids, so (s to  guar d against
deformlity.  In bt}urns and scalds' gre'at care will be nlecesskary iduring the cic.atricial period to preventt plastic
itunion of thet twXo lids it; the angles.'Thiis is to be prevtited bty ilnunctioon with simnple cerate, and tlb  directing  thfat tl e lids be freqtuently opened.  To  prevent
cctropinlll aid ait contractiont l wh\lich migh', llt prevent the
eye from  closing (Iagollthallmos),  the. lids should lbe
kept its much as possible on the stretchl, and be bandtaged w-ith extreme eare.  For the same reasions it is always advisable, when  possible, to bhring the edges of
wounds of  thel lids together byv fine ilnterrupted      turee,
ratlher thtan  lea ve t:hem  to unite by granulation, and
risk.   loss of substancee  and contractionl.
IN JURIES tO  TiHE CONJUNCTIVA,
of ta clhemical nature, art  (lquite colmmoni.'Those from
quicklim.e arle of the mo0st serious to which the eve  is
20




3806              iN JURIES OF TiE? EYE.
sutbje.et.   Complete dtstlructtito   of the tissues of t(he
lparts tvith whicth the limle comes inll c(fontat lmal  resullt.   Stlahked lime, mortar, and plaster are n0ot so'rapidly de struc:tive in their effect, but may in the eanld prove
inearly\ as fatal.'lt i (b elief danger, event  iil c tes    twere
the bih  i   t is. nt ver y extensi   ve o rvy deep, is il loss
of sight fro.n opacity of thte corlnea.  Th e wtititeness of
the corntcal oplacities in  these casets is very mat- rked, and
it has bIeen shown that the ciceatricial tissue reproduced
after tltese injurties contais 1iins lme.
ihe, Treatmtent.
It is wiser inot to attempt to  to   (lntr(aliz  the alkali
lib  the  tse ot  wefak  actid.  1Tht  eye  is ittolterant of4
acids i.n these cases, and they can hardly 1)e of stervice
iiniless applied immediately  after the accident.  It is
bettler therefore to resort  to o(lie  oil or liqltuid vaseline
at once, a smaltl  lquantity of whichl is to be droptpe''d into
th:e oye.'Ithe lids are t-lhen t: o he e'verI:-ted  a    tthe loose
particles oIf limet remove(d with a d. elicate spatiula. t!I  Ift
the epit.helia:l ltayer of the cornea. is dlest:roy)Nedt  i't shltotlt
be removed,   and, i:f possible, the cauteriszed port:ions of
the corneal sublstantce should also be take1t  off, so that:
the treiproduction of tissue may nott ot nly be spyeedy, but
thalt tlhe nlew  tissue may beN free f trom   dep(lositions:of
lite, and trani sparent.   After thle Iappl:iciation of at few
drops more of sweet oil or vaseline, t-he lids sb|houl. I be
closed, cold-water dressings used for the first few (days,
and aconite administe'red.
In injuries from l strongl acids a solution of.catrbonate
of pottsht, or soda, five graitls to ta  ounce of'water, 1may




INJUtRIES OF) TIIlE CONJUNXCTIVA,.  3"80"
be used at tfirstt if the eve is seen sotl  after tth inljryt
whienth this is not convenient. warm  water Xmax  be su.)bstitutetd.  ()live oil should then be used.  In b1urns atId
stalds of lthe conjtunti va. frolm  ht fluids, olive oil sholl:uld
also   e apd: {prlie d, the  lids closed, 1and  the eve'. itlitt t
batllagl'ed.  ()il should b)e idrol)tppe   into te(-   eve two ort
(three' times a tday, the lids cletansed from  all disctharlttl'e,
tand the lbanldag(0,e re(adljustted.
lftituies tfrom. t tutpowt der attre somoet ines seriolus, not
only fro   the seorching and burn ing of the contjun(ti.  va..
fromt  the e-xp<:losion, but from  the circumstanlee,  also,
tat::  xtll:x.)lodled g.rai:ints of the powder are depi ),sit'ed in
aitd  u:)pon  the collnjt'.ti va, and  are r    sometti res  for:ed'('
tlhr(ouTg h it; int'o the tissue of t h:le scler'ot:ic, aInid often imbe(ddcdt in tIthe substtiance of the (lcoea.  The lids tare to
-e e:veed a\nd syrillteld syto as to tremove all loose p(.)owde.'r,
1thenl aill stuperfllit iallyv  lt t        ibt'dded g'ais  i (he cljctiiva
iland (.o.:rnlea are to b.e lremoveld witl the spatulal, brtoad
needle, or )tcrved  scissors,'  anlld  o liv(- ot.' C:ast::or  oil
droltpped into the1 evye  or thr tw  ies a (lay,  t and stuch:l
e.(:..l al' treatl' ent resorted to as seens:. essa ry.
i:ii.ic.t!l i.nirwstri:      of' t/e coin tva,   from.fo reign
htodies sllc as  cinders    dust, particlles of i ron, steel,
gltass, tand tlhe like,  t        neral ly oc.tcasi(o   a gtt'0oo   d(eal tof
in jecti on, tand )ot tlt unt'frequently severe. cili ary Inteura lgia,
plhtotopdh(l!obia, and i aeb(h rymat ion,.  In the case  of a  Silngle.
fotreigu t hod^ l'ike a rcintder,' iit will gr'erltr'1 tlt  be foui)tlt
Ineath tt   the uplper lid neItar thet edge, an1d tra re ly fatr lba(.k
in the retrota sl trsl  egrion.  A. smldl  sl spa: tulah  may  be used
to remove it.  It:: is not worth while lhowever f or a stur-,geonr to adttemt to  t o this xwithout everting- the u.pper




808               INJUJIESS ()O  TImE'EYE.
lid, nor \b  the inttroduction o: other foreignt bodies, like
sio:l.oth pebl.)les called eye-stones, or slloot11h rloundtl    seeds.
tLeave( stuchl proceedings as tlhese to the foretmen of establishlellnts, attnd to domestic pral'.ctitionters,'the mlet.hod
of ('everting  the 11tiper lid is described  elsewhlere.  A.
yetar or more a0go a lady catt   me to me for a eontju l tivitt:is
of oe eve', accompll)anlied  by severe ciliary irritattion
tpainl  and 11ph.oto:ti )lobia(;.  Sloe  ad been fotr lthree (.lweeks'ultder tlhe treatmelnt of a. colleague, alntd during all this
t:ilne she tholught that she had(l  not1 had 1one comfortable
nightt's'-rest,.  l1ert symptomnl:l Is all ptointt(ed to a foreign
bodvy,   and on ever.t ing't tthe uppter lid t1here lay, p:a 1titall
imbeldd(ted ill th                te ustae of the  onunctival, a minultte
h1it of tuartz with  its shlarp (    tedges and angles.  She h.ad
sulffered for three weeks,  when the exercise of a little
citrumsptcct'ion) would t have relieved her att aty timhle in
thllree  1inuttes,  Slplilnt ers or ot(her substantces betneathl
tl. conlutncttiva, if found iimpracti:cable to  t'remo:)ve wvith
delicrate fortceps, Imay be cut out t  wt ith curved scissors.
Imiplpltat le par::ticles of d(ust or sand:lmay be washed out
withl tlthe syringe and warttlm watert.  T't   use otf cocaine
will render these 1tman ipullations com)paratively p ain less.
Ill the "A. ttrican Joultrnal tof the  f1ed ical Scientrces,
\Vol. L. ip, 51, among other cases of neglhected foreign
btodies in thet eye, is thatt tf a (l eran whto was treated
somet time for granulated lids, until fithially the cautse of
the affectilon was discoveredt in at negleted " eye-st)oe
which he had  lput into  i's eye six mio(nth1s previously,
and  \whrich  lie thought (:had dropped tout wVit 1  1e he  ws
asleep, as his wAife said lshe ha  sseen it in tiie bid.  T1t'h
tremoval of thle " ete-stoine "  cured   tthe eye.  11  the




SN MBLEPIIARO.N                      309
"O(h)l    Ithalm.ic n view,  Vol.     1p.. 3, is rela ted  i
full t t:h  ca se  o    lf an    1 l man wlho fell to the bottom:  of
tlhe stairs,  anlt( applied to a surgeon fo r a' wtt.   inl  the
con.jlnehtiva. at the inne.r angle of the right eve.  A. ftcr
a: week's trecatmtent the tresc'nctte  )of a ftoreign'(body was
suspected,  and the:next day at clast-itfron hat-peg three
andtt tlhree-t(:etlht    i inches in length wats d.rawn frotl tlhe
toundttt.   lThe plat icnt  irecovcred  without tunflavorable
symptoi'ms.  Stall p:article:s, like gravt l or dust, are to
he relmoved b)y e veurtilng t]he lids anti. syringing them
and also by th t:c use< of the spatula. or blunt pro)be, when
nccessary.  See Fi'i  8,t.   85.
A     N(Ht{ Y I OIILEPt ARON
is the un1ion of the mlargin of tlhe lids with each oither,
either directly or by  n ltembrtanous bnlds.  fit is a result of iinjry, or  nllceratt ion f.rom  dis(ease.   The Tuion
is to })C sevefr'ed withf the scissors or tlhe scalpel),   and
rettion prev ented bty frequ ntt  seltparation, and by anointing the cut surfaces with olive oil.
SYMt BLEPl l A RO)N
is thelc  unimon of the inner surface of the lids witlh the.
e  eball, and n tay a lso b e tdi re(t al nd cl.os, or hy  n metbranous hands.  In thle latter ease., the blands of union.
may be divid(ed., (and daily dressing'  withl olive oil lmayt
possibl   l prevent a reunion.  ( ctnrally, however, ald
esptecia-lly when the ladhesions are at all extensive, it
will hle necessary to resort; to an operation,.namely,
the sepa.ration of the< lid from  the  )baXll, and t I he tran splantingt  of conjunctiva flrom  beneath thell upper lid to




310                INJUI: S  TO     i EYEI.
tlhe  lnew surftace.'T1he caluse of the affcct ion is an injuit',  usllually a b})lur  ftrom  hoft  tl1uid, It  tal, tliie,  orl
mortar,
D)IA(.NOSIWS  ANDI TREAT:^'tMENT OF  FOREmIGN  -BODl)IES  WITHIIIN
TI  E (G LOBE.
Tlie diagntosis  is s )(omettilmes(  quitet difTicult.  Wtheni
tte f(oreignt  body cbati(ot bte sc..,en  witl o(r without; th.
taid of ateral  illumiatiom  and the op)htlmolno pe:o, we
tmy 1uect itsay  it C presence: --
If the p)aint does lnot yield to the ustual ptalliat:i ve treatIntfcit,  and is aipparently dislproportionalte t to ti  \visible
i  It tt fill  mat ion.
If thel infltammationl does not appetar to be cont rolled
lby tlte trea.tientll: t, to thtte tustuatl extent,
If symttNtIloms of inflamtnmation of the deeper strut'c'res
of thle eve, are l'present.
If tthre. is ta c irtcumscribed iritis with ext dation, limited to( a  given point,  no foreign body b:leinglt \visible, the
eve tha vinl been.y a st ttrk l    a splinter of tme}t:al,   I recall
at eas  t like tis i  te   inic: of  Vo::nt (ra-fe't,) a famous
etase where I happened to b.     e present., arnd  in whicht he(
maltte aln iridectott0y, and( tthetn removed  the invisible
b it o(f metal ftroln  bltehi:nd the iris.
If there. is no)n-union,  or only partial union, of a.
wound throtugh wict      a fotreign bodty nttay have centelred
the eye.
In cases liIke thl e above, where tihe irritatiton: or inflainmatttion  is contintuous,  an  attempt should lte madle to
find antd re)(move the foreign body, a)nd:failing in this,
the eve shlould be removed.  Whlere the foreign  body




TII -  U8iE OF T)tE MAJ GNE t'. L31:t.
can. )b  s'ten1 it shltould b!e remtovedl in all ctases -when it
cant )0 donle e wtitltout tselriout s risk of loss of t:le eve.  It
must bo ext rlact 1ed   t ant hazard t t::o  te e v    if  irritation l, l)atifn  ad  intfltanunationl are engendlt ed  by  its
presen(,. lest Svm:)athett:ic  in a1tnlat-ion  dtesttroy  t:he:'
otlher  eve.  I nfianlm  ttion  re urri ng  in an eye which
has lost    all visual povwer from  former injury, lwhet:et
the l resei ce of a f'oreign body be suslectcd ol  nol tc dmaniods the remloval of the eve.  When a foreign body,
like a, bit of percussion catp) for insttancce remaini,    i  the
eye, btt: callses no i rritattio, tie sight of the eye te tingtt
inil ttt aii ed      it i t, and its ext:raction would. be hazardot s
to the eye, it may be left  n it is place; b.)t the p1atientshould he cnligltlnct   d as to tohe tnaturtle of the risk hle
is takingt,   and instruct ed to rleturnt  to tl h   surgTeon if
sym)ptoms o)f ilrii;ation cte on i  tlhe injlttfd'eye.
TlHE USE OF T! I   MAG(NET IN TIE, Im IANOSIS ANDI) R -FIMO VAL.
OF F)OREI(:N B(OnDI I:S FRtO   T'I   E  Y'I
Tlhe em ploxyn:lt  t of the lmlagnetl in ophtha:lmic practice
is not of t relcentt origitn.  h11e ". B ritish Medical J(our.nalt 
for JItNl  17 I  8, 8  ix gives the f ollowing (utatti:on bearing date A. 1).  1. 745:  "''er   was one  in  Salisburv
hlho hd tau piece of iron or steel stuck. il the i    ris of his
0ee.  The tperson was in very go:'at painl, atlt  CatlO to
me.  1. ende1avored to plush the iron out:  with a. small
slpatuhla, but could tnot,, and then applied a loadstoe, tfo
it, a'tnd immediately it: jumped out. "  There is lately a
lrevival (of interetst in the use of the magnet: antd a n1timber of s- 1uccessful C ases are repi)ttt ed.  EHither pe)('rmlianentt.
or elect.r'o-nmagnets are tsed, anld the foreign body to be




312              INJUx IEwS OF  IZTE EYE,
re\moved must, of course,  e a fragment of either iron
or steel.  The prwesence of a bit of either of these
metal.s hiddern withilt the eve mat   sometimes be  ttm e
lkown b:  the pain induced  thouh thie influence of
ta powcerful matgnet h1lcd near the affected e et.  1 f,
hto'wever, an tWe iln 0wlich thert  is knolwn o  suspected
to be a foreign body lhas become blind, there should be no
hestitationl in advisin  its removal.  Pelrhaps an excpltioln midght hbe:.tmadef if tlhe patient is intelli-gent; and lives4
near tlhe sutrgeon, and: thl  e eye is painlless, and not tenlder
to the toucth in the ciliary region,
THEI: I COR':NE,:A.
Injluries of thei cornea lare mlore to be) feared than
those of the conjunctiva, from  the factt that opacitics
upon t its surfac  imnpair vision,   Fragmenits of metals,
or sp)linters, in its sublstnice occasiol gtract ci liafy i-rritati(o,  itailn, injection, plhotophtobia, and ltacth''lation.
If tthe foreign body, owing to its smtall size or color, is
dillicult of detection,  tlhe puptil m1ay be dilatked with atropiln  so as to cnlargel tlhe dark bacItkground, antd the
oblique illumination and a magnifyingla glass eImployid.
A delicate spaiutla: or broad unet dle mary hbe used for removingt thel. forecigint substane., and in  ll: cases  cocaine
i to be used.  Ch m.ical injuries of the corneat  may be
treated as directed iunder Illnjuries of the Con ( junctiva.
Clear cuts or punctures of the c'ornea he al readily, and
generally leave no scar: behlintl.    The d(ang'ler in the;s'
casels lies in the possibility that: tth  iris or the lens ma 
hlave been wotIunded, and ilritis or catiaract supecrvene.ll
The treatment of wounds or injuries of thelc cornea re'(.




TilE IRIS AND) LA:N'S.                  813
(lircs entirte rest of the eves, if thie eltiary neuralgia. be
eonsitdrablc;    wan:r  f>lomientati ons and the instillation
of atiropine  and  cocailne  as  palliatlives are  rleqtired.
(live oil or ca'stor oil is ve'r  gratefutl to the eve after
the remnoval of a foretign bodv and in abrasions of the
lepithelial surfacee of the cornea, andt ai simi.t'lie btadage
should be apptliced over the closed lids.
THE X  iS AND LENS.
If a wolnd of the iris is cleta, with no laceration, itI
may lheta  at; once wit   ithout iritis or s   uration.  If a
bit of iris protrudc thrtou'gh an opl:lenillg in the cornea,
anld cannot be re adily re t.placed, either b)y careful 1manipldat ion, or lie en.mp.loyment of atropinc or eserinc, it.
may be excised.  Foreign bodies........... such as hbits of percltssitlon c{.ap, or steel  -re... mai nin:E g ili the subllstaf'nce of the.
iris will taldmost: ilnv;riably st up aln iititis, andt sllt)uld
therefore be reloved by an i rid cet oniyv, exc.isilln   t hatt
port:ionl of the iris ill which the foreign body is sitlluated.
Inljuries of th:l  corntea and iris, like other injuries, son(metimes result; much less disastrously than we have reason
to predict,  I recall the. case of a child two years  (ld,
that lihad run the Iblade of a pair of scissors into the right
eve ti:owards the itnnr angle, penCeftrating  the c''ornea
land iris.  I exc td, oS   c urse,  tratumatic clat taractt; bult
the direct:ion of the instrtument was sfuch t:hat the capsule of tlhe lens was left' intact.  Iritis ensued; yet the
eye finally recovered perfectly, leavilng' no corlneal opac.ity beilnd, and tno def)ormity, excepts.  a slighlt Ldisplace-l
tment of the ptupil froml  a sall synechia possterior, at
the point of perforationt off the iris.  Now, aftfer t\wecnty




tINJU.IES O(F THlE EYE.
ye\ar s, thle deforilitv is lardly nofticeable.  In all wouds,
\when  the anterior or posterior cha;tlmber.t las been entered,  the elte shotld be bandaged inmmediately.
it'}mwrrutfe in to thte ateritor ciambtter iay  revlt front
ta wolndl of thet iris, or froml   a detachmentllllt of its ciliar
bortdlter.  It: may htt e Bso extn t sive a s to completely hide
the pupil and iris froml view.  I have knol wn it:to occlur
to this extent: in the operation. of iridectomiy.  It  is tthec:least (: dangeroust form  of intraoculatr hemorrlhtagec  and.l:the bl:ood  is      t  suall  stoo  absor bed.
Wh.en a wound oft tih  an terior chamber is large, and
thel iris btlges, f(tormiag a slac distedeld with aquetous
hunlmo', it is not safe to excise it lest a faartthr prolatpse
occur.  It shtould )be pricked ait interval s with  a line(
lneetle, so:as to cause it to dwindle, and petitrit; the edge:s
of tlh  wound to approx inate.  Later, it can be excised,
if ne'cessarv.  Traumatic        cataract ]has been  already
sp1{okfen of,.i.et.morr/itme of  blood tbinto the vitfeous is not very uncommil1on, eithert ftroin dlisease of the coats of tlhes vessels,
or, as a result of a t:ramlnatie injlury to the choroifd.  It
is sotnetltines distingttuitshable hy a red reflex, with the
oplht milltosct)l; at otlherI tithes the fttunus is cot1pietely darkene{d, and cannt 1)tbe lighted u p.
1. have treceintly  seen a copious bleed ing l,    ilnto the vitreous of onte eye in a1 e.aIse of posterior polar cataract in
atn.othe1rwise healthy iman Iwenty-seven yearsl old.  It
toc1curred at t   once, and duritng an iInterval in his visits to
n(e.  A.s this fo'rm of catatract is oftten connectt.ed with:  a
disease dt fuisfndi,  the hemoirrhltlage is ptrobably due to choroiditis;  butI in sol   ilsttances  the cause is more oh



TILE SCSLLHOTIC.                      81.5
scu'.re.   I remember aI lr1l of eigh'Iteen, in appar enti
goojd hlealti), \wlo had reti)atedt  bleeding  iln bo))th eveas.
lheit  blood  was partiatlly a!bsorlbed  but the final outtcotme
wa\s a- large scototlu  in titUlr eve.  In a strontg won.ntl
of fortv-eiight,  after cessation of mnast-rua:ti:n  bleediing
took pltace into tthe viit rcois of the rightt eye from  the
cilia'r.retgilt,  repeatedtly  dutring t:hree yea: rs at intervals of somne montt:is, and was trepeatedly albsorbed, titti    It:l ly a  i rge t' heitO orrha Fll   oce1ring  the eve  beeic amet
totally blindl a<nd rem1tained so.  1The left: eve\ is entireti
free from diseaset since the other vwas lost, iln  887,    Th'le
svsteina:ltic, use of hot water (from  10l 5  to 1:10  I~ahrenItcit) for:ft:omltet:ir g lth   e e    datil,  appear ed to tlstaen
thec  abt:sorp:tion of the blood  in  this  case, before the
he}morrhiage beca: lc too (co iouns.
TH'1 LE SCLE(''ROTIC'.r:eciste  wountr ds in the selera are not usuallv dalangeroti8s unleCss very e(xtensive\,  lbut do not heal as readily as
wounlds  ill the tsub stanct:le  of th:'e corne:a.  Care:'m Ilttst
thereforel t.:  b et l t alt t:h the tedges of the cut: ap)pro xitmate
exact.ly,   a tnd, if necessary  o othis  lnd, a finelt  sultiure tmayt
be (e:.mployedt.''iptu.re ot q   the slcrotiec  is a fiar mt ore
t:hdanltgerous ac:cient, frequently( involving dislocation of
the ltens,  trolaps:   of the iris, great loss of vitreols, andl
internal:hei(mor.rhage:0 of the eye.  Soothingt.  applicat ions
should btc    mtttadet,  taid  if after at few  (days no  perception of liglht rletu(rni it: is better and sa:fer to etnutelate
thoe inltured  gl:ob.  Ifj t'ries:in  the tciliairy reWtiftt are
esp)ecial y  dan ierout s  as  giving  rise  to  symplathetlic
-. —:.1 tt-tI [It: t,




316                IulNJURIES OF)  THtIrE EtE,
SYMPATl ETICl  OH"ITIIHALMIA (CY(LIXTS),
ot  op/htkalttwmie fit'r/Lt iIa,  s  i    n ft  itlf a:nn' ltiot l s12 set up
illt sa slo8 d e te      l       oas  tlhe result ol il'tjio   t  th}e fellow  eve(
ill the c.ilifar  reg"iont.  A-s ssmupi:at(hetlii  oj.phatlultmiat does
not u:nifotrmlv follow  sutich1 injury, it is probatble t:hai
septic  poisoning  in  thle wottnd  is ustally  a 1   i.pinia r'
factor of calsationl,   The inieroorganist is reacht   the
seuon d eve:ltrough thc mtedium  of i:th  optic and ciliarv
n crves.  It is a:t. ttr of some (1 doubt  whetlcr svyltpi
thetic itinflanination ever~ occurs1 except: after perl'oratito  of the evyeball of the  irst  eye.'1't. is t  oi nt, lt) owtev'er', lmav still be disputed.' lthe (tdisetase mnay  follow
atn tuleerat ion of theC corneat otr a ctelitis ill the firist eve,
if a  )perf.oration occur, and it is often  or not tvery unfreiquntlyi due to an operati on on the lirst eve, for cataract, glauctoma, (etc.  ForeCign bodies remaining   wilthin1
ithe eve  are also a. freCqientl cause; antd altlhougl  s-uclh
) bodties 1mayV lnoi  t give rise tor irritatt-io   in  tthe wounded
eyVe for' 111m      yeas, et where olne ethe: irritation occulrs,
sympaithetic oplthtli'lml: iia   the other eve is often  the
result.  Svtmpath}et;ic disease is  t\,neve  to be:onsidcred
imtpossible so long' as there is:tetde'rness of the iljlred
eve to toucht in the cilialry regiont.'.T l'I h nature of syml:t:t it:  ophtl:halntia: is thlat of seroius or ptlastic and destructivt  cctitis, -t sich sprettads..raidly t1 to the iris ad the ctoroit.   Int the begit nilg
tlhere is irritati(on, some injection of the conjunllctiva,
tpllhotophoblia,!lachtrymation., increased tension, and sevetre astlhenopi  slVymptoms qtuicky i   supervening utiponl
anyx attempt to muse the eyes for reading, or for any simn



PENUUCLEATI(ON OF Ti'lE INJlUItID EY.:),'I7
ltar pul)rpse.   A.t thlis stae of the afection tht re is 1no
pain whent   t he eves are at rest:; later,  there my lbe
Supraorbi(.al.lno.euralgia,   gpreat eftfiion  of vliplb adiihesion be)tween tihe iris a,1d anterior capsule, the choroid
tand vit reous b'ecome involvedi   at atrop)hy of the latter
is followed biv so(ftening of' the glob)e,
ENUTCCtiOATION OI THiE I- NJUlI) EiyftL
T'te 0onl  jiustifiable course to pursue wllen synipathetic op't'thalinia  threatens  ili tihe   ninjurel d  e.te is
to remiovel the injured one at once.   flnueleation of
thle bal, under e(:mp)lete etterizatilon of the patient,
is not a f:lormnidable pr(ocedure.  Tie lids are to h)e
wmll. separated.e)by a spehcui tl; one or twto assistants
witIh sp-oll'rges or absorbenl' t cotton Bshould be near to remove th:e bl:too-d t) dulinl   the operation, so ihat t-lhe view
of the operator mt ay be as little obstru('cted as possible.
Sup1pose the le ft eyt(e to be remnoved.'lThe operator stanlds
inl ftron(t (of the patientt:   w  ho lies on  a couch,   Seizing
the  onjllinetiva.  tthe outer side of the globe near the
insctrtion of thle rects   ex. terms8,'wi ithl thef forcepst, he
matkes an incision,   and catrrie.s his iblun t-ptointed sc.iseV
sots qutlite arouttd the c ircle of tihe cornea,  di-viin gl the
c.onjunet iva as near the corneal limbus as possible.  lie
then ilnsertsi a bhlade of thel curved scissor's tbenea th, 
ext.-erntal reetus,  and ditvides t  i. clos to is scleroti:  inserttion.   elinquislting  now his tirst hold wiith the forceps, lhe seizes tih  globe at the point of i lnsrtion of the:rectul mIustle,  justt -divided, in o-rder to obtain a firmler
hold so as to move the eyeball at will.  Th-  superior
and inferior reeti and oblique muscles are succes.sively




3~18               I NJ U RIEJ S OFI''I.  IO THE EYE.
dividetd  with  the scissors close to to Ite ball, and  then
with. ltargler s eisso:IarS te  lob ) being pll   llled as far fortwarld and tow Iards the n0asal side as poasible, the optiec
nerve i.s cut; a gushl of bl ood. follows.tfrom  the ()ophthaIlmlic  artet, the ftorce:ps are reli qltll,           e is}, tll   tll i
grasp.tedl with the  gfinx.It:s, the reetl' us itlternults divided,
and the elucleationl is comptleted.'the heorttlfLrha'g:e is
triviatl, and- readily\ control led by cold water.  I'n case:o et:ceph{.aloid of the globe, or tllmolrs of the orbit, atnd
like cases, the diffieulties of the op:eration arc munehlll
il1reased, and tl   varlious steps in i tt will be different,
Illet-  tt18  ill:tt'll:}.}:;  atl<X:\' 3:e'p l:z:'X:t tl'\.
and other inst rumentcs ma! bo neccessary,
WHE'IN TO   ETttiMOVE TOIE3 t'INJUHIX!) I;EYF.
If ow soo(), tafter the first symIptoms of symlipatlhetic
irritationt  mat iftest the}tmselves  inl the sount.ttd eve, shalll
the in jlured o)te bo 1rctinoved?  Inasmituchll  as snymplto-ms
of irr itat:ion do  not: alwas g'ivc  rise tor tfI t     disc:lsei a tnd
as the disease, if its occur, is not. absolutcly  cer:tain to be
of that fa-tal type which ends in destruction of the eye
tand the totall btlindness of out' 1patient, hlow  long may
\we't  ailt with saffety   t  T}is (qesttiont is sonmltimes dificult to answt e; but in ease,  tle in    ured tlcy il   alre.tady
blind, or all hope of restorlattion of vision lost, we need
not wait at all, for in such an event its reltmoval is isn
no respect contra-indicated, and will in ll all probab)ilit
guarantee th  integrit  of the remainin   eye, prov
nwo symptoms qfi ympaltk eti; ophthalmi  ( have yet madef
theitr  tppear(tan ce.   After s patheti e dse   has once
conmmenced in the uninjured eye, the removal of the
otller is not  a certain, although the best remedy known,




SYMPATXIt!C I      ITIE   1 TAt'I.ON.. 81...9;and succeed(s in s\aving  the re manlling;  eve, espciciatllv it
lonle ait  an} (Iarlv stage:C of  the diseas, s n a majori ty of
cases.'Tlec sympathetic inftlamlnation usuallv ap:      ars
in.from  three to six weeks after itnjt}ry to the f irst teve.
It may  cctr much later, but rarely earlier tanll this,
(s that an eve   ilare mov ed within thrce weekl  after its
injltur  is quite surel to )IprCvCe t the migration of thlc  affection to the stoul(nd.  Another meal(ns, that of 1di.visiolt of the ciittar  muscle,  has lrcnitly l et  tlracetised
with sonim stucess.  It 1mighlt be wvorthth while to t': y this,
provided tolerable sitgit iln the  injured eve were still
probltable.  An incision in the conjuntetiva at that p:oint
in th;e ciliay rtgion which. is setnsitive to tfhe touchtl,   is
made with  the foreltc:ps tand scistors,.    he eve beinl)
steadied, a   u: p ctture is lmade in  the scltlerotica over
the: cilia'trv'   muslt     \lt wth a cataract. knife, and the wound
is tlosed with ta suture.'lTe general t-eiatmtcent should  enforce the stricte;st.hvgienic regulationls, absolute rest of the ce ves a subdued liglt at lt home, and thel iprotecttion of dark glassts
out of ttdoors.  Tthe diet should be nuttttitious and gIen- 
erous.  lThe )pupil should be kept:i dilated ad  llmaximt n.,;
unlless the mvydtriatic cause irritation  b-y pulling on the
adhesions between iris and lens, cocaine an11(d hot fomenta.tions are t to b.e ur.-.ed to relieve pain, and internal and(
other remedies such as recommetnded for iritis are to be
availed of.
SYM 3TPATH ETIC I    T IXITA TION,
in the uninjured eye, may occur witl hout   iving rise
to ophthalmia.  It may be recurrent, coming on whenl




8320              INJUItXES OF T'  i   EYE.
ever there is an exacCrbation of the inflammation ini tle
injuredt eye, but it is to be distinguished front ssympathetic ophlthalnmia by thlte imp)ortantt  fact fltht no  iitis
with   f 1effsiio   of lyIv.11)lh is preseit.  I. T.here- is some0
injection),.achrymatioln ciliary nultralgia, altdl severe
asthe nopic svmptomts'whenever  1use  of th e  ev  is at
ttemptid.   It is prolbable  tlatt it  ever results in  intiammat ion, altlthoughO somle t witers mllailltain tle reverse.
D)IIVISION OF T' 11i   OPTIC A.Nt) CIN (At RY N1BRVEX't.
has lbeecn de'vised bt!    oc Sch.o el. ter,  ao  t stust iIttt:e for (enclt(leationl itt syIpl)athetie opl tlilntia.  It. is
dIone under ani-stl-esia.  An opteingt being tm ade in the
c'.onijuietiva  over t]he rectus ilnternlus or extern.ums  the
1tttisc.1   i s divided aft its insertion in the s:clrotic..tlhe
glo),be then bteingr convcenietntly rotatedl a pair of curvedl
scissors is passed thtrougit    thle opcningll   to lt-c posterior
part of the eVeball. and the optic and ciliary nerves sev-.(red.  The chemtorrhtageC is of course considerablec: the
blood escatpes into t:he eellular t issue of  the orl)t,  tle
gglobte prott'rudes, andl   t he.'r is sublseqtently severe iecel:ty.
mtosis of the eyelids.   Ltnder tlh utse of cold comi)Cresses
for some dtay\s, the blood is, however, absor}bed  and any
ciliatry irritationt or tetdernelss in the otlher eye rapidly
disappears, -the mt dia throutgh which the              athetich t   s a tic
irritatiotn passes being no longer in  co lnectiol with it:.
lhe advantages of this tprocedutre over  ltttuclcation arc
chiefly these:; ~
The expense and annoyance of anl artificial eye are
avoided.  If the eye, left in its place, is atrophlied, it
makes an excellent stump for the suplport of an artifi



DIVISO^)N OSF OPTIC AmN) CIiJA'Xt:IY NEIIES.  382
eiitl one.   n children, tihe remioval of an eve changes
the development o(f its surroundings' and this operation
offlers at chance of escapingi this dis disadvanltage.'The o(lt,
door expt:osure of the empty orbit;, in the poorer classes,
may be avoided.
T'l-e disadvantages are chiefly these:..
There.is  somet ies  considerable reaction and  p)ai.
after thle operation, and the effumsioni of blood disa ppleears
slowly.
-it is sonetimes necessary to remllove the eye subseqtuently, in consequetnc(e of the lin ltanlmation set.11)
the o.iperat ion1t may  l faoil fr    a reunion of the severed
It is txhere-fore too early t o determine the v-alut   of this
)t'procedure as a su:bst;ilute for enuletatio.n    I think tlhe
tendencyt is to adhere to enucleation..v.i8~sceration or: oi.ieft!erattio /,
<a remolsval of the contetts of the eyvebatll, is practisted
also to a considerabl.te extent.. Til.e cornea: is8 excised at
its litmblus,  and the contents of the glob:e evacuafted by
lthe aid of a: sl-malll s}poo)   o  sp:atu-la.  iThe reaction is
considerable.  I have seen at Moorfields a small glas.s
ball sewed upi in the cavity of the slera in place of the
vitreous to improve the' sttup for an artificial e e.  It
is said to work wecll.  (5tlle's opel'atiol.)
21




CIIA.P'T.E    XX.'i.tE.  ]EiY t  IN x   l'LATIO,.E.J NI.  T) ETO  TH   G -ENEXIRAL SYSTEM,
[IN cnsideringt the eve iln conitect:ion witht the general
Svsstemn, tlere are three relationlt in which its inl.'orta{nee'x
will be recognized  -.
1. As at aidt in the diagnosis of discases  otherwise
})l.)Se'.t't'rc
2. In regard to its own integrity.
8, As a possible ca.use of funtctional nlervons disease,
IN  )IAG'NOSIS,'.lte conjunctivira mar )c a     i. vauble)t c index of the condition of otiler lInntou  structutres.'lhe consttant h! pier-:a:nnia oif the boan viva.nt is no less characteristic than the
blianchingl in tihe sclerot ie.  In the corneaft   too, tle tdil.lesst or trillianey of reflex will im ticattetcp the physical fone
of the system  itn generaOll.  lThe atnnular zone or ar'us
senilis occasionallv  found may suggest a faitt  heart or
atherotmatl:tos dt(egenerattion of the arteries..'The.pupil, thlroulgh  its intilmate connection with the
spine by way of the symlnpathetic, anld with the brain by
the motor ocili may ilndicate profound central l  lesions.
In a case of spinal concussion that  recently cate under
my observation, iirt  pressure over the seventth  cervical
vertebra. caused instant dilatat ion of the pupil, and on




TII'E1 SECONI) H IEl.AT)IN.             823
relaxation of the Xpr.t.ssure. the tpupil would itmmediatelyt
contract:t   again.'The contracted tpul:ils of cerebro spinal  lnein.gitis are
faniliar characteristics; while the Argyle   Robertson
sytptoln in which the pup)ils do not respond to light;i,
but contract wheln the     eves are  cotnverged     is onle of the
eat rl  inldicatl:ionts of i locomotor a tasi.a.
W ith tlhe opllhalt oscoper the intrat-canlil circulation
is brolglt more or less into view, and thle conttinuity of
thie optic tnerve w itht the braint, ad the retinal v\ssels
wvithl t hose m1ore dlee'.ly sit atted,;  m take it possi.le  to dcm(onstrate colldit ionf s whichi mulst othelrwwiN,.e be gite-ssed.
Orlyanlic kidaney lesioMs may find'their first ma.,ifitestation  in anR  itflamned retina, while a retialll lheilcorrhage
11may anticipatie by morltht s the cotU;l1m, aptttplotx.  An\
optic neuritis is solneti itles tle only  evidence of a ehllromie
neltningitis or.'prssu:r from  a brain Ituntor, an.ld at de (fe-i.
tive vistul tfild maly serve to localize  a cerebral lneot
plasmt.   IProtruttsi(on of the eye(. b)\Nalls may be  the  first
svinpton  of mnortbus  Biasedlowii, and diplopia or pt.osis
the earlietst iltdicat:ioi  of at at:tpproaclhingt paralysis.
TISE SFtCOND IIMPOR'OfTANT RELATION
in  which I the  e    me ust  be  considered  in  systemic
diseases  is that iln  which  its own  integrity l.may )be
t hreatened.
In  the eru:pt'ive  letvers,   the etys  should  dalways be
watched.  The catarrhial ophlthfatllmia with wthich nmeasiles
is ushered in is usually coInjuctival.  In tlose predisposed1 fromt malnutition,  bad hygint.e, ot  r scro: fut si  the
cornea nmay be involved, and pihlyctenulae form  al ht ouglh




:.t824  TIE EYI RY'E IN JREILATION O0  TIlE G(NERAI SYS.TEM,.
dcst:rutct:ive inflamnmat-tion   arely  enlss.  The t eyes a1re
frequentt y left weak and snsit     iv   however, long after
thet eruptlion ha  disappetared.
Int s:arletil:v:e, th.rce is oftten somne h}Vpetrletim i  of thte
tcotjultivat cointcident with the skin erupttion,  ad  ex
cct.t ionauir, kceratitis.  In a mnalignant case which came
ullnder m   nolltice, a general telltnde(ul     towan trs pus f'ttatiotl was l resebt,.  Abtscesses formeld arould thle tinl'er
nails, iin the pahtlms of the hlaittlis, ill th0e foire 1armsl over
the st:lernmltl   ilt both ears, and in  tlhe atterior chantl:er
of both eves.
Ilt meniejt al ilfl/ta  matioa  whethel r untornplicated or
occurring as a feature e of  an cruptive fever, thie tnrvols
st:ructt urs arc more frequently a:ttacked.  In an e(xalmint
atiotiO  of tlie inmal' tes:)of tlhe Statet  Asylum'. for the Bt:Ulindt,
at Batavia,  New  York, aftr cornlcal optcities and statp-oma fr1om srome fo titrl f )of purulinlt. oplttltiia, the
-tlargest nulsmbher of inmates were ftond to have  optic
1ncrve atrophy following mneningitis,
if in diphtheria the exudation appears in the conjunetiva, danger to sighlt i iimmilnnt.  The substance of the
lidls bcomttets dtensctly  ilflttrated, tih  tissue swollen and
hard, and the lids are ra'is' t   on(lly with di ticulty.'Tlile
pressure, cuts off the niutrienl:t Suptly, and  unless  the
inttincslencel   can  be s; peedily  reduccd  the cornea. is
4de.stroyed.  In convalescence, paresis of that btrantch of
the: third pair stfpl'tying t1he muscles of accomtmiodationl
is nott unusuaLt'hlte:pupils may be (enlatrged, tihoulpgh
not:t         ncessarily, hut in ineat  visiolt sighlt is buiXtted.  Use
of thle eyes s hould no.t be plermitted until this condition
lias disat)peared, or permlantent \wakttnss may result.




'Tilm'1   SElCOND)!TLATION.X             2
B:efore tJcer's   tlime, to sinmall-po:x.. was aitrvibuted as
larger at proportion.l  of t h   p)revallenIt blidll'8Iess " as to all
other causet  s  put together."   Now, fortc tluately, scnll
serious renistl  aret,   cO)itn raiverly rarl'ITr e   hats b>een.
mnuch questioln as to wltthetfhr  tihe pusttules ever, f)orlm  in
the corneal tissue.  It seems far more plroh alhle  sittce
the microbial oritgint  of p.)us has  )(een stt(died(, thIat ahl.
sresses are th:  reslt tt of lthe'  iltr odu t  ti   of  )ail  frot n
the slti'iiiratit{lg  pocki  into  the eve.   T'lle epithelo iunll
tbeing denud i ed, (the cornea mtiglt be easilv invaded tl      r
tl)o pathogceneti. baceeria, and too geat care  could not
tbo t.exe.is.ed to  p!re.velnt such  infection,   tlleeattions,
p!rol}atblv front the ptoclk, occ('ur at -itimes in it he (tonljtune>ti\va, a n.d oeeasioally the eanlallictulus lhas been' oc..clutded
hr tlhe rcsultingr cicatrix.
W\hile' in ac, ute inflam nat.aory rheuitmatti.sml srius ophthalmnias are  not coinntim,  in  tlhe  chro~tnic formnt  alnd
iln ^got, bothl the extern al and  ilnteral eve  mn.seles
]ma\y  b}e  aflfected.   Rt-henumatic  tpa.ralvsis of  (.xtrinsie
musetles,  antd iritis, whiclh mav take on a reilapsing for)m, 
tare nlot ilt'freq-nt,.  Thle  latter is al.ways a:ldanget)rous
coimil icat:iont.
s:iphil.t,i thle sour'ce of so maty  lIhyxsieail ills, mary
mantifest  itself  during its course in anytt   of tI(he st': ruct tres
of? the eve.'he  iriis is most commonll  y at ffect.ed, adt tlhe
inflammation  is usually  of so passive a ci:a. racter that;
extensive adhesve adhio:ns may already halve fastenet'd the iris
to the lens  before the trouble is d iscovered.   (  tnmy
tumoris,  ehloroidal in ft lammatio ns,, a    less freqtently,t
retinitis, may be phases of tlis d vscrasia.  IHieredittiary
sypthilis may give rise to iritis with cata ract, i  infants,




32i)6'T      EYE IN REII.'1ATIX()N T')O THI   G(lNEItRA   SYSl:TEM.
ani ill child'ren f       t    t fr    t   ourttetenl years of age to a
p'are:tnlt vmaIt\'':lls keratditiis of a m'ost; p)er.silste':t cha:.racte:r.
Scareelyc less plrofoumtlt fla  sy p!)hiilis in its effectt upotnl
lthe eIye is scro"fi la.'1the lids anti antferior' portion of the
ball a.tre th:e plar(ts chttieft'l  affeceted, andi the itflammation
inay be (of any grade fromr the delicate red oin the margiin
of the litds to dteep cor.neal ulcers.
Pi l!ytentul:1ae:, cither of t:ie conljinctiva: r cornea, are
co1lmml:ll ai tid  aftel r t repeated  at tttack,  if the sears aret   int
1the. field of'vii ion,  the siHtt:  is likely to    oblsc. red.i  tblerellsiQ, tlte eyes a.re rarely involved,,although{l
deposit(s are occasitntally foundt in the clhoro(id.    In rare.
ittt-nstan'ces tthese deposits precedet'.( thltose in thle lttuns, andt
lthe:  ophthittttmoseope )may be of va.lue in dI..t.erxnlitniig at.early  ditagnosis.   Visi0on is not ustually inl)pairetd.
At t nl  t ion  l as  a reatltt y b>een  called  to  t (he  eves  ti
vatrious ftorms of.ri/lIt's disease.  In the albRlnintuia of
pjreg n ane, the retintitis is often rtrtpid in its de ve:lopment.
Ilt st.cl  at case t(he etes, al nmtost  as nmu.ch as the kid{eys,
nmav influene, thte  )physiian  in iid.tlcingt  - prV(.'t4iattre d(elilveryl.   f organic chanllges 1have 1noft: tfatkent ptlal   in  t-he
retinta,  I a  impl)rvement 1i  tl't renal c:- ondition is fo:ll t\wed
by better sight,. t If      eve, how ever:  tntorrhag'es Ithave oecurrted
and(t t:-le fit er n:'ervous strucllt:us in thet, ret imt hamve b'een,
dest royed,  vision  mlsl:t  rellmainl inmx:e rfecet  unll'der  t(he
imost favi(rabhle ci rte mstantces.
lra/ttiulr dfie(t.aes of the hea.rti   and athiero. ma  of the
arteie.s oclasioniatlyt give rise to emtloli, wh\'l.ih ntmy l'  e
ca rried into thte chatnnelss of tli intra-ocutlar ctirutl ationt
ausin.g bli ndnel ssl.
li  ao6rtic inlmstfitietinc   pulsat ion of the retinal vessels




TitfiE SEC(ONI) RELATIO'N,                827
can be discovered wit   th e eophtBalnmoscoe.    he  igh
arte'rial tension )predisposes to hemorrlhage -from  rupture
of t::lhe smaltler retimtal vessels.
I)iseases f thlte ste.rual sylstem  no n u frequet tly causei
disturblance  of sightd.  trritation of th:e generative ovrgalS,
depenldeni t eithter tp1)on mastturbation or oilter cause, such
as a cointracted and adherent: prepluce or hlvper-sensitive
and contgested ovaries       ay give trise to persis:ent and obstiliate  astlhnopia.   Conjunctivall congestioll or(  even.
more profotundl itflammations may restulL'tlThe eyes are
freucently influenced byr menst'ttrual  re/ula:t'ities.'I havet
setf.en   tret: iitis    as   result of amenorrtl{) ca and vision was
restored  onl  when. the menstrutal function was regularly
resumnned.  ()On the advent of puberty and at the  li macterir the eyes are frequently'afct ted, tand slirght retf racfive errors may cau e serious dlisturbtance.
In  diatbetes, if the sifgllt becomes obscured, the le ns
sl8tuld al ways t be examined, as catfaract occasionally occutrs.  TIheo swe-1lling  of the lens may  give rise to an
apparent myopia, and in such a case lenticular opacity
mttI I   al (ways     e t  l )ooked for.
As im irlht be expected the eyes are frequently involved
in diseases of the netrvous system.  lt. u locomotor ata xy 
gray atroIphyiv of the optic nerve maray ultitmately occur;
wlile in cerebral  t tinors, swelling of the 1)optic nervc....
the so-calltd e   d t choke   disc" -'' is8 tan imlporittantt feature.
Th.e va'riots cerebral nerves SUpl)1:dying the eye may lbe
affected from  cither cent ral or periphera tl causes,  andt'(aresis of individual muscles, or of a. group htavin g tihe
same nervou t' s sli suppml, is not 1ltcomtmn.1 1
I n her-5pes tLaseialis, vesicles occasionally appear upon the




328  JTin i: EYE IN  tEL ATION TO TIUlBl  G EN NEtAL SYSTE'M.
conjunctiva or cornea.  In such case the resulting ulcprs
are always slow  to heal.  When the irruption follows
the ophthalmic branch of the t rigeiminous, the ocular inflanumation is much more severe, involving as it may, the
iris and deeper structures.
TIIE TH)IRD 1ELA,.'rTION
in which the eve munst he considered in its conmnection
with the general system  is that in which it mav be a
cause of more or less severe nervous disturancees.
For a long time headaches have been definitely ascribed to refractive errors, or to i  lperfect( balance of (he
ocular muscles.  The paIinl is usually frontal or tetporal, often in the eves or back of them, rarei.  in the vertex, with frequently a drawing' sensation extending to
the back of the head.  These headaches, from  some tunexplained reason, are often worse tin'll the mlorning after
sleeping.   Sick  headaches or headaches produced 1b
travel or h   watchingr moving  o)bjects can  often he
traced to some form of heterophoria, and will be relieved
byv its correction.
Comnpar atively  recent investigation has shown that
more tremote nlrvous troubles imav be dependent. upon
eve-sttrain.  I have mvself ) the correction of astfigma
tism   relieved  persistent~ temporal neuralgia., antd Ib
tenotoml  of the muscles in heterophorias overcome an
insomniat of mani        vears' standing, and great ne.rvous
irritation.
In those of neurotic tendency, the number of nervous
symptoms whichl may arise as the result of eve-strain is
legion.
1O'0]1




THIlE T1HIfl I) IttlATION.              829
Drowsincss  is iot luncomltmlnlll, and distullbances of the
apettite anlt digestion atreI freqtuent.
Am:long  t:he sxy toims tnracedt directly to the   t, at.nd
said to bc  e lired b)y the (orrectiont of imuscular and refractive defects,  are mental dtistturbances, al pholtia', palpitation of the teart, pain  iI the ovaries, dia.rriho:ea recttal
irrit:ation, etc.
Reference has alretady been made to the effect obt(ained iln chorea an[d epilep'.sy, b. y re(ad}justiTng the tlmuseles
in heteropltoria..Bttt in t hese protfoultder lesions the
subject is still sub ju'lwice, and. it ctan }be only b1y continned  investigations, by  carcfut  and experienced  obser\vrs, tlat the exact relations between cause and effect;.
cain be ascertained.
Among t:he symptotms that slhould direct attention to
tlie eves as a ctiuse of nervous troublt, imperfect or painful vision  is, of coilrse, 1prominent.'Tlli s   ptonis of
astthenopia, if -persistent, should always  suggest a possible.refractive errort, o  musculalr meo-ord(imnation.
It rarely hltappens that nervous troubles distinctly dependent 11t)po   eye-:st:rain  obt ai   withou t  definite eve
syvnlltolns;  but it is not unconmmon to. find the nervous
symptltoms Ixtuch the more promintelt.
In any case  wberc the symptoms of eye-straitln  or
asthenopia  occur,  no  examilnation  can  be contsidered
complete uitil the eyes and eve-muscles have been subjected to a thorough and comprtehnsive examiniation.
1F. lP) T. ]




C(IAP t.1   X X I.
LIST  0V A PEIW  INTERNAL.!MEI)IES WITHi  THE fOP!THALSY'1 PTOMS Ot? OF1 TU   EYES,,  FOlt WHI ClHt THEY  HAVrtE. 
BI:EIN FO U NI) USB':EPU,l IN MY PAc (TICE.:,
TIE listi wh iliclh follows comprllises mrelvt tlett  remledies
%which l     ve been  adm( instered  from  itndicat ions  fiurlishlld by the eve alone.   Others hatve,beenl found lIseftl also, bult, they have }ben  selected  on  taccounlt of
syvnptomIs atIart; fron tlhose of the eye, an1(d Jfo  surch as
are fannilitar to al  gnl        p'1n. I I    Ittrac:tiit:ionltes.  Mallsny reetuttt(-ies  a      avi ngt  l   st ro.1n  atlfnity for th:e eve, jl:dged by their'pat-ho ettnesis,  haIve not,  in lty experience, been foulnd
reliable.   TI    d diseases s or svytnl iont    given.I telow have
iee n repeatedly cured or relieved by a single riemedy,:t le namel ofif witlic  is p1laced opposit    each group.'lThe
dil  tion  or  tt itr'attions used  wt ere the fir st, second,
or third.
ACONITE. itnt. the earlyv stage of inflaunmlatlions of the contjunletiv-a, cof'nel, atndi iris, antd after surlgical ope;rations.
ALtX UmIxNA..It   chlronic blepharitis of adults, aid in blennorrht.(at of the lacltirnal passtage,   witht tht iti dsc.iatge.
A tst;xCTs.  In suterficial and deep-seated uleeratidon of the
cornea, especially in scrofulous subjeets. Catarrhal  opht t}hal
rlia, with thitn secretion tand irritation of the edlges of the
lids. 1.lcetation of tthe tarsal edges, with ttin secretion,
antd 1in opht halnria scrofulosa generally.




INTE RNiAL,  1E-ME DIES,                      t.I
].:   IlA,  ONNAs..  In ihotophobia;   injec.tioi  of the ocular conjunctiva; con)gestion of the retina land optic nlerve; dilation
of the pupil; cl iarv neuralgia and tpai  in thle opctic nerve,
with conges tion.  Neuritis optica (diagnosed with the optthaholta scope).   Scrofulous ophtihaltnia, with great. coitgestionl of thle conjunctiva6 and photophoblia.,
BtlYONtIA.   Sclcrtitis or eplisclfeitis.  Rthe  natic Iritis.  Conjunctivitis with soreness of the eyeballs to the touch and on
tmovitn  thentm  (cocaite).
CoNIsM.t  Plhotophobia in scrofulous subjects or in. scrofulums
ophllthallnia; keratitis.,
(     uCAT.s..flypertinia of retina and optic nerve; optic neuritis..Astlientopic syn'ptom:   in conjunction with a tent entcy to
conf est:ive   eadacthlte or ft'uslhed facl.
Ci(   xt  t OMi t i  A.X.  C iliary  neuralttia, est peially in scrofulous or
purulent. op}tthahtlnia of childtrctt.
( ls ti  t xN. i.,  Accommodative asthenopia, with the usual subjective s ymtoins.  i)ilplopia (fromt functional disturbhanceof
taccom0ttodation in one eve).  Ptosis from partial paratlysis
(Ch rotnic spasms of the orbicularis.  MAtuscultar insutliciencies.  Nictitation.  I  lpenra.stletsia retin 0at, witil plhotoplio lia
(nux vomtica).  IRetinitis,
Gt,{oNoli^x.  Vettous hyperlatmia,o or congestion of thlt retiat tand
Optic nerve..if['AtAr -s i.tlt or sulptlide of alciutnt.  Purulent ophlit tlllnia
ntlveiterate blepi actitis with luruilent  secretion, in scroftulous
subjects.   Keratitis.  Contjuntttivitis tlerpetica.
I v"- >lr As'rt:N.  IXt acute catartrhal optlttaltmie, with profuse discharge, especially   in serofulous  or ill-nourishted sullj'ect
tIO:)> f, or POTASl'.  Inflammation of lal]ryttal sac, witlh miucous discharge.  Syphilitic il'itis, chorfoitditis, and keratitis.
1 ION, firrumt imettllicumt  in different prt'epia'ttions, int  vuarious
ophthalnmic diseases if 1anmla n:ic conditions are present.
MEiCt:c  Y.    Blephar:itis,  elrolic or otherwise;  pulrulent oph.
thalmnia vwith coplious discharge;.  ke ratitis diffsiusa, superlicial and deep-seated ulcerationl of the cornea'; phiyetenltar




382         -         INt EibNAiL  IREMD IE)S.
ophthalm n tia; syphtilitic diaseas  of any or all the different
stlrcturcs of t}oI (vc;,!piseleritis; scroftltorts olphtbalmia,
with photo)phol)ia.    In order to e'   t a local effect of this
drutt   in scrofutlous oplhtlalmiia! somentines  use an eye-waslh,
mtliad  otf (on  eighbtht  of otne grain of p!er(chlori(d  of mercuryt
to two 0.ounces of water,
Nu x vo. i:cA.  A stentoptic symlptonts.  I )hotophoita from rtirdal hyvperasthesia.  l)ilatation of the pupil from spinal irK'itation,.  1)iploptiat froml inu:ular asthe ntelt pia, from1:   paralytic
strabisms. Pi:aal;ysis  of sixth nert ve (rectts  extlernus)..I01tomonyious dip)lopti.  We'tcakeictd ptower of a(tccomlTimodatiion in one eve fro ut,  vetr-xettint' it.  Severe p)ain in the
eycs, aind during  the 1ig lit, wtitl  conjt 1 | etiva l i hjection.
broug}lt: on by over-tuse of the eyes, especially by artificial
liglt (gclsemilnum,  mcre(ry). )   Splasmodic or involuntary
closure of the eyes in adults (gclsemninum).
OPt.)m    H1 yperamitna of tim conjtiictiva and btorders tt   the tarsi,
with injection of the ocular conjunctiva in coneiicction with
co1ng(Cestive Iheadache.
P'   L8i i:SATILv,.   Catarrbanl op)hthalmalnt wit l mucous secretiont.
P'lIOSm: Ilu01.     e tinal hnypcrtrmia with cotngestioni to the head.
Iltashes of light, dazzling pointts, or rintgs of variotus colots,
before the eyes, iindicating extreme  sensitiveness of the
ret ina
QuxvtNIIx,:, 1st. trituration.  Asthenopia, in dcbility;  and in eye
aftections generally of maltarial origin.
SANXort;nAl  A,  lRctinal congestio)s, withl tendenDCcy to flushied
face and eong estive thead:aches. Sucperficial ilnjcetion of the
eyeb:all, with feelingi  of soreness.
SANTroxiNN i,  Asthenopia, especiallyn in cases where thiere s evident loss of tonte in t(he retina and accenom odative apparatns.  Such patients 0do not see q(uichly.
SovTer. LAF   a.,   Spasmodtic twitchiiigs of th e lids (gelsemitnill
nux vomica),
SECALE,    Asthenopia.  Asthenopia with enlargred pupils, due
to nervous debility.  Diplopia from  muscular asthenopia.




EIXTERNAL  ItM E. MI}S) T.                   888
8 1O'e 1BLIA.  C (onjutnc'tivitis and iritis it children, particularly  lt
those  of scrofulous diathesis.  (Coglesti(oll of the t  ilir;:t1
vessels, as ilndicated by the pinkish szon:tt around the cornea.
Severe pain in and aroundt the eyes, and on  moving them.
Severe phottophobia fl1rom  ciliary    r'vous irritaLtion,
STr LL  Xt i. NAsthenopia (clmracteriztc d by debility rather tlhan
inf aimlnation, or imarked irrtitat ion   f tlhe taccon  odat ive
tapparatius.  Astthenop.ia from  genfral  debility.
Sc;l, I-lm tn.  In chltromi  ophtthalina scrofulosa, with superficial
core itis, thie ptikish zoue wll   arkcl ed around tle edge of
the cornea, and photophobia.'AIRTAit  EMFTI'tC.,'tl}lotophlobia. in stcoftulous oplthalmtia of
clildren.  Piustular coljunlctivitis.
Zt  C M.    Retinal tasthenopia.  A. nasthcsia retina.  NeNuritis
opt ia.   Acu.te  retinlitis alntttrit'a.  Brigltt's disease
(arsen ic).
ZINCx.f XC I IOSi X'IATB.  A fflectionsof thel retina nmarked; by gr1eatt
irritation.   lixrpersthesia retinl., wtith photophobia, flashes
of lighctt alnd luminous spectra (zictunu, nux votlic'a, gelserminuii, plhosphioruls).
E.XTEI N AI I E M I;) IS.
l'he following are tiho-st thatt 1 havo found most satisfactctx  il pr}ivate ptt ac:ttitc.......
THE )IYI.)IlIATICS
tret  of COurttse, iiI almost constant 1use.
A/ropine suip/ate is always to be used in iritis.  See pages
161,  168.  D)tuboisin   may be sIulstituted if the atroplinet
causes irrtitatioifn,  or aftit.er a timre c tauses what: is caltcld an
atropie conjunctivitis.  It is used  like atropinec, of tihe
strlenlth of about one to four grains to the ounce.  When
used in strolgter solutions itn imav affect the btrain untplcasantlty..In a stolutiotn  of  1 sixteen g rainst to tlhe, ou0fnce   T.
found it to )prtodue a miild delirium  or intoxication whvich
lasted nearly twenty-four hours.  T1ere was an idiopathic




384                  EXTIERNAL REMEDEl)l S.
cont taction of the pupils in an elderly lady, and a s atropine
produced no effect, I wished to try at more powerful mytdr iatie.  It had no efftect onl tihe pupils.
tfmaittropzne hydrobromate is convoeien t where a temiporary
effect, only is desired.  It )paialyzes the aecot immotdatiol,
itut not always so persfectly as may be de sired   See page
169.  If, therefore, we wish to produce, a miortet positivs  effect oil accomtnilodatiol,,we use atrt opt}ie sul phltate. Even this
will sometinmt s fait to perfectly paralyze( tYh c:iliary mlnuscle.
Tli  effcet on accommlodation with either oft these sublstances is   ore certain if used at tfrcqultent in terwvals fort    a
day or two before making an cxllxaminatiot   of the state of
fthel vision,   For rapid  fflect on accommodation, it }tas )een
proposed to ust a solutiotn colntainitig two per en t homattlropi n  and two per cent coc'aine,.  The  nattxi1nmi effect
is obttained in 3 0 to 60 minut(es  butt soon dctlines.
C('caietf   muriate as a mlydriatic is us.eful in oplthahnoscopic
exas natt ti(onis.  A  two per centt solutioli enlarges the pupil
in a fCew mintutels,:   and the effect passes off in the course of
lte dhay. It increlases the mlydriatic effect of atropin  when
used with it, rhetce it is useful with thle tlatter in iritis for
this, as well as for its analgesic, property..It is used also as
an aid to the action of eserine in "glauioina,  As an aml sthetic it is available for tnearly  ll opt rattions on the eye.  I
1have removted the eyeball undtr its anaestlhetic effect without incolnvenienlce to eitlhcr pat ttie t    or surgeonX.  I [)owevert
in sutrgical operatiolts of long duration, timtimid patients do
better lunder ethler.  The proimptt t relief oltaitndc byi it in a
case of neuralgia of the eye is given on page 23:.'trtn   51MYO ICS
in most frequent use are et cseriAn  and  pdi ocra ne,.Lserine for glauco:ma, see pages 171, 191.  Its effects in reducing tension in glau tcoi' mt are sttluppos(ed to be ilncreased  )yv
u8sing cocailo wth it.  In sluqggish corneal ttlce ration it is
used also il coniljunrction with coc(taite.'lahe   o solutnion for' use
in glaucomal should be, weak,: or, grain to the ounce,
or it mays  act too enerfgetically.




EX.TENAL  bEMEDIES.                              833.Pidtcarpine acts similarly to eslrile on th   eve butt multch more
weakly, ian ed is use  in a solutiton of two to four gins to
tlhe olunce.   It, is less t irritina thtan escrinct, and I ttherefore use it mtore frequentlly ina tthe m.ydriasis of a tst-henoplia,
It contracts the pupil less quickly antd Icss focit fly than
eslrilltt and is piretferred for this reatson, by somte, int gilaucoma..   For sulbutaneous i    njecttion, in old scletrtist, ke ratitis iln gonutl  or rtheumatic subjects, and l it clioroiditis aitd
retinal dttacht lent, it it s used in t a solution of: alout four
grains to a driaclhmt  of water, threc  drops of which are injcted daily or less oftent      I have usually given it.b the
mouth), in (tosevs of about orltne tenth of a grain.
ANTi-SX EPTICS  AND  ASTI SINGESTS,.Tftrafc t  of fsihtter  for  use i  itnftectious diseases of the eve leads
aIll otlier substances.  It is spoken of t      af est p 98, I g, 1 0 11 2,
etct,,'as a p)lreentive of b litdness, used as a disinfectant
for mother an:di child in clases of  conlifnettleni, it. is noticed
at page 108,  in upward of 17,000 cases of this kind cofl
lated  by  Ilowe (Tr. N. Y   Stat   Stfeo.'89), 8.66 %  of
disease occt rred wt hre these measlures  were not taken; butt
only 0.656%  of disease was observed whlere ta drop of a'      2
solutioti   of nit rate of silver tfor disinfection wats fmade use of.
i]i'chlorid/e of mercury may be used like the above, for the p)urpose( of disinfecti onr  itn a strengtl of 1: 5o000 to I: 2000.
it tlmay possibly be used somewhat strotngxer thanlt this, iut
a   theal thy eye is intolerant  of it at 1I: 1000.  A  solut tion
of 1:5000 destroys germs itn three minxutes, and on(te of
1: 10000 in about five minutess
Chlorine water, when freshi, is the equaiil of thOe bi-chloride of
metrcttry as a gcrmi:idc         I t'formerl  used  it int pturulentll
ohthlttial, ttbutt it is very unstasle, and I rarely recur  to
it now.
Peroxitde o^ hydrofYge  is atn cquially reliable anlti-sep(tiet.  I have
hlad no experience with it..1toracic altid  ftur to e iht grains to the outce, is ustefu  in all
formns of colnjunctivitis, as Ia mild disinfectant.




olarLx, lbihlratle   of soda, ten graltins to the ounce, is chieflt  serviceable it lyperat'inc condition oft the conjutnctiva, or ill
mild c.on juntltivitis,
Su"phate of' Zinc  tt.t        / sulphate of copper, in  solutions, I. use
tvry  rarely  t present.'lhe latter in the for m of crystal
1lmay::  usedl ct:autioutsl  ill toutlchint,' ranulated lids with
trachttlomatous Spannl s.  See tIpage  1. 9
(Alum, im terstatl forml, may be frecly  umsed for grt.anular con junetivitis and is oftetn iprefratble t  t the copper, tas'ausii  only
slight react-ion.
OCti itrum atlminate my be uscf:     d altso in granualt r lidts, and in
crystal forml causes less ireactiont than  the cuprulm  sutlphate.  f.requently a five to tenl grain solution of nitrate
of silver painlted on the reversed lid is more effective ttan
either of the above,
UN(O UENTS,
Thle tunue1tnlits /t-t&t-'h i[  hat   1lO(t' haost uscful are the lf —
tfed oxide oft  mercr,'/,   in blepharitis, s(ee page 281, and  the
ci'tine ointment (ntit atet of merelury) in the stamtle affec tion,
about one p)li   t of thle citrine oint tnenlt to eight parts of
vaseline. Other unguents are mentionet        d aso at tagtc   28.t 
Yellow  oxide   f q' meruelr       ('tagenstchlerl s ointienlt), in  tihe
strengt:h of two to fotur gra ins to the ounce of vatseline, I
have, used occasionally to advantage in slulggish ulcerattiols
of t:hel cornea, a  asmall portion tbing inse'rtcel between the
lids daily or less ofteni.  It is tbettt'r lborll  w\ithin t he eve
thtan tihe otlier preparatiolns of mercury.  B )   cy advises its
(preptarattionl with stpermaceti ointmen(t, with a. few drop:s of
olive oil, ats less irritatilng to the eye.'Whnt(l indicated, tan
eighth of a grain of attopineo can be added to either of these
KOCH IS  llE MED1)Y IN  EYE AFFECTIONS,
Konigtshiifecr (Stuttgart) reports 1 the result of treatment in ten
casesS, with} K(och's remedyt.    I   four cases of cczenmatous
O)pthal. Review, February, 189t.




E:XTERNAL RBEMEDIES.                    837
uleers of cornea in serofulous childre n, and in two cases of
tubercular disease of lids, one of interstitial keratitis, tIe
effects were favorable, the corneal ulcers healitg remarkably
quickly. In three cases of iritis no results were reached.
I have remarked at page 169, in speaking of strong
solutions of atropine, that caution should be observed
in dropping them  into the eye, lest cerebral disturbance
should ensue.  It must be remembered tlhat liquids of
all kinds, when dro)pped into the eye, reachl the throat
through the lachrytal duct amostt l tas readily as when
taken into the mouth.  I think that tihis work was  the
first to call attention to this fact, and it would seeml to
be one of considerrablel importance.  A ny one who will 
take lthe trouble of testing in lis own eye the effeet of
a few drops of a solution of twNo or three graints of iodide of potash to an ounce of water wvill, I thilntk, be
surprised tto find how soon he will get the characteristic
bitter of the tlkalki in the throat.  T lhey alsom enter the
ciriculation by enllosloosis through the cornea.  I had
long noticedt the favorable t c  effect of a tcllyriumn of attropine (one) graintl to te outnce of( waater) inl the photophto.,:bia of scrofuloust ophthatlimia, before it occur'red(1   to me
that: t::he intteratl effect of the:belladonni a might be, at
least partially, the cause of the impruovlcnt.  In jrescribing  collyria for th ie cye, we should therefore a ttwa-ys
tarke into account  the: possible,  or perhapt s we tmay say
the iunalvoid.able, internatl  ifftets.,22




'I']i.SA1.' P'E'.Y X.I'L:
TEST TYPEi
it: fir.st- sePrics ofi tesat   Ity p    i   p''stet          d   m1rely  as  a
C(Icvieni(iiCei  e  ilt tttf oiltli' thO     stftte{  of(  the  visiot,    withl  ot'
willmltotl  g tlasstes   fot.r  reading  or1  near oba t.jects;.'TIhe  dtlfji:tttt siz8ed  print tl         is  nitnilt l'edt   so  that  t record-t st:t il tt
ilttade  ftttntrom- ti1e tot   tinel  antt(  t1tI the'      ttl 81 Noiitsi,  npoe-illtt.  t' orialiti tle..it' it ir   \\ e:''  (tvit('l.' power  a''t1 i el   detelmit ed.'11T)8   secott01     selrit'es,      4      tt tt: of  dittlereut  sit td   gotht 
totteis,  is ii  eltotftilenield           1 fo     ti1n  ot trl't      Itxact 1.11 tSreittlit  of
the   ati n il's  teiteness olf visiot.'The  Intttrllbt s il this
Sr: tieS s 11xtiedicaf     the d istanet n   at           ani teIlt a    lllllatlep    leve
shtould   dii   t     ristrl.      Ihe let  Itet'r,.lt  e  lett's:tf   itNo  
s11o.1Id  Ih  11an1111 i red1adi l,    i                 good  lihglt, at  six  feet,
1U0  at tI::en t feet: 0  at21)     teweattl   le,: tl.  and  N. 4:):1,    I'  N'o,
20 canr  le seeni  1l)8y! a1s otar a'1     s f tent f11 11 leet,  tfthen  \V, =..   i.or'
ey..e is(1 en tot pi0.    Oc,(eeasiona 11l  a p.e1rs           will  he  met' i-t! it:'.;>.:t:''!,~ lStt':,::.: l t iw~:?{:t ti:ct:t:7I:'l:t:'~.~t' V t.)......ft..
wi'th       o   clant  tet t: d  the. lett  s  a   a  11c10.t     1 gt'eat \       is
1:  tc', l    ttl 11t1   1       Na'  t l  tt.t    anl ld  t vei t't t t it'o    t'ig'ht is fa N.
oriaht le ftr' trIe  di tt.' thetit  t ('a gilret'    dista: e t.alo.  TIt    
=second==     ='e8i8 c1       )4:espon t.114 s tvery' nea'rl tI o  to he  sysst e:t  ot:1
Vot     Jaeg'1       aIt   S-e I  le.      thttt  is,  the'    tell        a.   i    of 
en. t   t   t   t l::lO p  ic   eye.'. 




TIRST TSERIES.
No. 1.
I 04t3Aa 4t    s L a I tt  t+   V 4 1 It:i:   Ttit 1e t9-, V' B'. f:ysr.f-!J    n-:. A  Oid.  r   lvn ae  t-x- z.ele.:
It tti^e: wlt   n~ > ite- -ittt   jass a I fimeta t-ostt-    Ssa' aass  s-If t-~z f  ^~a ysis ~- s-fs l  1
as~ <~~  eniastae s:.<~r xc-^a^  t r   -*, ^A ~~. ri..  et s  fll;tuhl ~ t t i  ir* l ea its  sexa't- ti'^'.
Watt 1t       sai s r-t    r  f  tata- g) ti:s:s- ta    Isa t  ti:n sS- i  {lftn   tstae, I ts    a a svtA - d  t oI:-t >>:'I), tat tr iDM s
st ia??aleti  Ies rA ltft^a  a -la^t   a Si p- t t S   satid'i  t    -- a;t't {my i a  a ie ita, itfat    la-f  rata s-:a$
triy p2> v9.i^ Ht~n~ F'- t:e  tkif a  e xit t m) X ~. a t F5^, ~ - >>te o2l ~tse t.ity e ^fit ~^c:~!3 y.- i of{ e w5 O ~  85 <-a e <. t
-a.ttsia,   I    aA-jf:,  a>- I  f-E 7 l   t     to!f:i t; a,   its 19    Str  -t. es ri *a sr. a t ~' s s }    <-f I saaa
ai4t~!i Ca*aCt~ a  a  Is~    s tj i hale itas f~, to a;y~-aias-ietar fi'sta t, s.al  -a Is d'tsass -Jit a -l^t2No. 2
tolleet.s-  the alerle':.s ttli-e  atih  holid your gaondeola to shore, at alWmet to do yl yea a  sert:i
nsdt notle at a.splte:aare, tand prted r- nt to be  abandonaet  svwndlatert^,''te Ve ta:,eaia l faIt theta
grsanlsfste, ot ert^-tateeh ts but  t as  yet IX t t s ktot  thlle ns3 ame or i.te ta lrt.sps of tht s p:;atlseriao,
at tha $B.aa.ion butat teely.:f a  thaIt the hai  tbhe Veatiitt sey  foer color: itn thlt ditfibuti6 sn Almd
a'raSnRugeatnt of or hit f -'agiacitt:s of dret.s he htatd )ttrodue<'lse w:ttsrac-Eutlo   ect.s of rea, a as<,te  ^.,t attougeithtear a: tultirota s a t'it.r' a., ay. fti'etnd of btigSant.l avosilsd ike to ateet s a ltonasly
plt. es  i      fie did not cftr to stabf.  e ant srla  my btoaty iaa s: a t ir.aat C:seM,  as., his all Venaetht:w
No. 3.
k3eepisg, I felt that lhe otught  to have sdoate  bIt tt he ijlI))ortcd t  a   tI alms, asid I htardly
know  now whethaer  to exult or <          i <It tlat I  it lA31 uot utterst nd hi, t ald lefAt hltu
etskpty th^ldea(t.  I suppose that Ie waithtdrew atgain the btSlles        ings     whvi h oet advatnedI
ste, a     wNe puthesdl  out Intoi ttlae cattalf: t l:   I Itheiardt notahing, s ts   thee twonder of
VelntCe wasin  anlready upos mse.  Al. t  y ml:t ho trpiit, 3     so to  s^peak,  as dutled at d
Jaded wittt tlhe loug,, cola, rai Ilvay jouft'iey frot    t Vie}tnna, twhile tever'ysu'rfacsense
weas taien and tiUt a ttaglcd inhe bt e wetldeArit   brieallaney a  n    tn novelty of Venice.  For I
No. 4.
tihhtk  there  ea   h be nothing else in  thie woisfd F.          fall of gitteui^stg  tasitl exquiaste
eurprise, as tthat first gliumtxsje   f Venice slwhich  thae tratveller ca(thes a  hie issues
from  the railway stati    on by nighslt, and looks tpotn ther acerlet              e           Th reet.
s somieth ing in thte be  sed be.tAli of Italy (how qutiekl' coti g   ea out   yout  know o          a
it, axnd how bland:lt it 1-, after the harsh  tras salp le air!) whtich  prep anes yoa   for
your naceturntt.  aves nt itoha  Vlat eel; atnd 0  yotu   t:shever yout arte, that jourtne.v
taowart  thifs enchant ated cit  ftor the fir st t ite, let met tell   a tyo     w ow hsa ppy X.I emtt
No. 5t
yv l I   There  lies befre  vou ft for your  pleasttre, the  ape hacle  of t such
intgular  beaity  as  t1o   pictume calt   ever $show   yot  nlor book  tell  you;
bentty which  )you sha l  i                 Cel  iperfectly  but once, and  regret fcr ever.
For  lmy  owt   piart, as the gondo0la  slipped  away tfiom   the  blaze  and
bustle of thIl   statiotn  dows  the glootm   an:         d silence   of the  broad eganal,   I
forgot tha t I lad been freezing  two dcays and  niglhts; that  I wast    at t  at
momenlt very' cold  and  a  little honiteliek,.   I could  at first  ceel nothilg
No. 6,
but that beautiful sitlence, bro'ken  only  by  the  star-silvered  clip  ot
the oars.  Then on eitither hand I saw stately patlaces rise gray -anti
lofty from  the lark waters, t            holding here and there a lam p against.
their  fitces, whicth   br lought  balconlies, antd  colmnnl s, and   cartven
arches into lmolmentary relief, tand threw lontig  streams of crimson
into  tl e  camnal    I   toutlt   see  by  ttat utncertaitl  glitlmmer  how   fltir




840                  TEST'YPE.
No. 7.
was all, but not how sad and old: and so unhaunted by any
pang for the decay that afterwards saddened me amid the forlorn beauty of Venice, I glided on. I have no doubt it was a
proper time to think all the fantastic things in the world, and
I thought them; but they passed vaguely through my mind,
without at all interrtpting the sensations of sight and sound.
Indeed, the past and present mixed there, and the moral and
No. 8.
material were blent in the sentiment of uttter novelty and
surprise.  The quick boat slid through old troubles of
mine, and unlooked-for eventsa gave it the impulse that
carried it beyond, and safely around sharp corners of life.
And all the while I knew ta tt this was a progress through
narrow and crooked canals, and past marble angles of
palaces.  But I did not know then that this fine confusion
No. 9.
of sense and spirit was the first faint perception of
the chlarm of life in Venice.
Dark, funcreal barges like my own had flitted by,
and the gondoliers had warned each other at every
turning with hoarse, lugunbrious cries; the lines of
balconied  palaces had  never endl ted; -  here and
there at their doors larger craft were moored, with
No. 10.
dim  figures of men moving uncertainly about
on tletm.  At last we had  passed abruptly out
of the G(rand Canal into one of the smaller
channels, and  fiom  comparative light into a
darkness only remotely affected by some farstreaming corner lanmp.  But always the pallid,
stately palaces; always the dark  heaven with




TEST rTYl'E. i      41
No.  1.
its tremibling stars above, and the dark
water with its trembling stars below;
but now innumerable bridges, and an
utter lonesomeness, and ceaseless sudden
turns and windings. One could not resist a vague feeling of anxiety, in these
No. 12.
strait  and  solitary  pass
ges, which was part of the
strange enjoynelnt of  the
time, and which was referable  to  the  novelty, the
hush, the darkness, and the
No. 13.
piratical appearance and
unaccountable pauses of
tlle gond oliers. Was ntot
this   enice, and   is  not
Venic  i or ever associ




...............
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al4  Otll lPL.
AtA/;o  sl~~'u ~!I
IN'oN
It
puetxlay^  I
g-lnOg'iA ^1




344            TES T TYP.
SECOND fERIfi~f.
No. a.
LH#xTVOtUO
No. 8.
UOF O PG T H L
No..
No. 6,
ia OTCLEFy
No. 10.
No. 12.
No. 14.
P F 11 F: _~'.M OC  TaI
p.'y
PDL  FH  OTG~~~~~~~~~




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IN DE X.
AirlwxviATmiNo   and signs for lentses,   Asthenopia, spectactes in, T4, 75,  70.
T9.  Astigmatism, 76,
Abscess, of cor-ea, 13, 18 compound, 70, 79.
globe, 176.                                    diiaginosis of, 77,
lachrymln sac, 29   irregulatr, 77.
AccmPtInimo datilon, 49.                           mixed, 77,  81.
anomalies of, 5 1.                            regular, simple, 76.
ditffers froms  refraction, 50.               spectaclts fsor, 8.
mechanisn of, 50.                             test type and lines for, 3-48
tparalsis of, 2068                        Atrophy of optic nerve, 218.
spasm of, 269.                                field of vision in, 21.9, 220,
Acthromatism, i3.                                  not: untiformly fatal to sight, 220,
Act of seeitg, 20.                                 ophthaltmoscopie  atppetarante      of,
Amatmrois,  18 etc.:1, 219.
rAmbl}yopia,'22.                            Atropine, action of, 108.
(cat es of, 2424.                            "ani aid to dliagnosis, 28.
diagnosis of, i222,                           strength of solution, 159.
treatmlent of, 224.                           use  in eye affecctionts, 161, 16
An }tatomly, 5.                                       169.
Aihyvloblepliaron, 309.                       Aut-otlptaif mosco pe, 40,
Anterior clhambetr, narrow  iu infants,'23,
Apf akia, 2A56.                              BlN.        )  coipre t   86,
Apoitlexy of retinat 206.                        tsiept,  3
Aqua chlori. the use of, 123.                  I   lloadlota, its internal use, 331.
Atlqueouls huttor4,I,                       I, Binocular vision, 21
iAr'utts senlis, 8.                           Blephauitis, 20..\.gtcn, nlit., extert al tse of, 95, 8 1   lI00,    t Bleptharo) s, 280.
l05t, 107, 1X:, 112, 120, 132, 118,   Blilndness, sixmlation of.7,
335.'rights di sease, 203.
aus a propvly lactic, 108.                Brvonia,  use of, 331.
ths ise of, 3 0.
At tici iial eies, 259.
p:tpil, it64.                             CANAr, otf  Schttlt 6.
As^ttthsn opia, taccoi)rniodative, 79,             of lFontlia. 6.
Iusilcular', 8b.                          Canaliculnu, obsrtutictins of, 291.
retinal,'280.                                anatomy of, 17.
irmedi es in, 76.                              to slit up, 290.




30                                                   IND i)X.
t'alt'er of tth  eve,  telultlary, 303..toroiditi;,   17.
(Ca.ipsiutar cata  act, 2Ya3.                                        amet opic,   17.
opacl'tits, 2.48.                                              central,   1 t4.
('tttaruncltl, 1.                                                  disseiinlated,   172.'ataract, 20.                                                        opht hiainoscopi    aiipperanc e    of,
caes e of,'28.                                                    172, t74.
complitt      ionlls in,:'237.                               siplext, t7I
ditanlosis     of, 23. -                                       suppurative, lUi.
by  lateral f      uillninatio, 2360.                Chronic healche  I ned  of oph ithatlInofb   opth:tilhatotoll  itt, 236.                        scopife  tex atin n tioni   iM, 47.
objeetive syviptu}iis ofm   23.                         Ciliarv  body, 1!.
prog:t  orsis i., 2  l.1.                                mutt    e, it
sul ltect   vce s  mt >tti  oml   of, 2,                   nerves, 
whelt   rifpe or voil' te}lt, 240.                        ti)r esit ^ss 1 tI.
blaie f.59.                                           Cliary         s scle, act ion of, 4i.
iaps)I\,'25i.                                             division  of, 319.
capi"u  o-lenttt ictnlalr, i24t                                 psaralvisis of, 2t8.
eol gei^ ilalit'249.                                        spant    (}f, 2;tof~.
e tica!  d     t. 2                                     C      tlosn:i. of pipililt in iritis,.10:, etc.
diatdvti iv, 2.                                           after cataract operait o}s, 247.
ittit, 23;3J.                                                  ope'ratiotllS forn, 1.6.
lhari,    0.                                            Coalne,       I T, t.t
opS rat ions for, 2.40.                             Coll yt    a  til conju1ictivitis, 335,;536.
tfter treatmrent,'24.                                      intrut  la  efiei  t of,   T7.
aXtieltliiat,'         )t.                            1Color  fiti ifl hne:':<, 2i,
nullclr~~, 2l. tColor of tlens,!                             i,
pyramda5:l-         ~.                                  C'oical cornclh0lea, i-l(.
secondar.,       n4i8g.xt' s                                          oix  of^    I 4i.
-chniltle,:;>V9).                                            alrtificial ptpil il, 147.
ioft, 2- 10.                                            Con liil +ju nicit tiva, a feetion}}   of,,4.
ol:erat io,,) l   for, 2-I0.          I        atatomt    of. t.
striat d:,   2:v  y                                                      fsts o', I;.
tra  niatict,   2:,.  foreign liidivis in.;0 7?.
tr  atl noIt,of   ca':trac,           it. edical, i.         niujiti' of.: 05
2:4tyt. 3           t                                  warts, if.I:
dici. -ion or ab-o:rpii onl ll  20,                 Co   tinitl  ivitt I   95.
extraction  ph  itfsi:          le,' t.>.         c       eatarrhali, 97,
flap tt'ex tr   iit oni.   tit 2,                          liiell ital, tt  3.
linear <:,xtractio:n,:TO-.                                di:phtherivti,   114.
iM' ripliv(. ~r~ic~l-f   tlt,:t incari s L: extractionrl,243:,  eruplt i v e, 1f'.
r-clination,'   l  45.'                                   exantlhemattoll,         1.31,
-uitiont, 2i     t.t fi.                                   iln I iIut iilar,  Ilt 
C'.Mataract Hgla-sss,    L. 4S                                  ))oi;rM }l{:ri   lI,  l {0.q.
(    "atl'tarrhal, )If{ til} iiaT                                           i ff7i. rat r,,  t It.
t rIatl       tof. i8,  100i. 1ttPl: tl(ntul}at. f it I.
I Chalalti oi}               i, 4.                              t      t ru lt,t It).
Ci tortoiil, at of      o' f, 8.                                     is tflntouit, t.
itpt;r mZia oft, T7'2.                                        simpio, 97.
ftarco a:-f, 2.l                                Conl agi otsnes   of   oi)lSitial;-        nia,  10it,
Choro^s~iit,  tu-bercles o~f, 178,                               1.^   18




IN DEIX.                                                "lt'o.vergetnt s' rab1ismnu:,? T).                          4 )ilhr..ation of  eltS,   n  -t
C:Orlv sis,        1;02.                                  Distance, how    etermtnined, t        2~,'4c41n 4, aliti1tcionsc      of1  It.,                     Divergent;stJ.rabisms 1?2,
abs)'cess of, t1, 148.                                  ivision of ciliary musle,   I02
abtnasions of, 3,                                    Ioubl e visiont,       o, 8 7,  281, 1t,   2i,5.
anato v ol, 8. i                                     Iropsy of tlhe ev', 404.
4o(114t,  1 4. 44                                    4b1isiw,   t148, O170:t.
1haziness o        2, f12,, 1  340, 312.
injuries  otf, 31,
lack of tra nspi) re 1cy of,.. "                              28.
o')a"cities of, 1          40.                      f 11ectric liglt1t,  eittets  of'; 2' i2.
pa4 aceu tesis of, t140.. Emboli sm of 4c ltual arterv of retina,
p.rforation (:if. 4*,.                                 2 I,2.staphil't  lna of,  1.4                                1c 1aloid 1i sease. 4'2,
u t1ce;s of, 1i4I4.  E41cry;sted t4 lm',r4   of lits,  Zs8!,
cr1tscnItie,  1112,  415.1 antrce of optic nerve, 15,
dcep, 14b.                                        Enlropiunm, 28:1.
su ri'errtial,13L'ucI.11t.' }mchat ioll i,' tlKe.i.\ re T ~;7,
tran1 nsI,are1 t. 1t 4 t.. 4E4tica n4t hu.11'p4.,
reatnment of, 1.li                               Epipho,,ra, "L..;'irossi( ldiplopia, 2i-,'265..Etsvch'riki -1. 5,
Cro ssi       of  optic  nlerve   libres,   14,    Epithelial, (a11tt114 of lid, 283.
B:0,  l                                                   tuilitbill-mo of muscvlcs tests f-orA, 84,8.
('Vstatlin1  e      mles,  2. 1E. E'r il', u    of' 441. 4:44 4.
4'Vclitis   1.   t, -, 31.s1,"h:i, 
('vst'.i rci, ISO4.    4Evi' eratio)                                               t  V, 21.
Cts of iri1,                                                              1.  Exam inatl ion of tiH  eve,   1.
of Hlifd%  238..                                           1v l4ateral   1m 4irni atio',    4'4.
l  ht <~lul lnio; cojlfi',;.~T,
i:)4At. hrtlYltt1   441 it::ii,                          Ex    ion ofI t14lt-l,    1 4,.
4Deta 1usnes    of retin1, N8  1of                                       ttaphv'. 411.
A[t  11   Of, 44 104.                                Ex1atio4.n of n:erve's of tl 4         eve. I*,
D)iaabetie  tai tat.  "    5.         1E Exco'riationl oft he (sr, fH i. 
14ila41te1d  i' il  in   ise'ts   of o,y44  1' 17...ltxoIphor t a, 8I).
182. 1 8N:   184, 8IL,:1                             4  41 Exo 4l1111ntos4:I{.
Dioptric SvWtit'l' (of lens"es', 0t;0.4)                Ex ern4l r1e441     ie.ics,';4;,
Ipith4eritic conjunctiviis,                i 4                         4 Extractionl.  See:;.
IDiplopclia, 35l  85t,, etc                                 of  foreig/n  bodie     fromn  tUK- eve,
scope, 41:  08.                                      I',:'.
i!iseases I,)f tle etye cotexist 4wit4h di:s- \I E'e prote''ctors. 444 
4~i~l~r-  t 41114  1)114 H, i.:14... ~ 1.'l           ic 4;.'4../ease of the.  brain, 40.:.2 -   4.      Eyeball,  Sec (;-'.
co, ex is4t with i1ns1: ity', 47.                   Eye lashest   rem'1i(val o. 2iS.
4n4l:4oss4lidi     t4o dliagniose  form,11rly, 1    Eyeids, a1lt'ec4tio'11s o1f.4 H:.81.
I44-.                                                   a4na1t4 o4,4 4    f, 1 i;.
144made1   a  sp:41cialty   ly  ltile  Egyp- 44            elpharo sp1a'", h841,
tians, 1.                                               d1 1tieha-is, 1.'1.:e~ess~ary  i, foplcl'e i l. i'O for.}en-  c.tropilon of -.
oral I pr4f act 1ition1e1r4s, 3I3.                      c       pe     o'tr t'i(:4444 4:4f1,'241-.




352                                      INDEX.
Eyelids, epic)autltis, 28 5.                    Glaucoma, premonitory  syvmptot         s of,
hordeolum, 285.                                    18'2.
paralysis of, 286                               prognosis in, 195.
ptosis of, 287.                                 secondary, 198.
sp:asm of orbicularis, 280.                     treatment, 190.
tinea tarsi, 280.                                  strgical, 193,
triehiasis, 283.                                rationale of iridectomy, 100l
tumors of, 284.                                 when to operate in, 194.
wounds of, 305,                            G tlioma retirte, 211.
Eves, artificial, 257.                               treatment of, 211.
to insert. atd remove, 2 59.               Globe, affections of the whole, 302.
descritption of, geographically, 5.
foreign bodies withil, 310.
FA~-sinTr.  See.Prt4'yp                          tension of, to (determine, 28.
Field of vision, 31.                            Goitre, exophlth'dta i, 302.
to ascertain the extent, 31.               (.Gonorrlihal ophthahnia, 109.
in atmaurosis, 213. 220, 2L 2l Glranular ophthallia, 11.t, etc,
in icataract, 237.                              treatment of chronic, 118.
import.ant to deten nine, 22'), 221.    Grave's  iseaste, 3;02.
Fistuula cor:.nea,'24 7.
lael'irv? alis, 291.
Flap extr action,'it 2II f                        i   Nlss   of  globe, to  determine,
accidents in, 24-1.                                28.
Fluid cataract, 253.                                 itt glaucoma, 182, 190. 
tFluor-escence of tens anld  orneta, 22t.        e1 tladacle, lneed  of  olpithalinoscopic
i:,,ontana, spaqcee  of, 0f.                       e xasiniation in, 47.
F'oreign bodiet  in t   heojuntiva,  307. li, lenieralo:lia,  28.
in fth  cornea, 31t2.                     1 femorrlgage il the antl  chamber, 314.
wtitthin the evetba;ll, 310.                    into tihe vitreoust,  3f1.
Furth nerve, paralysis.of, 2.00.                    under conjt  ntiva, 13,3.
l'ovea Ven tralis, II.                           Xepar. silph}., the ute oft 331.
Hlerpes  frontalis (seu  ophthahni ics),
282.
(h;~:sit..i:ro, thle u-e of, 331,          t lerpetic  op ltlaitdia. See PIt^ycitetnual;tatoma, i acute  intlamm atory8, 1'2,                 op:l/tha; ihit,
183.                                    I leterotporia  89.
eh toiti, 185.                            I tloidcl m,, 2i8i.
tclco d     ts  l.   a ry,:}8.           I vat i i  178.
dansgr tf de lay  in olteratug  for,   It taloid lt  nlt    ln'a t   13.
1i4 i.                                      d 4drasi n, the itue toL 332,
earlx' svmiptomu's oft 182.                I /!droldutihalni,:i0.
sexavation of neirve in. 187. Ii lvperini of  hor:iidlt t 1.
fiit, inans of Gut   ef itt, 188.:i t:jeCivai,  }i 4.
i:rit hdeutoni",.             i         is, l   S >.
mnedical treatentti t of:,1 l).                     l opt i} nierv, 214,
ilciraxlaict pain in 1, 1'2.                       reta 
nm-intllaminati,:ri   119,                 llv iru. t>-{cliei n: e, it 0,.
pht i     hal mo   pi l   ia;o' f 181,        ll  I y  per   e  irit    ia, 04.
perations lor, 193,                    i 97      l a ihe:tia  in,
patholov, of, 107.                       I      t dia no'i. 




INDEx.                                           8$3
ltypermnetropla, spectacles for distance              is, ( diseases of, 145.
in, not to be prescribed tunless                   pithelial covenrlng of, t2.
alsot lt:elv necessanr, 71.            I        ernia of, 1i3.
treatment tof, 71, 74.                              injuries of, 6t.
]typer)horia,t 89.                                       prolapse of, 103.
I typopion, t 39  t renulous, 171, 9.56.
lritis, chronic, 1.:3.
cause otf  160.
l1'ir rL Mt E.TS and instrnments, 33.                   diagnosis of,  O9*
Infilamtiattiont of clhroit, 172.                        serotu, 18S
of conjunlttiva, 95.                                suppurative, 156.
ciliary bodtt,      31.                          sypht6litie,  flo.
corntttia,!;.                              trautatic,   311.
i tis, l bi8                                     treat mlit of, 101.
lachnrymal apparatus, 259.  Iselmina reti'Viic  212,
litIs, 2.80.
optic nerve,'21, etc.
retinta, 200.                               K iRArTITIs, 1.34.
seler(otica, 142.                                bulbous) 1360.
vitreous humor, 178$.                            deindriforn, 137.
vwhle eve, 302.                                 tdiflfu'e, 138.
Injetitons of co(ijuneti va. 95.                         fasticullar, 134.
signifitea le  of  differentt  redtness             interstitial vascular, 137.
of the eve,,, 5, 9, etc.                    non vascular,  137.
Injuriers of conljuniti iva', 10 i                       puntll ata superficialis, 138,
cornea,   31 t'                                     suppurative, 13 4.1
of the eyes, 30I5                                   vascular suiperficial, 13.
globe fri'on gnlfpowder 3r07.                       vesicula r, t16,
froml pterie ssion  a   1,     t           tie 311  tratient  411,0.
of iM ais  t tents  313.                       Keratto-gtlob, 302.
lid, 305.                                  Koch's treatmet in eye affecti ons, a36<.
shlerotie, 315.
svnpatlhet ic   opitli taliiia,  froi,
310.                                       ILACtn vt appiaratus, affeetions of,
internal  reedties  in  eve  affections,                    28,
8330.                                                  enpipliora, 289.
titervaginal space, 15.                                  gland,  ait toniy o:f, 17.
Involnittarv oscillations of globe, 209.                    diseases of, 301.
lriidectoti, the operation, 1i,  193. p, passag',   nitoiv of, 1, 300.
iit cattaractJ, 2 i.                                obst) rti:t ion of, 289, etc.
choroidl it ist, 0-, etc.                         ca inaieul,  21i..
conical cornea, 3.19.                               duet, 297,
glaucoima, It93                                     sac, 201
Iridiodesis, the operation, 1605                         bleinorrlueca of sac, 294.
in Saitaract, 251.                                  l stitsa of sac, 2924.
conical cortsa, 14l,                         sf'riettre of, 2(9, etc.
Iridodone:sis, or tretmulous iri', 171                   treatmnlen t of 7,. etc.,
Iris, adhesions of, If l0, 161, 12                       S titling's operation, 299,
amntomy    of, f12                             Laop filtialt os, ~28,
boim)st, 1t0.                              l',a onmiia c ibrofitsa. ti
yts tof, 1 71.                               f, Lateral illunmiinatiot, 44.
23




P)504                                      INDE)X,
lakteral illumination, il cataract, i230,          N i,Ai   duct, 10, 800,
oix'teal opiacities, 27,1 0.                Neuralgia ocutli, 23I,
d4islocation of the lies, 25..             Neuritis  descert  ndet,   21
L.u ns, affections of,.it                         Neuro-retiniti, 213.
anatoniy   of, 12.                                 case of, 21-6
dislcaltions of,  2 -.          diagnosis of, 214, 215,
geographic)al iv ios   of, t                      teat      nt of, 217, etc,
v^lwounds of, t21.; 31.                      Nictitationt, 286,
Lfucomai of' corleit, Il50, etc                    N ight bltiidness, 2)28.
Levator  talpebr11tt, paralysis of, 260.        Nitrate of silver, u1ce of, 120.
Littme, injuries fton C, ~i                            iin granmlatl, ns,  20.
treatient for, 300.1                                  pturlent ophtlhahni al,     102, 105,:17, 112.
XiNx vonic,  iiiteraii  ust  of,.331.
MAtc::tOTi', the utse of, 33.                    Nystaglms, 269.
Macula ltt ta,  1,1 2t.
Ma1t-}osition of thi  lis, 282.
Meibonmt i    cysts 8S                            OltiEC mxni'     exa} mina tion of eye, 26.
glandts, It;                                Ofbliteration of laich. sac, 3.15.
Mercuiry, in disease of eye, 331,                  Obstruction  of  lach.  passiagea,  294,
externally, 130,.331, 336.                     etc.
Micropsia t  174,  2   17,  2 2 t.                 Op[acities of cornea, 15l.'Mortar, injuri, s from, 3106'.                         lens ali (a pule, 23
treatt ent t of, 30.                               vitreous, 1:78
Mules' operat1  ion,  32 1                         ( )phttlml iia,  catt rrhal,  at'
lMuNsa't  wolitanites,  179.                            diphtlheritic, 114.
Mluscles of eyeball,  description of,  t,               Eyin,         1
IS8,  go ttnoerrho aldI  1.09,
equtlibr itt  of, 31, 8 -i etc.                    g      ranulii, 
testing conldition of, 8,                          I herpeie, 12t).
by prism1s, 85. etc.                            neonator'ni, 103.
pi)horomreter, 87'.                             phtlyteltttel ar, 129.
affections of, 8$1, 263.                           purulint, f11.
paralysis of, 2)t                                  puistular, 129.
tMuscult    astheuopia,  84.                               s.erofutlotsi,  125.
treatment of, 8i.                [                 symlpatletic, 3I..1
tenotomn   ii, 87, 91                              tlarsi, 280.
Mydriasi, 167.                                    Ophtliamitisi, treatment of, 177.
Myopia, W1.                                       )Opht hal1toseope, t37
catse, 53, 54.                                     appeaatnet   of fitmdu  with, 42,
correction by glasses, 58.                         reutinal vessels with), 43.
senl is, 93.                                          bio t l t a, t  0.
diagnosis of, 054.                                 direct exa\niniation Awitli,'2,
ophthatllnioseopic ai ppearance  in,               how to u          se, 40.
oh57,  7,t  importance  to generil pr aetition-'pro}gress  oft 8,  2.                                erl, 4.
treatment of, 7[                                   indirect exain. witi, 41.
hygienic, 62.                                   inverted iniare with  41, 412.
preventitve, P62, etc,                          liebreich's, 3 8.
surgical, 6. t                                  the " refraction,'" 40.
M3yosi,I 0.                                            p rinciples of, 37.




INDEX.                                           855
Ophtthahnoscopic exam, nceessar   in l    Photopthobia, remedie:s fo, 131, 380.
tchromie  headaches  anfd in  tall Sut.  I Pysi >ol    ica l   excsaatito o4     f ot)ltie
pee(ed disease of  the brain  47, 21.  I    nerv,  180.
Optic axes, contverg enc  of, in ta cc         - I        t hyioloy of vtisiont, 19.
modation, t50.                              Piniitecula,   13:.
disc, how \to t rlt it,  1.1  Ptlstelr, ijuc  from, 8300.
Iiterve  anatomn   o tl It.                          reat e nt ott i,.0.,
atrophy oif, 2'.                            Posterior istapIli tln 5.0.  
tisiases tof, t, e.                Powdet,     injutries  frfom  explosionl  of,
ovdl aptpearai    e of,  2, 82.             I  07.
neuritis, 213.                              I      1esb( opi i, 0)2.
Optical defects' tl  irer-eindiable, 2,                   treatientt of, 92
thie remedtiablf     t                        I  riss,  ction oie, 4.    8isms, a n o f,,:, 88etc.i,
Orbicultarit s  para, pafl    s of t,                     f testi   ng  strl gtilt    of imutcles
jpasi t of,.t    2                                          8', 89 88 t.
Orbit; (iseas.'es   of, 30ifi. ProlaiSe of itri, 13.
diagltosis of, i2.                             Pterygiuitt  18.
Oscillations of the evebal,'09.,                  P'to as,  tieattientll  of, 287.
Pu pil abnoiiaI dilationt of I170
dettsctripftion o    f 14.
P1A,  d iaginostic value of,  ),                         eonti  action of, I 70.
irmcdies, external,  54, 147, 148,                 atrtiieia  dilation of, 171.
101, 1      2,  192, 1983, 21 -,                    contrai tioi  of, 17;.
remiedies, internal, 310, etc.                      closure of, 1041, 2.8.
Pannus;,    P.urulent ophthalmia, 01.
Panop0htha4itis.   t77.                                  of itnf a ts,      1:t3.
treatment of, t1.                              Pustulia  oiph.lthali-a, I'Patac   teCsis of cornea't, j4I), 143,  146.
Piaralvis of ciliary imntticl, 28,
levatot- palpeb l}l2ii   6.                    QUAt)tR     TS of 0corlea, 8,
nerlve, fourtfh, t 26f
sixth,   -4,'?
third., 2;0                                   Ai: 1.r) Y  increasing  IpresOyopia  02,
rectuls externst, i.i,                        Refraction, tanomatis   o           ft 5.
inferior, 2      >:,.                      e1i fraction ill ambltyopiat, 222.
titrnis, - 2f01.                                    asti    atfism i,   1t, 77
ttipl1ior,.85.1 hp 1rml ot ptl:ia, 04, $1, 15.
superior oblique, 25,                               inopia, o5.
Ptaralytic affecetios, ctauses of, 2              -4.       normally fretactive  tyes, 5., etc,
treatlcilent or t0;71                                differs ftrom  accomml odationt, t0.
surgical, of, 24t)'.                         e  imedtic:. istttea, tr:l430: 3..l   etectricity, 207.                      Retina,  lpopltexy ot, 201i.
fPasiamrmit's operation, 106.                             amneithesi   rctmre, 2:31.
iPertiotioa1o1n of cornea, 149f.                          anatony of, i,.
lac. sa.c, 9.                            h         lperta nii of, t   99.
Perichoroidal space, 9.                                   nerves ain  vessels of, 10.
Photophotbia i  corneitis 3, 13-  etc.                    pigment,  layer of, 10,
iritis, l5c. putrple of. 20.
ctitnal asthentltopia, 230.                      caner 1of, 2i11.
scroftltts ) ophthal., 131, etc,                detachtnenlt of, 208.
not a symptomo of retiitis, 310.                       diagnosis, 209.




356                                           INDEX.
tRetina, emlbolism., central artery oft21l           Speclact   es, pantoseopie, 2538.
klioain  of, 21.1                                      pris  tict, 258.
I'hyper'ania of, t99t1,                               stetiopt ait,   it3.,
lypei.   lithesti: a otf, 2:0.                   Spigelia, use of,: 333
il farnt mait io' 20,1.                       Staptihylona aterior, 148.
oi:htttlalinoseopic   appearance  of,   Staphtyagria, u  *of; C              33,.
20l,                                          Stillingin, use of, 33.
pitaralyx is of, I1S2.1                           Stratbisimus, 26-.
ttitlitis, 201.                                             alternating or binocular, 270.
albtttumn titm a, 203.                                 catu'es of,'*7i  2 71
apoplt.l'ctie ca  21i0.                                coleolitant, 20.
p)ar'eneltlymois, 201.                                e  ntvergeit, 270.
pigmlnittosa, 2)7.                                    di vergentt, i72,
sy p ti t icti, 2t,.                    dy rtinic, 81,
di ttagitmi   of, 201),                                   etasui ienr  t of,'27'.
Retinotscoti,  70.                                       o:perattiont   for, t 26.
lR ibeu imatic ii  tis,.1.                                pa raly t tic, 2;5, etc.
periodic  or conitiriled, it70, 27,5.
prilttry at.n secotllary  dteviation
SA8,  tile lael   rtal, It.  i,  272.
Stnitis: li operutilon, 14t 8                                re n tdiu's for, 274.
Sel tittml tclltalt of, 6.                                 surgictal treatt entt t of, 276.
Stceritis or ep:is:leritik, 1S2, 15.                   lhgieniC, 2t4.
Selerot Iu  atli\t:tt       otf  6.                    Stricture's of lach, passiages, 289, etc
antertior stitx)      m.  f, to 148.                   treattent oft  291, etc.
posterior staplht tolin  of, 5t.                          by probiti, 29).
iwoutnd  oft   ti,                                          stltves, 208.
Selerotico-choroi ditis   posterior, o5.                          Stilt ng  mtlhotod, 299.
ditagosis of, it).                              SItrmous  ophlttt alia i    1$5.
Selerotont, 197.                                           coorneiti., 134, etc.
Sercond   ight,  2                    it 1                      is,  i t6.
Setlle etalat-ra. 20,                                 Sutlpenso' tligiamn t of lens, 13.
Short sigcil, t   1.                                  Svmtbtephiaron, 309.,
Simulttion of blinteltse.;,  27.                       Sy7mpatt:p ti c irr itation, 319.
Sixtit  nerve,  paralysis of, S26,                          oph ilthatia, l 3:.:.
Sketch oif rise and progress of ophtltl- cIus, 316.
mnic surgery, I.                                             treatment, geeneral, 319.
Snowl   blind ntess, 231                                          by operat iot,:I7.
Soft: eaitrate, 2:9.                                           wthen to operate, 318.
treatmentt t  of, 2A                             Syn0tdeet'omy,.or peritomyt 123.
Sparkling synlthcltis, t' 8.                           Syphilitie diseae   of iris, 156.
Spasm  of ciitary mtstec, 218.                              corneatc, 138.
orbie nlaris i uscle, 28.                              retina, 205.
S'pectacleI, 257.
cattaact, 257,
c.ylindri.ct-lt  i.                             TAx,SA, ttlmors,  281.
rdtcentretd,  25.                                Itar-tr emetic, use otf, 333,
kinds of, 257.                                  ITatooing the cottia, b151




INIDX.                                         354'lcnollltU capsutile 17.                          Visio, state of, itf  diagin)stic  value,
vlymphI spwe, 18.                                   31, 22l, 2821
Terl0otoi y  in squint, St6.i                           wetakness of,  See Asihewt)piit.
in dynlvlamilic squint, 87.                Vitreous, affeetions of, 313.
Tesiul't  of globe, to dIctcrmineu, 28.                anatoimy of, 13.
in glaucoma, 20t, 2083,                          choestrine i $r 180,
operations for in trea, ed 0 93, 90s c    e ystieri in, 180.
I9H7.                                           i utidlit   of, 180.'Ts t tyvpe for astigmaatis,  80.                      foretin bodies in, t10.
for readingt,   39.                               hemorrllamg  into,  1-1.
to determine1 distant visioin  341.               inflamiationt of, 178,'Traumati ciatairact, 2 5                              opalities of, 178.
iritis, 313.
Tremultouts iris, 171, 265.
Trichiasis,  283.                W,   \                 ts of conjunctivai, 133.
Tumoir s ot choroidi,   11.                           eyelids, 285.
conjulnctliva, 133.                          Weak sight.  See As'Qihemt uit
eyeidts,  28.$                               Wouiii is of evebtall, 1t0.
iris, 17 l                                          eyetids  *$3i
retina, 2i                                          iris,  t 13'ilroi i  1,   5.
sypat etitc  inlttaunation   from,
tUiCmEs   of cornea, 144.                                 (ii
eyelids,'283.
ease of, 283.
pi)er lid, how to reverse it, 26.                Y    hil o        itsot, apitteantcte o, 4 t
how  to fid  it. wvit  the ophtllha
(oscop:e, 41,
Yi;ato, vorticosat, 7-0.
Vision,  aicuteness of, 30.                       ZtINC, use of, 333,
double, 32^26-4                              Z ine, phosph., use of, 333.
field of, 31.                               Zonule of  Zinn, 13.