THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
LOS ANGELES
LOGIN BROS.
A HANDBOOK
OPHTHALMIC SCIENCE AND PRACTICE.
BY
HENRY E. JULER, F.R.C.S.
JUNIOR OPHTHALMIC SURGEON TO ST, MARY S HOSPITAL; SENIOR ASSISTANT SURGEON
AND PATHOLOGIST TO THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL;
FORMERLY CLINICAL ASSISTANT AT THE ROYAL LONDON
OPHTHALMIC HOSPITAL, 3I00RFIELDS.
WITH ONE HUNDRED AND TWENTY-FIVE ILLUSTRATIONS.
PHILADELPHIA:
HEITRY C. LEA'S SON & CO.
1884.
DORNAN, PRINTER.
AMERICAN PUBLISHERS' NOTE.
In presenting to the profession in this country an edition
of a treatise on Ophthalmology which has been so favorably
received abroad, it is only necessary for the publishers to
acknowledge their indebtedness and call attention to the
valuable additions of Dr. Charles A. Oliver, of this city; among
which might be mentioned the description of a new astigmatic
disk, with an explanation of its use, and important material in
the shape of results and conclusions derived from his re-
searches as to the comparative effectiveness of the different
mydriatics, as well as the equivalents in English inches where
the metrical index is used in the original. A selection of the
test-types of Jaeger will also be found in addition to those of
Snellen, at the end of the volume.
It is, therefore, confidently hoped the work will be found to
meet fully the requirements of all those who desire to possess
a reliable guide in this branch of the science of medicine.
Philadelphia, November, 1884.
PREFACE.
In the preparation of the following work, it has been my
endeavor to produce concise descriptions and typical illustra-
tions of all the important affections of the eye.
With one exception, the colored plates have all been taken
from cases met with in the course of clinical work, chiefly at
the Royal Westminster Ophthalmic Hospital, St. Mary's Hos-
pital, and the Royal London Ophthalmic Hospital, Moorfields.
With regard to the drawings of these and the other illustra-
tions, I have received valuable suggestions and assistance
from Mr. E. Noble Smith.
The chapter on Refraction has been jointly written by my
colleague Mr. Adams Frost and myself, and that on color-
vision is entirely his work.
My best thanks are due to my friend and colleague, Mr.
Anderson Critchett, for the kind waj^ in which he has allowed
me to make use of any cases coming under his, or our joint,
care at St. Mary's Hospital, and for many valuable practical
suggestions as to diagnosis and treatment.
VI PREFACE.
I also have to thank Dr. E. J. Edwardes for considerable
help in the chapter on the Optic Nerve and Retina, more
especially with regard to the views of Continental writers.
Finally, I am indebted to Mr. Adams Frost and Mr. Arthur
K. "Willis for their valuable help and suggestions in passing
the book through the press.
77 WiMPOLE Street, Cavendish Square, W.
1884.
CONTENTS.
CHAPTER I.
THE EYELIDS.
PAGE
Anatomy and physiology — Ophthalmia tarsi — Hordeolum — Chalazion —
Dermoid cyst — Nsevi — Xanthelasma — Epithelioma (Rodent ulcer) —
Papilloma — Molluscum contagiosum — Sarcoma — Chancre — Gumma —
Blepharospasm — Ptosis — Trichiasis — Entropion — Ectropion — Epican-
thus — Injuries — Wounds — Burns — Ankylohlepharon — Symblepharon . 17
CHAPTER II.
THE LACHRYMAL APPARATUS.
Anatomy and physiology — Diseases of the lachrymal gland — Hypertrophy ■
— Sarcoma — Extirpation — Cysts — Fistula of gland — Displacement of
puncta — Slitting up canaliculus — Probing — Obstruction of canaliculi
and of nasal duct — Abscess of lachrymal sac — Fistula of sac . . 45
CHAPTER III.
THE CONJUNCTIVA.
Purulent conjunctivitis — Gonorrhoeal ophthalmia — Ophthalmia neonatorum
— Muco-purulent conjunctivitis — Granular conjunctivitis — Phlyctenular
conjunctivitis — Membranous conjunctivitis — Pterygium — Pinguecula
— Amyloid degeneration — Xerosis ........ 62
CHAPTER IV.
THE CORNEA.
Anatomy and physiology — Oblique focal illumination — Inflammation —
Interstitial keratitis — Punctate keratitis — Vascular keratitis (Pannus)
— Peritomy — Inoculation — Jequirity ophthalmia— Phlyctenular kera-
titis — Suppurative keratitis — Abscess — Onyx — Hypopyon — Ulcers (su-
perficial, deep, serpiginous) — Paracentesis — Saemisch's operation —
Opacities of the cornea — Tattooing — Transplantation — Deposits — An-
terior staphyloma — Enucleation of the eye — Artificial eyes — Conical
cornea — Wounds — Foreign bodies — Tumors — Epithelioma — Sarcoma . 84
Vm CONTENTS.
CHAPTER V.
THE SCLEROTIC.
PAGE
Anatomy and physiology — Canal of Schlenini — Ligamentum pectinatum —
Capsule of Tenon — Sclerotitis — Episcleritis — Contusions — Rupture —
Wounds 125
CHAPTER VI.
THE TUNICA VASCULOSA.
The iris and pupil — The ciliary body — The choroid — The lymphatics of the
eye — Iritis — Serous iritis — Plastic iritis — Suppurative iritis — Posterior
sj-ncchia — Cyelitis — The normal fundus — Choroiditis (serous, plastic,
disseminated) — Pseudo-glioma — Purulent choroiditis — Sjphilitic cho-
roido-retinitis — Central choroiditis — Myopic crescent — Posterior staph j--
loma — Tubercle of choroid — Rupture of choroid — Sympathetic irrita-
tion — Sympathetic ophthalmitis — Tumors — Gummata — Miliary Tu-
bercle — Sarcomata — Congenital aflections — Irideremia — Coloboma —
Persistent pupillary membrane — Iridectomj' — Iridodesis — Iridotomy . 130
CHAPTER VII.
THE OPTIC NERVE AND RETINA.
Anatomy and physiology of the optic nerve — Ophthalmoscopic appearance
of the optic disk — The physiological cup — Sclerotic ring — Anatomy and
physiology of the retina — Appearance of retina — Hypera^mia of the
disk — Optic neuritis (Papillitis) — Optic nerve atrophy — Optic nerve
hemorrhages — Opaque nerve fibres — Ischsemia of the retina — Embolism
of the retinal arteries — Retinal hemorrhages — Retinitis — Albuminuric
retinitis — Diabetic retinitis — Leucocythnemic retinitis — Syphilitic reti-
nitis — Pigmentary retinitis — Detachment of retina — Glioma of retina —
Pseudo-glioma 180
CHAPTER VIII.
AMAUROSIS, AMBLYOPIA, AND SOME FUNCTIONAL DISORDERS OF VISION.
Amaurosis — Tobacco amblyopia — Amaurosis in Infancy — Hemiopia — Hys-
terical and cerebral hemianivsthesia — Night-blindness — Malingering . 219
CHAPTER IX.
THE VISUAL FIELD AND THE PERIMETER.
The visual field — The perimeter — Scotomata — The blind spot — McUardy's
perimeter — Priestley Smith's perimeter — Importance of perimetry —
Field of fixation— The angle alpha 229
CONTENTS. IX
CHAPTEE X.
COLOR-VISION AND ITS DEFECTS.
(By W. Adams Frost, F.R.C.S.)
PAGE
Solar spectrum — Complementary colors — Young's theory — Young-Helm-
holtz theory — Hering's theory — Congenital defects of color-vision —
Total color-blindness — Complete blindness for one of the fundamental
colors — Incomplete blindness for one of the fundamental colors — In-
complete blindness for all three — Methods of testing color-vision —
Holmgren's wools — Thomson's arrangement of Holmgren's wools —
Frequency of color-blindness ......... 243
CHAPTER XL
THE CRYSTALLINE LENS.
Anatomy of lens — Suspensory ligament — Cataract — Varieties of cataract
— Causes — Symptoms — Treatment — Artificial pupil — Solution — Needle
operation — Linear operation — Suction operations — Extraction of the
entire cataract — Preliminary iridectomy — Flap operation — Von Graefe's
linear operation — Modifications of von Graefe's operation — Accidents and
complications of extraction — Extraction of the lens in the capsule —
Pagenstecher's operation — Macnamara's operation — After-treatment —
Spectacles — Opaque capsule — Dislocation of the lens .... 262
CHAPTER XII.
THE VITREOUS HUMOR.
Anatomy — Muscse volitantes — Opacities in the vitreous — Degenerative
changes — Abnormal fluidity — Synchisis scintillans — Foreign bodies —
The electro-magnet — Cysticercus — Pseudo-glioma — Hemorrhages . 302
CHAPTER XIII.
GLAUCOMA.
Symptoms — Premonitory — Increased tension — Cupping of disk — Pulsation
of vessels — Contraction of visual field — Varieties — P:ithology — Treat-
ment — Secondary glaucoma ......... 309
CHAPTER XIV.
ERRORS OF REFRACTION.
Section I. — Optical Principles.
Laws of refraction — Refraction at parallel surfaces — Refraction through a
prism — Refraction at single spherical surface — Refraction through a
biconvex lens — Images formed by spherical lenses — Spherical aberration
— Chromatic aberration .......•• 327
CONTENTS.
Section //.—The Eye Considered as an Optical Instrument.
Construction of the eye — Donders's schematic eye— Frost's artificial eye —
Accommodation and presbyopia— Optical defects of the eye — Visual
angle and visual acuteness — Snellen's test-types 337
Section III. — The Errors of Refraction.
Myopia. Definition — Symptoms — Pathology — Prevention . . . 346
Hyperynetropia. Definition — Far- and near-points — Symptoms . . 351
Asiigmatistn. Refraction at an astigmatic surface — Varieties of Astig-
matism — Vision in simple astigmatism ....... 355
Section IV. — Lenses Used in Testing Refraction : the Ophthalmoscope.
Trial lenses — Trial frame — Ophthalmoscopes — Direct ophthalmoscopic ex-
amination — Indirect method — Difficulties to be overcome . . . 357
Section V. — Methods of Estimating Refraction.
i. Testing by trial lenses— ii. Other subjective tests — iii. Testing by direct
ophthalmoscopic examination — iv. Testing by indirect method —
v. Testing by mirror alone at a distance — a. Fundus-image test —
b. Shadow-test 367
Section VI. — General Considerations.
Use of mydriatics — When full correction should be ordered — Whether
glasses should be worn constantly — Correction of presbyopia . . 405
CHAPTER XV.
affections of the ocular muscles.
Anatomy and physiology — Associated movements — Strabismus (false, para-
lytic, concomitant) — Angular measurement of strabismus — Operations
for strabismus — Nystagmus — Affections of the intraocular muscles . 410
CHAPTER XVI.
DISEASES OF THE O BIT.
Cellulitis — Acute abscess — Chronic abscess — Periostiti> — Distention of
frontal sinus — Exophthalmic goitre — Tumors — Pulsating exophthalmos
— Injuries and foreign bodies ......... 435
Appendix 447
Jaeger and Snellen's Reading Tyi'es 449
Large Test-types 455
Index 459
CHROMO-LITHOGRAPHIC PLATES.
FIG.
1. Epithelioma of Eyelid
2. Epithelioma of Cornea
3. Epithelioma of Cornea
To face p. 26
1. Ciliary Kegion (normal)
2. Corneal Corpuscles and Nerve Fi-
brils
3. Anterior part of Cornea
4. Section of Ulcer of Cornea
5. Section of Cornea in Pannus
To face p. 84
1. Pannus
2. Pterygium
3. Local Keratitis
4. Interstitial Keratitis
5. Punctate Keratitis
6. Ulcer of Cornea (healing)
7. Phlyctenular Conjunctivitis
8. Plastic Iritis
9. Severe Plastic Iritis
10. Posterior Synechias
11. Hypopyon
12. Blood in Anterior Chamber
To face p 90
1. Sarcoma of Cornea
2. Cells from Tumors
8. Sarcoma of Choroid
4. Section of Choroid
5. Structure of Lens
6. Lens Fibres
To face p. 124
1. Section of Ciliarj^ Region in Iritis
Serosa
2. Section of Ciliary Eegion in Iritis
Plastica
3. Section of Ciliary Region in" Iritis
Suppurativa
To face p. 143
1. Normal Fundus
2. Normal Fundus
To face p. 150
1. Disseminated Choroiditis
2. Disseminated and Central Choroi-
ditis
To face p. 154
1. Myopic Crescent
2. Posterior Staphyloma with patches
of Choroidal Atrophy
To face p. 158
1. Section through Optic Disk — J^or-
mal
2. Section through Optic Disk — Optic
Neuritis
3. Section through Optic Disk — Optic
Neuritis
To face p. 182
1. Section of Retina — Normal
2. Section of Retina — Hemorrhagic
Retinitis
3. Section of Retina — Albuminuric
Retinitis
To face p. 184
Xll
CHROMO-LITHOGRAPHIC PLATES.
FIG.
1. Physiological Cup
2. Hyperaemia of Optic Disk
To face p. 192
1. Neuro-retinitis
2. Neuro-retinitis with Hemorrhage
To face p. 193
1. Visual Field — Optic Atrophy
2. Visual Field — Hemiopia
To face p. 222
1. Visual Field — Normal
2. Visual Field — Commencing Optic
Atrophy
To face p. 232
1. Atrophy of Optic Nerve
2. Atrophy of Optic Nerve and Retina | ]. Visual Field— Chronic Glaucoma
To face p. 197 2. Visual Field— Pigmentary Keiinitis
To face p. 238
1. Opaque Nerve Fibres
2. Opaque Nerve Fibres
\ 1-13. Tests for Color-blindness
To face p. 201 To face p. 256
1. Embolism of Central Artery of
lletina
2. Eupture of Choroid
To face p. 202
1, 2. Dislocation of Lens
3, 4. Pyramidal Cataract
5, 6. Lamellar Cataract
7, 8. Cortical Cataract
1. Albuminuric Retinitis with Hcmor- 9, 10. Nuclear Cataract
rhages
2. Renal Peri-arteritis with Hemor
rhages
To face p. 200 ^- ^^'S^t Glaucoma Cupping
2. Deep Glaucoma Cupping
1. Pigmentary Retinitis I Tofacep.ZW
2. Pigmentary Retinitis (advanced) '
To face p. 210^ 1_4. Microscopic sections of Ciliary
11, 12. Posterior Polar Cataract
To face p. 266
1. Detachment of Retina
2. Detachment of Retina
1. Pseudo-glioma
2. Glioma of Retina
3. Glioma of Retina
4. Glioma of Retina
To face p. 212
To face p. 216
Region and Optic Disk in Pri-
mary Glaucoma
To face p. 319
1. Appearance of the Disk in Astig-
matism
2. Appearance of the Disk in Astig-
matism
To face p. 393
LIST OF ILLUSTRATIONS.
FIG.
1. Section through Upper Eyelid
2. Compressing Forceps for Eyelid .
3. Section of Dermoid Cyst
4. Compressing Forceps .
5. Subcutaneous Ligature for Trichiasis
6. Arlt's Operation for Entropion,
7. 8. Streatfeild-Snellen Operation for Entropion
9. Adams's Operation for Ectropion,
10, 11. "Wharton Jones's Operation
12, 13. Dieffenbach's Operation .
14. Symblepharon ....
15. Lachrymal Apparatus .
16. "VVeber's Canaliculus Knife
17. Probes for Nasal Duct .
18. Probe in First and Second Positions
19. Syringe for Lachrymal Sac .
20. Caiiulas f<jr Injecting Na<al Duct
21. Style for Nasal Duct .
22. Lid Retractor ....
23. Everted Granular Lids .
24. Oblique Focal Illumination .
25. Section of Anterior Chamber
26. Staphyloma of Cornea .
27. Paracentesis of Anterior Chamber
28. Blunt Probe
29. Tattooing Needle .
30. Shouldered Keratomes
31. Speculum
32. Fixation Forceps
33. Squint Hook
34. Curved Scissors
35. Corneal Trephine
36. Corneal Spud
37. Ciliary Region
38. The Bloodvessels of the Eye .
PAGE
18
23
24
31
33
34
35
37
38
39
43
46
51
55
56
58
59
59
69
73
86
97
100
102
103
108
109
113
113
113
113
118
123
132
136
XIV
LIST OF ILLUSTRATIONS,
FIG
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57-
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
79.
80.
81.
82.
83.
84.
85.
86.
87.
Artificial Leech .
Chnroido-retinitis
Bent Triangular Keratome .
Von Graefe's Cataract Knife
Iris Forceps ....
Iris Scissors ....
De AVecker's Iris Scissors
Iridectomy with Keratome .
Iridectomy ....
Bent Broad Needle
Iridectomy for Artificial Pupil
Tyrrel's Hook for Iridectomy
Diagram of the course of the Optic Nerve Fibres
De Wccker's Campimetre
McHardy's Perimeter .
Priestley Smith's Perimeter .
Testing for the Angle of Strabismus
Relative Color-sensations ....
59. Color-vision represented by Curves
Thomson's Arrangement of Holmgren's Wools
Cataract Needles
The Needle Operation for Cataract
Curette
Teale's Suction Apparatus for Cataract
Flap Operation — David's Incision
Beer's Cataract Knife .....
Flap Operation — Beer's Incision .
Flap operation — Jacobson's Incision
Speculum .......
Noyes's Specula .....
Fixation Forceps
Forceps for seizing the Sclerotic .
Double Fixation Hook .....
Von Graefe's Linear Cataract Knife
Von Graefe's Linear Operation
The Incision in Cataract Extraction
The Iridectomy in Cataract Extraction
Cystitome and Curette .....
The Removal of the Lens in Cataract Extraction
Critchett's Cataract Scoop ....
Sn ell's Electro- Mag net .....
Optical Parallax ......
Lines of Incision in Iridectomy and Sclerotomy
Refraction at Parallel Surfaces
Refraction through a Prism ....
Refraction at a Single Spherical Surface
Conjugate Foci on opposite sides of refracting surface
Conjugate Foci on the same side of refracting surface
(Charcot)
PAGB
. 145
. 155
. 172
. 172
. 172
. 173
. 173
. 174
. 175
. 176
. 176
. 177
. 223
. 230
. 235
. 236
. 241
. 247
249-2.54
. 259
. 274
. 275
. 278
. 279
. 282
. 282
. 282
. 283
. 284
. 284
. 285
. 285
. 285
. 285
. 286
. 286
. 288
. 288
. 289
. 292
. 306
. 312
. 324
. 328
329
. 830
. 331
. 332
LIST OF ILLUSTRATIONS.
FIG.
89. Axes of a Bispherical Lens
90-93. Images formed hy Bispherical Lenses .
94. Donders's Schematic Eye ....
95. Frost's Artificial Eye
96. Visual angle ......
97. Position of Ketina in Emmetropia and Ametropia
98. 99. Myopia
100. Correction by Concave Lens
101. Hypermetropia ......
102. Correction by Convex Lens
103. Kefraction at an Astigmatic Surface .
104. Adjustable Trial Frame ....
105. Couper's Ophthalmoscope ....
106. Juler's Ophthalmoscope ....
107. Correction of Myopia .....
108. Oliver's Revolving Astigmatic Disk .
109. Tweedy 's Optometer
110. Emergent Rays in Emmetropia .
111. Emergent Rays in Myopia ....
112. Emergent Rays in Hypermetropia
113. Appearance of Pupil in "Shadow-test "
114. Positions of Lamp, Mirror, and Eye in Shadow-test
115. 116. Shadow-test in Hypermetropia .
117, 118. Shadow-test in Myopia
119. Diagram of the Ocular Muscles .
120. The Visual Axes in Strabismus .
121. Measurement of the Angle of Strabismus .
122. Strabismometer ......
123. Strabismus Scissors . .
124. Double Strabismus Hook ....
125. Operation for Advancement of Internal Rectus
PAGE
. 333
335, 336
. 339
. 339
. 344
. 346
346, 347
. 348
. 352
. 352
. 355
. 360
. 361
. 363
. 385
. 388
. 390
. 395
. 395
. 396
. 396
. 397
398, 399
. 399
. 412
. 414
. 424
. 425
. 428
. 431
. 432
A HANDBOOK
OPHTHALMOLOGY.
CHAPTER I.
AFFECTIONS OF THE EYELIDS.
ANATOMY AND PHYSIOLOGY — OPHTHALMIA TARSI — HORDEOLUM — CHALAZION
— DERMOID CYST NiEVI — XANTHELASMA — EPITHELIOMA (RODENT ULCEr)
— PAPILLOMA — MOLLUSCUM CONTAGIOSUM — SARCOMA — CHANCRE — GUMMA
— BLEPHAROSPASM — PTOSIS — TRICHIASIS — ENTROPION ECTROPION — EPI-
CANTHUS — INJURIES - -WOUNDS — BURNS ANKYLOBLEPHARON — SYMBLE-
PHARON.
Anatomy and Physiology. — From without inwards each eye-
lid presents the following structures (Fig. 1): skin, connective
tissue, sphincter orbicularis, tarsus. Meibomian glands with the
glands of Moll, the ciliary muscle of Riolanus, and the con-
junctiva. The skin is continuous with that of the face; at
the free border of the lid it becomes continuous with the con-
junctiva. It is delicate, but otherwise resembles the general
integument; it is freely movable on the subjacent connective
tissue. The cilia are slightly curved, and are placed in from
two to four rows in the skin at the anterior border of the lids;
at each side of the follicle of each cilium there opens a seba-
ceous follicle. Immediately behind the cilia are found the
ducts of the glands of Moll, which are modified sweat-glands;
they often, but not always, open into the ducts of the sebaceous
glands. The subcutaneous connective tissue contains a few
fat-cells, and communicates with the subconjunctival tissue
by a plexiform meshwork, in which the fibres of the sphincter
2
18
AFFECTIONS OF THE EYELIDS.
orbicularis are embedded. The palpebral portion of the
orbicularis palpebrarwn muscle consists of thin, pale, and
slightly curved fibres, surrounding the fissure between the
eyelids. It is closely adherent to the skin by fine connective
tissue, but glides loosely over the tarsi; internally, it is attached
to the tendo oculi, and sends a few fibres in front and behind
the lachrymal sac. The tarsi (tarsal cartilages) are two thin
elongated plates composed of dense connective tissue, with a
few cartilage-cells. They give firmness and shape to each eye-
lid. They are situated beneath the fibres of the sphincter
Fig. 1. — Section through Upper Eyelid.
A, the ciliary muscle of Riolanus; b, follicles of the eyelashes; c, opening of the
Meibomian follicle.
orbicularis muscle, and their fibres communicate with the
connective tissue in front and behind them. The upper
tarsus is somewhat oval in shape, and is thickest at its anterior
edge; at its posterior edge it receives the levator palpebrte.
The lower tarsus is thinner, narrower, and of nearly uniform
breadth throughout. The tarsi are fixed by fibrous tissue
internally to the tendo oculi, externally to the malar bone,
and above and below to the margin of the orbit hy the
palpebral ligament. The Mdhomian glands number from
thirty to forty in the upper lid, and from twenty to thirty in
the lower. Thev are embedded in the under surface of each
MOVEMENTS OF THE EYELIDS. 19
tarsus, and are arranged in linear series parallel to the surfoce.
In structure thej exactly resemble sebaceous glands. Each
consists of an excretory duct, with numerous csecal appendages
arranged along its sides. The duct is lined, with laminated
and tessellated epithelium; the appendages are lined with cu-
boidal epithelium, and are filled with fatty secretion. Their
excretory ducts open on the free borders of the lids. Between
these- ducts and the cilia is a layer of muscular fibre, which
is an oifshoot of the orbicularis palpebrarum — the musculus
ciliaris Riolani. The conjunctiva is the delicate, highly
sensitive mucous membrane which is continuous with the
skin at the free edge of the lids; after lining their inner
surface it is reflected on to the globe and over the cornea,
as its anterior epithelium; at the inner canthus it becomes
continuous with the lining of the canaliculi. The palpebral
poriioi) is thickest and most vascular; it is firmly adherent
to the tarsus, and presents numerous fine papillje, freely sup-
plied with nerves. The portion which is reflected from the lid
to the globe {fornix conjunetioce) is thin and loose; beneath
it are found the ducts of a layer of racemose glands. The
sclerotic portion is thinner than the palpebral; it has no
papillee; it is loosely connected to the globe by connective
(episcleral) tissue. The corneal portion is almost entirely
epithelial (vide Cornea). The conjunctiva is supplied with
lymphatic vessels, which are arranged in the form of anasto-
mosing superficial and deep plexuses. The arteries of the eye-
lids proceed from the ophthalmic artery. The sensory nerves
are derived from the fifth pair. The orbicularis -muscle is
supplied by the facial and the levator palpebrae by the third
nerve.
The mechanism concerned in the movements of the eye-
lids is one of great pathological and physiological interest,
but is not yet thoroughly made out. The normal position of
the eyelids is such, that, when the eyes are open and looking
straight forwards, the corneee are exposed to view except at
their upper parts. This position is relatively nearly the same
when the eyes are directed either upwards or downwards, the
lids thus moving with the globes. The eyelids are opened by
the action of the levator palpebrne superioris, which is supplied
20 AFFECTIONS OF THE EYELIDS.
by the third nerve. They are closed by the relaxation of this
muscle, and by the contraction of the sphincter orbicularis,
Avhich is supplied by the facial nerve. The upward movement
of the upper lid is effected by the contraction of the levator
palpebrte superioris, acting probably in association with the
rectus superior and obliquus inferior; and the lower lid is
lifted up by means of its connection with the upper at the
canthi. The lower lid is probably depressed by means of the
relaxation of the levator palpebrae, and the contraction of the
rectus inferior, which acts upon Tenon's capsule, with which
the inferior tarsus is connected. The upper lid is thought to
be pulled downwards by the lower through its attachment at
the canthus. For further information on this subject, the
reader is referred to a paper by Mr. Lang and Dr. FitzGerald,
published in vol. ii. of the Dxinsactions of the Ophthalmological
Society.
The eyelids serve to protect the eye from injury and undue
exposure; their edges are lubricated by the secretion of the
Meibomian glands. By their closure at frequent intervals they
serve to convey the tears from the lachrymal gland to the
lachrymal sac, and thus to lubricate the surJiace of the con-
junctiva, and to clear away mucous secretion from the corneal
surface.
Blepharitis (ophthalmia tarsi, tinea tarsi, sycosis tarsi) is an
inflammation of the free edges of the eyelids.
Causes. — It frequently occurs in strumous subjects who have
been exposed to bad hygienic conditions. It is very common
in childhood, frequently following an attack of measles. It
may be brought on by excessive use of the eyes, especially
when working b}- artificial light. Other causes are errors of
refraction, and obstruction of the lachrymal passages.
Sym-ptoms and Pathology. — There are numerous degrees of
the aftection, varying from simple hypertemia to severe ulcera-
tion. It begins with a painful sensation of pricking and burning
in the eyelids, which is increased on exposure to bright light
or to cold winds. There is an increase of the orlandular secre-
tion, and the eyelids are found sticking together in the morn-
ings by gumni}' exudation. The patient experiences inability
to do prolonged eye-work. In the simplest forms there are only
BLEPHARITIS. 21
slight redness and swelling, no marked anatomical lesions. In
the more severe forms the smarting, pricking, and burning
sensations are more severe; and lachrjmation and photophobia
are present. The edges of the lids are red and thick, and
the roots of the lashes are seen to be surrounded by yellow in-
crustations of pus, beneath which are found more or less severe
ulcerations. The lids are so glued together in the morning
that the patient is unable to open them without the use of
warm water. If neglected, the ulceration may become deep
and severe, and thus destroy the glandular elements. The
fatty secretion is thus suppressed, the tears overflow and cause
irritation of the surrounding skin, which often becomes the
seat of chronic eczema. The edges of the lid become thick-
ened, the eyelashes become loose and ftill out and are replaced
by others of stunted growth, or the lids are deprived of lashes
(lippitudo), or everted (ectropion); the closure of the palpebral
aperture may be imperfect, and the globe of the eye, being ex-
posed, is frequently inflamed.
Prognosis and Treatment. — The treatment must be general
as well as local. Tonics should be administered : iron in some
form, quinine, cod-liver oil. The patient should avoid fatigue
of the eyes, cold winds, and artificial light. The lachrymal pas-
sages should be examined; any errors of refraction should be
corrected by spectacles. Locally, the treatment must depend on
the severity of the case; in the simpler forms it is generally
sufficient to cleanse the eyelids thoroughly from all incrustation
two or three times daily with warm water, or with warm alka-
line lotion, and then to smear the edges with some stimu-
lating ointment — such as that of the yellow or red oxide, or of
the nitrate of mercury (F. 24, 25, 26); or a lotion of acetate
of lead may be employed (F. 27). In the severer forms the
incrustations must be cleared awa}- by warm alkaline lotions,
as borax (F. 13), or carbonate of sodium (F. 11 and 12). Those
lashes which appear to be the seat of inflammation should be
pulled out with epilation forceps, and the edges of the lids
should be touched with solid nitrate of silver, or brushed with
a solution of this salt (gr. xx ad .Sj). This application should
be repeated once or twice a week until a healthy condition is
established; and an ointment of the red or yellow oxide, or
22 AFFECTIONS OF THE EYELIDS.
of the nitrate of mercurv should be smeared on the lids nii>:lit
and morning after each cleansing with the alkaline solution.
Hordeolum (stye) is an inflammation of one of the sebaceous
glands of the ciliary follicles at the margin of the lid.
Cause. — There is generally some constitutional derangement.
Over-use of the eyes, especially in hypermetropes, and expo-
sure to cold winds are exciting causes.
Symptoms and Pathology. — It begins as a circumscribed red
patch; the redness and swelling soon extend to the neighboring
parts, sometimes to an alarming extent. Pain is sometimes
very severe. At the end of three or four days a 3'ellowish
point appears at the centre of the swelling, generally around
the base of one of the lashes; this indicates that suppuration
has taken place, and that the abscess will point externally.
Several of these styes may occur at the same time, or there
may be successive crops of them.
Treatment must be constitutional as well as local. The
general health should be improved by exercise in the open air, '
and the administration of good food, and tonic medicines,
such as iron and quinine, or bark and ammonia. Great benefit
is often derived from the internal administration of small doses
of sulphide of calcium, a ^ or ^ grain in the form of a pill
immediately after meals three times daily. They should be
continued for at least a week or ten days after the disappear-
ance of the styes. Over-use of the eyes should be avoided.
Locally, the pain will be much relieved by frequent fomentation
with warm water, or the application of bread-and-water poultice.
An antiphlogistic lotion should be prescribed, to be used warm
(F. 27) ; and a pad of cotton-wool can be soaked in this and
placed over the eye in the form of a compress once or twice
daily for five minutes at a time. When pointing has com-
menced, the cure is accelerated and the pain relieved by an
incision.
Chalazion (Meibomian cyst, tarsal tumor) is a small tumor
situated in the substance of the tarsus.
Cause. — Obstruction of the excretory duct of a Meibomian
gland.
Syntptoiiis and Pathology. — The tumor is more commonly
situated in the upper lid than in the lower ; several ma^- occur
CHALAZION. 23
at the same time. They vary in size, their diameter ranging
from three to ten millimetres. Each consists of a chronic
hypertrophy of the deep portion of a Meibomian gland, con-
taining accumulated secretion which is sometimes liquid and
puriform, sometimes solid, homogeneous, and composed of
sebaceous substance. The tumor is generally hard and spheri-
cal, fixed to the tarsus, but not to the skin. On everting the
eyelid, a bluish discoloration is observed; this is due to thin-
ning of the tissues beneath, and corresponds to the position of
the tumor. It develops slowly, and maj- cause no inconve-
nience for several months, but, if left alone, it often inflames,
and sometimes suppurates, pointing generally through the con-
junctiva, but occasionally externally. In this way it may finally
disappear by contraction.
Trealiaent. — The tumor must be removed by surgical
means. In the majority of cases it is best to operate from the
Fig. 2. — Compressing Forceps for Eyelid.
inside of the lid, but when there is pointing outwards the in-
cision mu§t be made through the skin, and in the same direc-
tion as the fibres of the sphincter orbicularis muscle. The
nature of the operation should vary according to the character
of the tumor; if this has fluid contents, it will be sufficient to
make a crucial incision through the conjunctiva of the everted
lid, and to scoop out the contents with a curette. The cavity
often fills with blood after the operation, but this becomes ab-
sorbed in about ten days. When the tumor has thick walls
and solid contents extirpation is the only remedy. This may
be done by fixing the eyelid in compressing forceps (see Fig. 2).
If operating through the skin, the solid blade must be passed
under the lid and the ring-blade made to encircle the tumor.
An incision must then be made over the tumor, parallel to the
edge of the eyelid, through the skin and subcutaneous tissues
24
AFFECTIONS OF' THE EYELIDS.
until the tumor is visible, this is then transfixed by a tenaculum,
or seized with an artery forceps, and carefully dissected out
with a small scalpel. If removed from within, the solid blade
of the compressing forceps must be placed outside, and the
ring-blade inside the lid, which can then be easily everted with
the instrument attached to it, and the extirpation proceeded
with as before. Sutures are not required.
Dermoid cyst is congenital, and contains epithelial structures.
Syinptoiiis and Pathology. — It is a painless, uninflamed,
spheroidal mass, situated generally at the outer angle of the
orbit, on a level with the outer end of the eyebrow. Less fre-
Skin-like
structure
Hair-follicle
Connecti%"e
tissue
Fat-cells
/<3K&
Fig. 3. — Section of Dermoid Cyst.
quently it occurs at the inner angle above, and is then to be
approached with caution, as this is sometimes the position of
meningocele, which is a congenital affection, having the same
relation to the cranium and brain which spina bifida has to the
spinal column and cord — i e., incomplete development of the
bone, with protrusion of the dura mater, in the form of a sac
containing fluid. The meningocele can usually be emptied on
pressure; it also has a slight impulse, and is less movable. A
dermoid cyst cannot be emptied, it is more or less movable,
it is non-adherent to the skin; sometimes it is hard, sometimes
semifluctuant on pressure. It is found beneath the orbicularis
NuEVUS. XANTHELASMA. 25
muscle, and is often firmly attached to the periosteum; some-
times it extends deeply into the orbit.
On microscopic examination it is generally seen to contain
structures resembling the skin and its appendages, such as
hair-follicles, hairs, connective tissue, fat, etc. (see Fig. 3). It
develops slowly, but is usually seen during childhood. It
causes but little inconvenience beyond the deformity.
The treatment consists in early excision. A good large in-
cision must be made over the tumor, which should then be
well cleared from the surrounding tissues. This should if pos-
sible be done without rupturing the tumor, otherwise the white
sebaceous contents immediately escape, and the thin walls are
afterwards difiicult to find.
Nsevi occur in the eyelids. They are similar in appearance
and structure to those of other parts. Like dermoid cysts,
they occasionally extend into the orbital cavity.
Treatment is the same here as in other parts, but preference
should be given to those methods by which the destruction of
the surrounding healthy tissues can be reduced to a minimum,
on account of the deformity produced by subsequent cicati-iza-
tion. For this purpose I have found the galvano-puncture
most valuable.
Xanthelasma (vitiligo) is characterized by the presence of
yellowish patches, or nodosities, in the skin of the eyelids. The
upper lid is most frequently attacked, but both may be simul-
taneously affected. The patches first appear near the inner
angle and spread outwards parallel to the edges of the lids,
being always elongated in form. They occur most frequently
in women of middle age. The condition is due to proliferation
of certain granular cells, some of which are pigmented, which
appear normally in the deep parts of the skin of the eyelid ;
besides this the sebaceous glands of the part are hypertrophied,
and their epithelial cells are filled with molecules of fat. Their
presence causes no pain or inconvenience; but when numerous
and of considerable size they are cosmetically objectionable,
and the patient may desire to have them removed. This can
be easily done by raising them with forceps and using a pair
of curved scissors. Sutures are not generally required, and
no scar is perceptible after the operation.
26 AFFECTIONS OF THE EYELIDS.
Epithelioma (rodent ulcer, rodent cancer, flat epithelial can-
cer, cancroid) is the most frequent of malignant growths affect-
ing the eyelid.
S(/n)ptoms and Pathology. — It seldom appears before the age
of forty. It most commonly attacks the skin at the inner
angle of the lower lid just below its free edge, but it may occur
in other parts of the eyelids. It first appears as one or more
small hard nodules, which the patient describes as a " pimple ; "
this sooner or later becomes covered with a yellowish incrusta-
tion beneath which the skin is found to be excoriated. At tliis
stage it causes but little inconvenience; the patient is in the
habit of wiping away the scab from time to time, but finding
that it does not heal, he presents himself to the surgeon, and
it is at this period of the disease that we generally see it. It
now presents a brownish exudation, which is hard and dry, and
consists of inspissated sanio-purulent matter; beneath this is
an ulcerated surface, which at first may be little more than an
excoriation, and may appear to heal up for a time, but soon
breaks out again, and becomes deeper with hardened edges
and purulent secretion. It may remain indolent, or only occa-
sionally irritable, for months or even years, without making
visible progress, either in surface or depth: but sooner or later
it will take on a rapid action, destroying not only the skin but
the deeper parts of the eyelids, the connective tissues of the
orbit, the cornea and o-lobe of the eve, and finallv the bones of
the face. This disease is called rodent ulcer by many English
writers, and is regarded by them as the mildest expression of
a malignant disease — chiefly because of the long indolent stage,
during which there is no pain, and no infiltration of the neigh-
boring lymphatic glands; but as soon as the active stage has
commenced, and the deeper tissues have become affected,
the pain grows intense, the lymphatics in the neighborhood
of the parotid gland are affected, and the destruction of
tissue is so rapid that the term " mildness " is no longer
applicable.
Microsropy. — If the tumor be immersed in Miiller\s fluid
until it is sufficiently hard for section, and then cut vertically
just at the junction of the tumor with the healthy skin, and
stained with logwood, it will in many cases be found to consist
,Nt«' f^
.iCfv.
althy irjtefimertt
m0^
" /. * ■ -'^ ■^' ,M
¥]<;. 1. — Eiiithelionia of lower eyelid. , about .'>o diam.
.^v-
V
-Epiih,elioma whh'rie$ts!
^' ^^^j - Cmjumilyal ItJ^ep
Corneal hssue.
Fin. 2. — Epithelioma uf cornea. ^ about j.') diaii
/^C.^/ '
M^m^m^
M^
- i J r- ■ -
^^
ffi^^r'
'^^i^^iS''
Fig. :i. — Portion of tmiior of Fig. !?. > about l'!'! diaoi.
To /nee /.. 2f..
EPITHELIOMA, PAPILLOMATA. 27
of ingrowths of epithelial cells; these are very abundant, and
in the deeper layers typical "nests" composed of concentric
rings of flattened cells may often be seen — such an appearance,
in fact, as is represented in Figs. 2 and 3, opposite page 26,
which shows an epithelioma of cornea. Very often, however,
there is chronic inflammation of the part, so that the new
growth is infiltrated with leucocytes, which absorb the staining
fluid so readil}-, and are so abundant, that all other cells and
tissues are obscured. Fig. 1, opposite page 26, represents a
section from an epithelioma of over twenty years' standing, in
which this abundant ingrowth of epithelium is very evident.
The diagnosis of epithelioma from tertiary syphilitic ulcer
is sometimes diflicult. As a rule, however, there is more cica-
tricial tissue around the latter, which is often multiple, and
yields to the proper treatment for syphilis.
The treatment consists in the effectual removal of all the dis-
eased tissue. This may be done in various ways, either by the
knife or the thermal cautery. The method I have found most
successful is that of scraping away all the diseased tissue by
means of a small steel scoop, in a manner wdiich was first
pointed out to me b}' my friend and colleague, Mr. Malcolm
Morris. The patient is ansesthetized, and the whole surface, as
well as the thickened edge of the patch, is thoroughly scraped
away. This is attended with considerable hemorrhage, and is
a rather tedious process, but its success in arresting this malig-
nant afiection is marvellous.
Patients are often very reluctant to submit to operative in-
terference, and will sometimes allow the disease to advance
until it is too late to aflbrd relief. They should be warned of
the great danger of such neglect. In severe cases it is well to
apply chloride of zinc paste (F. 38) to the surface of the wound
after removal. Even in those cases in which the disease has
been allowed to proceed beyond hope of permanent recovery,
the removal of the diseased tissues by the knife or thermal
cautery, and the subsequent application of chloride of zinc
paste to the surfaces of the wound, appear to afford great
relief from pain, and even to check the progress of the disease.
Papillomata (warts) are occasionally found on the edge of the
eyelid, and upon the conjunctiva. Thej- should be snipped off
28 AFFECTIONS OF THK EYELIDS.
with curved scissors, taking care to cut well below their bases.
Horny growths are also sometimes seen, and should be treated
in a similar manner.
Molluscum contagiosum is an affection of the sebaceous glands
which atiects the eyelids and face as well as other parts of the
integument.
Symptoiiis and Pathology. — It begins as one or more hemi-
spherical prominences of a whitish appearance varying in
diameter from two to five millimetres, and is more commonly
seen toward the inner part of the lower lid and cheek than in
other parts. It consists of a hypertrophy of a sebaceous gland,
the contents of which are composed of epithelial elements. The
gland sometimes becomes inflamed, when the tumor will have a
reddish appearance, and may go on to suppuration. It is pos-
sible that the affection is contagious, but there is not much evi-
dence of such being: the fact.
Ireatment. — Each tumor must be transfixed through its base
with a small scalpel and divided, its contents should then be
evacuated either by squeezing between the thumb-nails or with
forceps.
Sarcoma of the conjunctiva is a rare affection; when it does
occur it is usually pigmented, and sometimes almost black; its
favorite situation is on the ocular conjunctiva near the cornea,
whence it spreads to the lower cul-de-sac and lower lid. Free
excision of the affected tissues is the onlj- hope for the cure of
this malignant growth, which is liable to recur after all efforts
have been made to remove it.
Lipoma and Fibroma of the eyelid are very rare. They pre-
sent the same characters here as in other regions.
Indurated Chancre sometimes occurs on the eyelids. It is
accompanied by much swelling. The glands of the parotid
region are also indurated.
Gummata occasionally occur in the eyelids, their seat of
election being usually at the outer part of the upper lid.
The induration is sometimes accompanied by swelling of the
surrounding tissues of the lid, and more or less redness.
The}' are accompanied by other symptoms of constitutional
syphilis.
Tertiary syphilitic ulcers also occur on the eyelids: when
BLEPHAROSPASM. 29
more than one ulcer is present thej are easily recognized, but
when occurring singly, with indurated edges and of slow
increase, they are frequently difiicult to distinguish from
epithelioma. The history of the case as to previous syphilitic
infection and duration of ulcer must be ascertained. Local
application of iodoform, or black wash, combined with the
internal administration of iodide of potassium, will here be
productive of early improvement, which at once conlirms the
diagnosis.
Blepharospasm (involuntar}' spasmodic contraction of the
orbicular muscle) is mostly associated with photophobia. It is
sometimes of the tonic kind, in which there is complete and
continued closure of the eyelids, with inversion of the lashes
against the corneal surface, thus causing great irritation of the
cornea, and, by the constant pressure upon the globe, setting-
up troubles in the intraocular circulation which are very pre-
judicial to vision. Sometimes the spasm is of the clonic variety^
in which the contractions of the sphincter last from a few
seconds to a minute, then ceasing entirelj" for a few seconds,
but to return again with the same intensity. In other cases
there is a severe spasm lasting for several hours and then dis-
appearing entirely.
Blepharospasm is usually due to irritation of some branch of
the fifth nerve which, reflected through the facial nerve to the
sphincter orbicularis, causes its contraction. Hence it is often
caused by a foreign body inside the lids, an ulcer of the cornea,
iritis, carious teeth, and other lesions in parts which are sup-
plied by the fifth nerve. Another common cause is catarrhal
conjunctivitis in children. It occasionally follovi's operations
upon the eye, especially cataract extraction. It is sometimes
due to errors of refraction.
The treatment must be chiefly directed to the cause of the
irritation. In the great majority of the cases the cornea is
ulcerated, although the loss of tissue is often so superficial and
so slight that it can only be observed by focal illumination.
In such cases the proper treatment will be pointed out under
the head of Corneal Ulcers. The division of the structures at
the outer canthus by means of scissors is advised by some sur-
geons. When the spasm is not caused by ocular lesions, the
30 AFFECTIONS OF THE EYELIDS.
treatment is less certain. Graefe found a '■'"point of election" in
certain cases, that is, a point where pressure upon the part
woukl cause cessation or diminution of" the spasm. This point
of election is difficult to find, its most common position is just
opposite the exit of the infraorhital nerve on the cheek.
The continuous current is sometimes very benelicial, the
positive pole being placed behind the mastoid process and the
negative passed along the surface of the lid.
Ptosis is a drooping of the upper eyelid. It may be complete
or partial. When complete., the eyelid covers the whole surface of
the globe, and cannot be raised by any ettbrt on the part of the
patient. When partial, more or less of the surface of the cornea is
exposed to view, and some elevation can be produced by volun-
tary eftbrt. It produces very unsightly deformity in either case.
Causes. — The most frequent is paralysis of the third nerve
(motor oculi), of which it is often one of the first symptoms.
Traumatic lesions involving injury of the levator palpebrse.
Hypertrophy of the upper lid itself may exist as the result of
chronic inflammation, erysipelas, or tumors. Ptosis may be
congenital, and is then usually associated with defect in the
other ocular muscles, and affects both the eyes.
Treatment must necessarily vary as the cause of the afiection.
When it is due to paralysis of the third nerve, the cause of that
paralysis should be carefully sought for. This may be due to
intracranial disease, as 'gumma of the base of brain, cerebral
tumor; to tumors or' other disases of the orbit, as exostosis,
sarcoma; to general diseases, as syphilis, gout, or rheumatism.
Of internal remedies, especially in cases in which syphilis is
the cause of the nerve lesion, the iodide of potassium is one of
the most reliable. It should be given three times daily, after
food; the dose being gradually increased from 3 to 15 or 20
grains, and its administration continued for several \veeks
after the cure of the patient. In recent cases, resulting from
defective innervation, counter-irritants, such as slight blisters,
iodine liniment, or compound camphor liniment, applied to
the temporal region may be of some benefit. Electricity in the
form of the continuous current is sometimes of great assistance
in conjunction with other remedies. The positive pole should
be applied to the forehead, the negative pole to the eyelids.
PTOSIS. 31
the ej'es being closed. Six or eight couples are sufficient.
The application should be made daily for five minutes at each
sitting. "When internal and local remedies fail to improve the
deformity, an operation for excision of a portion of the orbic-
ular muscle from the upper lid is recommended with the object
of diminishing its force, and consequently of increasing that of
its antagonist, the levator palpebra*. The operation is ver}'
easily performed, as follows: The upper lid is secured in the
compressing forceps (Fig. 4). A longitudinal incision is made
along the whole length of the lid about five millimetres from
its free edge, the skin is cut through and dissected upwards so
as to expose the fibres of the orbicularis muscle; these are
then seized with forceps and a strip of about five millimetres
width excised with scissors. Four or five sutures are then to
Fig. 4. — Compressing Forceps.
be introduced, each suture being passed through the upper
and low-er portions of the divided muscle as well as the skin.
The amount of muscle removed should be proportionate to the
severity of the ptosis. The mere excision of a strip of integu-
ment from the upper lid is of no use.
Dr. H. Pagenstecher's o-peration for ptosis was brought
before the notice of the International Congress b}' him in 1881.
It claims to bring the action of the occipito-frontalis muscle to
I)ear upon the upper lid by means of a subcutaneous cicatrix.
It is performed as follows :
I. Operation for complete ptosis. — A needle armed with a
thick thread is introduced beneath the skin about 2 cm. above
the supraciliary edge, and 2 mm. to the outer side of its middle
line. It is then guided downwards and inwards beneath the
skin, and brought out about the middle of the upper lid close
to its ciliary margin. The ends of the thread are then tied in a
knot, and moderate tension is made. The tension is gradually
increased day by day, so as to make it cut its way through the
32 AFFECTIONS OF THE EYELIDS.
skin, by drawing it tighter. The inflaniniatory symptoms are
comparatively slight. The scar is not extensive. One ligature
generally suffices, but two may be required.
11. Operation for partial ptosis is a modification of the
above. A strong thread is armed with a needle at each end. One
needle is then introduced beneath the skin of the upper lid
parallel to its ciliary border for about 1 mm. or 2 mm. At the
point of exit the same needle is again introduced and carried
beneath the skin, but over the tarsus, and again brought out
about 2 cm. above the supraciliary arch and 2 mm. external to
its middle line. The second needle is then introduced at the
point of entry of the first needle, directed upwards, and brought
out at the same point of exit above the supraciliary arch. The
two threads are then tied together and moderately tightened,
thus forming a subcutaneous ligature, which must be left a
longer or shorter time, and in extreme cases may be allowed
to cut its way out entirely. By this means a subcutaneous
cicatricial baud is produced, which. Dr. Pagenstecher main-
tains, will transmit the action of the occipito-frontalis to the
upper lid.
Trichiasis, Distichiasis, and Entropion, are all modifications of
the same affection of the eyelids. In trichiasis, the eyelashes are
inverted so as to rub against the surface of the o^lobe ; the
number of the lashes which are thus turned in varies from one,
two, or three, to the whole number. In distichiasis, there
appear to be supplementary rows of cilia developed, which are
also incurved; this development is generally attended with
more or less thickening of the free edge of the eyelid. In
entropion, there is inversion of the lid as well as the cilia.
The amount of inversion varies from a slight incurvation to
complete reduplication, so that the cilia are in contact with
the upper cul-de-sac. Entropion may be acute (spasmodic) or
chronic. The acute form is common in old people after an
operation on the eye. The chronic is usually due to cicatriza-
tion of the inner surface of the lid.
Causes. — The most common cause of all these affections
is chronic granular conjunctivitis, which, having been imper-
fectly cured, has been followed by contraction of the conjunctival
surface of the lid. Sometimes thev are due to contraction of
TRICHIASIS.
33
the sphincter orbicularis. They may be the result of injuries
of the conjunctiva, lacerations, burns, etc.
Treatmmt. — For trichiasis: (1) when the number of incurved
cilia is small they may be removed by epilation forceps. Each
lash should be tirmly seized close to its base and pulled out
steadily. They will probably recur after a few weeks, and may
be subjected to the same treatment. In case of a third or fourth
recurrence, some method of destroying the incurved lashes
should be adopted. Various methods are employed for this
purpose. Those of Gaillard and of Herzenstein consist in
surrounding the roots of the incurved lashes by a tight sub-
cutaneous ligature of fine silk, thus causing ulceration and
obliteration of the follicles of the cilia.
Operation. — The eye being protected by a horn spatula, a
needle which can be armed near its point with the ligature
(see Fig. 5), is introduced at the margin of the eyelid just below
the lashes which are to be strangulated, say at a, and passed
subcutaneously to a point (b) two or three millimetres above;
the ligature is secured at b, and the needle withdrawn, it is
then rethrcadcd and passed subcutaneouslj- from b to c. The
Fig. 5. — Subcutaneous Li^iiture for Trichiasis.
two ends of the ligature at a and c have now to be tightly tied
together so as to include the offending lashes, and its ends cut
short. Water dressing should be applied, and the ligature
allowed to come away of its own accord.
(2) The galvano-puncture has been successfully used in
3
34
AFFECTIONS OF THE EYELIDS.
destroying aberrant lashes of tins description by Dr. Benson,
of Dublin.
(3) In more severe cases of trichiasis the whole ciliary
margin of the eyelid should be shifted away from the cornea.
Arlt's method of doing this is as follows: A small double-
edffed straight knife is inserted at one or other end of the eve-
FiG. 6. — Lines of Incision in Arlt's Operation.
lid between the cilia and the Meibomian ducts, and its point is
made to come out through the skin about two millimetres
above the lashes. It is then made to cut its way along the
whole length of the edge of the lid (see Fig. 6), and thus forms
a bridge of tissue containing the lashes only. A second incision
is now made from the two extremities of the first, curving up-
wards to the extent of three or four millimetres. This tbrms
a semilunar flap on the upper lid which must be dissected oft".
The bridge of skin containing the cilia has now to be shifted
upwards, and its upper edge attached by sutures to the skin of
the lid, its lower edge being left free. Simple water dressing
is all that is necessar}'.
Another method of dealing with extensive trichiasis is that
of scalping. The whole ciliary margin of the lid is dissected
away. The practice is becoming obsolete.
Entropion, (1) when spasmodic^ is generally relieved by excis-
ing a strip of the skin and orbicularis muscle from the whole
length of the lid, parallel to its margin. The width of the
flap to be removed must vary according to the laxity of the
OPERATIONS FOR ENTROPION,
35
tissue, which is generally great in these cases. The edges of
the wound are united by sutures, and water dressing applied.
(2) When chronic it may be treated b}- either of the following
methods :
A. By Arlt's method of transplanting the ciliary border, which
is the same as that just described for trichiasis (Fig. 6, p. 34).
B. By Streatfeild's operation for " grooving " the tarsus.
This is best described in Mr. Streatfeild's own words : " The
lid is held with compressing forceps (Fig. 4, p. 30), the flat Ijlade
passed under the lid, and the ring fixed upon the skin so as to
make it tense, and expose the edge of the lid. An incision with
Upper flap
Groove in cartilage
Lower flap
Figs. 7 and 8. — The Streatfeild-Snellen Operation for Entropion.
the scalpel is made of the desired length, just through the skin,
along the palpebral margin, at the distance of a line or less, so
as to expose, but not to divide, the roots of the lashes; and
then just beyond, them the incision is continued down to the
cartilage (the extremities of this wound are inclined toward
the edge of the lid); a second incision, further from the pal-
pebral margin, is made at once down to the cartilage in a simi-
lar direction to the first, and at the distance of a line or more,
and joining it at both extremities; these two incisions are then
continued deepU' into the cartilage in an oblique direction
toward each other. With a pair of forceps the strip to be
excised is seized, and detached with the scalpel."^ Three sutures
are then introduced as follows: A small curved needle, armed
1 R. 0. H. Keports, vol. i. p. 125.
36 AFFECTIONS OF THE EYELIDS,
with tine silk, is passed first through the lower edge of the
skin wound, then through the upper edge of the groove in the
tarsus, and the two ends tied tightly together. The upper
edge of the skin wound is thus left free, and unites very well
without sutures.. Tliis operation gives excellent results. It
has been slightly modified by Snellen, who makes the groove
in the cartilage rather higher up, and uses a different form of
suture. Three sutures are used (see Figs. 7 and 8). A fine
silk suture is passed through the upper edge of the groove in
the tarsus for about one millimetre. It is armed at each end
with a needle; these needles are then passed through the lower
edge of the skin wound, just above the cilia; their distance
a[)art should be about four millimetres. All the sutures being
similarly introduced, a glass bead is passed over the end of
each, and they are all tightened together by gentle traction,
and then each suture tied.
Ectropion is that condition in which the eyelid is everted and
its conjunctival surface exposed. It most commonly afi:ectsthe
lower lid. It may be partial or complete, and the eversion may
cause displacement of the lower punctum lachrymale, drawing
it so much away from the globe as to prevent the tears from
entering it. The exposed conjunctiva is always more or less
thickened.
Causes. — An acute form of ectropion, due to tumefaction of
the conjunctiva, is sometimes met with in ophthalmia neona-
torum, in which the lids become everted on the orbicularis
muscle being called into action, as in crying, etc. Chronic
forms are generally caused by cicatrices of the skin of the
eyelid or neighboring parts following wounds, burns, scalds,
abscess, ulceration, etc.
Treatment must vary with the cause of the eversion.
1. In the acute form efforts must be made to reduce the
inflammation of the conjunctiva by leeches, scarification, com-
presses of lint dipped in iced water, or even the excision of a
portion of the mucous membrane with scissors.
2. When there is persistent eversion of the lower punctum
lachrymale the lower canaliculis should be slit up and kept
open.
OPERATIONS FOR ECTROPION.
37
Dr. Argyll Robertson's method is well suited for cases of
ectropion of the lower lid in old people, in whom the conjunc-
tiva is thickened and the tissues of the face lax. Each end of
a stout ligature, armed with a needle, is passed from without
inwards through the margin of the ej'elid, the punctures being
about a centimetre apart. In this way a loop is left externally
parallel with the edge of the lid. Each end is then thrust
through the lower cul-de-sac and made to emerge upon the
cheek well below the eyelid.
The operator now takes a piece of sheet-lead, shaped and
moulded to resemble the normal tarsus, this he places in the
conjunctival cul-de-sac, beneath the ligatures, so that on tight-
ening the latter, the lid is moulded to the lead, and lead and
eyelid are together drawn toward the eye. A stout piece of
drainage-tube is now placed beneath the external loop, and
the ends of the ligature tied over it below ; this prevents the
skin being cut, and by its elasticity allows a certain amount of
swelling to occur. After about ten days th^ ligatures are cut
and removed, when a considerable improvement, and often a
complete cure, will be found to have been etiected,
3. When the edge of the lid has become elongated as well
as everted Adam's operation may be performed. This consists
Fig. 9. — Adam's Operation for Ectropion.
in removing a triangular wedge from the whole thickness of
the lower lid (see Fig. 9). The base of the triangle must be
at the edge of the lid; its width may vary, according to cir-
38
AFFECTIONS OF THE EYELIDS.
cumstanoes, between 5 and 10 mm. The sides of the triangle
should be from 10 to 20 mm. The edges of the wound are
brought together by a tine pin, and secured by one or two
sutures. This operation is often more advantageously per-
formed near the outer cauthus.
4. AVhen the eversion is due to contraction of neighboring
cicatrices on the face, the nature of the operation must depend
upon the site and extent of the lesion, and much scope is often
afFordL'd for the exercise of ingenuity on the part of the
surgeon.
In all such cases no plastic operation should be attempted
until the skin of the affected part has as far as possible re-
covered from the injury. It sometimes requires six months or
more for the hardness and thickening of the skin and sub-
cutaneous tissue to pass away. The variety of plastic opera-
tions performed for ectropion is very great ; those of Wharton
Jones and of Dieifenbach will serve as examples.
Wharton Jones's Operation. — The eye is to be protected by a
horn spatula placed beneath the lower lid. A Y-shaped (Fig. 10)
#^
Ftg. 10. — Wharton Jones's Operation.
I First Stage.)
Fig. 11.— (Final Stage.
incision is to be made with a small scalpel, including as far as
possible the cicatricial tissue; the flap thus formed is to be
dissected from the subjacent parts sufficiently to enable the
lid to be pressed upwards to its normal position. There then
OPERATIONS FOR ECTROPION,
39
remains a raw surface, which is to be covered by bringing
together the edges of the V-shaped wound by means of tine
pins in such a manner that the V-shaped incision becomes
Y-shaped (see Figs. 10 and 21).
In Dieffenbach's operation the diseased tissue is dissected
away by a triangular incision, which has its base at the lower
6.
Fig. 12. — Dietfenbach's Operation
for Ectropion. (First Stage.)
Fig. 13.— (SeeonJ Stage.)
lid ; a flap of skin of equal size is then marked off from the
immediate neighborhood (see Fig. 12). This is loosened by
careful dissection and then glided on to the recently exposed
surface beneath the lower lid. It is then kept in position by
line harelip pins and sutures, as shown in Fig. 13. In slight
cases the surface from which the new skin has been removed
soon becomes covered over by growth from the edges of the
wound; but when a large surface is thus exposed, skin grafts
should be made from other parts of the body.
Wolfe's Operation. — The operation for the transplantation of
skin en masse in the treatment of ectropion and other deformi-
ties of the eyelids has been somewhat extensively practised
during the last few years. Professor "Wolfe, in his recent work,"
speaks very favorably of this method, which he brought before
the notice of the profession in 1875. Since that time a
1 Diseases and Injuries of the Eye, by J. R. Wolfe, M.D. 1882.
40 AFFECTIONS OF THE EYELIDS.
number of successful cases have ])een reported. It is particu-
larly valuable in all cases in Avhicli skin is required to replace
cicatricial tissue, sucli as that which so often follows burns of
the check and eyelids. The operation is long and tedious;
like all blepharoplastic procedures, it requires great care and
ingenuity on the part of the surgeon.
1. The mucous membrane is to be pared from the margins
of both eyelids, and the raw surfaces thus produced are to be
brought into a[tposition and united by four line silk sutures, in
order to produce temporary ankyloblepharon. The eyelashes
should, if possible, be undisturbed.
2. The affected eyelid is then to be liberated from the
cicatricial tissue by an incision through the skin along its whole
length, parallel to, and about 2 mm. from, its ciliary border.
The contracted skin is then to be loosened by subcutaneous
incision, so as to form a semihmar raw surface, or, if quite
deformed and useless, it had better be dissected away. The
bleeding from the surface thus exposed is to be entirely stopped.
3. Apiece of skin of similar shape and about one-third larger
in each diameter of the exposed surface is now to be carefully
dissected from some other part of the body of the patient, or of
another person. The inner side of the arm, the front of the
forearm, the front of the leg, and the foreskin are all convenient
parts for this dissection, which should be made as far as possible
without removing subcutaneous connective tissue and fat.
Before detaching the flap of skin which is to be transplanted,
it is well to pass three or four sutures into different points at
its margin, otherwise it shrivels up in such a manner that it
cannot be opened out without diiiiculty and loss of time. The
same sutures can be used to secure it in its new position.
The object of making the flap so much larger than the
surface is that it contracts immediately after removal, as well
as after union. As soon as removed it is to be transposed, and
secured in its new position by numerous tine silk sutures.
4. Various methods of dressing are recommended. Pro-
fessor AVolfe recommends the application of lint soaked in hot
water for a few minutes after the operation, and Anally dressing
with warm moist lint covered over with dry lint, gutta-percha
tissue, and bandage. The plan I have adopted with success is
SKIN-GRAFTING FOR ECTROPION". 41
to apply first a piece of goldl)eater's skin, then a dossil of drj
lint, and over these a large pad of dry and warm cotton-wool
and a bandage. The dressings should be carefully removed
once daily. The eyelids can remain united for a longer or
shorter period, according to the nature of the case. When
their union is considered to be no longer conducive to the pre-
vention of eversion of the lid, they can be carefully separated
by incision with a sharp scalpel on a grooved director.
Skin-grafting has, in my experience, been of greater utility
than either of the foregoing operations. The plan I adopt is
to loosen the unhealthj' skin by subcutaneous section, and to
shift it upwards so as to liberate the eyelid from its traction.
If the tissue is very much diseased, I remove it altogether by
dissection. Water dressing is then applied for one or two
•daj's to the exposed surface, with the object of inducing a con-
dition of healthy granulation. As soon as the surface looks
red and clean I make numerous small grafts of skin from some
other i)arts of the patient's body, preferably from the front of
the forearm. In order to detach these grafts from the forearm
I pass a flat surgical needle just beneath the true skin, so as to
raise a bridge of about 2 mm. This bridge is cut through at
each end by small thin scissors, and can be transferred to the
raw surface, ^o scar is left on the arm, nor is there any great
pain caused by the process. The more grafts thus made the
greater is the success of the operation. If the first batch does
not succeed, other attempts must be made. As soon as the
grafting is completed a piece of goldbeater's skin is placed
over the patch, then a piece of dry lint, and this is secured by
good strapping. The patient should remain as quiet as possible
after the operation, and should be cautioned not to rub the part
should it be irritable. The strapping and lint should be care-
fully removed once daily, and the condition of the grafts
examined through the transparent goldbeater's skin. The
grafts at first have a white sodden appearance, but on the
second or third day they become pink, and increase rapidly in
all directions.
Epicanthus is a congenital deformity in which a crescentic
fold of skin projects in front of the inner canthus. It is
generally symmetrical, giving a broad appearance to the root
42 AFFECTIONS OF THE EYELIDS.
of the nose. By pinching up the skin at the root of the nose
the epicanthus can be made to disappear. It generally im-
proves as the child grows and the bones of the face become
developed. Vision is not interfered with. Operative inter-
ference is seldom required except for cosmetic purposes, and
should not be adopted during childhood.
When required, it is simply necessary to remove an oval
flap of skin from the median line over the root of the nose, the
size of which must vary with the extent of the deformity, and
to bring the edges of the wound together by sutures.
Contusions are very common, and may vary from slight red-
ness to severe cutaneous and subcutaneous ecchymoses (" black-
ayo"). They are not unfrequently accompanied by other more
serious lesions of the globe, or of the orbit. The absorption
of the ecchymosis in " black-eye " is often hastened by the use<
of cold-water compresses or of evaporating lotions.
Wounds when incised or lacerated should have their edges
brought into exact apposition by tine sutures. Great attention
should be given in these cases to the position of the puncta
lachrymalia, as the slightest eversion of these from the globe
is sufficient to interfere with the natural flow of tears. When
wounds are penetrating, the condition of the globe and of the
orbit should be carefully examined. They heal with great
rapidity. A pad of lint and a light bandage should be applied
in either of the above cases.
Burns and scalds of the eyelids require similar treatment to
that employed in other parts of the body. In case of destruc-
tion of tissue great care should be exercised to keep the lids
from uniting to each other by their edges (ankyloblepharon),
and to prevent the ocular and palpebral portions of the con-
junctiva from becoming adherent (symblepharon). Burns from
quick-lime are of frequent occurrence; the eyelids should be
well everted and carefully washed with cotton-wool and water,
a little castor oil and atropine should then be dropped into the
palpebral aperture, and a compress of lint and a light bandage
applied. The eye should afterwards be examined daily, and
any adhesions broken down with a probe.
Ankyloblepharon signifies the adhesion of the ciliary margins
of the eyelids. It may be congenital or acquired, complete or
SYMBLEPHARON. 43
partial. It often accompanies and is produced by the same
cause as s3'mblepharon. The adhesion is rarely so complete as
to involve the entire edges of the lids; it usually only occupies
their outer half; even in the most complete cases a small
opening usually exists near the inner canthus, through which
the tears and mucus can escape. The treatment consists in di-
viding the cicatricial structures which hold the lids together.
To do this a grooved director should first be passed behind the
lids, and the incision made with a small scalpel.
Symblepharon is the abnormal adhesion of the ej'elids to the
globe. It is usually caused by burns or injuries, but occasion-
ally follows granular and diphtheritic conjunctivitis. Symble-
pharon may be partial, consisting of one or more bands ot
Fig. 14. — Symblepharon (after Anderson Critchett).
cicatricial tissue extending from the conjunctiva of the lid to
that of the globe, and thus forming a bridge of tissue, be-
neath which a probe can be passed; or it may be complete,
that is, the entire surface of the affected portion of the lids
becomes united to the globe. The lower lid is most commonly
adherent; in severe cases this becomes united to the cornea,
thus producing great deformity, limitation of the upward and
lateral movements of the globe, and partial or total loss of
vision (see Fig. 14).
Treatment. — In the simpler forms of partial symblepharon,
where only a band of cicatricial tissue extends from the palpe-
bral to the ocular conjunctiva, and where a probe can be passed
beneath, it is usuallj^ sufficient to snip away the adhesion close
to both surfaces with scissors, and to keep the raw surfaces
from uniting by separating them with a probe every day.
44 AFFECTIONS OF THE EYELIDS.
When more extensive adhesions exist we must have recourse
to otlier procedures.
1. Teale's operation consists in the dissection of the adherent
lid from the globe, so that the latter can move freely in all
directions. This done, the neighboring healthy conjunctiva
is utilized, by dissection and stretching, so as to form flaps to
cover the ocular, and, if possible, the palpebral surfaces. Nu-
merous fine silk sutures are used to draw the edges of the new
flaps together. Various modifications of this operation are
performed l)y difJerent surgeons.
2. Professor Wolfe has introduced an operation for trans-
plantation en masse of portions of conjunctiva from the eye of
a living rabbit, in lieu of transferring portions of conjunctiva
from one part to another of the same eye. He thus describes
the operation:^ "I put the patient and two rabbits under
chloroform, one of the latter being kept in reserve in case of
accident. I then separate the adhesions, so that the eyeball can
move in every direction. !N"ext, I mark the boundary of the
portion of the conjunctiva of the rabbit which I wish to trans-
plant, by inserting four black silk ligatures, which I secure with
a knot, leaving the needles attached; these black ligatures in-
dicate also the epithelial surface, which would be very difficult
to distinguish after separation, I take from the rabbit that
portion of the conjunctiva which lines the inner angle covering
the 'membrana nictitans,' and extending as far as the cornea,
selecting this on account of its vascularity and looseness. The
ligatures being put on the stretch, I separate the conjunctiva
to be removed with scissors, and transfer it quickly to replace
the lost conjunctiva palpebrae of the patient, securing it in its
place by means of the same needles, and adding two stitches,
or more if requisite. Both eyes are then covered with a band-
age and dry lint. For the first forty-eight hours- the conjunc-
tiva has a grayish look, but it gradually loses that appear-
ance, and, with the exception of some isolated patches here and
there, becomes glistening, in some parts looking not unlike
conjunctival thickening. These patches gradually decrease
until the whole assumes a red appearance. Should any irrita-
tion set in, I apply warm water fomentations."
^ Loc. cit.
CHAPTER II.
AFFECTIONS OF THE LACHEYMAL APPAEATUS.
ANATOMY AND PHYSIOLOGY — DISEASES OF LACHRYMAL GLAND INFLAMMA-
TION — HYPERTROPHY' — SARCOMA — EXTIRPATION — CYSTS FISTULA OF
GLAND— DISPLACEMENT OF PUNCTA — SLITTING UP CANALICULUS — PROBING
— OBSTRUCTION OF CANALICULI AND OF NASAL DUCT — ABSCESS OF LACH-
RY'MAL SAC — FISTULA OF SAC.
Anatomy and Physiology. — The lachrymal apparatus consists
of the lachrymal gland and its excretory ducts, the lachrymal
canalieuli, the lachrymal sac, and the nasal duct.
The lachrymal gland is placed in the upper and outer part
of the orhit, a little behind its anterior margin. It consists
of a large superior and a small inferior portion. The larger
portion is about 2 cm. in length, 1 cm. iu breadth, and 0.5 cm.
in thickness ; it is lodged in a depression in the orbital plate of
the frontal bone, to Avhich it adheres by librous bands. The
smaller portion is separated from the larger by connective
tissue; it is closely adherent to the back of the upper eyelid,
and is covered on its ocular surface by conjunctiva (see Fig. 15).
From both portions of the gland there proceed numerous
small ducts — the lachrymal ducts — varying from seven to four-
teen in number; they run obliquely under the conjunctiva,
and open by separate oritices into the fornix conjunctivae at its
upper and outer part.
The lachrymal gland is similar in structure to the salivary
glands, consisting of acini, which contain cuboidal cells
having a large nucleus. In the centre of each acinus the
duct begins.
The nervous mechanism of the lachrymal gland is very
complex. A flow of tears may easily be excited in a reflex
46 AFFECTIONS OF THE LACHRYMAL APPARATUS.
manner by stimuli applied to the conjunctiva, the nasal mucous
membrane, the tongue, the optic nerve, etc. : and in a direct
manner by the emotions.
Fig. 15. — Dissection of the Lachrymal Apparatus
The lachrymal canaliculi are two in number, situated on the
margin of each lid, at the inner angle. Each commences by
a small aperture, the punctum lachrymale, which may be seen
situated on a slight eminence (papilla). The upper canal is
rather smaller than the lower, it first ascends and then turns
downwards and inwards, to the lachrymal sac. The lower canal
lirst descends, and then runs horizontally to the sac. They
unite just before reaching the sac. Near the punctum the
diameter of each canaliculus is about 0.5 mm., just beyond this
it becomes suddenly dilated to 1 mm., and for the remaining
two-thirds of its course it is about 0.6 mm. Its walls are ex-
tremely thin, and are lined by pavement epithelium.
The lachrymal sac is the upper dilated portion of the passage
which conveys the tears from the lachrymal canals to the cavity
of the nose. It is situated in a deep groove formed by the
lachrymal and superior maxillary bones. Its upper end is closed
and rounded, and its lower part tapers off into the nasal duct.
On its outer side and rather anteriorly it receives the canaliculi.
INFLAMMATION OF THE LACHRYMAL GLAND. 47
In front of it are the tendo palpebrarum and some fibres of the
orbicular muscle. It is composed of fibrous and elastic tissue,
and adheres closely to the bones. It is lined by ciliated
epithelium.
The nasal duct extends from the lachrymal sac to the inferior
meatus of the nose. The osseous canal is formed by the supe-
rior maxillary, the lachrymal, and the inferior turbinated bones.
This is lined by a tube of fibrous membrane, continuous with
that of the lachrymal sac, and is similarly lined with ciliated
epithelium. At the entrance into the inferior meatus there is
sometimes an imperfect valvular arrangement of the mucous
membrane. The length of the duct varies with the develop-
ment of the face. Its direction is downwards, and slightly out-
Avards and backwards.
The lachrymal secretion is a faintly alkaline fluid containing
about one per cent, of solids, of which a small part is proteid
in composition. It passes by the lachrymal ducts into the sac
of the conjunctiva, where it serves to moisten the anterior part
of the eye. Its exit from the sac of the conjunctiva is efl'ected
by the act of winking, which takes place at frequent intervals.
In tins act of closure of the lids not only is there contraction
of the palpebral portion of the orbicularis, but also of those
fibres which are in front of the lachrymal sac; thus, the palpe-
bral fissure being closed, the tears are pressed successively
through the puncta lachrymalia, the canaliculi, the lachrj-mal
sac, and the nasal duct into the inferior meatus of the nose,
where they are evaporated by the act of respiration.
Diseases of the Lachrymal Gland.
Inflammation of the lachrymal gland (dacryo-adenitis) is ex-
tremely rare. It may be acute or chronic. In the acute form
there are great swelling and redness of the upper lid, especially
toward the outer angle of the orbit. The swelling may be so
great as to displace the globe downwards and inwards, in
which case the upward and outward movements of the e^e are
aftected. The conjunctiva is injected, and frequently there is
chemosis. Pain is severe, of a throbbing nature, and increased
on pressure. It may terminate by resolution, it may go on to
suppuration, or it may become chronic.
48 AFFECTIONS OF THE LACHRYMAL APPARATUS.
The formation of abscess is indicated by increased local red-
ness, swelling, and intensification of the throbbing pain.
In chronic inflammation of the gland there is also consider-
able swelling, but the other symptoms of the acute form are
less severe. Digital examination in the region of the gland
shows it to be distinctly enlarged, but there is less redness of
the skin of the eyelid, little or no chemosis, pain is slight, and
not of a throbbing nature; and there is scarcely any tenderness
on pressure.
Causes. — Dacryo-adenitis, whether acute or chronic, is gen-
erally caused by injury to the parts in the region of the gland.
It may be the result of chronic conjunctivitis.
Treatment. — In the early stage the acute form of inflamma-
tion should be combated by energetic antiphlogistic measures,
such as the local application of several leeches, frequent hot
water fomentations, emollient compresses bandaged on and
kept warm by a large pad of cotton-wool. When suppuration is
evidently established, a free incision should at once be made
by plunging a scalpel into the most prominent part of the
swelling, the point of the knife being carefully kept away from
the globe ; the incision should, if possible, be made through the
conjunctiva, so as to avoid the formation of a lachrymal fistula;
but if there is pointing through the skiu of the upper lid, this
must be the point of election. When the affection is chronic
any patent cause of the affection should be as far as possible
removed. The application of an ointment of mercury and
belladonna to the surrounding surface may be useful.
Hypertrophy of the lachrymal gland has been occasionally
seen, but is very rare, most of the cases described under this
name being probably sarcomata. It is characterized by the
presence of a circumscribed, nodular, somewhat elastic tumor
in the region of the gland. It is not painful or tender, nor is
there any marked swelling of the upper lid. It occurs in young
subjects, and has been seen shortly after birth. It always in-
creases, though its growth is usuall}' slow. The edge of the
tumor can be distinctly felt beneath the orbital ridge, as it
gradually extends over the upper part of the globe.
Pathology. — These tumors do not present the microscopic
characters of simple hypertrophy of gland tissue. Those which
EXTIRPATION O P^ THE LACHRYMAL GLAND. 49
I have examined have presented the appearance of fibro-sar-
coma or adeno-sarcoma.
Treatment of a palliative nature may at first be tried; iodide
of potassium may be given internally, and absorbents applied
locally to the surface: but the tumor will generally be found
to increase, in which case extirpation of the whole mass is the
only reliable remedy.
Operation for extirpation of the lachrymal gland. — The patient
is to be fully ansesthetized in the supine position upon a
moderately high table. The instruments required are a small
scalpel, a horn spatula, a vulsellum forceps, curved scissors,
toothed forceps, and artery forceps. The operator should
stand on the patient's right, his assistants on the patient's left.
The upper lid is to be drawn down until the lower edge of the
eyebrow becomes on a level with the edge of the orbit. An
incision is then made parallel Math the eyebrow and quite
close to its lower part, extending from the middle of the
upper edge of the orbit as far as its outer angle. All struc-
tures are to be divided down to the periosteum. The fibrous
tissue of the palpebral ligament will now be exposed, and must
be carefully divided close to the edge of the orbit with scissors
or scalpel. The lachrymal gland, if large, will now present
itself to view; if small, it will be found deeply seated in the
lachrj-mal fossa; in either case, it must be firmly seized with
the vulsellum forceps and dissected from its surrounding con-
nective tissue wdth scissors. The dissection should be besfun
from the orbital surface of the gland. In clearing it from its
ocular relations great care should be taken to avoid laceration
of the levator palpebrce muscle. The edges of the wound are
to be brought together by fine silk or catgut sutures, and a
light compress of dry lint applied. The antiseptic method of
operating is very desirable here.
Cysts of the lachrymal gland sometimes occur. They are
mostly due to obstruction of the excretory ducts, but some-
times are caused by hydatids. When present they may be
felt as a small tumor of from 1 cm. to 2 cm. diameter in the
upper and outer angle of the orbit. On raising the upper lid
they may often be recognized by their transparency beneath
the conjunctiva.
4
50 AFFECTIONS OF THE LACHRYMAL AITAKATUS.
Irealmeiif. — Simple puncture through the conjunctiva is
sometimes suUicient to establish a cure, but it is better to
remove a small portion of the wall of the cyst in addition to
the puncture. Some surgeons prefer to pass a ligature of silk
through the cyst, Avhich is gradually tightened, and iinally
ulcerates through ; others recommend extirpation of the lach-.
rymal gland.
Fistula of the lachrymal gland is usually the result of injury
or of abscess. A small opening exists in the skin near the upper
and outer angle of the orbit through which the tears almost
constantly escape. The flow of tears through this abnormal
passage may be increased by irritation of the conjunctiva.
Treatment. — The edges of the opening will sometimes unite
by the application of solid nitrate of silver every few days, or
by the introduction of a wire of the thermal cautery at a dull
red heat. These measures may be assisted by previously
establishing an artificial opening into the sac of the conjunc-
tiva by the introduction of a seton in the region of the lachry-
mal ducts. Some cases are obstinate and require ultimate
extirpation of the gland.
Affections of the drainage system may be classified as those
of the puncta lachrymalia, those of the canaliculi, and those of
the lachrymal sac and nasal duct. In each of these affections
lachrymation, or overflow of tears (epiphora), is a troublesome
symptom, Avhich is always aggravated by exposure of the eye
to cold or wind, or by any cause which would increase the
secretion of the lachrymal gland.
Displacement of the punctum of the lower lid is a not unfre-
quent cause of lachrymation. It occurs in elderly people in
whom the orbicularis muscle has become relaxed, so that the
lower lid, with its punctum, falls away from its proper apposi-
tion to the globe. The punctum is often drawn outwards in
cases of ectropion.
Treatment. — This must vary with the cause of the eversion,
and its degree. If the punctum cannot be restored to its proper
position, the best method of restoring conduction of the tears
into the lachrymal sac is by slitting up the lower canaliculus,
so that thev mav enter its channel nearer the sac.
1) I S P L A C E :\t E N T OF THE P U N C T U M ,
51
Operation for slitting up the lower canaliculus. — No anses-
thetic is required, except in the case of children and persons
of nervous temperament. The patient is to be seated on an
ordinary chair with the head thrown back, so that «
the face looks toward the ceiling. The operator is
to stand behind the chair. The lower lid is to
be tensely drawn downwards and outwards, and
slightly everted by the thumb of one hand (Fig. 18),
while with the other hand the probe-point of
Weber's canaliculus knife (Fig. 16) is introduced
vertically. When the knife has well entered the
canaliculus its point is to be directed inwards, and
slightly backwards in the direction of the lachry-
mal sac, until it reaches the inner wall. The edge
of the knife during its passage is to be turned
toward the conjunctiva, so as to divide the canali-
culus close to the muco-cutaneous junction. When
the knife has thus reached the inner wall of the sac,
it must be boldly brought up from the horizontal
to the vertical position, the eyelid being still kept
tensely drawn outwards by the opposite thumb.
Thus the whole length of the canaliculus is divided
quite into the sac.
Several other methods of slitting up the canali-
culus are adopted. A line grooved director (Crit-
chett's) is passed through the canaliculus, along
which a fine knife is passed into the sac. Fine
scissors are sometimes used, one blade of which is
passed into the canaliculus.
Various modifications of the knife represented in
Fig. 16, such as Bowman's, de Wecker's, Liebreich's,
and others, are used. It sometimes happens that
the punctum is very small, and wall not admit the
probe-point of the knife; in these cases a fine coni-
cal probe should be first introduced, by which means
it may be sufficiently dilated to admit the knife.
Obstruction of the lower canaliculus is not unfre-
quent. It may be caused by inflammation of the
mucous membrane extending from the conjunctiva, or by the
presence of a foreign body such as an eyelash. It is sometimes
Fig. 16.—
Weber's
Canaliculus
Knife.
52 AFFECTIONS OF THE LACHRYMAL APPARATUS.
due to chalky concretions, und is often the result of cicatrix fol-
lowing burns, and lacerated wounds. The upper canaliculus is
less frequently attected, except in the^ase of wounds and burns.
Treatment. — This must vary as the cause of the obstruction
or obliteration. When a foreign body or concretion is present
it should, if possible, be removed with fine forceps. When its
removal is found to be impracticable, the canaliculus should be
slit up. There is sometimes a difficulty in finding any opening
into the canaliculus. In this case careful search should be made
in the region of the punctura with a fine conical probe ; this
will sometimes find an entrance when no aperture is visible, and
should then be forcibly passed in the direction of the canali-
culus, so as to dilate it sufficiently for the reception of the knife.
Mr. Streatfeild has an ingenious method of finding the canal
in these cases. Having first slit up the upper canaliculus, he
passes a piece of bent silver wire through this into the lower
one. When no opening can thus be found, a minute aperture
should be made in the direction of the canal at its middle
third; this can be done with a fine knife or scissors, and will
affi)rd greater facility of entrance than incision of the tissues
about the punctum. A very frequent point of obstruction is
just at the entrance to the lachrj-mal sac. This is indicated
by the movement of the whole lower lid when the knife or
probe is pressed toward the sac. Firm pressure in the inward
and slightly backward direction will generally overcome this
resistance.
Stricture of the nasal duct is the most common affection of
the lachrymal apparatus.
Cause. — The original cause of this aff"ection is frequently
difficult to make out. It appears in man}' cases, however, to
commence by extension of catarrhal inflammation of the lining
membrane of the nose. It is possible for it to be caused by
extension from the conjunctiva through the lachrymal sac, but
more frequently it is the obstruction which causes the con-
junctivitis. In strumous and syphilitic subjects, periostitis of
the bones forming the nasal canal is a frequent cause of obstruc-
tion by extension of inflammation to the fibro-mucous lining.
It may also be caused b}' injury to the nasal bones, and by the
existence of carious teeth in the upper jaw. Pressure, causing
STRICTURE OF NASAL DUCT. 53
more or less obliteration of the canal by tumors of various
kinds, as fibro-sarcoma, myxoma, and exostosis developed in
the upper jaw, the antrum, or the nasal fossa, is not uncommon.
The seat of the stricture is usually at the upper part of the
tube just below its junction with the lachrymal sac, but it may
be situated anywhere in its course.
The symptoms of stricture of the nasal duct are very variable.
In some cases the only observable departure from the normal
condition is an overflow of the tears, which is increased by ex-
posure to cold wind or bright light. There may be little or no
inflammatory redness of the conjunctiva. The puncta lachry-
malia and canaliculi are found to be quite patent, and in their
normal position. There is no perceptible tumor in the region
of the lachrymal sac. On making firm pressure with the finger
over the region of the sac, there may be no regurgitation of its
contents; more frequently, however, there is some reflux of a
viscid secretion through the canaliculi, which may be quite
clear and colorless, or may be more or less purulent, but is
always of a more tenacious character than the tears. In the
majority of cases, however, there is distinct swelling of the
lachrymal sac (chronic dacryo-cystitis, mucocele, blennorrhcea).
The amount of sw^elling varies from a mere fulness to an abso-
lute protuberance of the skin just below the internal palpebral
ligament. Firm pressure with the finger over this will usually
cause the dispersion of its contents either upwards through the
canaliculi, or downwards through the nasal duct. The nature
of this liquid varies according to the gravity of the lesions
of the sac; it may be simple mucus or muco-pus, or even pus.
Lachryraation is troublesome, causing irritation and redness of
the conjunctiva and eyelids. The swelling is usually free from
pain and devoid of tenderness, even on pressure ; it is localized,
and increases but slowly. It is, however, liable at any time to
take on an active state of inflammation and suppuration, thus
constituting abscess of the lachrymal sac, in which the symp-
toms are altogether more severe. The swelling now becomes
suddenly' increased, and of a tense, brawny nature. The root of
the nose, the lower part of the frontal region, the upper part
of the cheek, are oedematous; the eyelids, also, are frequently
infiltrated. The skin over the region of the lachrymal sac and
54 AFFECTIONS OF THE LATHRVMAL APPARATUS.
the surrounding parts is of a dusky-red color. There are in-
tense local pain and heat in addition to the redness and swell-
ing. General symptoms, such as pyrexia, rigors, and even .vomit-
ing, may occur. This kind of inflammation of the sac never
terminates in resolution; suppuration lirst takes place inside
the sac, forming an abscess, which soon perforates its walls,
setting up inflammation of the surrounding cellular tissue.
Perforation of the wall of the sac is attended by a diminu-
tion of the pain, which, although it does not disappear, be-
comes greatly lessened in intensity. Then commence the
more serious inflammation and swelling of the tissues around
the sac and in its vicinity, leading to the formation of abscess,
which, if untreated by surgical interference, usually terminates
by pointing through the skin about 1 cm. below the lower
punctum lachrymale. This opening gives exit at first to
purulent matter, which gradually decreases as the inflamma-
tion and swelling subside. It may heal up of its own accord,
but generally remains as a fistula of the lachrymal sac, giving
exit at first to the purulent matter, then to muco-pus mixed
with the tears, and finally to the tears alone, which ought to
have passed down the nasal duct.
The diagnosis of swelling of the lachrymal sac is easily made
when there is but little inflammatory trouble. Its situation,
its history and accompanying lachryination, its more or less
complete disappearance on firm pressure, serve to distinguish
it from other tumors of this region. When inflammation is
severe, it may at first simulate erysipelas of the eyelids, but
in abscess of the sac we have seen that the redness is most
intense over the seat of inflammation, and shades oflf and
becomes simple oedema of the surrounding parts, that there is
always a history of lachrymation, and generally of tumor of
the sac. In erysipelas the redness is equal all over the swell-
ing, its outer edge is seen to spread to surrounding parts, and
there is no history of previous lachrymation or tumor. It may
also be difficult to say whether an abscess at the inner angle of
the eye had its commencement within or outside the sac.
Here again the previous history' of overflow of tears and of
tumor of the sac are useful aids to diagnosis, and all doubt can
STRICTURE OF NASAL DUCT.
55
often be dispelled by pressure over the swelling, when a regur-
gitation takes place through the puncta lachrjmalia.
Stricture of the nasal duct also gives rise to the development
of serious lesions of the cornea, conjunctiva, and eyelids. After
prolonged obstruction a chronic inflammation of the conjunc-
tiva is often established. This may spread to the edges of the
eyelids, causing blepharitis and even ulceration. The cornea
also often becomes affected with superficial, ill-detined, grayish-
white opacities and ulcers. An}^ operation involving wound
of the cornea, such as that of iridectomy or extraction of cata-
ract that might be performed under this condition of lachryma-
tion, would be seriously interfered with ; the wound healing
but slowly, if at all, and suppuration being very easily provoked.
Treatment must be directed to the permanent cure of the
stricture.
I. When there is no abscess of the sac, but only swelling, or even
only lachrymation, the lower canaliculus should be slit up in the
manner indicated on page 51, and a probe should be passed
through the stricture at once. It should be passed again
within forty-eight hours to prevent the closing up of the canali-
culus, and the operation should be repeated twice or thrice a
week until lachrymation has ceased, and all symptoms of ob-
struction have disappeared. Even then it is well to continue
the probing once a week for a few times.
The kind of probe used is a matter of little importance so
long as it is of the right calibre, and is passed in the proper
Fig. 17. — Set of Probes for Nasal Duct.
direction — viz., downwards and rather outwards and back-
wards. Many varieties of probes are now in use. The original
probes of Bowman were straight; they were about 12 cm. long
and six in number, the largest, 'Ro. 6, being about 1 mm. in
diameter. These are now^ altered in shape and size; instead of
56 AFFECTIONS OF THE LACHRYMAL APPARATUS.
being straio-ht they are curved in opposite directions toward
each end, and instead of being of equal calibre throughout
they are bulbous toward each extremity, as shown in Fig. 17.
These larger probes number from 1 to 8, ISTo. 1 being about
Fig. l!^. — Probe in First and Second Position?.
1 mm. across the bulb, Xo. 8 about 3.5 mm., and the remainder
of intermediate sizes. There are numerous other varieties of
probes which it is not necessary to describe.
The mode of introducing- the probe is similar to that of intro-
STRICTURE OF NASAL DUCT. 57
ducing the canaliculus knife (see Fig. 18). It is passed horizon-
tally along the canaliculus until it reaches the inner wall of the
lachrymal sac, the lower lid being kept tense by the thumb of
the opposite hand. The probe is known to be well inside the
sac by the resistance offered by the lachrymal bone, and by the
absence of dragging on the skin of the lower lid. The end of
the probe being kept in contact with the inner wall of the sac,
it must now be brought from the horizontal to the vertical
position and pushed down the duct. The direction of the duct,
as we have seen, is downwards and slightly backwards and out-
wards; pretty firm pressure can be made in this direction. I
usually commence with a probe of 2 mm. diameter; if this
passes easily, I try the next size larger; if it does not pass with-
out great force, I try smaller sizes until one is found which
will pass through the stricture. It seldom happens that a
stricture is so tight that it will not admit a probe of 0.5 mm.
diameter. Thus we are enabled to form an estimate of the
extent and the nature of the constriction. One of three
methods can now be adopted, viz. : 1. Gradual dilatation, by
slightly increasing the diameter of the probe used at each
sitting. 2. Bapid dilatation, by the passage at one sitting of
a probe of 2.5 mm. to 3.5 mm., and continuing this practice
at after-sittings. 3. The incision of the stricture by means of
a knife, and the subsequent passage of probes. This is of great
service in very tight strictures. The best knife for this purpose
is that of Stilling. It is introduced into the lachrymal sac in
the same way as the probe, and then forced dow'n in the
direction of the duct two or three times in succession, the
blade being turned in different directions at each passage, after
which probes of 1 mm., 2 mm., or 3 mm. can be passed. Other
knives, such as those of Bowman and Weber, can be used for
this purpose, but, owing to their brittleness and delicacy, their
blades are apt to be left in the stricture.
II. When there is abscess of the sac, and a fistula has not yet
formed, an immediate effort should be made to give free exit
to the pus. This should, if possible, be effected by slitting up
one of the canaliculi; if, however, the swelling is so great as to
prevent this, a puncture should be made by thrusting a small
scalpel through the skin 1 cm. below the inner canthus, the
58 AFFECTIONS OF THE LACHRYMAL APPAKATUS.
direction of the cut being downwards and outwards. When a
iistula has been established b\' ruptui'C of the abscess, or when
the abscess has been opened by incision and the swelling has
subsided, the lower canaliculus should be slit up so as to
establish a free exit for any pus that may yet be retained in
the sac or may be afterwards formed. Probing must now be
attempted, but should there be any difficulty of introduction
to the nasal duct, it is well to wait a few days for subsidence
of inilammatcr\' swelling of the mucous membrane of the sac
and duct. Then a small probe can generally be introduced,
and gradual or rapid dilatation or incision by Stilling's method
may be performed. These inflammations of the sac, whether
chronic or acute, very frequently yield to treatment by dilata-
tion only; but in some cases, especially in those in which there
has been much suppuration, the cure is often accelerated by
local astringents. An excellent astringent and antiseptic for
this purpose is to be found in a 2 to 4 per cent, solution of
pure boracic acid. It should be injected into the sac by means
of a syringe, the nozzle of which (Fig. 19, 8) can be easily
Fig. 19. — Syringe for Injecting Lachrymal Sac.
introduced, or the whole length of the duct can be treated
by the use of a canula (Fig. 20, b) which is flrst passed
down the duct in the same way as a probe, then attached to
the syringe by the connecting tube d, and then gradually
withdrawn as the solution is injected. Other solutions than
that of boracic acid can be used for this purpose, such as those
of alum, sulphate of zinc, and lapis divinus of the same strength.
Solution of nitrate of silver of strength h per cent, is beneficial
in some cases.
It sometimes happens that there is a tendency to closure by
cicatrization of the entrance to the sac, which renders the in-
STRICTUEE OF NASAL DUCT.
59
troduction of the probe difficult at each sitting. In such a case
the insertion of a small silver or lead style of the shape shown
in Fig. 21 is very convenient. A probe should first be passed
to ascertain the length of the duct, and a style of proper length
being chosen, its upper end should be bent at right angles to
the extent of 4 mm. or 5 mm. It is then introduced so that
its lower end rests on the floor of the nose, and its upper bent
C li
Fig. 20. — Canulas for Injecting Na^al Duct.
portion lies in the groove of the open canaliculus. After its
introduction it must be watched lest the parts become inflamed,
in which case it must be removed and reinserted after a few
days; if the parts remain quiet, it can be allowed to remain
for several weeks, and will be found to be of great service, the
lachrymation being often improved even whilst the patient is
wearino; the stvle. This method is also useful in ordinarv cases
Fig. 21.— Style for Nasal Duct.
in which the passage of the probe is inconvenient or impossible,
owing to the patient living at a distance, or being unable to
attend.
The general health of the patient should be carefully looked
after. Fresh air, good nourishing diet, tonic medicines, and
local cleanliness are very important here as in other surgical
afltections. When there has been great distention of the sac,
60 AFFECTIONS OF THE LACHRYMAL APPARATUS.
its restoration is much facilitated by gentle pressure in the
form of a compress and light bandage.
In certain obstinate cases, in which overflow of the tears still
persists after all the efforts above indicated have failed, the
extirpation of the lachrymal gland is recommended. The re-
moval of this organ (see p. 49) has been repeatedly performed
without injurious results; and the operation is well spoken of
by Lawrence, Abadie, and other surgeons.
Obliteration of the lachrj-mal sac, by means of the actual
cautery, strong caustics, as the potassa cum calce, chloride of
zinc, etc., is also occasionally practised by some surgeons in
obstinate ulceration of that organ, the sac being first laid open
by a free external incision. I have never had occasion to re-
sort to this heroic treatment.
The above methods of treatment are strongly objected to by
some surgeons on the grounds (1) that the lachrymal sac acts as
an aspirator to the tears, and that its action as such is impaired
by an artificial opening; (2) that the normal condition of the
nasal duct is that of a capillary tube, or a system of such tubes,
and that the passage of a probe of above 0.75 mm. or 1 mm. in
diameter is likelj- to destroy this capillary action. Perhaps
the best answer to these objections is to be found in the fact
that so many eases are thus successfully treated by this method;
and further, that those who condemn this practice in theory
are frequently obliged to resort to it in practice, although they
may content themselves with probes rather smaller than we
are accustomed to use.
Fistula of the lachrymal sac is a frequent result of neglected
inflammation. It consists of a sinus extending from the sac to
the skin just below (about 1 cm.) the inner cauthus. The
opening is usually small, and gives passage to the tears and
mucus, which ought to pass down the nasal duct. The skin
and subcutaneous tissue in the vicinity of the fistula may be
but little afiected, but are usually swollen and red; sometimes
there is indolent ulceration extending: over a considerable area
of the cheek.
Treatment must first be directed to the stricture (p. 55). This
being so improved that the tears can flow through the nasal
duct, we may attack the fistula. In slight cases the applica-
FISTULA OF LACHRYMAL SAC. 61
tion of simple astringents by means of a compress of lint is
often sufficient. In old, inflamed, and ulcerated cases this is
not sufficient. Various methods of promoting their healing
are employed, such as paring the edges, the galvano-cautery,
etc. I liave found the most speedy and efficient help in these
chronic cases from the use of the lupus scoop. I first open up
the canaliculus and nasal duct, and then proceed to scrape
away all the red unhealthy surrounding skin as well as the
ulcerated surface. The process is very painful, and requires
an anaesthetic. When the scraping is effectually done there is
considerable oozing of blood. Water dressing is applied, and
the surface usually heals rapidly. To prevent or lessen cica-
tricial contraction, I usually graft some patches of skin from
another part of the bod.y in the same way as indicated on p. 40 ;
this accelerates the healing of the wound.
CHAPTER III.
AFFECTIONS OF THE CONJUNCTIVA.
THE VAKIKTIES OF CONJUNCTIVITIS — PTERYGIUM — PINGUECULA —
AMYLOID DEGENERATION — XEROSIS — SARCOMA.
Inflammations of the conjunctiva can be conveniently
divided into the following live classes:
1. Purulent conjunctivitis: a, gonorrha'al ophthalmia; by
ophthalmia neonatorum.
2. Maco-pundent conjunctivitis.
3. Granular conjunctivitis.
4. Phlyctenular conjunctivitis.
5. Membranous conjunctivitis.
Purulent conjunctivitis (also called purulent ophthalmia,
gonorrha?al ophthalmia, ophthalmia neonatorum, contagious
ophthalmia, military ophthalmia, Egyptian ophthalmia).
Causes. — The best known cause is indisputably that of the
inoculation of the conjunctiva with certain pathological pro-
ducts. Of these, the discharge from the urethra or vagina
during an attack of acute or chronic gonorrhoea is a very com-
mon example. It is remarkable that discharge from a very
slight affection of the urethra will often set up a violent
inflammation in the conjunctiva. This, no doubt, is due to
the susceptibility of the recipient, and is also influenced by the
previous condition of the eyelids, and of the general health.
If a patient has been previously suflering from granuhn- con-
junctivitis, a very slight cause is sufiicient to establish purulent
inflammation. The discharge from an eye affected with puru-
lent conjunctivitis is very liable to set up a similar and even
more severe affection in a healthy eye, either of the same
patient or of others. Hence the necessity of great caution and
PURULENT CONJUNCTIVITIS. 63
cleanliness, both on the part of the patient and of the surgeon,
and others who have to do with the patient. With regard to
the period of the disease at which the discharge is most viru-
lent by inoculation, Piringer^ has made some interesting ex-
periments, from which he infers that for the first few honrs,
whilst the secretion is serous, it is comparatively inoffensive,
producing only a slight rauco-purulent affection, or no percep-
tible efi'ect; that when suppuration has set in, the effect of the
inoculation is much more powerful, producing in all cases puru-
lent conjunctivitis, which is sometimes of the most violent and
destructive nature; and that a step later, when suppuration has
ceased and given place to serous exudation, the effect of inocu-
lation is similar to that of the very early secretion. He also
found that by dilution with water the most active and virulent
pus rapidly lost its contagious properties.
Muco-purulent conjunctivitis, when conveyed from one person
to another, who is in a weak condition, may become entireh'
purulent.
The atmosphere is considered by some high authorities to
be the means of the conveyance of contagious particles, and
so placing them in contact with the conjunctiva; this theory
is advanced in explanation of epidemic outbreaks such as
occur in crowded dwellings, hospitals, barracks, etc. Careful
inquiry, however, in such cases will generally elicit the fact
that many facilities of direct inoculation are present, such as
several children sleeping together, the use of a common towel,
etc. Such outbreaks of the disease illustrate very well what
has been said above as to the susceptibility to infection of pa-
tients who have suffered from granular conjunctivitis; and in
order to check such an outbreak in a school or similar institu-
tion, it is essential, not only to isolate those actually suffering
from purulent conjunctivitis, but also those who present the
granular affection, lest the latter should themselves become foci
of infection. Concerning the cause of this affection in the
newly born (ophthalmia neonatorum"!, the prevailing opinion,
and that in which I heartily concur, is that it arises from the
introduction of purulent discharge from some part of the
1 Quoted by Abadie. Maladies des Yeux. Paris, 1876.
64 AFFECTIONS OF THE CON J L^ N CT I V A .
genito-urinary tract of the motlier into tlic conjunctival sac of
the infant shortly after parturition. The great frequency of
purulent discharges from the os uteri in pregnant wonien is
universally admitted; and it is easy to understand how this
could come into contact with the eyelids during the passage of
the head per vaginam, shortly after which the child opens its
eyes. Hence the necessity of scrupulous care in washing the
eyes of the newly born.
Symptoms. — Purulent conjunctivitis usually commences in
from one to four days after infection ; in some cases its progress
is so rapid that it attains its maximum intensity in forty-eight
hours. At first there is a gritty sensation in the eye; this is
soon followed by pain, which sometimes becomes excruciating
in character. The eyelids become red, infiltrated, and swollen
to such a degree that they can only with difficulty be everted ;
the palpebral conjunctiva is greatly congested and swollen; the
ocular conjunctiva is also infiltrated, and forms an elevated
ridge of chemosis all round the cornea, which in some cases is
sulficiently prominent to overlap and conceal its peripheral
portion. The discharge at first consists only of a serous fluid
containing a few flocculi of pus, but it soon becomes thicker,
and of a yellow or even greenish-yellow color. This purulent
secretion fills the palpebral sac, and generally flows over on to
the cheek; at times it is retained by the swollen lids, and
causes great danger to the globe by the pressure thus exerted.
The establishment of free suppuration is marked by immediate
relief of pain and some diminution of swelling; this may lead
the patient to consider his condition to be improving, but in
reality the risk of serious and irreparable mischief commencing
in the cornea is greater now than at any other period of the
disease. The great danger of purulent conjunctivitis is lest
the cornea should slough or become ulcerated. Ulcers vary in
their position and depth; a very common situation is beneath
the limbus conjunctivae; in whatever part of the cornea they
occur, they are very likely indeed to lead to its perforation.
When we come to treat of affections of the cornea, we shall see
that a perforating ulcer from any cause may be followed by
dangerous sequela?; but when the perforation takes place in
the course of an attack of purulent conjunctivitis, we have the
GONOERHCEAL OPHTHALMIA. 65
additional danger lest the suppuration should immediately
extend to the whole eye.
It occasionally happens that the peripheral ulceration, ex-
tending round a large portion or the whole of the circumfer-
ence of the cornea, so interferes with its nutrition that the
whole membrane sloughs.
When the swelling of the lids has subsided, the conjunctiva
is found to have lost its normal smooth appearance, and to
have become rough and rugose, presenting numerous papillae
over its entire surface, more especially over the upper and
lower culs-de-sac.
After a variable time the discharge diminishes in quantity,
becomes thinner, and finally gives place to a serous fluid con-
taining a few flocculi of muco-pus. If untreated, this condition
may become chronic, giving rise to deformities of the lids,
such as trichiasis, entropion, ectropion, and to corneal affec-
tions, as ulcers, pannus, etc.
Gonorrhoeal ophthalmia is the most acute form of purulent
conjunctivitis. It is caused by the introduction of the urethral
discharge to the conjunctival sac, either directly by means of
the hand, or indirectly by the use of a contaminated towel or
pocket-handkerchief. It is more common in men than in
women. The right eye is more frequently attacked than the
left. Its progress is usually very rapid and severe ; from the
outset there are acute pain, chemosis, and great swelling of the
lids. If neglected or improperly treated, there may be total
destruction of the cornea, from abscess, ulceration, or slough-
ing, in the course of a few days.
Ophthalmia neonatorum — the form of purulent conjunctivitis
which attacks newly born children — is less virulent than the
gonorrhoeal, but is sufiiciently destructive in its nature to
require prompt and energetic treatment. Its probable cause
has been already mentioned. Its sjmiptoms and complications
are essentially the same as those of the gonorrhoeal and other
forms of the aflfection occurring in adults, although somewhat
less pronounced in degree. It usually occurs about the third
or fourth day after birth. More blindness is caused by oph-
thalmia neonatorum than by any other single aflection of the
eyes ; but this is due solely to the fact that its treatment is
5
66 AFFECTIONS OF THE CONJUNCTIVA.
frequently left to persons Avho are ignorant or incompe-
tent.
Treatment. — When not occurring in the newly born, the
indications are :
1. To protect the healthy eye when only one is attacked.
2. To reduce the pressure upon the globe which is caused by
the swollen lids and the retained purulent secretion.
3. To cut short the inflammatory process, and to restore the
conjunctiva to its normal condition.
4. To treat the complications.
1. To "protect the healthy eye. — (i) The closed lids may be
covered with absorbent cotton-wool, which is secured by col-
lodion and a bandage or sticking-plaster.
(ii) Buller's shield may be employed. This has the double
advantage of giving the patient a certain amount of vision, and
of enabling the surgeon to examine the eye without disturbing
its dressings. It is constructed as follows : Take a watch-
glass and two pieces of India-rubber plaster, one about ^h inches
the other 4 inches square ; cut a round hole slightly smaller
than the watch-glass in the middle of each piece of plaster.
Then insert the watch-glass between the two pieces of plaster,
and stick them together so as to form a small window. Now
arrange the plaster by its free edge along the nose, forehead,
and cheek, leaving only the lower and outer angle a little open
for purposes of ventilation.
2. To reduce the pressure upon the globe. — In some cases
the tension of the eyelids is so great that the cornea is in
danger of strangulation from pressure. Under these circum-
stances the lids should, if possible, be everted and their inner
surfaces freely scarified. Incisions with a small, sharp scalpel
should be made parallel to the edge of the everted lids from
near the ciliary margin as far back as the fornix conjunctivae.
Even the ocular conjunctiva may be benefited by a few radial
cuts. The incisions should be sufiiciently deep to induce free
hemorrhage. When it is found impossible to evert the eyelids,
either of the following methods may be adopted: (1) Division
of the outer canthus as far as the outer angle of the orbit.
This can be done with a pair of strong, sharp scissors, or by
means of a scalpel and a grooved director. (2) By vertical
PURULENT CONJUNCTIVITIS — TREATMENT. 67
division of the upper lid as recommended by the late Mr.
Critchett. A grooved director is first passed beneath the middle
of the upper lid; a sharp-pointed bistoury is then inserted into
the groove of the director, and made to perforate the lid at its
upper part ; all the structures of the latter are then divided.
The flaps thus formed can, if desirable, be stitched back. The
hemorrhage following these scarifications, and even that of the
division of the lids, is always beneficial in reducing the swelling
and cutting short the inflammatory process. The incisions
should be immediately followed by the copious use of tepid,
slightly carbolized water, with the object of encouraging the
local bleeding and thoroughly removing accumulated pus. This
done, the closed lids should be kept constantly cold and wet by
means of pledgets of lint dipped in iced water. The latter may
with advantage contain J per cent, of carbolic acid; and the
lint should be changed every half hour or so. Besides this, the
inside of the lids must be frequently cleansed, say every one or
two hours, by thorough washing with similar carbolized water.
On the following day the congestion and swelling may still be
so great as to render a second scarification advisable, or it may
be better to cauterize the inner surface of the lids with strong
nitrate of silver, and to continue the frequent ablutions and
cold applications.
3. To cut short the inflammatory jwocess. — (i) The best and
most effectual treatment consists in the application of solid nitrate
of silver (F. 1) to the inner surfaces of the eyelids once in twenty-
four hours, combined with the constant external application of
iced carbolized water, and frequent ablutions of the conjunctival
sac. The process is tedious, and requires the services of one
or two nurses. The lids must be well everted and cleansed,
and the caustic freely passed over the conjunctival surface.;
they must then be again washed, in order to remove the
superfluous silver nitrate before they are inverted. This
should be repeated once in twenty-four hours, and in the in-
terval the eyelids are to be everted, and the conjunctival sac
well cleared of all accumulated secretion every one or two
hours. Ice-cold applications should be kept constantly applied
to the outside of the lids. This may be effected by a dry ice
bag, or, better, by pledgets of lint dipped in iced carbolized
68 AFFECTIONS OF THE CONJUNCTIVA.
(^ per cent.) water. It will be found that the lint requires
changing every ten or fifteen minutes.
Two or three days of such treatment usually suffice to re-
duce the swelling, inflammation, and amount of discharge,
after which the use of milder astringent applications, as the
sulphate of copper or iodoform, may be substituted for the
nitrate of silver; and the cold applications may be discontinued
whilst a simple ointment is used to anoint the lids.
(ii) When the above process cannot be thoroughly carried
out, and when the aflfection is comparatively mild in degree,
we may use a 4 per cent, solution of nitrate of silver to paint
the conjunctiva, instead of the solid nitrate. It should be
washed off again before the lids are inverted. The conjuncti-
val sac should be thoroughly cleansed with | per cent, solution
of boracic or carbolic acid every one or two hours, and the
eyelids either anointed with simple ointment, or kept cool by
wet lint.
Iodoform has been recently used with great success in the
treatment of purulent conjunctivitis. It can be best used in
vaseline of 4 per cent, strength, and a very convenient and
efficient way of applying it is by means of a glass syringe with
a flattened nozzle (Bader's). By means of this the ointment
can be introduced well into the upper cul-de-sac without evert-
ing the lids.
As the acute symptoms of purulent conjunctivitis subside,
the discharge becomes diminished in quantity, then thin and
muco-purulent, and finally ceases. The mucous membrane of
the lids continues to be thickened and red; it is often very
rough, and sometimes quite granular. The treatment at this
stage must be similar to that for granular conjunctivitis.
(iii) In ophthalmia neonatorum both eyes are generally at-
tacked; even when one eye only is affected the use of Buller's
shield is hardly applicable. The other eye should therefore be
closed and secured from infection by cotton-w^ool, collodion,
and strapping. The treatment here is the same in principle
as in the adult; but, owing to the tender age and delicacy of
the subject, it requires a few remarks as to detail. The sur-
geon should always see the child at least once in twenty-four
hours. In order to examine the eye, he, being seated, directs
PURULENT CONJUNCTIVITIS — TREATMENT. 69
the nurse to place the child's head between his knees, which
are protected by a towel. He then first cleanses the eyes by
douching with pellets of cotton-wool and carbolized tepid
water; next he thoroughly everts both the eyelids and cleanses
them; then he applies, not the solid stick, but a 4 per cent,
solution of nitrate of silver by means of a camel's-hair brush to
the whole of the mucous membrane of the lids, and particularly
to that of the upper cul-de-sac; he then again washes away the
superfluous nitrate by douching with the carbolized water, and
finally closes the lids. Having done this he raises the upper
lid by means of Desmarre's retractor (Fig. 22), in order to
Fig. 22.— Lid Retractor.
examine the condition of the cornea. If there are signs of
inflammation or ulcer of this structure, a few drops of atropine
solution should be applied. Finally he anoints the edges of
the lids with simple or iodoform ointment, and instructs the
nurse or mother of the child to cleanse the eyes thoroughly
every hour with tepid carbolized water (| per cent.).
4. To treat the complicatio?is. — When cases are seen in the
very early stage, and can be properly treated, the inflamma-
tory process can generally be subdued before the cornea or the
deeper structures are aft'ected.
AVhen the cornea is found to present signs of inflammation,
abscess, or ulcer, some atropine solution, 1 per cent., should
be dropped into the palpebral aperture after each dressing.
The iris in such cases is very likely to be inflamed, and this
will tend to dilate the pupil and so prevent the formation of
adhesions (synechise). The existence of lesions of the cornea
does not contraindicate the treatment above described ; but
in the case of ulcers, especially when deep, greater care is
required in everting the lids, lest the pressure upon the globe
should cause perforation of the ulcer. "Where perforation of
the cornea is imminent, it may be advisable to perform para-
70 AFFECTIONS OF THE CONJUXCTIVA.
centesis of the anterior chamber toward the periphery of the
cornea, with the view of reducing intraocuLar tension, and so
preventing the rupture. When the conjunctivitis has sub-
sided, the corneal lesions can be treated according to the rules
given under tlie head of Ulcers of the Cornea.
Muco-purulent conjunctivitis (catarrhal ophthalmia) is of very
frequent occurrence.
Causes. — Contagion, sudden exposure to cold, irritating
particles of dust in the atmosphere, aftections of the eyelids, as
trichiasis, entropion, ectropion, and obstructed lachrymal
ducts, are all causes, as also are errors of refraction, especially
hypermetropia and hypermetropic astigmatism, in which con-
stant exercise of the accommodation tends to induce hyper-
emia of the conjunctiva. The secretions of muco-purulent
conjunctivitis are themselves contagious, and it is usual to lind
various members of the same household simultaneously or suc-
cessively attacked. The contagious nature of the aifection
renders an outbreak in large communities of great importance.
Cases should be isolated, and strict cleanliness enforced, not
only to prevent actual contact of the discharge with the eyes
of others by means of towels, etc., but also to prevent the
atmosphere becoming charged with particles of secretion; a
precaution which is especially necessary in the case of schools
of the poorer class, where the dormitories are often over-
crowded and ill-veutilated. This form of ophthalmia is much
more common among the poor than the well-to-do, although
the latter class is by no means exempt from the malady-.
It also occurs in the exanthemata of childhood, especially
measles.
Si/mp(oms. — This aftection presents itself under many dif-
ferent aspects. (1) In the milder cases we find only slight
redness of the palpebral conjunctiva and of the fornix con-
junctivae, hypersecretion of mucus, sticking together of the
lids on awaking in the morning, and a more or less gritty
feeling in the eyes.
(2) In the severer cases these symptoms are exaggerated;
the mucous membrane of the lids and fornix is not only in-
jected, but perceptibly swollen; and there is some injection of
the ocular conjunctiva. In addition to hypersecretion of mucus,
MUCO-PURULENT CONJUNCTIVITIS. 71
we iincl flocculi of muco-pus floating in the lower cul-cle-sac.
The adhesion of the eyelids on awaking is more marked, and
the edges of the lids are covered with a yellowish incrustation
of inspissated muco-pus.
(3) A few cases are much more severe, and are often diflfi-
cult to distinguish from purulent conjunctivitis. In fact, there
is no sharp line of demarcation between the two aflections,
since cases of every intermediate degree of severity are met
with. The chief diagnostic signs are the amount of oedema-
tous tension of the lids and the character of the discharge.
When muco-purulent conjunctivitis is attended with redness of
the circumcorneal zone, it becomes important to distinguish
it from other affections in which the same symptom exists.
The chief of these are iritis, episcleritis, and keratitis.
(a) In muco-purulent conjunctivitis the redness, at first, is super-
ficial, and chiefly confined to the conjunctiva. If the ocular
conjunctiva be moved up and down by pressure of the finger
through the lower lid, the injected vessels will be seen to move
with the mucous membrane. The redness of the ocular con-
junctiva is always accompanied by redness of the fornix con-
junctivae, and generally of that of the lids. The redness is
not localized in patches. The iris is clear and bright, the
pupil active, and the cornea clear.
(b) In iritis the circumcorneal zone of redness is deep-seated,
and is not accompanied by redness of the fornix and palpebral
conjunctiva. The injected vessels, being chiefly situated be-
neath the conjunctiva, do not move with the latter. The iris
is less brilliant than normal, and at times is much altered iu
color. The pupil is sluggish or inactive. The vision is im-
paired.
(e) In episcleritis the congestion is of a deep red color; it is
subconjunctival and localized — that is, it does not invade the
whole circumcorneal zone, but appears in patches, which are
usually situated opposite the palpebral fissure, near the outer
edge of the cornea.
(d) In keratitis the injected vessels are deep-seated and fixed.
The redness is most marked in the circumcorneal zone. The
transparency of the cornea is always more or less diminished.
72 AFFECTIONS OF THE COxNTJUNCTI V A.
Treatment. — Any general predisposing causes should be as far
as possible removed. Any error of refraction should be at once
corrected by spectacles. When due to a local cause, such as
trichiasis, entropion, stricture of nasal duct, etc., these should
be cured by appropriate treatment. In the mildest forms of
class 1, the use of any mild astringent (Formulae Nos. 5, 8, 9,
14), to be dropped into the palpebral aperture three times
daily, or used in the form of a lotion, together with the anoint-
ing of the lids with a simple ointment at night, is sufficient to
arrest the disease. In class 2 it is necessary to inculcate strict
cleanliness and caution with regard to the discharge. The eyes
should be washed four or five times daily with tepid water and
cotton-wool; after this astringent lotions should be applied, as
for class 1, or a piece of cotton-wool may be soaked in the
lotion and applied over the closed eyelids for ten or fifteen
minutes at a time in the form of a compress. The edges of
the lids should be constantlj^ anointed with simple ointment to
prevent adhesion, When the swelling and discharge are severe,
as in class 3, the above rules as to treatment still apply ; but I
do not hesitate to evert the lids and apply a 4 per cent, solu-
tion of nitrate of silver to their inner surface once daily. This
must, of course, be well washed away before inverting the lids.
Granular conjunctivitis (trachoma, follicular conjunctivitis,
granular ophthalmia).
Causes. — The chief cause of this affection is contagion. This
view is substantiated by the fact of its prevalence in pauper
schools in past and even present times, also in prisons, bar-
racks, and other places where there are crowded communities
having facilities for the conveyance of the unhealthy secretions
from eye to eye by means of towels and otherwise.
Cases do occur, however, which appear to be spontaneous,
no source of infection appearing to be within the patient's reach.
In all cases, whether produced by contagion or otherwise, the
subjects of the aftection appear to have been predisposed to it
by ill-feeding, over-fatigue, bad ventilation, and other debili-
tating causes. It is rarely seen in the better classes of society.
Symptoms and Pathology. — This disease first appears in the
form of numerous small, grayish, hemispherical, semi-trans-
parent elevations, having a great resemblance to boiled sago
GRANULAR CONJUNCTIVITIS.
73
grains (follicular granulations). These usually appear first in
the upper and lower culs-de-sac, and thence spread to the
lower and upper lids. This granular appearance, from which
the malady derives its name, differs from pathological "granu-
lation-tissue," inasmuch as the mucous membrane is not
ulcerated, and the submucous tissues have a characteristic ar-
rangement. Beneath the mucous, membrane we find these
elevations to be composed of aggregations of lymphoid cells,
those nearest the surface having undergone partial fatty de-
generation. In the superficial part there is but little inter-
cellular substance, but toward the base we find more or less
connective-tissue formation, with small branches of blood-
vessels. After the follicular granulations have existed some
time the adjacent papillae become hypertrophied, and the whole
lid assumes the rough villous appearance which is often left
Fig. 23. — Everted Granular Lids.
after catarrhal or purulent conjunctivitis (papillary granula-
tions) (see Fig. 23). As time goes on, the connective-tissue
element increases, and thus converts the papillfe and sub-
mucous tissue of the whole lid into a dense fibrous structure,
which finally contracts and undergoes changes resembling those
of cicatrices. The attack may be acute or chronic. There is a
more or less copious muco-purulent secretion, gritty feeling as
of sand in the eye, and photophobia. Sooner or later the
cornea begins to suffer from the friction and irritation of the
granular lids, and becomes ulcerated; or, more frequentl}", its
74 AFFECTIONS OF THE CONJUNCTIVA.
superficial la^'ers become opaque and vascular, which latter
condition is known as pannus.
Follicular granulations may he classified into three chief
groups: (a) Simple forms, in which there is but slight redness
of the free edges of the lids, a feeling of grittiness in the eyes,
and an increase in the secretion of mucus. On everting the
lids, however, we find fine granulations disseminated over the
conjunctiva, mostly in the position of the upper and lower culs-
de-sac. The conjunctiva over the tarsi is often free, or the
granulations may be seen creeping over their borders near the
outer canthus. The submucous tissues are but little affected.
[b) In a second class of cases the granulations constitute a
diffuse infiltration of the conjunctiva of the culs-de-sac and of
the palpebrte. The mucous membrane is greatly thickened,
and presents a grayish, gelatinous appearance. The edges of
the lids are reddened; the mucous secretion is much increased,
and often semi-purulent. Besides this, there soon supervene
increased lachrymation, photophobia, and lesions of the cornea
— pannus, ulceration, etc,
(c) llalignant. — In a third group may be placed a still more
grave and troublesome class of cases, viz., those in which
the granular affection extends to the ocular conjunctiva, and
even to the cornea; whilst the whole inner surface of the eye-
lids is infiltrated and thickened with villous-looking hyper-
trophies of the mucous and submucous tissues, which bleed on
the slightest touch, and which are so extensive as to cov^er up
the upper and lower culs-de-sac when the lids are everted.
The whole episcleral and corneal surfaces become filled with
tortuous bloodvessels, and the cornea becomes quite opaque
and fleshy-looking. There may be superficial, deep, or even
perforating ulcer. The iris also may be inflamed by continuity
of tissue.
The most discouracjinsr feature of this malignant form of
granular conjunctivitis is its obstinate progress from bad to
worse. The inflamed tissues do not return to their normal
state, but all appear to undergo an ultimate fibroid. degenera-
tion, similar, in fact, to the cicatricial contraction which follows
true ojranulatins: ulcers of the skin. Thus the mucous mem-
GRANULAR CONJUNCTIVITIS — TREATMENT. 75
brane becomes thin and shrunken and tightly adherent to the
tarsi, and the latter become shrunken and incurved.
Treatment must in all cases be general as well as local.
The general treatment consists in placing the patient under
the best possible hygienic conditions. Good and plentiful
nourishment, exercise in the open air, and well-ventilated
sleeping accommodations are essential adjuncts to local treat-
ment. Change of air or a sea voyage is frequently of great
assistance. The eyes should be protected from bright light
and from dust by smoked glasses. The patient should avoid as
far as possible over-fatigue of the eyes, especially by artificial
light. Tonics, such as iron, quinine, cinchona, and cod-liver
oil, should be administered. Parrish's food, Easton's syrup,
and similar forms of medicine are beneficial.
The local treatment consists in the application of astringents
or caustics (F. 4, 8, 24, 33) to the inner surfaces of the lids and
the culs-de-sac at regular periods.
In the use of these remedies it is important to bear in mind
the delicate structure of the mucous membrane we are dealing
with, and to realize the fact that our object is to restore it
to its proper condition and function, and not to destroy it
altogether.
1. Whe)i the granular conjunctivitis is free from purulent
discharge, the safest and perhaps the most efficient remedy is
the daili/ application of a crystal of sulphate of copper. The
lids should be everted (see Fig. 23), and a smooth crystal of this
substance or of the lapis divinus (F. 33) applied to the surface
of all the granulations, and especially to the upper cul-de-sac.
These surfaces should then be lightly washed with cotton-wool
and water, and the lids restored to their position. The appli-
cations should be repeated every twenty -four hours witliout
remission until the granulations have disappeared, and even
then they should be continued twice a week for several weeks.
Should there be a lull in the apparent improvement by this
daily application, it is well to substitute the weak nitrate of
silver crayon (F. 4) for the copper every third or fourth day,
always remembering to wash away the superfluous salt before
returning the eyelids.
With these efforts, combined with attention to the improve-
76 AFFECTIONS OF THE CONJUNCTIVA.
ment of the general health, there are few cases that will not
yield to treatment in from five to ten weeks, especially when
seen in the early stage. Unfortunately, however, this method
is too elaborate to be carried out in any but private cases, the
demand of time being greater than either the physician or the
patient can aftbrd to give. It remains therefore either to teach
the patient to apply the remedy himself, or to instruct some
friend how to do it for him.
No doubt other remedies, such as the lapis divinus (F. 33),
the glycerine of tannin, or the solution of tannin in syrup,
would be equally beneficial if constantly applied. The subace-
tate of lead in solution or in powder is recommended by some
surgeons ; but knowing the facility with which lead becomes
reduced, and deposited upon the cornea even in the slightest
abrasions of that structure, and being also aware of the great
frequency of these abrasions or ulcerations in trachomatous
afifections, I never employ this reniedv.
2. When there is considerable furulent discharge in addition
to the granular condition, the treatment should be similar to
that prescribed for the severer forms of muco-purulent con-
junctivitis. The granular surface of the eyelids and culs-de-
sac should be first cleansed with water and cotton-wool, then
painted with a 2 per cent, solution of nitrate of silver (F. 6),
and again immediately washed, and the edges of the lids
anointed with a simple ointment. This should be repeated
every twenty-four hours until the discharge is diminished,
when it may be replaced by a 1 per cent, solution of the same,
or by the crystal of sulphate of copper.
3. If the patient is unable to attend for treatment more
than once or twice a week, and is unable to get the sulphate
of copper applied at home, I find it more effectual to use the
strong form of nitrate of silver crayon (F. 1) at each interview,
and to prescribe an ointment of yellow oxide of mercury for
use at home (F. 24), directing the patient to introduce a small
quantity into the palpebral aperture twice daily.
When granulations have become excessively large it may be
well to excise them at once before commencing treatment by
astringents or caustics. Dr. Wolfe, of Glasgow, states that
he finds very beneficial results from the combination of scarifi-
PHLYCTENULAR CONJUNCTIVITIS. 77
cation of the granular surfaces, and the subsequent application
of a solution of tannin in simple syrup. Some surgeons recom-
mend the excision of the upper cul-de-sac of the conjunctiva
as a radical cure for granulations. MM. Galezowski and
Richet report very favorably of their results of this practice.
I have performed this operation about a dozen times in con-
junction with peritomy, and from this limited experience I
consider it to be beneficial as regards the granulations.
4. In the malignant forms of this disease the results of treat-
ment are most unsatisfactory. Here again the benefits of
good constitutional treatment cannot be over-estimated. The
local remedies must depend upon the condition of the con-
junctiva. Daily applications, either of astringents or caustics,
as the case may indicate, will do much to mitigate the results
which would supervene were the disease left to itself.
Phlyctenular conjunctivitis (also called pustular, scrofulous,
strumous, and herpetic conjunctivitis) is characterized by the
presence of one or more small vesicles attacking the sclerotic
portion of the conjunctiva (see Fig. 7, opposite p. 90). Each is
at first small, conical, and well defined ; it seldom measures
more than from 1 to 2 mm. across the base. Its contents are
at first clear and transparent, but soon become yellowish, in-
dicating the formation of pus. Sometimes it becomes solid
in texture, forming a somewhat hard prominence. The sur-
rounding conjunctiva is swollen and injected, and there is fre-
quently a triangular leash of enlarged bloodvessels, having its
apex at the phlyctenula and its base toward either the inner
or the outer canthus. The number of these phlyctenulae varies
from one to five or six. One or two will appear by preference
at the sclero-corneal junction, although they may be entirely
corneal, or entirely in the sclerotic portion of the conjunctiva,
or they may occupy any of these positions simultaneously ;
when, however, more than two occur, they generally appear
in successive crops. So long as the corneal portion of the con-
junctiva is not simultaneously afi:ected, there is little or no in-
convenience beyond a pricking sensation, increased secretion
of mucus, and more frequent blinking than normal. As
soon, however, as the cornea is attacked (phlyctenular kera-
titis), even though it be near the periphery, there is increased
78 AFFECTIONS OF THE CONJUNCTIVA.
lachrvmation, and photophobia may be so great as to cause
blepharospasm (p. 95). In some cases these pustules are ac-
companied by a more extended inflammation of the conjunc-
tiva, presenting the combined symptoms of muco-purulent and
phlyctenular conjunctivitis.
This aiiection is common in children up to the age often or
twelve years, but may occur at any period of life. It is fre-
quently accompanied by impetigo of the face and head. The
subjects are generally anaemic, badly nourished, and live in
crowded and ill-ventilated dwellings.
Prognosis and Treatment. — So long as the corneal conjunctiva
is unaffected, the phlyctenulae break down after a few days,
leaving a superficial ulcer, which rapidly heals, and the con-
junctival redness disappears. The disease, however, shows a
great tendenc}' to recurrence.
The process of healing is assisted by the use of mild astrin-
gents, such as the yellow oxide of mercury ointment (F. 24),
the solution of boracic acid (F. 14), and other simple astringents.
Constitutional treatment is also important. A wholesome
diet and good hygienic conditions should be prescribed ; also
plentiful exercise in the open air, and the internal administra-
tion of tonic medicines — Parrish's food, cod-liver oil, decoction
or tincture of cinchona, etc. ; also sulphide of calcium in -^^ gr.
doses every few hours.
Membranous or diphtheritic conjunctivitis is comparatively
rare in this country; nevertheless, a good number of cases
have been recorded, and in Germany, where the graver forms
of the affection appear to be of more frequent occurrence than
in Great Britain and France, the subject has received consider-
able attention.
A. von Graefe^ endeavored to arrange these cases into two
classes :
{a) The diphtheritic, in which in the first stage there are
brawny swelling of the lids, a pale, bloodless condition of the
conjunctiva, a very adherent whitish membrane, and a thin,
scanty discharge.
(6) The pseudo-membranous, or croupous, in which there
are a slightly adherent pellicle of exudation, a succulent con-
1 A. von Graefe, Arch. f. Oph., I., i. 1G8, 1854.
MEMBRANOUS COX JUNCTI VITIS. 79
junctiva, which bleeds easily when touched, and more or less
mueo-purulent or purulent discharge. He admitted, how-
ever, that cases intermediate between these two classes do
sometimes occur.
De Wecker' also draws a line of demarcation between what
he terms croapal and diphtheritic conjunctivitis.
Professor Tweedy- also maintains the classical distinction
between membranous and diphtheritic affections.
I fully acknowledge the extreme severity of the majority of
those cases which are directly traceable to diphtheria; yet some
of these are of a milder type and less pernicious in their results
than others of the so-called membranous conjunctivitis, in
which, beyond the condition of the conjunctiva, no symptom
of diphtheria can be found. I have made microscopic examina-
tions of both the diphtheritic and the membranous forms of
conjunctivitis.* In each the conjunctiva is thickened by infil-
tration, consisting chiefly of leucocytes; toward the surface
these are so thick and numerous that nothing else is visible.
Deeper down the bloodvessels are completely occluded by
similar cells, no red blood-corpuscles are visible; even in the
deepest parts these leucocytes are very numerous, occupying
the interstices between the connective tissue. In some of the
chronic cases the white, caseous-looking substance, which can
be separated with forceps, presents a semicrystalline appear-
ance, simulating cholesterine. This condition of an opaque,
whitish, adherent membrane, with more or less solid infiltra-
tion of the ocular or palpebral conjunctiva, may occur in con-
junction with throat diphtheria; it may be the result of
inoculation with diphtheritic discharge from another person;
it may occur as one of the sequelae of an acute illness, or
during the course of an attack of scarlet fever; or it may
supervene in a case of simple muco-purulent or purulent con-
junctivitis, especially when strong caustics are too freely
applied. For these reasons I am inclined to think with Mr.
Nettleship,* that we should abandon the distinction between
■diphtheritic and membranous conjunctivitis.
1 Therapeutique Oculaire. ^ Lancet, 1880, vol. i. pp. 125, 282.
3 See Ophthal. Soc. Trans., vol. iii. p. 1.
* St. Thomas's Hospital Reports, vol. x., 1880.
80 AFFECTIONS OF THE CONJUNCTIVA.
Tliere are man}' degrees of severity in this affection, varying
from a simple patch of a few millimetres diameter of slow
increase, and unattended by constitutional disturbance, to that
condition in which the whole of the palpebral and ocular con-
junctiva is involved, causing rapid destruction of the cornea,
and attended by considerable pyrexia, with severe pain in the
eyes, the temples, and the head.
Treatment. — In the severe and acute forms active measures
must be taken to reduce the local inflammation, to prevent the
destruction of the cornea by pressure of the swollen conjunctiva,
and to support the constitution of the patient. Unfortunately,
all the means we possess are too frequently futile in preventing
partial or complete sloughing of the cornea. The application
of caustics is generally regarded as increasing the danger.
Jacobson recommends the use of iced compresses continuously
applied; the effect, however, should be watched, and if the
symptoms do not improve, or should appear to be aggravated,
they must be substituted by hot fomentations, which may
with advantage contain a small percentage of carbolic or
salicylic acid. A few leeches may be applied to the temple,
or to the lids, if the patient can afford the loss of blood.
Moderate scarification of the mucous surfaces may also be of
great benefit, and even the division of the outer canthus may
be efiective in relieving the globe from the bad results of com-
pression, and in favoring the local applications. With regard
to constitutional treatment, some surgeons recommend the ,
administration of mercury till slight salivation is produced.
Others prefer a tonic and supporting plan of treatment by the
copious use of nutrient foods, iron, quinine, ammonia, bark, etc.
In the milder and chronic forms the exudation should be, as
far as possible, peeled off" dailj'; the surface should then be
treated with some astringent, such as the lapis divinus, once
daily, or with lotion of quinine (2 per cent.), or of salicylic
acid at frequent intervals.
Pterygium is a thickened condition of a part of the ocular
conjunctiva. It usually commences opposite to the aperture
formed by the opened eyelids, and is more common on the
nasal than on the temporal side of the cornea, although it raa}^
occupy both these positions in the same eye, or even in both
PTERYGIUM. 81
eyes, at the same time. Each patch appears in the form of a
triangle, of which the apex is directed toward, or encroaches
upon, the cornea, the sides being free and formed by a double
fold of the mucous membrane, under which a probe can be
easily passed. Its color is general!}^ so similar to that of the
conjunctiva that it usual!}' passes unnoticed until it attacks
the cornea (see Fig. 2, opposite p. 90) ; sometimes, however,
it becomes vascular in structure, and then has a bright red
color. It varies greatly in thickness and in the rapidity of
its growth. In some cases it continues for many years with-
out apparent increase; in others, especially those of the vascu-
lar kind, the increase may be rapid. In the majority of cases
it causes but little or no inconvenience; but when the thick-
ening is great the conjunctiva is liable to inflammatory at-
tacks. So long as the growth does not extend lo the front
of the pupillary aperture, the vision is unafiected; but after
it has reached this region, the vision decreases in proportion
to the extent of the pterygium. Pterygium is thought to be
caused by persistent exposure of the conjunctiva to irritating
substances, and to commence as a small abrasion or ulcer
opposite the sclerno-corneal junction. It is most common in
those who have travelled or spent some years in hot, dusty
countries, and in stonemasons and others who are exposed to
irritating substances.
Treatment. — When the cornea is only slightly or not at all
involved, and when the increase is evidently slow — that is,
where increase is imperceptible during six or twelve months'
observation — no treatment is called for.
Where increase is evident, and the pterygium has com-
menced its march upon the cornea, its removal by operation
should be at once resorted to. This can be effected by (1)
transplantation, (2) excision, or (3) ligation.
1. Transplantation (Desmarre's operation). — The lids being
separated by a speculum, the pterygium is seized with forceps
and dissected completely away from the cornea and the con-
junctiva as far as its base. The lower flap of the incision
formed in the ocular conjunctiva by the removal of the ptery-
gium is now enlarged by an incision of several millimetres in
length, made parallel to the lower margin of the cornea. The
QJ, AFFECTIONS OF THE CONJUNCTIVA.
conjunctiva is then dissected away from the globe to an extent
sufficient to receive the pterygium beneath it. The pterygium
is then twisted under this flap of conjunctiva and fastened in
its new position by one or two fine silk sutures. Finally, the
cut edges of the conjunctiva are brought into apposition by
similar sutures.
The dissection can be made w^ith curved scissoi-s or a Beer's
cataract knife. An excellent little knife is used for this pur-
pose by Mr. Anderson Critchett. It is rounded at its extremity,
and the cutting edge is continued a short way up the back of
the blade. It is made by Weiss. This method gives very
satisfactory results; the transplanted conjunctiva soon becomes
shrunken and imperceptible.
2. Excision is performed in a manner similar to the first
stage of transplantation, the mass being cut away at its base
by two incisions meeting at the commissure. The edges of
the wound are brought together by fine silk sutures.
3. Ligation is performed by transfixing the base of the ptery-
gium by several silk ligatures and tying them tightly in such
a manner as to involve the whole of the base of the growth,
which soon sloughs, and can be removed with forceps.
Pinguecula is a small whitish or yellowish-white tumor of
from 1 mm. to 4 mm. diameter, situated in the ocular con-
junctiva close to the cornea, and opposite the palpebral fissure.
It more commonly occurs on the temporal than on the nasal
side of the cornea, but it frequently comes on both sides and in
both eyes. It involves the whole thickness of the conjunctiva,
with which it moves when the latter is displaced. It is more
common after middle age than before that period ; also in per-
sons who are exposed by their occupation to irritating vapors
and substances. Microscopically, pinguecula consists chiefly
of condensed cellular tissue; the epithelial layer of the con-
junctiva is thickened, and the bloodvessels are obliterated. It
causes no trouble or inconvenience; after attaining a certain
magnitude it remains stationary. As a rule, no treatment is
required, but no harm would be done by its removal.
Amyloid degeneration of the conjunctiva. — This is a rare
afl'ection, in which there is a soft, gelatinous-looking iiyper-
trophy of the conjunctiva, unattended by inflammation or pain.
XEROSIS. 83
It appears first to attack the sclerotic portion of the conjunc-
tiva, and thence to spread to that of the palpebrpe and the
cornea. According to Leber, amyloid degeneration is a purely
local malady ; it may come on as a primary affection of the
conjunctiva, or it may be consecutive to chronic granular con-
junctivitis. The process consists in the development of amy-
loid corpuscles or trabecule, which are situated in a clear,
liquid matrix, and are enclosed in a special membrane, con-
taining numerous nuclei. The corpuscles and trabeculse give
a decided amyloid reaction when treated witli iodine and sul-
phuric acid.
Xerosis is a very uncommon form of disease, which is charac-
terized by a peculiar drj-ness of the conjunctiva, giving it a
shrivelled, skin-like character, in consequence of atrophy of its
tissue, and obliteration of its secretory elements. Its treat-
ment is very unsatisfactory. The application of glycerine and
bandaging is advised as a palliative. M. Oilier, of Lyons, has
found benefit from keeping the eyelids closed for man}- months.
In order to eftect this he pares the edges of the lids, and brings
them together by sutures, so as to produce symblepharon.
CHAPTER IV.
DISEASES OF THE CORNEA.
ANATOMY — INFLAMMATION — PHLYCTENULAR KERATITIS — INTERSTITIAL KERA-
TITIS VASCULAR KERATITIS — PUNCTATE KERATITIS — ULCERATIVE AND
SUPPURATIVE KERATITIS — LEUCOMA — STAPHYLOMA.
Anatomy and Physiology. — The cornea is nearly circular in
shape, and is quite transparent ; its arc extends to about one-
sixth of the circumference of the globe. It has a smaller
radius of curvature than that of the sclerotic, and so projects
forwards beyond the general surfiice of curvature of that mem-
brane.
In the cornea (Fig. 1, on the opposite page), we find from
before backwards the anterior epithelium, Bowman's mem-
brane, the substantia propria, the posterior elastic lamina, or
Descemet's membrane, and the endothelium.
The anterior epithelium is of the stratified pavement variety,
arranged in several layers, the deepest of which is composed of
columnar cells, each with an oval nucleus; then follow two or
three layers of pol^-hedral cells, each with a spherical nucleus;
lastly, there are two or three layers of fiattened cells, each with
a discoid nucleus. This epithelium is continuous with that of
the conjunctiva, from which it difters in being thicker and
more transparent (see Fig. 3, on the opposite page).
Bowman's membrane is the transparent homogeneous-looking
anterior part of the substantia propria. It is considered by
some high authorities to be a distinct and almost structureless
membrane, but recent researches show that it only differs from
the rest of the lamellee in containing fewer lacunse and corneal
corpuscles.
The substantia propria is continuous with the sclerotic ; it
Ca7ial tifgcTilcmm.
^Jtrtiie-
Fig. 1. — Ciliarj- region (normal). X about 40 diain.
Fig. 2. — Corneal Corpuscles and nerve fibrils.
X •♦50 diani.
(After Klein and Xoble Smith.)
TTrf^f (if Corneal Vleer-
Troir^iili nnlris.
— ^amuai's mtvibn
-SuiafaKf.ra jiivpriit. ,
Fig. '•'>. — Anierior part of human cornea.
X about i!50 diam.
(.\fter Klein and Xoble .Smith.)
>:^ -Cilia, y
hody
Fig. 4. — Perforating ulcer of cornea. X about l>h <liai:
I Ihie^itned. efiiKtlium:
Layers of eorne cu
Tlrsveniets mcr:i7 .
Fig. 5. — Pannu*. ; ; about 40 diniii.
Tu face p. 84.
ANATOMY OF THE CORNEA, 85
consists of numerous lamellfe of bundles of fibrillar connective
tissue. The bundles and the fibrillae are united by a semifluid,
albuminous, interstitial cement substance. This cement sub-
stance is arranged in distinct layers between the lamellse, and
in each of these layers are found lacunse, and anastomosing
canaliculi, constituting the lymph canalicular system of Reck-
linghausen. These anastomose freely with the lymphatics of
the conjunctiva at the circumference of the cornea. Each
lacuna contains a corneal corpuscle, from which branches
extend into all the canaliculi, thus forming an anastomosis of
corneal corpuscles (see Fig. 2, opposite page 84). The lacunae,
however, are not completely filled by these branched corneal
corpuscles, there is suflcicient space left for the circulation of
plasma, for the passage of migratory cells, and in some parts
for the passage of nerve-fibrils (Klein, Recklinghausen, Strieker,
Rollett). Each corneal corpuscle contains an oval nucleus, and
exhibits contractile movements under the influence of electrical,
thermal, and mechanical influences. In the normal cornea only
a few migratory cells can be observed in these lacunse, but in
inflammatory conditions they can be seen squeezing themselves
through the finest canaliculi (Klein).
The posterior elastic lamina, or Descemet's membrane, is
strongly resistant, and is composed of bundles of very fine
elastic tissue. At the circumference of the cornea it becomes
split up into a leash of fibres to form the ligamentum pectina-
tum, these pass to the iris and ciliary body, they also give
attachment to some fibres of the ciliary muscle. Its posterior
surface is lined by a single layer of flattened, nucleated cells.
These cells are continued along the fibres of the ligamentum
pectinatum, and over the anterior surface of the iris.
The nerves of the cornea are derived from the ciliary nerves ;
they enter the forepart of the sclerotic and thence pass to the
substantia propria of the cornea; they retain their dark outline
for about one mm,, but then become transparent, and form a
plexus throughout the laminated structure. From this primary
plexus, other nerves proceed to form a finer plexus just beneath
the epithelial layer, and this gives off" branches between the
epithelial cells, to form a still more superficial network (see
Fig. 2, opposite page 84).
86
DISEASES OF THE CORNEA.
All round the periphery of the cornea is a fringe of capil-
laries; these are continuous with the vessels of the limbus
eonjunctivfe and extend for about 1.5 mm. into the corneal
tissue.
Oblique focal illumination is a useful method of examining
the cornea, the anterior chamber, the iris, the crystalline lens,
and even the anterior part of the vitreous. It should be
adopted as a routine practice in all cases when the presence of
a foreign body or of disease in these parts is suspected. The
Fig. 24. — Oblique Focal Illumination.
patient should be seated in a dark room with the ophthalmo-
scope lamp placed about 30 cm. to 40 cm. to the temporal side
and slightly in front of the plane of the patient's face. Then
by using a convex lens of 14 D, or 16 I)., and .slightly changing
the position of the lamp and lens, the light can be easily brought
to a focus upon either of these structures. The part thus illu-
minated can at the same time be magnified by using a second
lens heldjin the other hand (see Fig. 24). This lens should
be held at its own focal distance from the part to be viewed ;
the rays are then parallel as they reach the observer's eye, E'.
INFLAMMATION OF THE CORNEA. 87
Inflammation of the cornea (keratitis, corneitis) occurs in
various forms and degrees of severity. It is nearlj^ always
accompanied by more or less injection of the vessels of the
circumcorneal zone. There is always some loss of trans-
parency in the corneal tissue, although this may in some cases
be so slight that it can only be seen by focal illumination.
The vision is impaired in proportion to the corneal opacity.
The following classiiication of inflammations of the cornea is
convenient :
1. Interstitial or diffuse keratitis.
2. Punctate keratitis.
3. Vascular keratitis or pannus.
4. Phlyctenular keratitis.
5. Suppurative keratitis.
^a. Superficial ulcers.
6. Ulcerative keratitis J b. Deep ulcers.
\.c. Serpiginous ulcers.
1. Interstitial keratitis (syphilitic, strumous, parenchyma-
tous).
Syinpioms. — In these forms of keratitis, the whole cornea
undergoes a chronic inflammatory change, and evinces no
tendency either to the formation of pus or to ulceration.
First, there is slight congestion of the vessels in the ciliary
region around the margin of the cornea, then a difl"used grayish
opacity at the centre ; this may be so slight that it is only
recognized by oblique focal illumination; soon, however, it
becomes decidedly cloudy, some of the opacity being near the
surfaces, and other patches deeper. This cloudiness, or ground-
glass appearance, gradually extends over the cornea, until the
pupil and iris are more or less hidden from view. In the most
severe cases the opacity assumes a yellowish tint, and no trace
of the iris can then be seen, even with the oblique illumination.
The degree of pain, photophobia, and congestion -of the con-
junctiva are variable. In some cases these symptoms are very
slight from the beginning to the end of the case, in others the
eyes are extremely hypersensitive to light, very painful, and
the ocular conjunctiva much congested.
In many cases, very minute bloodvessels are formed in the
layers of the cornea. These are derived from branches of the
88 DISEASES OF THE CORNEA.
ciliarv vessels; they are extremely tine aiul their separate
branches can only be distinguished by means of a magnifying
lens, when they appear in the form of a line network of
branches which are given oft" from a larger trunk at the
periphery of the cornea. These vascular areas are not of a
bright red color, unless they are very near the surface; when
deep down in the corneal tissue their color is modified by
the opacity, and they appear to be of a dull, reddish color,
the " salmon patch " of Hutchinson. They may occur in any
position, and often attack the upper or lower margin of the
cornea. Fig. 4, opposite page 90, represents a severe case of
this disease. The whole cornea is opaque, and a salmon patch
is seen over its upper third.
Complications are not unfrequent in the tissues of the neigh-
boring parts. The most common of these are iritis and
cyclitis. Diffuse keratitis usually attacks both eyes, but as a
rule one cornea is tirst invaded and rendered fairly opaque,
before the attack in the second eye commences. The interval
between the attacks in the two eyes is variable, from two or
three weeks to as many months. It generally occurs between
the ages of 6 and 15, although it is sometimes seen as early as
three, and has been known as late as thirty-live years.
The duration of this affection under proper treatment is, on
an average, from about six months to a year ; but severe cases
are sometimes several years before they become stationary.
Vision is nearly alwaj-s somewhat impaired after this disease.
The cornea may look very transparent, and only the faintest
haze may be detectable by focal illumination; but this will
almost invariably be found to interfere with distinct vision.
Causes. — The majority of cases of dilfuse keratitis undoubt-
edly result from inherited sjphilis, and in a few it has been
traced to acquired syphilis. Many cases, however, come under
notice in which no specific history can be traced. When due
to inherited syphilis, other symptoms of this affection can
generally be discovered. The patient " presents a very peculiar
ph>/siogno7ny, of which a coarse, flabby skin, pits and scars on
the face and forehead, cicatrices of old fissures at the angles of
the mouth, a sunken bridge to the nose, and a set of permanent
teeth peculiar for their smallness, bad color, and the vertically
INTERSTITIAL KEKATITIS TREATMENT. 89
notched edges of the upper central incisors, are the most striking
characters."^
Other symptoms of inherited specific disease can often be
detected in the brothers and sisters of the patient, and the
history of acquired syphilis can often be elicited from one of
the parents, either directly from their own statements, or in-
directly by interrogation; thus it will frequently be found
that the mother of the patient suffered from numerous mis-
carriages, or that several children prior to the patient were
either prematurely born, stillborn, or died in early infancy,
often with specific symptoms. With regard to this method of
ascertaining the cause of diffuse keratitis otherwise than in the
eyes of the patient, Mr. Xettleship says: "I have found other
personal evidence of inherited syphilis in 54 per cent, of my
cases of interstitial keratitis, and evidence from the family
history in 14 per cent, more: total, 68 per cent.; and in most
of the remaining 32 per cent, there have been strong reasons
to suspect syphilis."^
Treatment must be directed to the improvement and sup-
port of the general health as well as to the local condition.
The subjects of this disease are generally weak, and frequently
anaemic. It is important that they should be placed under the
best hygienic conditions, that they should have abundance
of nutritious food, and plenty of exercise in the open air.
Strong alcoholic drinks should be scrupulously avoided. A
prolonged course of mercury should be prescribed ; an}' of the
mercurial preparations will answer the purpose, such as pil.
hydrargyri, hydrarg. cum creta, the perchloride, etc., or the
inunction of unguentum hydrargyri in the axillae. Which-
ever form is prescribed it should be continued for a long time,
but its action must be carefully watched lest salivation be pro-
duced. The state of the gums and inside of the lips should be
examined at each visit, and any sponginess being observed,
the medicine should be stopped until these symptoms have
disappeared. In addition to mercury, the internal administra-
tion of cod-liver oil, of the syrup of phosphates of iron, qui-
nine, and strychnine, of the sj-rup of the iodide of iron, or of
^ Syphilitic Diseases of the Eye and Ear, by Jonathan Hutchinson, p. 30.
2 Diseases of the Eye, by E. Xettleship, 1882, p. 104.
DESCRIPTION OF PLATE.
Fi(i. 1. — Pannus (partial).
± — Pteiygiuui.
• 3. — Local Keratitis.
" 4. — Interstitial Keratitis (Salmon patch above).
" 5. — Punctate Keratiti.s.
(■). — Ulcer of Cornea (healing).
7. — Phlyctenular Conjunctivitis.
" 8.— Plastic Iritis.
9. — Severe Plastic Iritis.
" lu. — Posterior Sj'oechije (Atropine has been used)
" 11. — Hypopyon.
■■ lii. — Blood in Anterior Chamber.
-r-^T.^ 3.
#'%.
'i^ y^
W^^''
12.
r .f=!b>f5n X Co
:>'•
PUNCTATE KERATITIS. FANNUS. 91
the perchloride of iron with quassia, is a very valuable adjunct.
The eyes should be shaded from bright light and exposure to
cold by means of tinted glasses; if there Is photophobia, they
had better be closed, and covered by small pads of cotton-wool
and a bandage. A | per cent, solution of atropine should be
systematically dropped into the palpebral aperture once or
twice daily throughout the active, inflammatory stage; this
not only acts as a sedative, but by causing dilatation of the
pupil prevents adhesions (synechiBe) if iritis is present. When
inflammation has subsided, and there is no redness in the cir-
cumcorneal zone, nor any photophobia remaining, the use of
the yellow oxide of mercury ointment (F. 24) is advisable, as
it promotes absorption of the opacity; it should be put into
the palpebral aperture night and morning.
2. Punctate keratitis is characterized by the existence of dots
of opacity on the posterior surface of Descemet's membrane
(see Fig. 5, opposite p. 90). The term was formerly employed
by some surgeons to indicate any dotted appearance in this or
other parts of the cornea. The dots are variable in size and
arrangement, sometimes being visible to the naked eye, at
others requiring oblique focal illumination and the use of a
magnifying lens. Microscopically, they are seen to be as accu-
mulations of nucleated cells of similar nature to those of the
epithelioid layer, which is also thickened in other parts (see
Fig. 1, opposite p. 142). Keratitis punctata is almost invariably
secondary to inflammation of some neighboring part, as the
iris, ciliary body, or choroid. It occurs in the sympathising
eye in sympathetic ophthalmitis, where the dots are usually
distributed irregularly over the epithelioid layer. It often
appears in the course of specific serous iritis, where it usually
assumes a triangular form; the apex of the triangle is in front
of the pupil, and the base at the circumference of the cornea,
usual Ij' below.
3. Vascular keratitis or pannus is a superficial vascularity and
opacity of the cornea (Fig. 1, opposite p. 90, also Fig. 5, opposite
p. 84). In it we find the deep portions of the epithelial layer
of the cornea infiltrated with a number of nucleated cells,
amongst which very fine bloodvessels make their appearance
and finally become so large as to be visible to the naked eye;
92 DISEASES OF THE CORNKA.
these vessels arc contimious with those of tlie limbus conjunc-
tivfie, and when sufficient!}' far apart to be seen separately,
present a tortuosity which distinguishes them from those met
with in other forms of inflammation of the cornea. The super-
ficial layers of the corneal tissue also become somewhat affected,
being invaded by patches of opacity. The number of vessels
varies with the severity of the case; sometimes they are only
three or four in number, and the opacity so slight as to be
hardly perceptible. In the severer forms they are so numerous
as to constitute a thick, fleshy-looking web, and the opacity of
the sub-epithelial tissue is so great that the patient's vision is
reduced to mere perception of light.
Pannus is almost invariably caused by granular conjunc-
tivitis, and commences usually in that part of the cornea which
is rubbed against by the upper lid; it is always accompanied by
more or less photophobia, lachrymation, pain in the eye, sw^ell-
ing of the edges of the lids, and impairment of vision. It is
sometimes complicated by other lesions, as ulcer of cornea,
iritis, etc.
Treatment. — In all cases of pannus Ave have to direct our
attention to the removal of two conditions, viz., the granular
condition of the conjunctiva, and the vascular web and opacity
of the surface of the cornea. As the morbid condition of the
cornea is secondary to that of the granular lids, this should be
first treated by the methods recommended under the head of
granular conjunctivitis (p. 75), If these measures fail to cure
the pannus, the operation of peritomy (syndectom}') ma}' be
performed. This consists in the removal of a zone of conjunc-
tiva and subconjunctival tissue from the immediate vicinity of
the cornea. The patient being fully under the influence of
ether, and the eyelids widely separated by a spring speculum,
the conjunctiva is divided by small blunt-ending scissors, at a
distance of from 3 to 4 mm. from the entire circumference of the
cornea; the strip thus formed between the incision and the cor-
nea is then to be dissected oft" with the same scissors as close as
possible to the edge of the cornea and to the surface of the
sclerotic. This operation was extensively practised by the late
Mr. Critchett,^ who found that it accelerated the cure of the
' Transactions of the Ophthalmological Society, vol. i. p. 9, 1881.
TREATMENT OF PANNUS, 93
granular lids as well as that of the pannus. Its beneficial
results do not immediately appear; in fact, the condition
sometimes seems rather aggravated during the first week fol-
lowing the operation; but as soon as new tissue has been
deposited, and a white cicatricial line is observed around the
corneal margin, there is marked improvement. When pannus
has been allowed to become complete, so that a fleshy-looking
vascular web has formed over the whole cornea and no trans-
parent portion remains, inoculation of pus is sometimes per-
formed. The process consists in simply transferring some
purulent matter from the eye of an infant during the first
week of an attack of ophthalmia neonatorum into the palpe-
bral aperture of the patient. An acute attack of purulent
conjunctivitis is thus established, and is sometimes followed
by clearing up of the cornea. !N^ot unfrequently, however, the
process is followed by complete destruction of the eye. The
contagious and destructive nature of this remedy renders it very
objectionable. It should onl^^ be adopted as a last resource.
De Wecker^ has recently introduced the artificial produc-
tion of purulent conjunctivitis by means of jequirity, as a
means of cure both for granular lids and for pannus. An in-
fusion of the seeds of jequirity^ is used for this purpose. It is
prepared as follows: Take 3 grammes of the pulverized seeds,
and macerate for twenty-four hours in 500 grammes of cold
water, and then add 500 grammes of boiling water. Allow
the infusion to cool, then filter immediately.
The patient is to bathe his eyes with this infusion three
times in the day. If the resulting irritation is severe, this will
be sufficient, otherwise the application must be continued on
the second, and, if necessary, on the third day.
It is followed in a few hours by severe irritation of the
ocular and palpebral conjunctiva. Acute inflammation follows
the next day, the patient can no longer open his eyes, the lids
are (Edematous, and there is serous secretion, which is suffi-
ciently copious to drop from the lids if the patient lowers his
'head.
^ Annales d'Oculistiqne, August, 1882, p. 24. Also see Ophthalmic Review,
vol. ii. p. 19.
- The seeds are supplied by Rigaud, Rue Vivienne, Paris.
9-1 DISEASES OF THE CORNEA.
Tliis continues for several days, and is accompanied by
pyrexia, sleeplessness, headache, and constipation. After the
third day the period of suppuration sets in, and lasts about five
days. The suppuration then gradually decreases, and the
patient begins to feel improvement up to the fifteenth day,
when he is finally free from inflammation, and cured of his
granulations, and the cornea gradually hegins to clear.
As the result of his first experiences of this drug, de AVecker
arrived at the following conclusions:
(1) Infusion of jequirity attbrds a means of promptly setting
up a purulent or croupous ophthalmia, the intensity of which
is greater if the infusion, instead of heing used merely as a
lotion, is swabbed on the everted lids, and applied in the form
of compresses. In the majority of cases the swollen conjunctiva
becomes covered with croupous membrane like that sometimes
met with in the ophthalmia of new-born children, when the
secretion coagulates on contact with air.
(2) The employment of the infusion is not painful; purulent
conjunctivitis is induced by it as promptly as by inoculation,
and with the advantage of avoiding the use of matter borrowed
from an individual about whose constitution one can never be
quite certain.
(8) By moderating the use of the jequirity, the degree of
suppuration required may be regulated far more accurately
than is possible in inoculation. In the latter proceeding
neither the quantity nor the quality of the matter afibrds any
control, whereas with jequirit}', if the action is insuificient, it
may readily be augmented by a fresh and more energetic np-
plication.
This method has since been tried by other ophthalmic
surgeons, but the hope that it might prove a real and eflicient
remedy for trachoma and pannus has not as yet been fully
realized.
M. Deneffe, of Ghent, ^ has tried it in his practice. He states
that in some cases the inflammation was extremely violent by
the third day, resembling a true purulent conjunctivitis; in
others it was much less intense, and in some it did not occur
' See Ophthalmic Keview, vol. ii. p. 174.
PHLYCTENULAR KERATITIS. 95
at all. Therapeutically considered, the inflammation produced
by jequirity gave no results. The granulations were not re-
moved, and the pannus was not influenced in any way. Not
one of his patients found benefit.
Dr. Brailey records a favorable experience of this method
in his practice at Guy's Hospital.^ Three cases of trachoma
which had resisted other treatment, were considerably im-
proved by the jequirity infusion. He considers it to be a drug
of considerable value. It does not appear to aflect the cornea
injuriously, and in this respect must be admitted to have a
great advantage over inoculation with pus.
4. Phlyctenular keratitis (pustular keratitis, vesicular kera-
titis, herpes corneae) is characterized by the appearance of one
or more small pustules on the surface of the cornea. They are
similar to those occurring in phlyctenular conjunctivitis (p. 77),
in fact, both cornea and conjunctiva are frequently attacked
together. Each consists of an aggregation of leucocytes just
beneath the epithelial layer. They maj^ occur simultaneously
or in successive crops. They may attack any part of the cornea,
but are usually found near the sclero-corneal junction. At the
end of three or four days they usually rupture, and form a
superficial ulcer.
There is always photophobia, which is sometimes so great
as to cause acute blepharospasm. The ocular conjunctiva is
usually injected, and often contains similar pustules. As the
ulcer heals, a leash of vessels is often developed between it and
the margin of the cornea. This disappears when the ulcer has
quite healed.
This affection is common amongst strumous children, and
occurs more frequently amongst the poor and ill-fed than
amongst the well-to-do.
Treatment. — The local treatment consists in shading the eyes
from light, and in applying slightly astringent and antiseptic
remedies to the affected part. The drops of boracic acid (F.
14) and the oxide of mercury ointment (F. 24) are beneficial,
and when there is much pain these can be combined with
atropine drops or ointment of similar strength. The general
health must be improved.
1 Brit. Med. .Touinal, ^U\y I'.t, 1883, p. 9o4.
96 DISEASES OF THE CORNEA,
5. Suppurative keratitis may be diffuse or circumscribed. In
tbe diffuse form tbe cornea first loses its brilliancy, then assumes
a grayish-white appearance, Avhich soon becomes of a yellowisli
tint, indicating the formation of pus between the lamellae. This
process of infiltration and suppuration takes place very rapidly,
a few days suflicing for the whole of the cornea to become
involved. The epithelium disappears, the more superficial
lamellae become separated from the deeper by a layer of pus,
and are detached, causing so much loss of substance that the
deeper parts, unable to resist the intraocular pressure, are
pushed forwards and ruptured, thus forming an extensive per-
foration. In the more favorable cases of diffuse keratitis, there
may be no perforation, but there is always considerable bulg-
ing forwards (staphyloma) of the anterior part of the globe, and
so much corneal opacity that vision is greatly interfered with.
This affection ma}' come on as a complication or extension
of some other local affection; thus it is frequently found during
the course of purulent conjunctivitis; it not unfrequently ap-
pears with traumatic iritis and irido-cyclitis after the extraction
of cataract.
In the circumscribed form of keratitis, some portion of the
cornea becomes dull in appearance, an opaque whitish patch
appears, and is surrounded by a grayish halo; the central part
of the patch then assumes a yellowish tint, indicating the ex-
istence of abscess of the cornea. AVhen the abscess is near the
surface, the superficial layers of the cornea break down and
form a superficial ulcer. When it is deeply situated, the
pointing takes place inwards, and the pus passes into the
anterior chamber. It occasionally happens that an abscess
opens both outwards and inwards, and so forms a fistulous
opening into the anterior chamber. The contents of the
localized sup})urations are more tenacious in character than
pus from other tissues; this is particularly evident after rupture,
or after incision by the surgeon, when the contained matter
comes away en masse rather than in the liquid form. Micro-
scopically it consists of pus-cells, and broken-down connective
tissue of the cornea.
The laminae, between which the pus is situated, are some-
times so separated that the latter gravitates toward the inferior
HYPOPYON
ONYX.
97
Abscess
part, and so presents a fancied resemblance to the luniile at the
base of the finger-nail ; hence the condition has been termed
onyx. When puro-lymph is present in the anterior chamber
it gravitates toward the lower part, and the condition is then
termed hypopyon ; this is a frequent complication of deep ulcers
of the cornea, especially in old people. The quantity of pus in
the anterior chamber is very variable,
sometimes only a faint j-ellow line
can be seen at the lower part of the
chamber. Hypopyon can generally
be distinguished from onyx by the
fact that the upper level of the fl.uid
is a horizontal line, while in onyx
the limit is usually irregular. If
the pus in hypopyon is sufficiently
fluid to shift its position with move-
ments of the head, this fact at once
establishes the diagnosis (see Fig.
11, opposite p. 90, also Fig. 25). In
onyx focal illumination will gener-
ally render it evident that the pus
is in the substance of the cornea.
The two conditions may, however,
coexist.
Suppurative keratitis may come on
spontaneously in persons of scrofu-
lous diathesis. It may occur at any
age, and is common in old people in whom the cornea has
received some injury, as from a foreign body under the eyelid,
or an abrasion near the centre.
Treatment. — In the early stage the eyelids should be well
fomented with warm water or warm decoction of poppy-heads
every few hours, and a i per cent, solution of atropine dropped
into the palpebral aperture at frequent intervals. The eyes
after each bathing should be covered by a compress of lint
dipped in hot water, and covered over with cotton-wool or a
light bandage. Some surgeons prefer that the fomentation
should be rendered antiseptic by the presence of h per cent, of
carbolic or salicylic acid. When the abscess is established, it
Hypopyon
Onyx
Fig. 25. — Vertical Section through
Anterior part of Globe (diagram-
matic).
98 DISEASES OF THE COKNEA.
may be treated either ]\y puncture, or by the method of
Saemisch (see p. 104). When hypopyon exists, paracentesis of
the anterior chamber should be performed. Small collections
of puro-lymph are, however, frequently absorbed from the
anterior chamber. The general health of the patient should
be sustained by good food, fresh air, ammonia and bark, or
quinine.
6. Ulcers of the cornea constitute an important part of oph-
thalmic practice. They are always preceded by more or less
infiltration and grayish opacity ; first the superficial and then
the deeper laminse break down at the centre of the part thus
affected, causing actual loss of corneal tissue. In all cases of
ulcer there is more or less pain, intolerance of light, and in-
jection of the circumcorneal zone of vessels.
Ulcers may be classified into three chief groups : a. Super-
ficial, h. Deep. c. Serpiginous.
a. Superficial ulcers are usually circumscribed, and often so
transparent that they may escape attention unless oblique focal
illumination is used ; by this method of examination, however,
they can always be detected, and are usually found to have
margins more or less infiltrated and opalescent. The}' are
attended by severe photophobia, lachrymation, and neuralgic
pains in and around the eye. When situated near the centre
of the cornea vision is much interfered with, when peripheral
it is but slightly afiected.
They are frequently of traumatic origin, being caused by
a slight scratch or blow, or by the presence of a foreign body.
They sometimes come on during the course of an attack of
conjunctivitis, more especially in the phlyctenular form. As
a rule, early and proper treatment will cause healing of the
ulcer without leaving any permanent opacity.
b. Deep ulcers are frequently caused by injury, such as an
abrasion, a scratch, or a contused wound of the cornea; they
occasionally follow the rupture of a pustule, as in phlyctenular
keratitis. The}- are not unfrequent complications during an
attack of smallpox, or after measles. They constitute, as we
have seen, a serious feature in severe inflammation of the con-
junctiva, be it granular, purulent, or diphtheritic. Occasion-
ally w^e find ulceration of the cornea supervening in cases of
ULCERS OF THE COENEA. 99
paralysis of the fifth nerve, which supplies the trophic and
sensory fibres to the eyeball; in such cases the inflammatory
symptoms are very slight.
Deep ulcers commence by first attacking the epithelium
and then spreading both in extent and depth to the proper
tissue of the cornea, destroying both the corneal corpuscles
and the intercellular substance. Their edges are copiously
infiltrated with leucocytes and present a grayish-white color,
which gradually shades off into clear corneal substance. When
the process has ceased to be progressive, the edges of the ulcer
become less abrupt, and its floor is gradually filled by regular
layers of cells, which become organized; the epithelium then
begins to be restored, and the surrounding corneal tissue re-
gains its transparency. Ulcers vary much in size and may
attack any part of the cornea. They are always attended by
photophobia, lachrymation, and pain in and around the eye;
the degree of severity of these symptoms is very variable. In
deep ulcers there is always danger of perforation. The poste-
rior elastic lamina may be ruptured by intraocular pressure ;
or it may be pushed forwards, so as to protrude in the form
of a small transparent bladder. This protrusion may contain
more or less of the pupillary margin of the iris, especially if
rupture takes place; the crystalline lens and its capsule may
also be pushed forwards against the back of the corneal fistula
thus established. Iritis follows, and plastic exudation is thrown
out, by which the iris becomes adherent to the cicatrix in the
cornea (anterior synechia, see Fig. 2, opposite page 142), and
the inflammatory process and exudation may extend to the
capsule of the lens, producing a permanent white opacity
(pyramidal cataract) such as we so frequently see after ulcera-
tion in ophthalmia neonatorum.
When the deep ulceration has been extensive, we may find
forward bulging of part or whole of the altered cornea to a
variable extent (anterior staphyloma, see Fig. 26). When j)er-
foration is large, almost the whole of the iris may be protruded,
and in some severe cases even the crystalline lens, and the
vitreous humor may be pushed forwards and evacuated. In
a few cases of deep ulcer the loss of substance of the cornea is
100
DISEASES OF THE CORNEA,
f Thinning of Cor-
\ neal Tissue
replaced by new transparent tissue. In the majority, however,
the position of the ulcer is marked by a persistent patch of
opacity; the density of this
presents every shade of va-
riety; when very slight, so
as to be perceptible only on
close examination, it is usu-
ally called a nebula; when
distinctly opalescent, a leu-
coma.
If the patch of opacity thus
established happens to be op-
posite the aperture of the pu-
pil, there is necessarily much
interference with vision; if
situated near the periphery,
this is less marked, but in
either case it often happens
that after cicatrization the
cornea is not restored to its
normal thickness, but has a
facetted appearance, or even
a depression corresponding
to the position of the ulcer. This irregularity of surface is in
itself sufficient to cause serious diminution of vision. (See
Irregular Astigmatism.)
c. Serpiginous ulcer generally occurs in elderly or prematurely
old people. They are most common amongst those whose oc-
cupation exposes them to slight wounds of the cornea. A
strongly predisposing and aggravating cause undoubtedly
exists in obstruction of the nasal duct.
This kind of ulcer may commence in any part of the cornea.
It is usually crescentic in form, and presents the appearance of
a deep groove having almost perpendicular walls. The edges
of the ulcer are swollen and infiltrated, they have a grayish
yellow tint and a punched-out appearance. The surrounding
cornea is frequently more or less infiltrated. The part first
attacked may become filled up by new tissue, whilst the ulcera-
tion creeps along the cornea.
Protrusion of the
Posterior Elastic
Lamina
Fig. 26. — Staphyloma of Cornea (after
Stellwag von Carion).
ULCEES OF THE CORNEA. 101
A serpiginous ulcer may be comparatively chronic, but is
generally attended with considerable pain, photophobia, and
lachrymation. Unless its progress can be checked by treat-
ment it usually involves a large extent of the cornea, which,
by thus having its nutrition cut oft*, may partly or entirely
slough. Hypopyon, iritis, and even panophthalmitis may also
be set up by severe ulcer of this kind.
The treatment of ulcers of the cornea. — The chief objects to be
aimed at in treatment are:
1. To soothe local pain.
2. To protect the ulcer from friction against the eyelids, and
from exposure to light.
3. To diminish intraocular tension.
4. To stimulate the ulcer.
5. To produce counter-irritation,
6. To improve the general health.
1. Local pain can be soothed by the use of atropine drops
every few hours (F. 19 and 20). The sedative action of atro-
pine will be increased by hot fomentations and by a compress
of lint dipped into hot water containing some tincture of opium
or morphia; the lint should be covered over with a large pad
of dry cotton-wool so as to keep it warm.
Belladonna fomentations and compresses (F. 23) are also
useful in allaying pain, but the odor is very offensive, and
the skin of the face is stained by them. Subcutaneous injec-
tion of morphia over the temporal region gives temporary
relief.
Where there is acute and prolonged blepharospasm, as not
unfrequently happens in ulcers of the cornea, great relief is
sometimes given by paracentesis of the anterior chamber. It
is also often relieved by treating the skin over the eyebrows
and lower frontal regions by the solid nitrate of silver stick.
The application should be repeated every second day. Both
of these remedies may be combined.
2. Friction of the lids against the ulcer by constant winking
and exposure to light can be diminished by wearing a large
black or green shade over both eyes. In the majority of
ulcers, however, especially when only one eye is affected, it is
102
DISEASES OF THE CORNEA.
better to close the eyelids by means of a light compress of lint.
Iso friction can then take place, and the irritation from the
action of light is more effectually prevented.
3. Diminution of intraocular tension is often indicated. In
deep ulcers, where there is danger of perforation or protrusion
Fig. 27. — Paracentesis of the Anterior Chamber.
of Descemet's membrane, this is very desirable. The intra-
ocular tension may be reduced in several ways.
(i) The nse of esei'ine drops (F. 31) every few hours has the
combined effect of relieving the tension and stimulating
the ulcerated surface. In hypopyon ulcers occurring in old
people, where there is no iritis, this remedy often acts like a
charm.
PARACENTESIS OF ANTERIOR CHAMBER.
103
(ii) Paracentesis of the anterior chamber is very beneficial
when deep or serpiginous ulcer is accompanied by hypopyon.
It facilitates the escape of the pus, reduces the intraocular
tension, and is often followed by marked relief
from the intense pain which is frequently ex-
perienced.
The operation is performed as follows: The
patient being anesthetized in the horizontal
posture, and the eyelids separated by a speculum,
the eye is fixed by means of fixation forceps in
the manner shown in Fig. 27. A triangular
keratome is then introduced at the lower part
of the sclero-corneal junction. Moderately firm
pressure is first made in the direction of the
centre of the globe, that is, at right angles to its
surface. As soon as the point of the instrument
is seen just within the periphery of the anterior
chamber, its direction is immediately changed, so
that the blade passes in a plane parallel to and
just in front of the iris; it is continued in this
direction until the external wound is about 3 mm.
or 4 mm. in length. The keratome is then grad-
ually withdrawn, its blade being kept nearer to
the back of the cornea than before.
In performing this operation attention should
be paid to the following points: (1) If the incision
is made obliquely, and not at right angles to the
surface, there is danger of passing the blade of
the instrument between the lamellse of the cornea
instead of directly into the anterior chamber.
(2) The direction of the instrument must be
changed as soon as the point has entered the
anterior chamber, otherwise there is danger of
wounding the iris and the crystalline lens. (3)
During the withdrawal of the keratome, its blade
should be still more approximated to the cornea,
as, with the escape of the aqueous, the lens and iris frequently
bulge forwards. (4) Should the iris protrude through the
wound it must, if possible, be returned by means of a blunt
Fig. 28.
Blunt Spatula.
104 DISEASES OF THE CORNEA.
spatula (Fig. 28), or, if this cannot be accomplished, the hernia
must be seized with the iris forceps and cut ofl" as in the
operation for iridectomy.
In the serpiginous forms of ulcer, which are generally at-
tended by more or less purulent infiltration, and in localized
abscess of the cornea the method of Saemisch is preferable to
the ordinary paracentesis. Saemisch's operation consists in cut-
ting across the whole width of the ulcer. The patient is anaes-
thetized in the horizontal posture, the eyelids are separated by a
spring speculum, and the globe is held steady. A von Graefe's
linear cataract knife is passed through the non-ulcerated tissue
of the cornea about 1 mm. from the ulcer, it is then passed
across the anterior chamber behind the ulcer, and is brought
out by a counter-puncture in the healthy tissue about 1 mm. on
the opposite side. The blade is now made to cut its way out
through the affected part so as to favor the escape of purulent
matter from between the infiltrated laminae. After the opera-
tion a light compress is applied, and the parts cleansed from
time to time with warm water, or with a h per cent, solution
of salicylic acid. After the lapse of twenty-four hours the
wound must be reopened by means of a blunt probe (Fig. 28),
so as to favor the escape of aqueous humor and the infiltrating
pus. The wound should be reopened in this manner daily
until suppuration appears to be diminishing, when it may be
allowed to heal. This operation is particularly beneficial in
many chronic painful ulcers. It produces two important ef-
fects, viz., the reduction of intraocular tension, and the stimu-
lation of the edges of the ulcer.
Scraping the edges of a chronic ulcer, with or without paracen-
tesis, is now practised with good results. It can be eftiected
by means of a very small lupus scoop.
4. Stimulation of the ulcer is frequently indicated. This is
particularly the case when it has ber-ome indolent and chronic,
and when there is but little congestion of the ciliary region,
although there may be some vascularity of the cornea at the
edge of the ulcer. One of the best stimulants and absorb-
ents for this purpose is the yellow oxide of mercury ; it may
be applied in the form of ointment (F. 24), a few grains
being placed inside the palpebral aperture twice daily. This
TREATMENT OF ULCERS OF THE CORNEA. 105
sometimes causes considerable pain and congestion, in which
case its strength should be diminished by one-half, and it may
be well to combine a little atropine with this. If the irritation
should still continue, or become increased, the ointment must
be left off.
Solid mitigated nitrate of silver (F, 4) or a 2 per cent, solu-
tion of nitrate of silver is a useful application in ulcers of long
standing, especially if thej^ are accompanied by conjunctivitis.
It should be applied once in twenty-four or forty-eight hours,
and its action requires to be watched for fear of aggravating
the disease.
Calomel dusted into the palpebral aperture is often bene-
ficial in these chronic ulcers; this practice, however, some-
times causes intense pain, and I prefer the use of the yellow
oxide of mercury ointment.
Eserine in ^ per cent, solution applied several times daily
is also an excellent stimulant to the ulcerated corneal tissue,
apart from its physiological effect of reducing the tension of
the globe. Even when there are much congestion and severe
pain the use of eserine in conjunction with warm fomentations
has been found beneficial in ulcerative keratitis. The patient
is directed to foment the eye for fifteen or twenty minutes
three or four times a day, or oftener. The fomentation should
be used as hot as can be borne, and may consist of simple hot
water, decoction of poppy-heads, or chamomile. A solution of
eserine i to J per cent, should be dropped into the eye three
or four times a day after the fomentations have been used.
A large pad of cotton-wool thoroughly warmed before a fire,
or by holding it against a can of hot water, should be laid
upon the closed eyelids, and secured by a bandage. This
should be replaced by a freshly warmed one as often as may
be necessary for the patient's comfort.
5. Coiinter-irritalioH is an old and well-known assistant in
the cure of chronic forms of ulcer. If the foreojoino- remedies
have failed to produce the desired effect, they will be more
likely to succeed in conjunction with a seton. This should
consist of a ligature of stout silk passed beneath the skin for
a distance of about 2 cm. It should be introduced just below
the hair at the nape of the neck, or in the temporal region,
106 DISEASES OF THE CORNEA.
and retained for many weeks, if necessary, not being removed
nntil at least two weeks after the cure of the ulcer. A blister
to the temporal region or behind the ears, although useful, is
less effectual than the seton.
G. Improvetnmt of the general health is also a cardinal point
in the treatment of all ulcers of the cornea. The patient
should be placed under the best possible hygienic conditions.
Good food, plentiful exercise in the open air, and the internal
use of tonic medicines, such as iron, quinine, ammonia and
bark, or cod-liver oil, as the nature of the case may indi-
cate.
In the case of ulcer from nerve-lesion, the eye should be
closed by means of a light compress and bandage. A little
atropine should be used daily to prevent iritic adhesions, while
the affection of the nerve is treated by the primary galvanic
current, iodide of potassium, and other remedies.
The use of applications containing the salts of lead is par-
ticularly to be avoided in all corneal ulcerations, inasmuch as
a permanent opacity ma}- be formed from the deposit of an
insoluble carbonate of the metal.
Opacities of the cornea. — These are chiefly due to ulcera-
tion, but may result from other causes, as local or diffuse
keratitis, metallic deposits, burns, etc. "When they are the
result of ulceration or inflammation, much improvement may
be hoped for by the continued use of such remedies as are
prescribed under the respective headings; indeed, no opera-
tive interference is justifiable until the opacity shows no further
signs of absorption.
In cases in which the opacity is slight, but the vision much
impaired, we generally find that the regularity of the curva-
ture of the cornea is interfered with, thus producing irregular
astigmatism.
When the opacity is dense, and situated in front of the
pupillary aperture, but not involving the whole extent of the
cornea, the vision may be very much improved by the formation
of an artificial pupil. For this purpose that part of the cornea
which is clearest and most regular in curvature should be
chosen. In order to ascertain the position best suited for
this operation, the pupil should be dilated with atropine, and
TATTOOING THE CORNEA. 107
the eye examined by the oblique focal illumination (p. 86), and
by the ophthalmoscope. With the former any nebulous
opacities will appear as a grayish haze, and any facets or de-
pressions will be directly seen ; with the latter tilting the mirror
in various directions at 20 to 40 cm. without a lens, the red
fundus-reflex is interfered with by the appearance of dark
patches of the cornea. The methods of operating for artificial
pupil are described under the head of Iridectomy (p. 176).
When the opacity of the cornea is only slight (nebula), it
can still be penetrated by rays of light, but, as these are dis-
torted, and thus interfere with the images formed by rays
passing through the clear portion of the cornea, the optical
effect of an artificial pupil is unsatisfactory. In such cases to
make an artificial pupil alone is useless, but great improve-
ment is often obtained by rendering the nebula completely
opaque by tattooing; then, if the nebula is of large size, an
artificial pupil may still further assist vision.
The probable effect of an artificial pupil may be ascertained
by dilating the pupil with atropine; if the distant vision is
improved by this, an artificial pupil will be still more bene-
ficial; if, on the contrary, the distant vision is confused, the
operation would probably cause confusion also.
When the opacity is not central, the vision may not be
much interfered with, but here the appearance of the eye
might also be improved by tattooing the leucoma.
The operation for tattooing the cornea. — The patient must
be anaesthetized, as the operation is tedious and painful. The
eyelids are separated by a speculum, and the globe held in
position by a fixation forceps. An assistant should hold a
small sponge firmly against the upper and outer side of the
globe to prevent any tears running over the cornea during the
operation. The portion to be tattooed should be well covered
with punctures or scratches, either by using a single needle
or with an instrument such as is shown in Fig. 29; then
Indian-ink in very fine powder or made into a thick paste
should be thoroughly rubbed in with a blunt instrument, such
as a spud or the back of a cataract scoop.
Except in the case of large leucomata, a single sitting will
usually suffice.
108 DISEASES OF THE CORNEA.
It is sometimes advisable to tattoo also the periphery of the
cornea opposite the artificial pupil, so as to prevent the entry
of rays through the part, which otherwise cause some blurring
of the retinal image from spherical aberration.
Owing to the impossibility of rendering an opaque cornea
clear, and the absolute destruction of useful vision which its
presence entails, the attention of ophthalmic surgeons has
naturally turned in the direction of inquiring whether it would
not be possible to transplant a transparent cornea in the place
of the opaque one; so far it must be confessed that experiments
on transplantation of the cornea have not been followed by much
success. The cornea of one rabbit has been transplanted on to
the eye of another both in France and Germany, by Mlinck,
Ktrnigshoffer, Desmarres, and others, but always with the re-
sult that although union might take place between the new
Fig. 29.— Tatooing Needle.
and the old tissues, yet the new cornea became shrunken and
opaque. The cornea of the rabbit and other animals has also
been transplanted to the human eye by Pluvier, Power, and
others with similar results. The partial successes thus obtained
are, however, encouraging; and Professor Wolfe, of Glasgow,
states^ that he successfully transplanted the cornea from a
recently extirpated human eye into the eye of a man of forty,
whose cornea had been rendered quite opaque and useless by
a gunpowder explosion. Good union took place, and on the
fourteenth day after the operation he could see sufficiently
well to point out a ring on the finger. Before dismissal from
the hospital he could "distinguish between half a sovereign
and a shilling." After dismissal he was exposed to severe cold
and privation, and the new cornea became opaque.
From his experience of this and other transplanting opera-
tions on the cornea and conjunctiva, Professor Wolfe expresses
1 Op. cit. p. 97.
TRANSPLANTATION OF THE CORNEA.
109
his conviction that we shall ultimately succeed in replacing an
opaque by a transparent cornea. His conclusions with regard
to this subject are as follows : 1. That the cornea can main-
tain its vitality and transparency when trans-
planted from one place to another, but must
be taken from a freshly enucleated human
eye.
2. All the incisions must be clean, as any
tearing is likely to lead to suppuration ; and
the measurements of the graft must be exact.
3. The operation must be done in such
a manner as not to injure the subjacent
structures. To facilitate this he does not
remove the entire cornea, but takes a hori-
zontal strip from the middle, transplanting
with this a strip of conjunctiva from each
side.
The operation is conducted as follows :
The patient who is to receive the graft
is aneesthetized, and the eyelids separated
by a spring-stop speculum. A band of con-
junctiva of about 5 mm. width is now dis-
sected from the ocular conjunctiva on each
side of the cornea. This done, a shouldered
keratome (Fig. 30) is introduced into the
margin of the cornea just below the horizon-
tal meridian and pushed across the anterior
chamber in a plane anterior and parallel
to the iris. A similar incision is then
made on the opposite side of the cornea,
and the width of the flap to be removed
thus corresponds to that of the keratome
used, which should be from 4 mm. to 5 mm.
at its base.
A probe-pointed linear knife is now passed in at one wound
through the anterior chamber and out at the other, and is then
made to cut its way out, its edge between turned forwards.
Whilst making this section Professor Wolfe supports the
cornea by slight pressure with a flat silver spatula, so as to
Fig. 30.— Shouldered
Keratomes.
110 DISEASES OF THE CORNEA.
prevent tearing of the cornea or displacement of the deeper
structures. The Hap thus formed is now gently seized with
forceps and the lower section made, either with a cataract knife
or prohe-pointed thin scissors. The eyelids are then gently
closed until the graft is ready.
The patient about to lose an eye is at the same time anaes-
thetized, and two flaps of conjunctiva are dissected up as before
and turned over the cornea. The eye is then enucleated in
the usual manner, and a strip of cornea of similar dimensions
is excised in the same way as the last. The strip of clear
cornea with the tvro conjunctival flaps is now placed in its
new position, and is secured by means of sutures placed in the
corners of the flaps of conjunctiva.
Metallic and chalky deposits. — When resulting from the use
of lead lotion in ulcer or abrasion of the cornea, the carbonate
of lead is seen as an opaque, milky-white patch, situated just
beneath the epithelial layer. This and other deposits can be
removed either by scraping or by excision en masse of the super-
ficial part of the cornea in which the foreign substance is
lodged.
Scraping is best performed by means of a small lupus scoop.
The eyelids are separated by a speculum, and the globe held in
a convenient position by fixation forceps. By gentle scraping,
first the epithelium and then the deposit is gradually removed.
After the operation, a few^ drops of olive oil and atropine
are applied, the lids closed, and a light compress of wet lint is
put on.
Excision of the deposit is performed with a Beer's cataract
knife. An incision is made all round the deposit into the
corneal tissue, and the whole superficial part of the cornea
thus marked out is carefully dissected up. The after-treat-
ment is the same as for scraping.
Anterior synechia, or adhesion of the iris to the cornea, is
caused by perforation of the latter, either from disease or in-
jury. The anterior chamber being thus emptied of its aqueous
humor, the iris is pushed forwards so as to come into contact
with the perforation, inflammatory exudation takes place, and
the iris becomes adherent, either to the posterior surface or in
the depths of the cicatrix (see Fig. 2, opposite p. 142).
OPAQUE ANTERIOR STAPHYLOMA. Ill
The symptoms, and the consequences of anterior synechia,
vary in proportion to the extent of the lesion. In sliglit cases,
where there is only an adhesion of a portion of the pupillary
edge of the iris to the posterior surface of the cornea, there
may be but little inconvenience ; the vision, however, is usually
more or less defective, and, the movements of the iris being
limited by the synechia, the patient is always liable to attacks
of iritis, pain, etc.
When the iris is entangled in the cicatrix it shows itself as a
black patch in the cornea; the vision here is always extremely
deficient, and although sometimes there is no great incon-
venience, except that of the loss of vision, yet these cases are
liable to attacks of severe pain in and around the eye, to recur-
rent iritis, and even to panophthalmitis.
When the iris protrudes through a perforation, and becomes
adherent in that position, there is frequently at first a leakage
of the aqueous humor from the exposed surface; as contraction
of the cicatrix goes on, however, this leakage lessens, and the
surface of the iris becomes finally covered with a layer of
lymph; the organization of this lymph so stops the filtration
as to increase the intraocular tension. (See Secondary Glau-
coma.)
Anterior staphyloma signifies a bulging forwards of the whole
or part of the cornea beyond its normal curvature. Of this
there are two distinct classes, viz., the opaque and the trans-
par eiU or conical cornea.
Opaque anterior staphyloma is almost invariably the result of
perforation of the cornea, either from ulceration or from injury.
As soon as perforation takes place, there is immediate escape
of the aqueous humor, and, as we have just seen, the iris comes
forwards in contact with the opening and may protrude through
it; inflammation then takes place from exposure, and the parts
become matted together by exudation, so as to fill up the
orifice. The cicatrix, however, being weaker, is unable to
resist intraocular tension, which is now reestablished by the
closure of the perforation, and bulges forwards; the extent of
this deformity presents every degree of variation, from a small
bladder-like protrusion to that of the whole corneal surface ;
the extent of the projection is sometimes so great as to prevent
112 DISEASES OF THE CORNEA.
complete closure of the lids. The structure of the cornea
becomes much altered, the epithelial layer is thickened, the
substantia propria is thin, oi)aque, and of a gray or yellowish
color; the iris also is much altered, and often becomes atro-
phied. Vision is impaired in proportion to the extent and
position of the corneal surface affected. This condition of
bulging of the cornea and consequent dragging upon the ad-
herent iris is liable to set up serious trouble, not only of these
structures, but also of the neighboring structures in the ciliary
region, which may lead to complete disorganization of the
globe.
Treatment. — Directions have alreadj^ been given under the
head of Ulcers of the Cornea for the prevention of staphy-
loma. When once fully formed, it is far from amenable to
treatment.
In small, partial, and recent cases the compress should be
continued, and the intraocular tension diminished by para-
centesis of the anterior chamber; by repeating this every
second or third day for a few times, the cicatrix often gains
strength and becomes stationary. Should the tension not be
sufficiently diminished by this means, or should it become
increased above the normal, more benefit would be derived by
excising a portion of the iris. (See Iridectomy.) A good large
iridectomy should be performed opposite the clearest portion
of the cornea. This would permanently relieve the tension,
and an artificial pupil would be at the same time established.
When the staphyloma is small and circumscribed, some por-
tion of the cornea remaining sufficiently clear for useful vision,
the projection may with advantage be excised and an artificial
pupil at the same time made by a small iridectomy behind the
clear cornea. The excision may be performed either by seizing
the projection with forceps and cutting it oflJ'with curved scis-
sors, or b}' using the corneal trephine as for conical cornea. This
mode of procedure often results in a sufficiently firm cicatrix.
When the whole cornea has become involved, the eye often
becomes the seat of severe pain, and the increased dragging
of the iris upon the ciliary region causes its disorganization,
the lens becomes opaque and perhaps dislocated. The staphy-
loma may become so large as to be unsightly, and to prevent
ENUCLEATIOM OF THE EYE,
113
proper closure of the eyelids. la this case the removal of the
globe becomes necessary.
Enucleation of the eye. — Operation. The patient to be fully
aneesthetized. The operator to stand behind the patient's
head. The instruments required are speculum, fixation for-
ceps, curved scissors, and strabismus hook (Figs. 31 to 34).
Fig. 31. Fig. 32. Fig. 33. Fig. ,34.
Speculum. Fixation Forceps. Squint Hook. Curved Scissors.
The eyelids to be widely separated by the speculum, and the
globe held steady by seizing the conjunctiva with the forceps
near the margin of the cornea.
The conjunctiva is then divided all round, and close to, the
114 DISEASES OF THE CORNEA.
cornea, leaving only sufficient for the forceps to hold on by;
the capsule of Tenon is at the same time opened by carrying
the deeper blade of the scissors well beneath the conjunctiva
close to the sclerotic.
The strabismus hook is now passed into Tenon's capsule and
glided beneath the tendon of each muscle, which is divided
with the scissors between the hook and the globe. The specu-
lum is now allowed to open more widely by loosening the
screw, and is pressed slightly backwards; the globe then starts
forwards and protrudes through the palpebral aperture. The
scissors are now introduced either at the inner or outer canthus.
having their concavity toward the globe. As they reach the
back of the eye, the blades are opened, and they are pushed in
till they are felt to grip the optic nerve, which is then divided.
One or two more snips are now required to sever the oblique
muscles and any remaining tissues, and the globe is removed.
The speculum should be taken out immediately after the re-
moval of the globe, unless it falls out, as it generally does.
Hemorrhage is easily stopped by firm pressure with small
sponges and cold water. This done, a tight compress of two or
three small sponges covered over by cotton-wool is applied.
This should be retained for at least six hours. It can then be
removed and replaced by water dressing or dry lint.
In excising an eye, care must be taken not to puncture the
globe, as the flaccidity caused by the consequent escape of
vitreous renders the completion of the operation more difficult
than when the globe is intact. The presence of old or recent
inflammatory adhesions often renders excision difficult. In this
case, if it is found that the hook cannot be passed under the
tendons, the adherent tissues must be carefull}' dissected away
from the globe with the scissors alone. When an eve is exces-
sively large and elongated, as happens in some cases of buph-
thalmos and myopia, it is very difficult to divide the optic
nerve without cutting the sclerotic at the posterior pole of the
eye. Should this accident occur, and the back of the globe be
left in the orbit, it can afterwards be removed.
Some surgeons prefer to bring the edges of the conjunctiva
together by fine silk sutures after excision.
ARTIFICIAL EYES. 115
Another method of excision, which is quicker, but does not
leave quite as good a stump, is to divide either the internal or
external rectus first, then to pass the scissors to the back of the
globe and sever the nerve, and finally to complete the operation
by dividing the conjunctiva and the remaining muscles by
sweeping the scissors round with one blade beneath the muscles
and the other above the conjunctiva.
Artificial eyes are made of glass, and are kept in great
variety as to size and color by the best opticians. When the
cicatrix of the conjunctiva and other tissues of the orbit is
firm, and quite free from ulceration or discharge, it is ready to
receive the artificial eye ; this condition is usually established
in from four to eight weeks. The eye should not be worn
continuously. For the first few weeks it may be worn a few
hours daily ; after that, if no irritation is experienced, it can be
worn all day, but never during the night. The artificial eyes
in ordinary use require to be renewed about every six months,
as they are apt to become rough, and therefore irritating to the
conjunctiva.
Quite recently celluloid has been used as a substitute for
glass in the manufacture of artificial eyes.^ The eyes made of
this substance are unbreakable, and are lighter than the glass
eyes. The edges can be cut with an ordinary penknife to
adapt the eye to any peculiarity^ of the stump. In appearance
they exactly resemble those made of glass, and they are said
to be more durable.
The insertion of an artificial eye is very easy, and is soon
learned by the patient. It must first be steadily pushed be-
neath the upper lid, and held there whilst the lower lid is
brought round its lower edge.
Its removal is still more simple. The lower lid is depressed
so as to expose the lower edge of the eye, and beneath this a
probe is placed, by which the eye is brought forwards. It
then slips out by its own weight, and should be caught in a
handkerchief held for its reception.
Conical cornea, or Transparent anterior staphyloma, consists
in a bulging forwards of the central part of the cornea beyond
^ These eyes are manufactured by Schutze & Co., 14 South Street, Finsburj^,
London.
116 DISEASES OF THE CORNEA.
its normal curvature, so that it assumes the form of an obtuse
transparent cone.
Unless a careful examination is made as to the state of re-
fraction of the eye, the early stage of this disease may be mis-
taken for ordinary myopia or regular myopic astigmatism. By
the ophthalraometre of Javal and Schiotz, the reflected images
are of various sizes and cannot be brought into parallel lines ;
this shows an irregular astigmatism of the cornea.
By retinoscopy we iind the shadow to be quite different in
appearance and movement from those of myopia and hyper-
raetropia. There is a bright central reflex surrounded by a
crescentic shadow which moves around the centre, but never
crosses it as the mirror is rotated.
By the ophthalmoscope the vessels of the optic disk and the
optic disk itself appear to be distorted, and to alter in shape
and size with each movement of the observer's head, just as
occurs in looking at an object through a pane of bad glass.
The first symptom of the disease is that of diminished vision,
first for distant and then for near and small objects. The dis-
ease usually comes on gradually, and without pain or inflam-
mation. As it progresses, the cornea becomes perceptibly
conical in appearance, and the vision sometimes so defective
that the patient can only read large type (Snellen, 6, 9, or 12).
Often, however, with very great conicity the near vision re-
mains good, but the object has to be brought extremely close
to the eye. Such cases difler from simple myopia, however,
in the fact that no lens improves the distant vision. In ad-
vanced cases, the top of the cone sometimes becomes opaque,
but there is seldom perforation of the cornea, unless the case
is complicated by injury.
The disease generally comes on at the age of fifteen to
twenty years, sometimes later ; it usually undergoes a steady
progress for two or three years, and then remains stationary.
It appears to be more common in young women than in men,
and to occur more frequently in England than in other parts
of the world.
The pathology of conical cornea is still obscure. The cornea,
especiall}' at its central part, is always thinned; it may
be that this thinning of the corneal tissue is the essential
CONICAL COKNEA. 117
feature of the affection, causing the weakened cornea to yield
to the normal intraocular tension. On the other hand, it is
possible, as was supposed by von Graefe, that the affection
commences with increased intraocular tension, and that the
thinning and bulging of the cornea are secondary to this.
Against this theory, however, are the facts that no history of the
symptoms which generally accompany increased tension can
usually be obtahied, and that the rare cases of glaucoma in
subjects of this age do not follow this course.
Treatment. — The treatment of this very serious affection has
received much attention during the last half century. Bowman,
Critchett, von Graefe, Donders, de Wecker, and many others,
have spared no pains in their endeavors to prevent its progress
and to remedy its bad results,
Bonders found that near vision could be improved by placing
a stenopaic disk in front of the affected eye ; but the smallness
of the circle which he found it necessary to use for this purpose
was too limited to be useful for distant vision, the visual field
being so contracted that the patient could only see objects
wdiich were situated immediately in front of the eye. These
stenopaic spectacles are therefore only useful for near work,
such as reading, needlework, and the like. They are of but
little use during the progressive stage of the disease, as, owing
to the increasing myopia, they would require to be changed
too frequently before the eye had reached a stationary con-
dition. In exceptional cases, a strong concave glass (15 D. to
20 D.) without the stenopaic circle or slit is beneficial.
The advantage obtained by the stenopaic slit induced Mr.
Bowman to try to diminish the aperture of the pupil by lateral
deviation and elongation. This he succeeded in doing by the
operation of iridodesis, and the method was attended with con-
siderable improvement as to vision, and was at one time
much practised. The delicacy of the operation, however, re-
quires great skill in its performance, and the act of incar-
cerating the iris in a corneal cicatrix is one which is rather to
be avoided, owing to the troubles which may be thereby set
up, not only in the wounded eye, but in that of the opposite
side. (See Sympathetic Ophthalmitis.)
Von Graefe first suggested imitating the contraction of
118 DISEASES OF THE CORNEA.
tissue, which occurs iu the healiug of perforating ulcers, by
the production of an ulcer artificially. To eftect this he re-
moved the apex of the cone ; the part excised was about 2 mru.
or 3 mm. in diameter, and involved about two-thirds of the
thickness of the cornea. For some ten to fifteen days after
this excision he applied the crayon of nitrate of silver to the
exposed surface, and finall}- allowed the surface to heal; the
result was that the curvature of the cornea became reduced
and the vision considerably improved. It must be admitted
that the operation of removing so thin a portion from the apex
of the cone is not easy to perform. The cornea is ver}' thin,
and perforation is most likely to be the result of such an
attempt. The application of nitrate of silver for so many con-
secutive days is again very painful. The operation is also
certain to produce a dense opacity of the central parts of the
cornea, and is pretty sure to necessitate the formation of an
artificial pupil.
Bowman, acting on the same principle as that of von Graefe,
determined to remove a circular piece from the apex of the
cone, involving its whole thickness. He did not apply caustic
to the wound, but allowed it to cicatrize.
The operation is performed with a small trephine (Fig. 35),
oooo
Fig. 35. — Corneal Trephine.
Avhich consists of a simple tube having one extremity ground
down to a tine cutting edge at the expense of its outer surface,
so that it tapers slightly ; within the tube, and fitting it accu-
rately, is a piston, by means of which the depth to which the
instrument is allowed to cut can be regulated. The upper end
of the piston projects, and is marked by a small scale showing
the distance of the other end of the piston from the cutting
edge. The whole instrument is about 5 cm. long, and in use
is rotated by the finger and thumb. It is well to be provided
with three sizes, having a diameter of 1 mm., 2 mm., and
3 mm. respectively.
CONICAL CORNEA. 119
Before using the instrument the piston is set to correspond
with the supposed thickness of the cornea; it is then placed
on the apex of the cone and rotated rapidly backwards and
forwards. Every few seconds it is removed to see whether the
cornea has been penetrated, "When this has been done, the
aqueous does not escape as long as the trephine is in position,
because its conical extremity prevents leaking by the side of
the cutting edge, while the calibre of the tube is closed by the
piston. When the whole thickness of the cornea has been
penetrated, the small piece may come away with the instru-
ment; usually, however, owing to the unequal thinning of the
membrane, it is held in situ by a few undivided portions and
corneal tissue; perforation is then only known to have taken
place by the fact that the aqueous escapes when the trephine is
removed. The little scale can now be easily removed with
forceps and fine scissors. The portion excised should corre-
spond to the apex of the cone.
After the cicatrix has formed, an artificial pupil is made
opposite that part of the cornea which is thought to be most
desirable.
Abadie states that he has been successful in combining the
operation of iridotomy with that of trephining. He first excises
the circular piece of cornea as recommended by Bowman, and
then introduces the blades of the iridotomy scissors through
the opening thus made, and divides the iris vertically down-
wards.^ This method of Bowman, with or without modifica-
tions as to the shape of the trephine, has been extensively
practised, and is often attended with excellent results in the
improvement of vision.
During the after-treatment the eyelids should be kept con-
stantly closed for a week; and as it is desirable to obtain dila-
tation of the pupil as soon as possible, atropine ointment (F.
34) should be applied to the outside of the closed lids.
Excision of an oval piece of the cornea (Bader) is an operative
procedure which is now frequently adopted. Similar in prin-
ciple to the preceding, it is followed by equally good results,
and takes less time in healing.
1 Maladies des Yeiix, par Ch. Abadie. Paris, 1876.
120 DISEASES OF THE CORNEA.
Operation. — A von Graefe's linear knife is made to transfix
the apex of the cone, so that the point just passes through the
forepart of the anterior chamber; the distance between the
puncture and the counter-puncture should not exceed 3 mm.
Having transfixed in this way, the knife must be made to cut
its way out in a direction upwards and forwards, the eye being
held steady with the fixation forceps. The lower tiap of the
wound is now seized with forceps, and an oval portion is cut
from it with scissors; the widest part of this portion should
not exceed 1 mm. The eyelids are then closed, and the case
is afterwards treated as for trephining. I have seen very good
results from this method of operating, both in my own practice
and in that of others.
In the early stages of conical cornea, before operation has
been decided upon, or when the patient will not submit to
operation, the general health should be supported by tonic
regimen. The application of a compress of lint to the closed
eyelids daily, taking each eye on alternate days has also been
advised. The use of J or 1 per cent, solution of eserine dropped
into the eyes three times daily, with the hope of diminishing
intraocular tension, may also be tried. Paracentesis of the
anterior chamber at intervals may also be of benefit.
Burns, wounds, and other injuries of the cornea are of fre-
quent occurrence.
Burns are produced by quicklime, mineral acids, caustics,
boiling water, strong ammonia, fusing metals, gunpowder, and
the like. The action of quicklime upon the cornea is very
destructive, more so than the appearance of the cornea imme-
diately after the accident would lead us to imagine. When
only the superficial portion of the corneal tissue is cloudy, the
deeper parts remaining transparent, we may hope for some
preservation of vision, but when there is a diffused and deep
gray appearance, the prognosis is very unfavorable.
Treatment must be immediate. Both the eyelids should be
everted and thoroughh' cleansed with tepid water and cotton-
wool, and all particles of lime having been removed from the
conjunctival sac, a drop of h per cent, solution of atropine
should be placed in the eye, and a light compress applied.
Should the conjunctiva and neighboring parts become much
WOUNDS OF THE CORNEA. 121
inflamed, soothing lotions and atropine drops must be em-
ployed. The eyelids must be opened daily, and precautions
taken to prevent adhesions between the globe and the lids.
(See Symblepharon.)
Wounds of the cornea are of frequent occurrence. They may
be superficial or penetrating.
Superficial wounds may consist of a simple abrasion, or a
scratch, with or without contusion. These injuries usually
heal without trouble; they simply require that the eye should
be thoroughly cleansed, that a few drops of J per cent, solu-
tion of atropine and a light compress should be applied. A
nebula or leucoma may remain at the seat of injury, and the
patient should be prepared for this defect, which may interfere
with the vision of that eye. When there is any persisting
purulent affection of the injured eye, such as dacryo-cystitis, or
granular conjunctivitis, the cornea is less able to recover from
the traumatism. The wound may become inflamed, and sup-
puration with hypopyon supervene.
Penetrating wounds of the cornea are of great importance,
on account of the grave complications which sometimes attend
them. In all cases there is immediate escape of the aqueous
humor through the wound, and, the anterior chamber being
thus emptied, the iris is approximated, if not brought into
actual contact with the posterior surface of the cornea. Some-
times it protrudes through the wound.
Treatment. — If the wound is near the periphery of the cornea,
eserine (J per cent, solution) should be dropped into the palpe-
bral aperture so as to contract the pupil, and so draw the iris
from the wound. If the wound is at or near the centre, then
for similar reasons the use of a solution of atropine (1 per cent.)
is indicated. The eye should be at once closed by a light com-
press of lint, which can be kept moist with cold water.
When the iris is entangled or protruding from the wound, the
case is more serious. If seen within a few hours after the
accident an attempt should be made to return it. Bearing in
mind that the anterior chamber is now quite shallow, Ave must
be careful not to wound the crystalline lens, which is immedi-
ately behind the iris. For reducing the hernia of the iris a
blunt-ended caoutchouc spatula (Fig. 28) may be used, com-
122 DISEASES OF THE CORNEA.
bined at the same time witli the local use of atropine or eserine,
according as the wound is central or peripheral.
It is sometimes found impossible to effect a return of the
iris in this manner; in which case the protruding portion
should be seized with forceps and snipped off with scissors on
a level with the surface, and the edges of the prolapsed portion
reduced if possible; atropine or eserine should be instilled
and a light compress applied.
If the case is not seen till two or three days after the acci-
dent, no attempt should be made to return the iris, as it will
by that time have become inflamed, swollen, and perhaps
adherent; the projecting portion must be excised with scissors
in the manner just indicated.
When the crystalline lens is wounded it is liable to become
greatly swollen, and to set up glaucomatous tension and inflam-
matory trouble.
The cause of injury should always be carefully ascertained,
in order to be sure that no foreign body has entered the eye-
ball.
Foreign bodies in the cornea are of frequent occurrence, and
of great variety. Those most commonly met with are small
bits of metal, coal-dust, and sand.
The presence of a foreign body in the corneal tissue is
marked by immediate pain, photophobia, and lachrymation;
the pain is most intense when the substance is so situated as
to be rubbed against and pressed upon by the eyelid. If not
quickly removed, local keratitis is set up. The presence of a
foreign body is sometimes difficult to recognize, especiall}^
when it is very small, but by careful examination with oblique
focal illumination (p. 86) it can always be detected.
Immediate removal is in all cases imperative. The difficulty
of this will depend upon the depth to which the particle has
become embedded in the tissue. For ordinary cases in which
it is situated on a level with the surf\\ce the surgeon stands
behind the i)atient, who is seated in a good light, with his
head thrown back and protected by a towel, so that it can
be steadied against the surgeon's chest; the eyelids are now
separated by the fingers of the left hand and the globe held
in position by firm pressure of the same fingers against the
TUMORS OF THE CORNEA. 123
ocular conjunctiva. The patient is directed to look in such
a direction as may bring the foreign body most clearly into
view, and to fix his vision in that direction as much as possible.
A small spud, Fig. 36, is now used; this should be passed fairly
beneath the embedded particle, which can then be elevated
and removed.
Fig. 36.— Corneal Spud.
When the foreign body is deeply embedded in the cornea,
so that it touches or even perforates Descemet's membrane, it
may be impossible to remove it by the above method ; in this
case the patient should be anaesthetized, and a broad needle
passed through the cornea into the anterior chamber, in such a
way that the flat portion of the needle can be passed behind
the part where the foreign body is embedded. A little pressure
is here made, and the point of a Beer's cataract knife or a
keratome can now be used to cut down to the particle, and
remove it without fear of its falling into the anterior chamber.
This done, the broad needle is withdrawn. A drop of atropine
solution is used, and the eye closed by a light compress for a
few days.
When a foreign body is allowed to remain in the cornea it
establishes local keratitis, which may be very severe and extend
to the whole cornea; the surrounding tissue becomes hazy
and rather swollen, and the particle sooner or later becomes
loose and detached. The resulting opacity in this case is
much greater than it would have been had the particle been
removed at once ; and in the case of some metals there is often
a considerable stain left from deposit of the oxide.
Tumors of the cornea are very rare. They occasionally occur
primarily in this tissue, but usually extend from similar
growths either of the ocular conjunctiva or of the interior of
the eye. The chief tumors are epithelioma, sarcoma, fibroma,
and dermoid cyst.
Epithelioma of the cornea usually invades this structure by
extension from the ocular conjunctiva; it sometimes, however,
appears as a small whitish or yellowish-white nodule at the
124 DISEASES OF THE CORNEA.
sclerocorneal junction. At first it causes but slight pain or
inconvenience, and may be mistaken for a phlyctenule ; sooner
or later it spreads and becomes painful ; the surface may soften
and break down.
Figs. 1 and 2 (opposite p. 26) represent a section of epithe-
lioma in this region. Tliey present the typical appearance of
epithelioma, viz., excessive ingrowths of epithelial tissue, in the
depths of which the colls arrange themselves in concentric
circles, thus assuming a " nest-like " form.
Treatment. — Complete removal of the diseased tissue is the
only way of preventing the spread of this new growth. This
may be attempted by scraping with the lupus scoop, or by
excising with a knife. As a rule the disease returns and
spreads to the surrounding tissues. Under such circumstances
the eye had better be enucleated, and any surrounding tissues
that may be affected should at the same time be cut away.
Sarcoma of the cornea more commonlj^ occurs by extension
from neighboring tissues. It varies in its rate of progress,
but as a rule is rapidly destructive. Figs. 1 and 2 represent
sections of this tumor. In Fig. 1 it will be observed that the
epithelial or conjunctival layer is left intact, while the new
growth has attacked only the tissue beneath this.
Treatment consists in early excision of the eye and all sur-
rounding tissues which may be implicated.
Conju/iei ival Toyeu
Fig. 2. — Cells fmm tumor. Fig. 5. — Laminated structure of the lens.
yjyr:\ ^ — f.'hmi'- oapillaris.
^ Via7n.\a-scie.?ojia.
^^^—Salcrotiea.-
Fig. 4. — Dragrammatic section of choroid. X about 150 diaiu.
■R/t'Tia^.
Choroid.
J 1 J i s 7 ■!.; ° , > Pt -'Mer\ c slicaih
fi^i I (5/11^511 .'.11 1 M!i
[ ■ r j ;
Fig. 3. — Sarcoma of choroid. X about 40 diam. To face p. 124.
CHAPTER V.
DISEASES OF THE SCLEEOTIC.
ANATOMY — SCLERITIS EPISCLERITIS — CONXrSIONS RUPTURE — WOUNDS.
Anatomy and Physiology. — The sclerotic is a strong, opaque,
librous structure continuous with the cornea, from which it ex-
tends backwards so as to complete the external coat of the eye.
Its outer surface is white and smooth; its inner surface is of a
light brown color. It is thickest at the back part of the eye,
and thinnest about 6 mm. from the cornea; at the point of
union with the latter it again becomes thicker. Posteriorly it
is pierced by the optic nerve at a point about 2.5 mm, internal
to the anterior posterior axis of the globe.
At the opening through which the optic nerve passes, the
sclerotic is not altogether absent, for it sends across fine trabe-
culge, which form a sieve-like membrane through which the
nerve-fibres pass. This, which is called the lamina cribrosa, is
composed of bundles of white fibrous tissue, amongst which
are found numerous fibres of elastic tissue, abundant connec-
tive-tissue corpuscles, and some pigment-cells.
The texture of the sclerotic is permeated by a network of
capillaries having very wide meshes; toward the periphery of
the cornea this network becomes much increased, forming a
vascular ring, the ciliary or eircumcorneal zone, from which loops
are supplied to the cornea.
The canal of Schlemm (see Fig. 1, opposite p. 84, also Fig.
37) is a small, flattened, somewhat oval space, situated in the
anterior part of the sclerotic, close to its junction with the
cornea. It communicates with the anterior chamber by fine
clefts between the fibres of the ligamentum pectinatum. The
precise manner in which it communicates with the veins in its
126 DISEASES OF THE SCLEROTIC.
immediate vicinity is still disputed. lu all probability certain
valvular arrangements exist which, under ordinary conditions
of intraocular pressure, allow the contents of the canal to pass
outwards, either directly into the veins or into lymphatic
spaces surrounding the latter.
The ligamentum pectinatum is situated just inside the sclero-
corneal junction (Fig. 37). It is intimately attached to this
part, and thence extends to the iris, the ciliary processes, and
the ciliary muscle. Its trabecuhe and lamellae are composed
of elastic fibres, which are derived from the splitting up of the
membrane of Descemet. The endothelium from the posterior
surface of Descemet's membrane is continued over these fibres,
and on to the anterior surface of the iris.
Between the sclerotic and the anterior part of the ocular
conjunctiva is found some loose connective tissue; this, which
varies in amount in different individuals, is called episcleral
tissue.
Covering the sclerotic is the capsule of Tenon. This is a
fibrous capsule, which envelops the sclerotic and sends off
processes in various directions. Anteriorly it extends to
within about 3 mm. of the cornea, and blends with the scle-
rotic and conjunctiva. Another portion passes in a radial
direction behind the conjunctiva and the palpebral ligament,
to become united with the periosteum; other reflections take
place along the ocular muscles in the form of sheaths; poste-
riori}' the capsule is continued along the optic nerve as far
as the optic foramen. This capsule is lined by flattened
epithelioid cells, similar to those of serous membrane. It
forms a socket in which the globe can rotate in any direction.
Its cavity communicates with the lamina suprachoroidea by
means of the perivascular lymph-spaces surrounding the venae
vorticosa^.
Sclerotitis or Scleritis is characterized by general injection
of the superficial vessels, which produces a faint pinkish tint.
The ocular conjunctiva may be at the same time aftected, but
the color of this is of a deeper red, and its vessels can be
made to move with the membrane, and can be emptied by
slight digital pressure, whilst the pink hue of the scleral
injection still shows through. As the inflammation increases,
EPISCLERITIS. 127
the sclerotic becomes of a deeper color, and assumes a bluish
tint. Scleritis is occasionally met with in rheumatic and gouty
subjects.
Episcleritis is an inflamed condition of the episcleral tissue,
which may exist with or without sclerotitis. It consists of a
dusk^'-red nodular swelling beneath the ocular conjunctiva.
It usually occurs in single patches, measuring from 4 mm. to
6 mm. in diameter, liut two or more lumps may form in the
same eye. It is slow in progress, often lasting many months.
It is usually unattended by pain; occasionally, however, this
is considerable, and is then accompanied by photophobia and
lachrymation. Vision is not often interfered with, but in some
cases the part of the cornea which is nearest the patch of
episcleritis becomes hazy, and in others the sclerotic and the
choroid are aflfected ; under these circumstances the vision will
be defective in proportion to the severity of the complication.
Generally the patch disappears, leaving no perceptible lesion.
In prolonged cases, however, it not unfrequently causes some
thinning of the sclerotic, which, in slight degrees, is indicated
by a dark, bluish appearance, and in more extreme cases so
weakens the tissue of the sclerotic that it yields to the intra-
ocular pressure and becomes staphylomatous. Episcleritis is
somewhat rare ; it appears to be most common in adult females,
and to be in some way associated with uterine disorders. It
also occurs by preference in those who suffer from rheumatism,
and in persons affected with syphilis. A slight injury is not
unfrequently its exciting cause.
Treatment. — The eyes should be protected from light by a
shade, or by blue-tinted spectacles. Atropine drops (strength
^ or 1 per cent.) should be used several times daily. Caustics
and irritating astringents should be strictly avoided. When
there is much pain, a few leeches applied to the temporal
region may be of service.
In prescribing internal remedies, the probable cause of the
aftection must, as fiir as possible, be treated.
Contusions of the sclerotic are only of importance in propor-
tion as they affect other structures.
Eupture of the sclerotic occasionally results from a severe
blow upon the eye, and the violence of the injury is generally
128 DISEASES OF THE SCLEROTIC.
sufficient to produce other lesions at the same time. The most
common situation of the rupture is from 2 mm. to 4 mm. from
the corneal margin, and therefore in the ciliary region ; the
rent is usually somewhat irregular, but its general direction is
often that of a curve concentric with the margin of the cornea.
It frequently happens that the contents of the globe are at the
same time evacuated or so displaced as to cause intiammatory
and other troubles. Thus the lens may be dislocated, and
may make its escape through the wound ; the iris may be
partially or entirely detached and protruding, and the vitreous
may have partly escaped. There is usually copious hemor-
rhage into the globe, and as this, for the most part, comes
from the choroid, it generally indicates that the retina is ex-
tensively detached.
Treatment must depend upon the seat and extent of the
rupture and the state of the contents of the globe. If the
rupture is situated in the ciliary region the risks of sympa-
thetic inflammation attacking the other eye have to be con-
sidered, as well as the extent of the injury, and in such a case
immediate enucleation is the safest course to adopt. If, how-
ever, the ciliar}' region is only slightly encroached upon, and
the conjunctiva is entire, the choice between enucleation and
saving the eye will depend upon the presence and extent of
other lesions.
When the eye is soft and evidently disorganized, its removal
should be effected without loss of time.
When there is hemorrhage into the globe, and the tension is not di-
minished, it is often difficult to say to what extent the eye is
damaged internally. In this case it is best to apply an ice
compress to the closed eyelids, and to wait for some days
until the blood may be absorbed; the vision can then be
tested, and a diagnosis established by the aid of the ophthal-
moscope.
Slight ruptures, which may be unaccompanied by total loss
of vision, should be placed under the expectant plan of treat-
ment, including the use of iced compresses, and rest of both
eyes.
Superficial wounds are of but slight importance, and usually
heal without trouble.
WOUNDS OF THE SCLEROTIC. 129
Penetrating wounds are always serious, but their gravity
varies with the extent and the nature of the wound, the
physiological importance of the parts wounded, and with the
presence or absence of any foreign body within the globe.
Incised wounds, posterior to the ciliary region, even though
there be some escape of vitreous, are not necessarily attended
by bad results. Incised wounds in the ciliary region are also
usually unattended by bad results, so long as the parts beneath
are not wounded or involved in the resulting cicatrix. The
cases which are especially dangerous are those in which the
ciliary body, the iris, or the lens, is wounded. When the iris
or ciliary body is injured and incarcerated in the cicatrix of the
wound, there is especial danger of local inflammation and of
sympathetic ophthalmitis. In such a case if the vision is lost
or reduced to mere perception of light, and especially if the
eye is soft, the globe should be immediately excised; but if it
is still found to retain useful vision it need not be sacrificed.
An attempt should be made to return the protruding iris or
ciliary body by means of a spatula (Fig. 28). This failing,
the protrusion should be seized with iris forceps and excised
as in iridectomy. Both the eyes should then be shaded from
the light, and a strict watch kept against sympathetic trouble
in the other eye.
The question of saving or enucleating the eye will hinge
upon the position and nature of the wound and the probability
of a foreign body being present. The desirability of removing
the lens will be more conveniently considered in the chapter
devoted to the subject of Cataract.
CHAPTER VI.
DISEASES OF THE IKIS, THE CILIARY BODY, AND THE
CHOROID.
ANATOMY AND PHYSIOLOGY — IRITIS — IRIDO-CYCLITIS CYCLITIS — IRIDO-CHO-
ROIDITIS SYMPATHETIC IRRITATION SYMPATHETIC OPHTHALMITIS —
INJURIES — TUMORS — CONGENITAL DEFORMITIES — OPERATIONS — IRIDEC-
TOMY — IRIDODESIS — CORELYSIS IRIDOTOMY.
The Tunica Vasculosa or Uveal Tract.
Anatomy and Physiology. — This, the second tunic of the eye,
is found immediately beneath the sclerotic. It consists of
three parts, which, from before backwards, are respectively
called the iris, the ciliary body, and the choroid.
The Iris is the anterior part of the tunica vasculosa, which
is suspended in front of the crystalline lens. It is the beauti-
fully colored and contractile membrane which is seen through
the transparent cornea. By its circumference it is attached to
the ligamentum pectinatum and to the ciliary body. At its
centre is the aperture of the pupil. Its anterior surface is
free, whilst the posterior surface rests by its pupillary edge
against the capsule of the crystalline lens.
On section of the iris we find from before backwards the
following structures:
1. The epithelioid membrane, which is continuous with, and
similar to, that on the back of Descemet's membrane.
2, The substantia propria, which consists of a stroma of
connective-tissue fibre, and of flattened branching connective-
tissue cells, many of which, in dark eyes, contain pigment
granules. Within this stroma are found muscular fibres, blood-
vessels, lymphatic tissue, and nerves. The muscular fibres are
of the unstriped variety, and consist of a flattened ring around
the edge of the pupil nearer to the posterior than to the
anterior surface (the sphincter pupillce), and of some deeper
THE IRIS. 131
fibres which extend in a radial direction from the centre to the
circumference (the dilatator pupillce). The arteries are derived
from the circulus iridis major and from the ciliary processes.
They proceed in the middle of the stroma toward the pupil-
lary edge, and there form a free anastomosis, the circulus
iridis minor; they give off capillary networks in front and
behind. The middle and outer coats of the arteries are thick.
The veins accompany the arteries. There are no distinct lym-
phatic vessels in the iris, but the sheaths of the bloodvessels
contain lymphatic sinuses, as also do the trabeculfe of the
stroma, which open into the spaces between the fibres of the
ligamentum pectinatum. The nerves of the iris follow the
same course as the vessels ; they are very numerous, and are
derived from the short ciliary nerves coming from the ophthal-
mic ganglion which is connected by its roots with the third
nerve, the cervical sympathetic, and with the nasal branch of
the ophthalmic division of the fifth nerve. The short ciliary
nerves are, moreover, accompanied by the long ciliary nerves
coming: from the same nasal branch of the fifth nerve. Enterino;
the peripheral portion of the iris, they form a plexus from
which branches are given off as follows: (a) non-medullated
fibres terminating as a delicate network on the dilatator ; (6)
medullated nerves passing eventually into fine non-medullated
fibrils arranged as a network close to the anterior surface; and
(c) a network of non-medullated fibres belonging to the sphinc-
ter pupillee. According to A. Meyer, there are in addition fine
non-medullated nerve-fibrils, which accompany the capillaries ;
and Faber considers that there are ganglion cells contained in
the nerve networks of the iris. (Klein and Koble Smith.)
3. A hyaline thin membrane (membrana pigmenti) which is
continuous with the lamina vitrea of the ciliary body.
4. The uvea, consisting of one or two layers of polyhedral
cells, each containing an oval nucleus, and a number of dark
brown pigment granules. In blue eyes this is the only part of
the iris containing pigment. In the eyes of albinos the pig-
ment is absent even here. This layer is continuous with that
of the ciliary body.
The iris in health presents a brilliant appearance ; its color
in dark eyes is due to the presence of pigment granules in
132 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
Fig. 37. — Sectiun of the ( iiu.ry Region (after Waldeyer).
a, cavernous tissue of the ligamentum pectinatum ; h, prolongation of the iris : o, canal
of Schlemm; dd, bloodvessels; ee, spaoes of Fontana; /, Descemet's membrane;
/, iris; 3/, ciliary muscle ; (7r, cornea; 5c, sclerotic ; f;^:, epithelium.
MOVEMENTS OF THE PUPIL. 133
the cells of the substantia propria; in blue eyes, the color is
not due to the pigment of the uvea, but to " interference "
phenomena. The eyes of newly born children, even among
the dark races, are always blue, the pigmentation taking place
after birth.
The iris with its central aperture, the pupil, serves as a
diaphragm to shut off marginal rays, it also regulates the
amount of light entering the eye, and it acts as an auxiliary
to accommodation. The size of the pupil depends upon the
state of contraction of the two antagonistic sets of muscular
fibres, the sphincter and the dilatator pupillse.
In testing the mobility of the pupil, the patient should be
placed in front of a bright light, the other eye being first
closed and shielded ; the hand is then placed in front of the
eye under examination, and after being held there for a few^
seconds, is suddenly withdrawn. In the normal eye the pupil
slowly dilates while the eye is shaded, and wdien the hand is
withdrawn there is a quick contraction, followed by a very
slight dilatation.
The nervous mechanism of the pupil is of a peculiar and
complex nature. Contraction of the pupil occurs : (1) When the
retina is stimulated, as when light falls upon the retina, the
brighter the light the greater the contraction. (2) When the
optic nerve is stimulated by other agents, as electricity. (3)
When the eyes are accommodated for near vision. (4) In the
early stages of poisoning by chloroform, alcohol, etc.; and in
nearly all stages of poisoning by morphia, eserine, and some
other drugs. (5) In deep sleep. (6) After the local applica-
tion of eserine and other myotics. Dilatation of the pupil occurs :
(1) When the stimulus of light is withdrawn from the retina,
as by passing from a bright into a dim light. (2) When the
eye is adjusted for distant vision. (3) During d\'spncea, during
powerful irritation of the sensory nerves, during violent mus-
cular efforts, in the later stages of poisoning bj' chloroform,
and in all stages of poisoning by atropine and other drugs.
(4) After the local action of atropine and other mydriatics.
" The pupil may be considered to be under the dominion of
two antagonistic mechanisms: one a contracting mechanism,
reflex in nature, the third nerve serving as the efferent, and
134 DISEASES OF IKIS, CILIARY BODY, AND CHOROID.
the optic as the aflerent tract; the other a dilating mechanism,
apparently tonic in nature, but subject to augmentation from
various causes, and of this the cervical sympathetic is the
efferent channel. Hence, when the optic or third nerve is
divided, not only does contraction of the pupil cease to be
manifest, but active dilatation occurs, on account of the tonic
dilating influence of the sympathetic being left free to work.
When, on the other hand, the sympathetic is divided, this
tonic influence falls away, and contraction results. When the
optic or third nerve is stimulated, the dilating effect of the
sympathetic is overcome, and contraction results; and when
the sympathetic is stimulated, any contracting influence of the
third nerve which may be present is overcome, and dilatation
ensues" (M. Foster).
Further considerations, however, show that the matter is
still more complex than this. When eserine is applied to the
eye, contraction of the pupil is caused whether the third nerve
has been divided or not, and with a strong dose the contrac-
tion is so great that it cannot be overcome by stimulation of
the sympathetic. From these and other facts it is evident that
this myotic acts either directly upon the plain muscular fibres
of the iris, or upon some local mechanism which is supposed
to exist either in the iris itself or in the choroid, where, indeed,
sransrlionic cells are abundant.
With regard to the contraction of the pupils which takes
place when the eyes are accommodated for near vision, and
turned inwards (the two actions being closely allied, since the
eyes converge to see near objects), and the return to the more
dilated condition when the eyes return to rest and regain the
accommodation for distant objects; these actions are explained
by what are called "associated movements." Two movements
are said to be "associated" when the special central nervous
mechanism employed in carrying out the one act is so con-
nected with that employed in carrying out the other, that when
we set the one mechanism in action we unintentionally set the
other in action also.
The Ciliary Body is that part of the tunica vasculosa which
extends backwards from the base of the iris to the anterior part
of the choroid (see Fig. 37). It consists of the ciliary processes
THE CILIARY BODY. 135
and the ciliary muscle. The ciliary processes are composed of
a connective-tissue stroma, similar to that of the iris, and con-
tinuous with it; the stroma is also continuous with the liga-
mentum pectinatum ; the part nearest the sclerotic is of loose
texture and contains the larger vessels, the internal portion
contains the dense network of capillaries.
Internal to the stroma is the lamina vitrea, a hyaline layer
continuous with that of the iris, but rather thicker. Internal
to this is the uvea; and on the inner surface of the uvea is the
pars ciliaris retince; this consists of a layer of rod-like cells of
two kinds, one being stout, coarse, and nucleated, and the
other extremely fine and elongated, so as to form fine fibrils,
which unite together and go to the suspensory ligament. The
ciliary processes are thus brought into proximity with the edge
of the capsule of the lens.
The ciliary muscle (Bowman) arises from the fibres of the
ligamentum pectinatum opposite to the sclero-corneal junction;
from this origin the greater part of its fibres (meridianal) pass
directly backwards to be inserted into the choroid. Other
fasciculi (oblique) pass inwards to the ciliary processes ; these
run divergingly, and frequently anastomose with one another;
having reached the inner side they become circular. Others
appear to pass in a direction almost circular (Milller's annular
muscle).
In hypermetropes this annular muscle is more developed
than in the emmetropic eye. In myopes, on the contrary, the
circular fasciculi are feebly developed, the meridianal fibres
constituting nearly all the muscle (A. Iwanoff).
The fibres are of the unstriped variety ; the muscle possesses
a network of capillaries and a plexus of non-medullated nerve-
fibres, with numerous ganglion cells.
For the action of the muscle, see Refraction.
The choroid is the posterior part of the tunica vasculosa,
which extends from the ciliary body to the optic disk, and lies
between the sclerotic and the retina. On microscopic section
it presents from w^ithout inwards the following parts (see Fig. 4,
opposite p. 124) :
1. The lamina fusca. — This consists of lamellae of loose con-
nective tissue containing pigment cells; it adheres to the
sclerotic when this is separated from the choroid.
136 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
Fig. 38. — Diagrammatic Representation of the course of the Vessels in the Eye. Ilori-
zontal Section (after Leber). The veins are represented black, the arteries clear.
a, arterifB ciliares posteriores breves: b, arteriaj ciliares posteriores longfe ; c'c, arterioe
et venae ciliares anteriores; dd', arteria; et venae conjuncti vales posteriores; e'e,
arteria; et venre centrales retiniv ; /, vessels of the internal, and g, of the external
optic sheath ; h, vena vorticosa ; i, vena; ciliares posteriores breves ; k, branch of
the posterior short ciliary artery to the optic nerve; /, anastomes of the choroidal
vessels with those of the optic nerve; m, choroi-capillaris; n, episcleral branches;
o, arteria recurrens choroidalis; p, circulus arteriosus iridis major; q, vessels of
iris; r, of the ciliary processes; «, branch to the vena vorticalia from the ciliary
muscle; u, circulus venosus ; r, marginal loop plexus of the cornea; ic, arteria et
vena conjuncti ralis anterior.
THE CHOROID. 137
2. The lamina suprachoroidea, which is similar in structure
to the lamina fusca, being composed of lamellae of connective
tissue and network of elastic tissue ; when the choroid is sepa-
rated from the sclerotic this part adheres to the former. The
space between the lamina fusca and the lamina suprachoroidea
is lined b}^ two layers of endothelium and is considered to be a
lymph space ; in the deeper part of this lamina numerous vessels
are seen in section, and each is surrounded by a lymph sheath.
This is therefore called the lamina vasculosa by some observers.
3. The elastic layer of Sattler, consisting of two endothelial
layers.
4. The chorio-capillaris, a dense network of capillaries con-
taining numerous spindle-shaped and flattened cells, many of
which are pigmented.
5. The lamina vitrea, continuous with that of the ciliary bod}',
6. The uvea is continuous with that of the ciliary body, and
similar to it. It is considered to belong to the retina. It is
this pigment layer which prevents the details of the choroid
from being seen with the ophthalmoscope; when it contains
little or no pigment, as in fair persons and albinos, the cho-
roidal vessels can be distinctly seen.
The blood supply of the tunica vasculosa is very free (see Fig. 38),
and is divided into two distinct regions, the posterior part or
choroid being supplied by the short posterior ciliary arteries,
whilst the ciliary body and the iris are supplied by branches
from the long posterior ciliary and the anterior ciliary arteries.
The short posterior ciliary arteries, ten or twelve in number,
pierce the sclerotic close to the optic nerve, passing through
the lamina fusca into the deeper part of the lamina supra-
choroidea, they divide dichotomously, and ultimatelj^pass into
the capillaries of the chorio-capillaris. Except in the region
of the optic nerve the branches do not anastomose much with
one another. Anteriorly they receive a few anastomotic com-
munications from the ciliary region.
The long posterior ciliary arteries, two in number, pierce the
sclerotic posteriorly, and pass forwards between this and the
choroid as far as the ciliary body. They give off no branches
until they arrive at the ciliarj^ region. Having reached this,
they give branches to the ciliary muscle, and then, uniting
138 DISEASES OF IRIS, CILIARY BODY, AXD CHOROID.
with branches from the anterior ciliaries, which have pierced
the sclerotic from the front, they take a circular direction and
form the circulus iridis major.
The anterior ciliari/ arteries, about live in number, are supplied
from the muscular and lachrymal branches of the ophthalmic
artery; they pierce the sclerotic near the margin of the cornea,
and then divide into branches to the ciliary muscle and to the
circulus iridis major above mentioned.
The circulus iridis major gives off branches to the ciliary
processes, which divide up into numberless line branches. It
also gives branches to the iris, which pass radially toward the
pupillary margin, where they form an anastomotic ring, the
circulus iridis minor.
The veins of the tunica vasculosa are somewhat different in
their mode of termination to that of the arteries. Thus the
anterior ciliary veins are quite rudimentary, and the blood
from the veins of the iris and ciliary region is all returned to
the choroidal veins. In the region of the canal of Schlemm
there is a venous plexus, which also sends its blood to the
choroidal veins.
The veins of the choroid anastomose very freely with one
another; they do not accompany the posterior short ciliary
arteries, but are arranged in curves (vente vorticos^e) as they
converge to about four principal trunks; these pierce the
sclerotic very obliquely about half-way between the optic
nerve and the cornea to join the ophthalmic vein (A, Fig. 38).
The function of the tunica vasculosa is of great importance.
In the first place, there is a slight anastomosis between the
vessels of the choroid at the edge of the optic disk and those of
the optic nerve at the same place, so that these may have some
influence in the nutrition of the optic nerve and retina.
Secondly, the capillary layers of the choroid, the chorio-capil-
laris, and its corresponding parts in the ciliary processes and in
the iris, are of great importance in the general nutrition of the
eye, and in the regulation of intraocular tension. Then the
chorio-capillaris undoubtedly supplies nutrition and warmth to
the outer layers of the retina ; in conjunction with the ciliary pro-
cesses it also supplies nourishment to the vitreous. The ciliary
processes, by their proximity to the edge of the lens, are con-
sidered to be the chief agents of nutrition to that body (Brailey).
THE LYMPHATICS OF THE EYE. 139
The aqueous humor is secreted by the ciliary processes and
the posterior surface of the iris. The course of the circulation
of the aqueous humor will be presently considered under the
lymphatic sj'stem of the eye.
The ciliary nerves, about fifteen in number, are derived from
the ophthalmic ganglion and from the nasal branch of the tifth
nerve. They pierce the sclerotic near the optic nerve entrance;
passing forwards between this tunic and choroid they send
branches to the latter, and to the ciliarj' body, iris, and cornea.
The lymphatics of the eye. — Schwalbe^ has shown that there
exist in the eye several spaces in which lymph is formed, and
from which it is discharged in three directions. These he
classifies into an anterior and two posterior systems.
The anterior li/mphaiic system comprises the canal of Petit,
the aqueous chamber, the spaces of Fontana, the canal of
Schlemm, and the venous or lymphatic plexus in connection
with this canal. The Ij-mph secreted by the ciliary processes
travels to the aqueous chamber by three channels; a large pro-
portion passes to the vitreous humor and the canal of Petit,
and thence through the suspensory ligament to the aqueous
chamber, then forwards through the pupil; another portion
passes directly into the aqueous chamber, and then forwards
through the pupil; a third current takes place from the ciliary
processes through the base of the iris into the periphery of the
aqueous chamber. The posterior surface of the iris probably
secretes a very small quantity of lymph, which passes through
the pupil. The aqueous humor thus formed leaves the aqueous
chamber at the angle between the iris and the cornea by pass-
ing through the meshwork of the ligamentum pectinatum
(spaces of Fontana); it then reaches the canal of Schlemm,
where there exists a system of valves through which the
aqueous passes directly into the plexus of veins in its imme-
diate vicinity. Having thus reached the blood-current, it is
conveyed to the choroidal veins.
ThQ posterior lymphatic spaces are two in number, viz., those
of the choroid and the sclerotic, and those of the retina and
optic nerve. The first of these has already been mentioned as
existing between the lamina fusca and lamina suprachoroidea;
* Strieker's Hand-book of Histology.
140 DISEASES OF IRIS. CILIARY BODY, AND CHOROID.
this space communicates, by means of perivascular sheaths
surrounding the venae vorticosfe, with the lymph space within
the capsule of Tenon, which, as we have seen, extends along
the outside of the optic nerve, through the cranium, and into
the lymphatics of the neck.
The lymphatics of the retina form sheaths to the blood-
vessels, and so pass to the optic nerve. The optic nerve also
possesses another lymph space between its pial and dural
sheaths, the miersheath spare, which communicates posteriorly
with the subarachnoid cavity, and terminates anteriorly at the
lamina cribrosa.
Iritis. — Sympfoms. .1. The mobility of the iris is diminished. —
In all cases of inflammation of the iris the pupil will be found
to move less actively than in health; in some cases its move-
ments are sluggish, in others it is quite inactive.
2. Visio7i is impaired. — The normal eye, when emmetropic,
is able to read No. 6 of Snellen's test-types at six metres dis-
tance, but in iritis this will nearly always be found to be im-
possible. The patient will only be able to see the larger
types, Nos. 9 to 60, at this distance.
3. The color of the iris is altered. — This change is sometimes
very slight, and liable to escape notice, but by a careful ex-
amination with oblique focal illumination, there will nearly
always be found a change in the color of the tissue surround-
ing the edge of the pupil. In many cases this is very marked,
the blue or gray iris becoming of a yellowish-green tint, whilst
the dark brown color assumes a brownish-red, or rust color.
Besides this, there is generally a dull, muddy appearance of
the tissue of the iris.
4. The bloodvessels immediately surrounding the cornea are in-
jected. — These are always seen as a pink, or deep red ring,
whenever iritis is present (see Fig. 8, opposite p. 90).
5. Pain may be entirely absent, or may exist in various
degrees within the eye, and in the surrounding temporal,
frontal, and malar regions. It is often associated with photo-
phobia and lachrymation.
Pathology. — Three chief forms of iritis are found, viz., the
serous, the plastic, and the suppurative.
1. Iritis serosa (keratitis punctata, descemetitis, aquocapsu-
IRITIS. 141
litis). In this affection the jyvpil is sluggish in action and is some-
what dilated. The iris becomes lustreless, and rather muddy in
appearance; it evinces but little tendency to the formation of
plastic exudations, but the inflammatorj' action is prone to
extend backwards to the ciliary body, and the choroid, and
forwards along the fibres of the ligamentum pectinatum to the
epithelioid layer at the back of Descemet's membrane, the cells
of which become proliferated, and heaped up into little masses
which, as the disease advances, may be seen b}' the oblique
focal illumination as small dots of ojMcity at the back of the
cornea. In this condition, which is known' as keratitis punctata,
the dots of opacity may be irregularly scattered, or they may
occupy a triangular area, the apex of which is opposite the
pupil, and the base at the periphery of the cornea, either below
or at one side (see Fig. 5, opposite p. 90).
The tension of the globe is increased, and the aqueous humor is
turbid. This is due in the first place to hypersecretion of
lymph from the posterior surfaces of the iris and the ciliary
body; and, secondly, to obstructed outflow of the aqueous into
the canal of Schlemm, owing to the swelling of the fibres of
the ligamentum pectinatum, which guard the entrance to that
cavity.
Fig, 1, opposite p. 142, represent? a section of the ciliary
region of such a case, in which we see that the iris is some-
what thickened and hypernucleated, that the posterior part of
the uveal tract is but little affected, and that there are no
plastic exudations upon its surface. The walls of the arteries
are thickened; the inflammation has extended backwards to
the ciliary body, which is swollen and also infiltrated with
leucocytes; it has also extended forwards along the fibres of
the ligamentum pectinatum, to the epithelioid layer at the
back of Descemet's membrane, where the cells have also un-
dergone proliferation.
2, Iritis plastica. — Under this head may be placed a large
and varied class of cases, in all of which, however, we find a
tendency to the exudation of plastic mattel* within the sub-
stance, or upon the surface of the iris. These forms are de-
scribed under various headings, such as Syphilitic Iritis, Rheu-
matic Iritis, etc. In plastic iritis, the pupil is always more or
142 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
less contracted. The iris is changed in color; this is most
marked immediately around the edge of the pupil, but the
whole tissue of the iris loses its brilliancy, and assumes a
muddy appearance (see Fig. 8, opposite p. 90).
Syphilitic iritis comes on as a secondary symptom, generally
appearing some weeks after the occurrence of the rash. It
difters from other forms of plastic iritis in the large amount of
lymph which is thrown out, and in the rapidity with which
this becomes organized, causing change in the color of the iris,
and extensive adhesions. Gummatous nodules (p. 166) also
are sometimes seen. Pain and conjunctival injection are often
comparatively insignificant.
Bheumatic iritis is most common in the chronic forms of
rheumatism. It is attended with greater pain and conjuncti-
val injection than the syphilitic form. The plastic exudation,
however, is less, and there is consequently less change of color
in the iris, and the adhesions are less extensive and form less
rapidly. It shows great tendency to relapse.
The change of color is due to the exudation of lymphoid
cells, and to turbidity of the aqueous; it is most marked near
the pupillary edge; the whole thickness of the iris becomes
inflamed, and the cells of the posterior uveal portion undergo
proliferation, throwing out a layer of lymph upon the surface
between the iris and capsule of the lens (Fig. 2, opposite p. 143).
Unless the pupil is dilated by atropine, or some otlier mydri-
atic, this lymph becomes organized, and causes posterior syne-
chia, or adhesion between the back of the iris and the capsule
of the lens. This synechia may be partial or complete; when
partial, there may be one or many points of attachment, so that
when atropine is used, the unattached portion of the iris is
drawn out, whilst the attached portion remains in position,
giving the pupil an irregular outline, which varies considerably
in different cases (see Fig. 10, opposite p. 90). When the whole
of the edge of the pupil is adherent to the capsule of the lens,
so that no fluid can pass from behind through its aperture, the
condition is called total posterior synechia, or exclusion of the
pupil. It not unfrequently happens in severe plastic iritis that
lymph is also thrown out, so as to occupy the area of the pupil,
there becoming organized into an opaque persistent membrane,
Fcleoti'r.
Vovuect.
Vesceyricte weinlrani'.^*
Fii;. 1.— Iriti.* serosa. ; about 40 'liaiii
Anterior .'^■nechiW-
Fig. 2. — Iritis plastica. X about 40 diam.
Iris.
M:
-raiary'i»"k^-
Fig. 3. — Iritis suppurativa. X about 40 diam.
To face p.UZ
IRITIS. 143
whicli may be perforated by one or more small apertures. This
condition is termed occlusion of the pupil.
In cases of iritis following penetrating wounds, and per-
forating ulcers of the cornea, the escape of the aqueous having
allowed the iris to come into contact with the cornea, an ad-
hesion — anterior synechia — often takes place betw^een the iris
and cornea.
Fig. 2, on the opposite page, shows a section of severe plastic
iritis, in w^hich it will be seen that the tissue of the iris is ex-
cessively hypernucleated and altered. On its anterior surface
is a definite layer of organized lymph, forming an anterior
synechia. On the posterior surface the pigment layer is
greatly thickened, and presents a portion of exudation which
has been torn from the capsule of the lens. The ciliary body
is but little affected.
3. Iritis suppurativa is characterized by marked and rapid
changes in the iris. The pupil is contracted, and either slug-
gish or immovable. The tissue of the iris is swollen, and its
color changed to a muddy-green or brownish-yellow. The
aqueous humor is at first slightly turbid, but before long there
is a collection of yellowish puro-lymph at the bottom of, the
anterior chamber, which may increase so much as to occupy
the greater part of that cavity. Suppurative iritis is seldom
confined to the tissue of the iris, but is usually either derived
from or extends to the surrounding tissues, as the cornea, the
ciliary body, the choroid, and the vitreous. When not due to
injury, it is usually associated with a low state of health.
Fig. 3, on the opposite page, represents a section of the
ciliary region of such a case. This shows the iris to be greatly
swollen, and infiltrated throughout with inflammatory cells.
The walls of the vessels are thickened, and with a hie-her
power are found to be completely blocked with leucocytes.
The ciliary body, and even the choroid and sclerotic in the
ciliary region, are also thickened by inflammatory infiltration.
Causes of iritis. — In many cases of either serous, plastic, or
suppurative iritis it is quite impossible to trace any cause
whatever. The plastic and suppurative forms are frequently
set up by wounds of the cornea or anterior part of the sclerotic,
and may follow operations in which the iris has been bruised,
144 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
as in cataract extraction, also by other injuries of the eye, such
as contusions without wounds. Si/philis is an occasional cause
of serous iritis and a very frequent cause of the plastic form.
Rheumatism is also a common cause of plastic iritis, and occa-
sionally gives rise to the serous and the suppurative forms.
A gouty diathesis is also thought to predispose to iritis. The
serous form of iritis may at any time take on a plastic nature,
and both the serous and the plastic forms may go on to suppu-
ration. Iritis is more common in adults than in young sub-
jects. "When observed in children under ten years of age, it is
almost invariably due to an injury, to inflammation or ulcer of
the cornea, or to inherited syphilis. It may even occur in utero.
Prognosis, Treatment, and Complications.
In the treatment of iritis the first and most important object
is to dilate the pupil. This is best eftected by the use of a 1 per
cent, solution of atropine dropped into the eyes every three or
four hours. This causes the widest possible dilatation of the
pupil, and by keeping the pupillary edge of the iris away from
the capsule of the lens prevents the formation of posterior
synechia. If adhesions have already formed and are recent, it
is a good plan to use atropine every hour for a few hours ; this
treatment is likely to break them down, leaving perhaps a few
dots, or a ring of pigmented lymph upon the capsule, which,
however, may partially or entirely disappear. If the adhesions
are of sufficient age to have become firmly organized, the atro-
pine will not break them down, but it will still cause dilatation
of any part of the pupil that may be unattached, and so pre-
vent further complication of this kind.
In using atropine, it must be remembered that the ciliary
muscle is temporarily paralyzed, and that near vision is, there-
fore, greatly impaired for the time. Again, the use of this
drug occasionally gives rise to what is called atropine irrita-
tion. This consists of irritable conjunctivitis, and of swelling
and erythema of the skin of the eyelids and surrounding
reo-ion. In some cases it is ver^^ severe. I have a patient
under my care, aged twenty-three, in whom a single applica-
tion of atropine is sufficient to set up violent pain in the eyes
with photophobia, intense injection of the conjunctiva with
TREATMENT OF IRITIS.
145
chemosis, great redness, swelling, and a vesicular eruption of
the skin of the eyelids, cheeks, and forehead. When this
complication arises, the atropine must at once be stopped, and
some other mydriatic substituted. For this purpose a h per
cent, solution of Duboisin, or a 5 per cent, solution of hyoscya-
mine, should be tried with caution. I have found that patients
who cannot tolerate atropine, are in some cases also unable to
withstand the action of these agents, although, as a rule, they
Fig. o9. — Heurteloup's Leech.
are less irritating than atropine. The second indication for
treatment of iritis is to relieve pain and congestion. One of the
best methods we possess of doing this is by the alternate ap-
plication of moist and dry heat. For this purpose, let the eye
be bathed every few hours with hot water, and then apply a
large pad of hot, dry cotton-wool to the closed eyelids, and
keep it there until the next fomentation. The wool is easily
made hot by contact with the outside of a can of boiling water.
The dry, hot wool alone is also very comforting and beneficial.
The atropine which has been used for dilating the pupil is also
a sedative, and will help to relieve the pain. The use of several
leeches applied to the malar eminence, or to the side of the
10
146 DISEASES OF IRIS, CILIA RY BODY, AND CHOROID .
nose, or the application of Heurteloup's artificial leech to the
temple, often gives relief. Heurteloup's artificial leech con-
sists of a sharp cylindrical drill, and a glass exhausting-tube
with an air-tight piston (see Fig. 39). The drill can be set at
any depth by means of a screw. It is applied to the temple,
the hair having been previously shaved off from a space suffi-
ciently large to accommodate the end of the cylinder. The
blade being set at a depth sufficient to penetrate the skin, is
firmly applied to the temple, and the incision made by rotating
the upper knob ; this done, and the cutter being withdrawn,
the exhaustion is effected by gradually rotating the two lower
knobs. The cylinder holds about an ounce of blood, and
ought to fill in the course of five minutes. Light should be
excluded from the eye for about twelve hours after the use of
the artificial leech. Alcoholic stimulants of all kinds should
be avoided during iritis.
Another important aid in the relief of pain and congestion
is the operation of paracentesis of the anterior chamber (see
p. 103). This simple ])roceeding will often give immediate
relief when other methods are only partially successful. It is
never attended by bad results, and its value should not be
overlooked, especially when other means have failed, and the
aqueous humor is turbid. After the operation has been per-
formed, the wound should be prevented from healing for a
few days, by the introduction of a small blunt probe (Fig. 28)
between the lips of the wound.
General treatment is also of great importance. Sleep and
relief from pain may often be procured by the use of opium or
chloral internally, or by the hypodermic injection of morphia.
When Syphilis is found to be the cause of the iritis, the general
disease must be rigorously treated in addition to the local
affection. Mercury (F. 35, 36, or 37) should be given twice
or three times daily until the gums are slightly red and
tender, and then by reducing the dose this condition, just
short of salivation, should be kept up, until all symptoms of
the general disease have disappeared.
In the rheumatic form the iodide of potassium, and other
remedies suitable for the general disease, will be found to
alleviate the inflammation of the iris.
TEEATMENT OF IRITIS. 147
By the combination of these local and general remedies it
will usually be found that iritis, when treated at an early stage,
will progress favorably, and leave no trace of its existence.
One or two precautions in treatment are necessary; thus in
iritis serosa, if the tension of the globe becomes much increased
the use of atropine must be discontinued, and either replaced by
a ^ per cent, solution of eserine, by paracentesis, or iridectomy.
In iritis resulting from injury, when seen in the early stage
the continuous application of cold to the closed eyelids, by
means of lint dipped in iced water, is the best means of allaying
inflammation ; this should be combined with the use of atro-
pine, and the application of leeches.
In certain cases, however, the most judicious local and in-
ternal treatment fails to cure the disease ; the symptoms may
become somewhat abated, but will, nevertheless, continue week
after week, constituting a state of chronic iritis. Under these
circumstances the most reliable remedy is iridectomy. It is
diflicult to lay down any precise rule as to tbe exact period at
wdiich this operation should be performed. Each case must be
judged upon its own merits. My rule is to desist as long as
the case appears to progress favorably, but should the pupil
continue sluggish or iixed, the iris discolored, the aqueous
turbid, the circumcorncal zone injected, and especially should
the tension of the eye increase, I do not hesitate to perform
iridectomy upwards. This is usually followed by great relief
of pain, and diminution of other inflammatory sj'mptoms.
When posterior synecMae have formed, the number and extent
of the adhesions will be shown by the eftect of a 1 per cent,
solution of atropine dropped into the palpebral aperture. If
only one or two points of attachment exist, they may be left
alone and disregarded, so long as the eye remains quiet; but
should they be found to cause recurrent inflammatory attacks,
something must be done in the way of operative procedure.
By most ophthalmic surgeons such cases are treated by iridec-
tomy, but some operators prefer to detach the adherent portion
of the iris from the capsule of the lens. This may be done
either by the method of Passavant or by that of Streatfeild.
Passavant's method consists in making an incision in the
periphery of that part of the cornea which is in front of the
148 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
synechia, seizing with forceps and drawing outwards the
attached portion of the iris; the internal margin of the iris
being thus set free, it is released from the forceps and the
latter withdrawn from the wound. In this method the capsule
of the lens is not touched, so that it is not likely to be wounded
by the forceps.
Streatfeild's method (Corelysis) consists in making a puncture
in the cornea with a broad needle, on the side opposite to the
principal adliesion, and then passing a Streatfeild's hooked
spatula through the wound into the anterior chamber across
the pupil, and between the iris and lens, taking care to direct
the blunt end of the instrument away from the latter, and far
enough beneath the iris to be able, by lateral movements and
traction, to lift the iris away from the capsule, and so to break
down the adhesion.
The after-treatment of both these operations consists in the
use of atropine, with a light pad and a bandage, keeping the
eye closed for ten days.
When extensive synechiae, or total posterior synechia, with or
without occlusion of the pupil, are found to exist during or after
an attack of iritis, their presence must be regarded as antago-
nistic to the welfare of the eye. By the dragging and limited
movement thus imposed upon the iris, and by the obstruction
constantly oft'ered to the circulation of the intraocular Huids
through their ordinary channel, the pupil, they are sure at
some time to set up further trouble. This may appear in the
form of recurrent inflammation, which often extends from the
iris to the ciliary body and the choroid, or it may manifest
itself by increased tension of the globe, either with or without
these inflammations. After this condition has existed for some
time the periphery of the iris will be observed to bulge for-
wards, whilst its pupillary margin is bound down to the lens.
This is caused by the pressure of the fluid which is pent up
behind the iris. Every possible effort must therefore be made
to remove these adhesions, and to establish the circulation of
the aqueous humor through the pupil. In the tirst place, by
the use of strong mydriatics, such as atropine, and by the
treatment of constitutional symptoms, much breaking down
and reabsorption of the plastic exudation may sometimes be
CYCLITIS. 149
accomplished. If tliese means fail to liberate the iris from its
iidhesive bonds, the next step is to perform a free iridectomy
without further delay. This should be done whether chronic
recurrent iritis be present or not. The position of the section
of the iris must depend upon the condition of the pupil ; if
this be occluded, the iridectomy should be made downwards
and inwards, so as to give an artificial pupil ; if the pupil be
tolerably clear, the section may be made upwards. Von Graefe
found this operation to be of the greatest service, not only in
the reduction of inflammation and intraocular tension, but in
the improvement of vision, and in the prevention of recurrent
attacks. His experience has been fully contirmed by others,
iind his practice is now generally adopted, with the best results.
When iritis becomes suppurative the internal use of tonics,
as bark and ammonia, with good food and fresh air, is advis-
able. The use of mercury, bloodletting, and other lowering
remedies, is to be avoided. Locally, w^arm fomentations or
poultices to the eyelids are of use; and should the pus be
copious, or the eye painful, paracentesis of the anterior
■chamber will be found to give great relief. The section should
be made below (see p. 103), and the wound kept open by the
use of a fine probe (Fig. 28), for a few days.
Cyclitis. — Inflammation of the ciliary body is rarely found
to exist without a similar condition of either the iris or the
choroid, or both.
When cyclitis is present, we find intense injection of the
vessels in the circumcorneal zone of the sclerotic and episcleral
tissues. The aqueous humor is turbid, and presents flocculi
of lymph; sometimes flakes of pus, and even of blood, may be
seen in the anterior chamber. On making slight digital press-
ure through the closed eyelids, we find the ciliary region to
be intensely tender. The vision is always impaired. If we
try to explore the fundus oculi by means of the ophthalmo-
scope, after dilatation of the pupil by atropine, it is impossible
to gain any definite outline of the optic disk, or of the vessels
of the retina. This obscurity is due, in the first place, to the
turbidity of the aqueous alread}' mentioned; and, secondly, to
a similar condition of the vitreous, in which floating opacities
can often be seen. After cyclitis has existed for some time
150 DISEASES OF IRIS, CILIARY BODY, AND CUIOROID.
the sclerotic becomes thinned, and allows the dark color of
the ciliary body to be seen through it, whilst, owing to the
diminished resistance which it otters to the intraocular press-
ure, it sometimes bulges, forming a ciliary staphyloma, and
the globe becomes softened.
The appearance of the healthy choroid must be carefully
studied bt'ft)rc wo can properly ap[)reciate the localized intlam-
raatory and other changes which occur in the course of the
diseases of that part of the eye.
We have seen (p. 135) that the choroid consists from within
outwards of six layers of structure, which, for convenience o^
description, are called (1) tlie uvea, (2) the lamina vitrea, (3)
the chorio-capillaris, (4) the elastic layer of Sattler, (5) the
layer of larger vessels with the lamina supi-a-choroidea, and
(6) the lamina fusca.
Now the color of the fandas ocali, which is seen by reflected
light Avhen we use the ophthalmoscope, is due to two chief
causes, viz., the blood contained in the chorio-capillaris, and
the pigment granules contained in the cells of the uvea, and of
the interstices of the chorio-capillaris, the vascular layer, and
the lamina fusca.
When this pigment is altogether absent, as in the case of
albinos, we get a light yellowish-red color, reflected from the
blood within the capillaries; whilst the interstices between
the latter are seen to be of a lighter, almost white, appearance,
owing to the reflection from the sclerotic beyond the lamina
fusca, and thus a fairly well deflned outline of the choroidal
vessels is obtained.
In fair persons, in whom the pigment granules contained
within the cells are only of a faintly brown color, the fundus
has a yellowish-red color, and the vessels of the choroid can
often be seen, although less distinctly than in albinos.
In moderately dark persons this pigment becomes of a deeper
brown, and the fundus presents a light brownish-red color, no
choroidal vessels being seen (see Figs. 1 and 2, on the opposite
page). In very dark persons the brown tint becomes more
predominant, at the expense of the yellowish-red.
In negroes, and all dark races, the pigment is so abundant
as to prevent the appearance of almost all red reflex from the
Fuj. 2. Nonruxly -fhrtcLns.
LtBON a CO
GENERAL CHOROIDITIS. 151
choroid, the fundus assuming a brownish-gray, or even slate
color.
The color of the fundus varies very much with the intensity
and color of the light used, and with the state of dilatation of
the pupil. It is brighter, cceteris paribus, in proportion to the
number of rays of light that can be thrown into the eye.
Choroiditis. — Inflammation of the choroid may be general, or
it may be more or less localized.
General choroiditis may be serous, plastic, or purulent.
In serous choroiditis the objective symptoms are not greatly
marked ; there is usually slight redness of the circumcorneal
zone, and frequently a finely dotted appearance at the back of
the cornea — " keratitis punctata." Both the aqueous and the
vitreous humors are slightly turbid, so that the papilla and
retinal vessels cannot be distinctly seen, but present a hazy
appearance, simulating papillitis, or neuro-retinitis. If, how-
ever, the case were one of simple neuritis, or neuro-retinitis,
the media remaining clear, we should be able at least to see
the peripheral portions of the retinal vessels, whereas in serous
choroiditis the whole fundus is hazy.
Again, in this disease if we use a plane-mirror, having a
convex lens behind its sight-hole, to illuminate the fundus, and
direct the patient to look alternately upwards and then back
to the mirror, we can perceive the presence of numerous float-
ing opacities in the vitreous, which do not present themselves
in optic neuritis. Vision is impaired in proportion to the
opacity of the media. This aftection is usually associated with
some constitutional dyscrasia, as syphilis, rheumatism, or gout.
As we shall presently see, it may mark the onset of sj-mpathetic
ophthalmitis; in foct, it appears to be due to the same causes
as serous iritis.
The tension of the globe is usually normal at the commence-
ment, but it often becomes afterwards increased, and the case
may be mistaken for glaucoma. (See Glaucoma.)
Dratmenf must first be directed to any existing constitu-
tional d3-scrasia, the eyes being kept in a state of rest, and
shaded from the light. Should the tension of the globe be-
come increased, paracentesis of the anterior chamber (see p.
103) is advisable. This operation is often of great use in re-
152 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
ducing pain, which may be considerable, and in retarding the
progress of the inflammation; it may in some cases be repeated
several times at intervals of two or three da3's, with benefit.
Should the paracentesis prove insufficient to reduce the tension
and to relieve the intraocular trouble, iridectomy should be
performed upwards.
Plastic choroiditis, when general, is accompanied by symp-
toms of violent inflammation. There is intense redness of the
circumcorneal zone of vessels, and more or less chemosis of the
ocular conjunctiva. The aqueous humor is turbid, and may
contain pus or even blood. The vitreous is also found to be
even more cloudy than the aqueous, so that no detail of the
fundus can be made out with the ophthalmoscope; in fact, in
many cases not even the red reflex from the choroid can be
obtained. Sometimes the opacity is almost confined to the
vitreous humor. The iris and the ciliary body usually partici-
pate in this inflammation. Vision is, of course, gravely inter-
fered with, and nuiy only amount to bare perception of light.
There is often severe pain in and around the globe.
The disease is most serious from its onset; masses of exuda-
tion are thrown out, causing detachment of the retina. The
inflammation usually goes on from bad to worse, causing dis-
organization, and Anally softening of the globe, and leaving the
patient without even perception of light. This aflfection mostly
occurs in young children ; sometimes as a complication in some
severe illness, as meningitis. In adults it also usually dates
from some severe malady, in which there may have been grave
meningeal or cerebral lesions; but it may come on sponta-
neously, and without any assignable cause. In young children
it sometimes attacks onl^^ the parts posterior to the crystalline
lens, and by a more or less circumscribed exudation beneath
the retina, causes this to bulge forwards as a yellowish-white
mass, which can be seen by the oblique focal illumination, and
by the ophthalmoscope, to project into the vitreous chamber.
It has a yellowish or yellowish-white color, and may easily be
mistaken for glioma. To this condition the term Pseudoglioma
is often applied. The points of distinction between these will
be found under the head of Glioma.
Treatment is unfortunately of but little service in these con-
PURULENT CHOROIDITIS. 153
ditions. Local depletion, as by leeches, may be useful in the
earh' stages, but as a rule the eye is doomed to u disorganized
condition of the structures essential to vision.
In purulent choroiditis, the sym.jptoms from the first are those
of intense inflammation. The conjunctiva and subconjunctival
tissues are densely infiltrated with serum, so that the cornea
is partly covered in b}- the swollen tissues. The eyelids, also,
are red and swollen, so much so that were it not for the absence
of discharge the case might be considered to be one of purulent
conjunctivitis. The iris is changed in color, and becomes
muddy in appearance, the pupil fixed, and the cornea hazy
and anaesthetic. The globe of the eye appears swollen and
pushed forwards, it is hard to the touch, and extremely painful
on pressure. There is excessive pain, at first in the eye, and
afterwards in and around the orbit. Vision is of course soon
diminished, and finally lost altogether. Pus forms in the
anterior chamber, and is accompanied by general pyrexia.
The causes of purulent choroiditis are various. It may
follow a perforating wound, whether caused by an accident or
operation — e.g.^ that of cataract extraction, or it may be caused
by the entry of a foreign body. It may be caused by extension
of inflammation from the cornea and iris, as in perforating
and serpiginous ulcers of the cornea with hypopyon. It some-
times occurs in typhoid and puerperal fevers. Occasionally it
is seen as a metastatic phenomenon in amputations, and other
states in which, owing to septicaemia, thromboses are liable to
occur. In some cases, however, the cause of this affection is
difficult to trace.
The treafment is here again but a sorry undertaking. Local
leeching, hot fomentations and poultices, combined with mor-
phia, either hypodermically or otherwise administered, are
very useful in allaying pain. As soon as pus is evidently
accumulating in or behind the aqueous chamber, prompt sur-
gical interference is indicated. If the eye be left to itself, there
is considerable risk of the inflammation extending backwards
along the optic nerve to the brain and its membranes, and so
causing a fatal termination. Excision of the globe is, in my
opiinon, the best and safest way of treating this severe con-
dition. Some surgeons, however, are doubtful as to the pro-
154 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
priety of removing an eye whilst in tins inflamed and suppu-
rating condition, and prefer flrst to make an incision through
the anterior part of the globe so as to relieve pain, tension,
etc., and to postpone the excision until the inflammatory
symptoms have suhsidcd.
Disseminated choroiditis. — The si/mptoms which first induce
the patient to seek advice are various; there may be muscje
volitantes, defective vision, or pain in the eyes. On ophthalmo-
scopic examination we find one or more patches distributed
over the fundus, either toward the periphery, or nearer the
central region. These patches vary considerably in size, shape,
and color. The recent ones have a yellowish-red appearance,
and differ but little from the rest of the fundus; in fact, with-
out a careful examination by the direct method, they may
easily escape notice, ^"hen more advanced, they become
whitish-yellow ; and still later we find them to be quite white,
and glistening with little aggregations of pigment attached to
their edges or in some part of the area. Sometimes they be-
come confluent, and form large tracts of atrophy, in which only
white cicatricial tissue and aggregations of pigment can be seen.
Figs. 1 and 2, on the opposite page, represent a typical case
of this kind. They were drawn from a case which is still under
my care at the Westminster Ophthalmic Hospital. Both fundi
are affected; in the right eye, however (Fig. 2), the disease is
more advanced than in the left, and has become confluent in the
yellow spot region.
Both the visual acuity and the visual field are affected in
proportion to the extent of the disease, and the part of the
fundus attacked.
In many cases the vitreous humor is also found to be more
or less aflected. This shows itself more especially when the
disease can be directly traced to syphilis. Forster^ is of
opinion that these deserve a separate classification, and desig-
nates them syphilitic choroido-retinitis. The vitreous attection
is indicated by the presence of opacities; these may be very fine
("dust-like"), and only to be observed by careful examination;
they ma}' be confined to the posterior part of the vitreous, and
so give a hazy outline to the optic disk and the yellow spot
' Archiv fiir Ophtlialm., vol. xx., part i.
Fig.Z. Dhssermruxtecb and/ centred/ chorouLutw .
LEBON > CO
Fig. 40. — Choroido-retinitis (after IwanofiF).
B, choroid ; c, retina ; 3, nodule on choroidto which the retina is adherent by its
radial tibres ; dd, reunion of the retina and choroid.
156 DISEASES OF IRIS. CILIARY BODY. AND CHOROID.
region ; or they may consist of larger opacities occupying the
entire vitreous, which sometimes render any view of the fundus
impossible. When the vitreous haze is present, the vision is
greath' impaired, and the sensibility of the retina is very
obtuse. Patients suffering from syphilitic choroido-retinitis
require a bright light in order to see at all well. In dull
illumination the vision is extremely bad.
The cause of disseminated choroiditis is often obscure. It
is, as we have just remarked, frequently traceable to syphilis,
either acquired or inherited. It is sometimes associated with
rheumatism and gout. It is not uncommon in progressive
myopia.
Pathology. — When a recent patch of this affection is ex-
amined microscopically, we find a cluster of round and fusi-
form cells in the region of the lamina vitrea and the choroi-
capillaris. The pigment layer is then unaffected. As the
disease progresses, the cells of the pigment layer begin to pro-
liferate, and the part which is immediately opposite to the
patch becomes absorbed, giving it a white appearance; the
pigment becomes accumulated at the edges of the patch, and
the inflammation extends to the layer of rods and cones, and
the outer granular layer of the retina. Later on, this inflam-
matory deposit becomes absorbed, and gives place to cicatricial
tissue; but the structures involved, viz., the outer granular
layer, the rods and cones, the uveal tract, and the vessels of
the choroid, are found to be destroyed, and. their place occupied
by this new cicatricial tissue.
Fig. 40 represents a section of the choroid thus affected. At
the point 3, cicatricial contraction is seen to be well advanced.
Treatment. — When seen early these cases are often benefited
by the internal use of mercury ; in fact, by this treatment the
patches will sometimes disappear. During the active stage of
the disease the eye should be rested, and shaded from all
bright light. When the disease has become stationary, and
the patches are white and atrophic, nothing can be done ; but
should the vision continue to decrease, or fresh failures occur,
the eyes should still be protected and rested, and a long course
of mercury and iodide of potassium given internally.
Central choroiditis only differs from the disseminated forms
in its clinical features. In this affection the inflammatory
MYOPIC ORESCENT. 157
lesion is limited to the yellow spot region of the fundus. As
in the former case, we have first the exudation of plastic
matter in the region of the lamina vitrea, giving a 3'ellowish-
white appearance ; next there is proliferation and absorption of
the central portions of the pigment of the uveal tract, giving
a white appearance to the centre of the patch, with masses of
pigment scattered irregularly around its edges. Finally, re-
absorption of the exudation, with destruction of the proper
tissue of the choroid, and of the outer granules, and the rods
and cones of the retina.
The symptoms of central choroiditis are peculiar from the
first. In addition to the exudative or atrophic patch at the
yellow spot which may be seen with the ophthalmoscope, we
find the patient at first complaining that objects seem to be
contorted. IN'ot unfrequently they appear to be diminished
(micropsia) and distorted; this is more especially marked when
the accommodation is paralyzed, and when one eye only is
affected. The micropsia and distortion are caused by the dis-
placement of the cones; if these are pressed asunder by inflam-
matory effusion, a retinal image covers fewer cones than if
these were in their normal position, hence an object appears
smaller. Unless the case is quickly and properly treated, the
central vision undergoes rapid derangement. The patient sees
a gra}^ patch upon the book or work before him, which
moves about as he moves the eye; this patch becomes darker
and darker, until finally all central vision is lost. The scotoma
will of course vary with the extent of the area of atrophy in
the choroid, but the patient will be quite unable to read small
type, and can only make out large objects by so deviating the
eyes that images may fall upon the peripheral parts of the
retina. The causes and treatment are the same as for dissemi-
nated choroiditis.
Myopic Crescent is an atrophied condition of the choroid at
the posterior pole of the eye. It is similar in microscopic
character to the atrophied patches already described in cho-
roiditis disseminata, but appears to have little or no cicatricial
tissue. It is sometimes congenital; its occurrence is common
in myopia, more especially in cases of high degree. Occasion-
ally it occurs in emmetropic, and even in hypermetropic, eyes.
158 DISEASES OF IHIS. CILIARY BODY. AND CHOROID.
It usually appears in the form of a crescent situated at the
outer side of the optic disk: the concavity of the crescent coin-
ciding with the edge of the disk, wliilst its convexity projects
toward the yellow spot (see Fig. 1, on the opposite page). It
varies in size, from a very narrow rim to an area equal to
several times that of the optic disk, round which it occasionally
forms a complete ring. When there is bulging backwards of
the sclerotic at the posterior pole of the eye in addition to the
atrophy of the choroid, the term posterior staphyloma is used.
This is the result o^ 'posterior sderotko-choroiditis. Sometimes it
remains quite stationary, but it is frequently [)rogressive. In
the latter case the bulging backwards at the posterior pole
t>-oes on increasing, as well as the inflammatory change in the
choroid at the outer edge of the crescent. We can often see
the effects of successive outbreaks of the disease by the appear-
ance of the staphyloma, which then presents several secondary
crescentic edges, each being less white than the first.
The siibjects of these changes at the posterior pole of the
eye are sometimes able to see very well when the proper cor-
recting glass is used. When, however, there is a posterior
staphyloma, and especially when this is progressive, the vision
is almost invariably diminished to a great extent. When the
yellow spot is actually involved, we. of course, find that all
central vision is lost. The patient can then only see large
objects, and to effect this he is obliged to rotate the head or
the eyes to one side, so that rays from the object may fall on
the peripheral parts of the retina. During the course of a pro-
gressive posterior staphyloma, which is usually very slow, it is
not uncommon to find hyper?emia of the papilla, and even
small hemorrhages at the edge of the stajthyloma.
The treatment of myopic crescent and progressive posterior
staphyloma will be considered in the chapter devoted to the
subject of Refraction.
Tubercle of the choroid occupies the region of the chorio-
capillaris and the vascular layer, and is quite behind the uvea.
It is most commonly found in cases of acute miliary tuber-
culosis, but it may be present in all forms and stages of
tubercular disease.
When seen with the ophthalmoscope, it appears as a grayish
LEBON & CO
Fig. Z. Posterior stxtphyLorruju.
Patdies of airoplvf -fhUxmdnff ckaroiditis.
SYMPATHETIC OPHTHALMITIS. 159
hemispherical eminence, varying from one to three millimetres
in diameter. One or several of these first appear in the yellow
spot region, and are afterwards followed by others in the sur-
rounding neighborhood. The youngest tubercles are verv
small ; the oldest are the largest, and are somewhat white at
the centre. They are distinguished from patches of choroidal
atrophy in being more clearly defined, less brilliantly white,
and in presenting no pigment masses around the edges.
In cases of acute tubercular disease in which there are typhoid
symptoms, and in tubercular meningitis, in which the diagnosis
is not always easy, the detection of tubercles of the choroid is
of great assistance in clearing up the case, although the absence
of choroidal tubercle does not prove the absence of tubercular
disease in other organs.
Rupture of the choroid is always the result of external vio-
lence, such as a blow, a kick, or a fall, in which the eye is
struck with great force, causing sudden change of form. The
accident is usually followed by hemorrhage into the vicinity of
the wound, causing opacity of the vitreous. This at first pre-
vents the choroidal lesion from being seen with the ophthal-
moscope ; after a few days, however, as the blood becomes ab-
sorbed, we can see a whitish line in the fundus, immediately
opposite to that part of the globe which received the blow.
There is usually a little blood clinging to the edges of the rup-
ture for some time after the rupture is visible, but finally the
rupture appears as a permanent white or yellowish-white line,
w^iich is usually curved in a direction concentric with the edge
of the disk, but occasionally it runs obliquely. Fig. 2, oppo-
site p. 202, shows a drawing which I made from a boy set. 14,
who had received a blow on his eye from a stick.
Sympathetic Irritation and Sympathetic Ophthalmitis.
These terms are applied to certain affections which are set
up in one eye in consequence of some organic lesions of its
fellow on the opposite side. The eye whi^h is first affected is
usually spoken of as the exciting eye, whilst the second is called
the sympathizing eye.
In the exciting eye there is almost always a history of an
injury at some time or other. In the majority of cases this
160 DISEASES OF IKIS, CILIARY BOin'. AND CHOROID.
has been a penetrating, incised, lacerated, or contused wound
of the ciliary rec^ion. It sometimes happens that the wound
produced by a blow is subconjunctival, and so may escape the
notice of the surgeon.
The presence of a foreign body lodged within any part of
the globe, such as a shot or a chip of metal, is, if not removed,
very likely to cause disorganization of the injured eye and a
ver}' probable forerunner of sympathetic trouble in the other.
Wounds of the cornea which do not extend to the ciliary
region, have of themselves little tendency to set up sympathetic
inflammation ; but should they be attended by dislocation of
the crystalline lens, or by the formation of anterior synechia,
these lesions are very liable to produce it.
In the case of spontaneous inflammation of one eye, followed
by similar symptoms in the other — as, for example, chronic
irido-choroiditis, ciliary staphyloma, glaucoma, etc. — it is difli-
cult or impossible to prove that the affection of the second eye
is due to an extension of the disease from the lirst, and not to
a common cause. An eye, however, which is shrunken and
disorganized is very liable to take on an inflammatory condi-
tion which may cause irritative symptoms in its fellow, and
such an eye should therefore always be regarded with suspi-
cion, especially when the other eye is in any way irritable, or
inflamed without apparent cause.
Condition of the exciting eye. — In the majority of cases in which
a wound of the ciliary region is followed by such a condition
as to set up sympathetic inflammation, we find the presence of
plastic inflammation of the iris, the ciliary body, and the cho-
roid (irido-cyclo-choroiditis). During the first week after the
infliction of the wound a violent recction is set up, in which
there is intense pain, in the eye, orbit, and the surrounding
temporal, frontal, and malar regions. There is marked con-
gestion of the circumcorneal zone of vessels, and the ciliary
region is tender when digital pressure is made through the
closed eyelids. There is great intolerance of light and over-
flowing of tears. The vision is much impaired. These symp-
toms are succeeded by those of chronic irido-cyclitis. The
iris becomes extensively adherent to the capsule of the lens,
it is changed in color, and the pupil may be occluded with
SYMPATHETIC O P ]I TH AL M I TI S . 161
organized Ijinph. The vitreous, when the pupil is not oc-
cluded, is found to be so hazy, and crowded with opacities,
as to prevent the retina and choroid from being seen with the
ophthalmoscope. If the lens has been wounded in the acci-
dent, it of course becomes swollen and opaque. Upon section
and microscopic examination of an eye in this condition of
traumatic irido-cyclitis, from five to ten days after the inflic-
tion of the wound, we tind evidence of severe plastic inflam-
mation in the iris, ciliary body, and choroid. The iris is
thickened by inflltration with lymphoid cells, which are ar-
ranged in clusters. These first appear in the middle strata,
and then coalesce, and extend to all the tissues of the iris. The
bloodvessels appear to be blocked' by white corpuscles, and
their walls are thick and translucent. The pigment layer at
the back of the iris is altered in appearance, its cells having
undergone proliferation, it is less dark in color, and there is a
thick deposit of lymphoid cells on its posterior surface. The
ciliary body is similarly affected. Clusters of cells first appear
on the inner surface of the ciliary muscle; these increase and
coalesce until they occupy the entire part between the muscle
and the pigment layer. The pigment layer again is much
altered, and only appears as an irregularly scattered line in
the midst of lymphoid cells. The fibres of the ciliary muscle
are not much infiltrated. The pars ciliaris retinae is but little
altered, except that it is separated from the basement mem-
brane by exudation. The choroid also shows clusters of leu-
cocytes, first appearing in the middle or vascular layer, which
multiply, coalesce, and finally occupy its whole extent. Its
thickness may be increased eight or ten times. The blood-
vessels are blocked with leucocj^tes, and are ultimately de-
stroyed. The pigment layer is not afiected. In the lymph
spaces around the bloodvessels of the retina, clusters of lym-
phoid cells are also sometimes seen. Similar cells are also
found in the intersheath space, and around the vessels of the
optic nerve.
Septic bacteria can often be found in eyes which have been
enucleated. Snellen has traced these along the optic nerve
sheath, and believes that they are concerned in the production
of sympathetic inflammation.
11
162 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
In some cases the active inflammatory changes in the ex-
citing eye as above described are much less marked.
Symptoms and pathology of the sympathizing eye. — It is im-
portant to distingui^^h between irritation and injlainination of
tliis ej-e.
By sympathetic irritation is meant a functional derangement
only. It i.s cliaractfrized by intolerance of light, lai-hryma-
tion, and inability to use the eye for reading or work for more
than a short period without a sense of fatigue. The vision
may be normal, but is sometimes impaired. There are some-
times temporary sensations of darkness (obscurations) which
last for several seconds. There may be considerable neuralgic
pains in and around the eye. Ko physical signs of inflamma-
tion can be detected, either with the oblique focal illumina-
tion or with the ophthalmoscope. Sympathetic irritation fre-
quently precedes inflammation, but it may exist for weeks,
months, or even years before the inflammation of the eye
supervenes. It is not a necessary forerunner of sympathetic
inflammation, inasmuch as the latter often comes on without
any sj'mptom of irritation ; on the other hand, it often sub-
sides and is not followed by sympathetic inflammation. The
excision of the exciting eye usually causes speedy removal of
the symptoms of irritation.
Sympathetic ophthalmitis may, as we have just seen, be ush-
ered in by irritation, but it may come on in the most insidious
manner, without pain, photophobia, or lachrymation ; it usually
commences as a serous iritis, the inflammation thence extend-
ing to the ciliary body, and the choroid. The symptoms of
this early stage are easily overlooked, but when carefully
examined the pupil is found to be sluggish, the vision more or
less impaired, the vitreous hazy so as to prevent a clear view
of the retina and choroid. Floating opacities of the vitreous
are often present. Dots of opacity on the back of the cornea
can usually be seen as soon as this disease has fully set in.
These are sometimes extremely minute, and then can only be
seen by using a magnifying lens with the oblique focal illumi-
nation (p. 86). The dots are either scattered irregularly over
the surface, or they assume a triangular arrangement, the apex
of which is ojiposite to the pupil, and the base either below or
SYMPATHETIC OPHTHALMITIS. 163
on one side. This serous inflammation may continue as such
throughout the whole course of the disease, or it may at any
time assume the more severe plastic form. In the majority of
cases of long-standing sympatlietic disease, we find both the
clinical and anatomical characters of severe plastic wflammation
of the whole uveal tract. The iris looks thick and fleshy, and is
changed to a butt" or brownish-yellow color. Its bloodvessels
become large and visible. The pupil may be blocked by
lymph. The vitreous, when visible, is found to be hazy, and
to contain floating opacities. The zone of vessels around the
cornea is intensely congested. There is sometimes intense
neuralgic pain in the regions supplied b}' the fifth nerve.
The interval of time between the injury of the exciting eye
and the onset of inflammation in the sympathizing eye is very
variable. It is seldom less than three weeks. The usual
period is from eight to twelve weeks, but cases not unfre-
quently occur after a much longer period, even many years
from the date of the original injury or disease.
The mode of production of sympathetic disease has yet to be
explained. The oldest theor}', which goes by the name of
Mackenzie's, is that the inflammation spreads to the sympa-
thizing eye along the optic nerve and chiasma. More recently
it has been held that the ciliary nerves formed the conducting
paths, the inflammation being conveyed to a centre of the cili-
ary nerves of the injured eye, and thence reflected down the
ciliary nerves of the other eye, or else that the vaso-motor
centre was acted upon in such a way as to interfere with the
nutrition of the other eye. Pathological proof in support of
this theory is wanting; the material, however, is not plentiful,
and it would be easy to overlook morbid changes in nerves so
minute and numerous as are the ciliary nerves. A more pow-
erful argument against the reflex production of sympathetic
ophthalmitis lies in the fact that true inflammation has never
been produced experimentally by irritation of a nerve.
Recent observations and experiments have proved that the
space between the dural and pial sheaths of the optic nerve
and the lymph sheaths surrounding the arteries of the retina
and of the optic nerve, arc often occupied by a number of
lymphoid cells, similar in nature to those which are so abun-
104 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
dant in tlie uveal tracts of the ej-es afteeted. This fact has
led to the theory that it is along these lymphatic spaces that
the morbid process extends to the second eye ; the chain of
evidence is, however, incomplete, for it has not been proved
that the chiasma is affected; while the fact that in some of the
cases examined the changes have become less marked in each
nerve as the chiasma was approached, renders it quite possible
that the change observed indicated a morbid process extending
backwards from each eye. The known facts about the occur-
rence of sympathetic ophthalmitis are hardly yet sufficient to
establish a theory as to its mode of transmission ; before this
can be done more data must be collected as to the essential
nature of the injury which gives rise to it, the shortest interval
that can elapse between the receipt of the injury and the ap-
pearance of symptoms in the other eye, and, above all, as to
the exact nature of the morbid changes in all the possible
paths in both eyes.
Prevention and Treatment. — The exciting eye should be care-
fully treated, and every effort made to allay inflammation in
this, as well as to prevent irritation or inflammation in that of
the opposite side. The patient must be warned of the pos-
sible danger to the opposite eye, which should be shaded from
light, and kept at rest, not only during the attack, but for sev-
eral weeks after the inflammation of the exciting eye has ap-
parently subsided.
When the exciting eye is evidently rendered useless, either by the
wound or by the consequent inflammation, that is, when its
vision has quite gone, or only amounts to perception of light,
and when there is no probability that its sight will improve, it
should be immediately excised. The necessity for its imme-
diate removal is still more urgent when it is giving rise to irri-
tation or to inflammation in the opposite eye.
When the exciting eye, although damaged, is still in the possession
of useful vision, or if there is hope of such being restored to it,
the question as to whether it should be removed or not be-
comes most difficult to decide.
If the sympathizing eye is only suffering from irritation,
and presents no symptom of inflammation, the removal of the
exciting eye is usually attended by immediate relief of the
SYMPATHETIC OPHTHALMITIS. 1G5
irritation, and no symptoms of inflammation are likely to
appear; whilst, as we Lave just seen, the danger of inflam-
mation is very great if the eye is not removed. It therefore
heeomes a most important and urgent matter to decide whether
it is not better to sustain the loss of the eye which is already
partially disabled, than to incur the risk of loss of sight to the
sympathizing eye. Careful consideration of the bearings of
the case is necessary in accidents of this kind, which in prac-
tice are liable to occur at any moment. A decision having
been arrived at, the patient and his friends should be clearly
and forcibly warned of the danger to which the sympathizing
eye is exposed by further retention of the injured eye.
If sympathetic inflammation has already commenced in the
second eye, although it may only be of the serous type, then
the exciting eye should be preserved ; its removal at this late
period is not likely to stop the disease in the other eye ; in
fact, the sympathizing eye may become so aftected by the
progress of the disease that the exciting eye may ultimately
prove to possess the better vision of the two. When it is de-
cided to preserve the exciting eye, this should be carefully
treated in the manner recommended for plastic iritis, light
being carefully excluded from both eyes.
The sympathizing eye must be treated in the same way as a
case of severe plastic iritis (p. 144), that is, with complete rest,
exclusion of light, the alternate application of moist and dry
warmth, atropine, and leeches, if necessary. In no case, how-
ever, must any operative interference, as iridectomy, be at-
tempted, as the aperture caused by the excision of the iris
would immediately become filled up by the same exudation
as has been thrown out elsewhere. Tonics are to be adminis-
tered internally. Mercurials are given by some surgeons ; but
unless constitutional syphilis is suspected, I should hesitate
before adopting this treatment.
Operative treatment of either the exciting or the sympathiz-
ing eye must not be commenced until all inflammatory symp-
toms have entirely passed away.
The condition of the sympathizing eye after the inflamma-
tion has subsided is generally very bad. In the mildest cases
there are usually extensive posterior synechipe, but the pupil
166 DISEASES OF I RIS, CILI A K Y BODY , A ND CHO ROI D.
may remain sufficiently clear to allow of some useful vision.
The fixed position of the iris, however, is likely to lead to
future inflammatory trouble in the eye, the risk of which
would be diminished by the removal of a portion of the adhe-
rent iris by the operation of iridectomy upwards. In other
cases, the layer of plastic exudation between the iris and the
lens capsule is more excessive, and extends to the area of the
pupil, which is quite occluded.
The crystalline lens also is frequently involved, and is found
to be more or less opaque. Here, of course, the vision is
greatly impaired and may amount to perception of light only.
An attempt to restore the sight may be commenced by the
performance of iridectomy in the upward direction. The oper-
ation is by no means easy to perform, owing to the toughness
of the adhesions and the rottenness of the iris tissue. If an
artificial pupil can be thus made, and the lens substance is
found to be transparent, no further proceeding is at present
necessary. Should the lens be found to be opaque, an attempt
must be made to extract it through the wound already made
for the iridectomy. Its removal is usually attended with diffi-
culty, owing to the extensive iritic adhesions. These may
sometimes be more or less detached by means of a Streatfeild's
hook ; and even then it is usually necessary to use the scoop
in order to get the lens away from its incarcerated capsule.
After the recovery from the iridectomy or the extraction of the
lens, the vision may sometimes be still more improved by iri-
dotomy (see p. 178).
Tumors of the tunica vasculosa. — Gumma occasionally occurs
during the secondary stage of constitutional syphilis. It may
attack either portion of the tunica vasculosa, and it may be
single or multiple.
Gumma of the iris appears in the form of one or several
nodules, which nui}' be clearl\- seen through the cornea. The
inflammatory deposit first commences in the connective tissue
of the middle strata of the iris and causes a slight change of
color only ; the swelling gradually increases until there is dis-
tinct bulging of the anterior surface. In light-colored eyes
these little hemispherical elevations are of a reddish-yellow
color ; in dark ones they are more of a tan color. Their diam-
SARCOMA OF THE CHOROID. 167
/
eter varies from 1 to 6 mm. AVlieu small, they may, under
proper treatment, become absorbed and disappear ; when
large, they usually suppurate, causing hypopyon, and perma-
nent alteration in the tissue of the iris.
GuMMATA of the ciliary body and of the choroid also occur,
but their presence is usually attended by a haz}' condition of
the vitreous humor, which renders their diagnosis more diffi-
cult than gumma of the iris. The connective tissue of the
middle part of both structures is lirst affected.
Miliary tubercle is sometimes seen in the iris and in the cho-
roid. Tubercle of the iris occurs less frequently than gumma,
but when present it occupies a similar position and presents a
similar appearance to that affection, so much so that it is only
by the collateral symptoms of the presence of constitutional
syphilis, or tuberculosis, that a diagnosis can be correctU^
arrived at.
Tubercle of the choroid has been already described (see p.
158).
Sarcoma mostly attacks the choroid or the ciliary body; it
hardlv ever occurs primarily in the iris.
Sarcoma of the choroid and ciliary body usuall}'^ commences
in a nuinner so insidious as to be unnoticed even by the patient
until the tumor has attained a considerable magnitude ; even
then it is sometimes discovered accidentally by the patient
closing one eye and finding the vision of the affected eye
diminished. Sometimes, however, the growth of sarcoma is
accompanied by local pains, flashings of light, etc. It usually
occurs during middle life or old age, being seldom seen before
the age of thirty-five.
Symptoms. — When seen at an earhj stage, there may be noth-
ing in the exterior of the eye to attract notice.
In addition to the dimness of sight which may have first
caused the patient to apply for advice, we find that the visual
field is deficient in some parts, and when it is examined by
means of the perimeter, presents a scotoma corresponding to
the position of the tumor. With the ophthalmoscope an out-
line of the tumor can sometimes be seen to form a rounded
prominence, pushing the retina forwards into the vitreous
cavity. It is, however, always a matter of difficulty to say
168 DISEASES OF IRIS. CILIARY BO D Y . AXD CH O ROI 1) .
whether this is due to a sarcomatous growtli in the choroid, or
to simple detachment from suhretinal effusion. When due to
sarcoma, the detached or hulging portion of the retina may
retain some color, it may occur at an}- part of the fundus, and
it does not flap about when the eye is moved. In simple de-
tachment, the detached portion has a bluish-white appearance ;
it usually occurs at the lower segment of the fundus, and it
may flap about freely when the eye is moved. Occasionally
a vascular network of the sarcomatous growth can be detected
through the retina.
In the advanced stage, the presence of the tumor is accom-
panied by a distinct increase of the tension of the globe, and
the eye presents other symptoms of glaucoma. Tlie anterior
ciliary vessels are congested; the cornea becomes dull in ap-
pearance and is more or less deprived of sensation. The an-
terior chamber gradually becomes shallow by the pressure
from behind the iris. The iris is sometimes subaculely in-
flamed, and forms posterior adhesions to the capsule of the
lens, which render the pupil irregular. Not unfrequently the
iris is atrophied, and it may be detached at that part of its per-
iphery which corresponds to the position of the tumor. The
vitreous also is frequently rendered cloud}' by the presence of
numerous opacities. The vision has gradually become worse,
and is now reduced to bare perception of light. When the
disease has progressed to such an extent as to destroy vision,
there is frequently considerable trouble from pain in the ciliary
region and lachrymation, which are of a more severe character
than those met with in true glaucoma.
Examination of the fundus with the ophthalmoscope is now
rendered impossible by the opacity of the media; and the in-
creased tension of the globe, together with the history of the
symptoms and the general appearance of the eye, fre(piently
render it a matter of difficulty to decide whether the case
be one of sarcoma or true glaucoma. So much is this the
case that it occasionally happens that the true state of the
eye is not discovered until an operation for iridectomy has
been attempted, and is found to be accompanied by escape of
vitreous and by greater hemorrhage than is usual in glau-
coma.
SARCOMA OF THE CHOROID. 169
Sarcoma of the choroid should always be suspected when
an eye that has been losing sight, or quite blind for some time,
is suddenly attacked by pain, congestion, and increased ten-
sion, or even if the tension be normal, while the other symp-
toms exist. In any case of extensive detachment of retina
occurring in one eye only, and when there has been no myopia
or history of a blow upon the eye, we must be cautious in
prognosis. Sarcoma of the choroid is usually more or less
pigmented (melanotic), and consists of spindle-shaped and
round cells, such as are shown at Fig. 2, opposite p. 124.
These spindle cells are about j-q\-^ inch in diameter. They
contain a large nucleus, surrounded by a h^-aline substance
(protoplasm), which tapers off at each end. The tumors are
usually of firm consistence, they generally contain some blood-
vessels, and sometimes are very vascular. They usually bulge
toward the vitreous cavity in the manner represented in Fig.
3, opposite p. 124, where the retina is seen to be pushed for-
wards in front of the tumor. Sometimes there is also effusion
of serum or blood beneath the retina. They may increase so
as to fill the whole globe and distend its walls before invading
the extraocular tissues of the orbit; but in many cases the
tissues outside the sclerotic are affected by the new growth,
whilst the tumor within the globe is quite small ; in these
cases the cells pass to the outside by means of the sheaths of
the bloodvessels, which are seen to be thickened and altered
by the presence of cells similar in character to those of the
tumor.
The state of tension of the globe is of importance, as it
helps us to form some idea of the progress which the new^
growth may have made. Thus, if the tension has steadily in-
creased to -t- 1, -f- 2, or + 3, we infer that the sclerotic coat is
still unaffected. If tension is reduced from + 1, 2, or 3, to
normal, this indicates that there may be thinning of this tunic.
Should the tension be diminished to — 1, — 2, or — 3, we
know that the sclerotic has given w^ay in one or more places,
and so offers no further resistance to the intraocular fluids.
The neighboring lymphatic glands are not affected, but
secondary sarcoma is liable to be set up in distant parts of the
body, the cells being conducted from this primary source by
170 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
means of the blood current. The liver is the organ which is
usually first aflected in this way.
The period of duration of sarcoma of the choroid varies
from a few months to several 3'ears.
The only intraocular tumor for which it might be mistaken
is that of glioma, which we shall see only occurs in young
children.
The treatnwit consists in the enucleation of the eye as soon
as the disease is recognized.
In removing the eye it is well to take away 4 to mm. of
the o[)tic nerve, and to examine the cut end of this after re-
moval. If it should be found to be pigmented or thickened,
as much of the remaining nerve as possible should be removed,
as well as any other tissues that may be considered to be at-
tacked by the new growth. Besides this removal with the
scissors or knife, the treatment of the orbital contents by means
of chloride of zinc paste should be rigorousl}' carried out, as
the only possible means of saving the life of the patient.
Congenital Affections of the Tunica Vasculosa.
Irideremia, or congenital absence of the iris, is occasionally
met with. Sometimes the iris is not altogether absent, but is
only represented by a mere rudimentary band of tissue, occu-
pying the periphery of the anterior chamber. This affection
is often accompanied by other defects of the eye, such as par-
tial dislocation of the lens, cataract, nystagmus, and imperfect
power of accommodation.
Coloboma iridis consists in a congenital cleft in the iris. It is
usually directed downwards, or downwards and slightly in-
wards, and may easily be mistaken for the gap which is made by
iridectomy. It varies in extent, and sometimes occurs in both
eyes. It is generally accompanied by coloboma of the choroid.
Persistent remains of the pupillary membrane are sometimes
found. This membrane is a foetal structure, which closes the
aperture of the pupil. Normally it disappears before birth.
"When persistent, it appears as one or more very slender
threads extending across the pupil, and attached to the ante-
rior surface of the iris. It can be best seen by the oblique
focal illumination.
IRIDECTOMY. 171
Coloboma of the choroid is a congenital deformity, which con-
sists in the absence of a more or less considerable portion of
this part of the tunica vasculosa at the lower and internal
part of the globe. When examined by means of the ophthal-
moscope, it appears of a bluish-white color; a few small ves-
sels are seen scattered over its area, and masses of pigment,
varying in quantity, are sometimes present. The surface of
the sclerotic olten appears very irregular. The extent of the
coloboma is variable ; it usually extends from the edge of the
optic disk nearly as far as the ciliary body. It may embrace
the optic disk, in which case the latter is changed in appear-
ance, and looks as if it were hypersemic by contrast with the
white area round it. It may occur in the yellow spot region ;
it is often accompanied by a coloboma of the iris. Occasion-
ally it occurs in both eyes, but when unilateral the left eye is
most commonly afiected. There is of course a large scotoma
in the visual field, corresponding to the extent of the coloboma,
but otherwise the sight in some cases is fairly good.
Operations on the Iris.
Iridectomy consists in the excision of a portion of the iris.
This operation, as is mentioned under the diti'erent headings,
is frequently performed in various affections of the eye ; it
forms the preliminary stage of some of the operations for the
extraction of cataract; it constitutes a prominent feature in
the treatment of glaucoma; it is occasionally resorted to in
purulent infiltration, and in certain forms of ulcer of the cor-
nea; it is adopted, with great benefit, in mau}^ cases of chronic,
recurrent, and serous iritis, of irido-choroiditis, and of anterior
staphyloma.
Iridectomy is also resorted to in the majority of cases in which
an artificial pupil is required for optical purposes, as in central
opacities of the cornea, which cover up the front of the
pupil, and so prevent vision. Also in some forms of cataract,
as the lamellar and the anterior pyramidal, which, having be-
come stationary, are still sufficiently clear at the peripheral
zone to admit of distinct vision, after an artificial pupil has
been made.
172 DISEASES OF IRIS, CILIARY BODY. AND CHOROID.
The instruments required for iridectomy are: (1) speculum,
Fig. 31 ; (2) fixation forceps, Fig. 32 ; (3) either a bent trian-
gular keratome, Fig. 41, or von Graefe's cataract knife. Fig. 42;
Fig. 41.
Kent Triangular Keratome.
Fig. 42. — Graefe's
Cataract Knife.
Fig. 43.
Iris Forceps.
(4) a pair of straight or curved iris forceps. Fig. 43 ; (5) a pair
of iris scissors. Fig. 44 or 45.
IRIDECTOMY,
173
The operation varies in detail according to the object with
which it is performed. It is divided into two stages; the first
stage consists in opening the anterior chamber by an incision of
the sclerotic or the sclero-corneal junction, the second in seiz-
ing, drawing out, and excising the portion of iris to be re-
FiG. 44. — Iris Scissors.
Fig. 45. — De Wecker's Iris Scissors.
moved. When the operation is intended for the relief of
glaucoma, or for the purpose of subduing or preventing in-
flammatory affections, the iridectomy should be made in the
upward direction, so that the gap thus formed in the iris shall
be situated beneath the upper eyelid. The patient must be
thoroughly anaesthetized upon a firm table or couch, of such a
174 DISEASES OF IRIS. CILIARY BODY, AND CHOROID.
heiorht that his head reaches the level of the umbilical reorion
of the operator, who stands behind the patient's head. The
eyelids are kept open by means of a spring-stop speculum
(Fig. 31), and the globe is held steady by seizing the conjunc-
tiva and subconjunctival tissue with fixation forceps (Fig. 32)
at the part immediately opposite to that at which the incision
is about to be made. A bent triangular keratome (Fig. 41) is
then deliberatel\' inserted into the sclerotic at from 1 to 2 mm.
from the edge of the cornea, and pushed downwards across the
anterior eliamber until the wound thus made is from G to 8
Fk;. 46. — Iridectiimv with Keratome.
mm. wide (see Fig. 46). In doing this, tiie instrument is passed
in obliquely and in such a direction that if continued it would
cause a wound of the iris and lens; as soon, therefore, as its
point is seen through the clear cornea, the handle is slightly
depressed, so as to bring the blade into a plane anterior and
parallel to that of the iris (Fig. 46).
The keratome is now steadily withdrawn. In doing this it
is important to keep its apex well away from the plane of the
iris and lens. Its withdrawal is accompanied by an escape of
the aqueous, which may cause protrusion of the iris between
the lips of the wound.
The keratome is now laid aside, and the fixation forceps
IRIDECTOMY.
175
entrusted to an assistant, who, if necessary, holds the globe
in a state of slight rotation downwards, but without undue pres-
sure or traction. The closed iris forceps (Fig. 43) are now
passed into the anterior chamber, the iris is seized near its
pupillary edge, and dragged just outside one angle of the
wound; whilst slight traction is made upon it in this position
a snip is made through its outer part with the iris scissors
(Figs. 44 and 45) in the manner shown in Fig. 47; the por-
tion of iris held in the forceps is then gently drawn across to
the other angle, and the excision completed as near to its per-
iphery as possible. Finallj', the curette, or the probe (Fig.
28), should be passed into the angles of the wound, so as to
Fi(i. 47. — The Iridectomy.
liberate any portion of iris that is entangled there, and the
edges of the wound are brought into exact apposition. The
speculum is then removed, the eyelids are gently closed, and
a light compress of wet lint and a bandage are applied.
When the anterior chamber is very shallow, by the bulging
forwards of the iris and crystalline lens, the danger of wound-
ing the latter is lessened by the use of the linear knife (Fig. 42),
as in the preliminary iridectomy for cataract extraction. (See
Cataract.) Some surgeons, however, always make use of the
linear knife in performing iridectomy.
Mr. Streatfeild makes an incision at the peripher3' of the
cornea by the use of a Sichel's knife. (See Cataract.)
When the operation is required for optical purposes only,
176 DISEASES OF IKIS, CILIARY HODY, AND CHOROU),
^
the position of the new pupil necessarily depends upon that
of tlic lesion of the cornea. The best position, when possible,
is either downwards and slio^htlv inwards, or straio;ht down-
wards. The object here is not to remove a largo
portion of the iris, but only so much as is neces-
sary for distinct vision. Instead of the large
bent keratome, a narrower one (broad needle,
Fig. 48) is employed for the first stage of the oper-
ation. The position of the first incision must de-
pend upon the situation in which the new pupil
is required. AVhen this is only slightly eccentric,
the incision can be made just within the margin
of the cornea. When the pupil is required to be
Fir. 49.— Iridectomy for Artificial Pupil.
opposite the margin of the cornea, the incision
must be made in the sclerotic, about 1 mm. beyond
the sclero-corneal junction. The width of the in-
cision should in either case be at least 3 mm.
The globe is fixed by the assistant. The iris
forceps. Fig. 43, are now passed into the anterior
chamber, and the iris seized at its pupillary edge
and gently withdrawn through the wound, and,
whilst held in this position, the portion which is
outside the wound is snipped off close to the
globe with the iris scissors (see Fig. 49).
When the pupil is required to extend quite to the margin
Fig. 4S.— Bent
Broad Needle.
IRIDECTOMY,
177
of the cornea, slight pressure should be made upon the globe
with the scissors as the iris is being cut away.
Instead of the iris forceps, a Tyrrel's hook (Fig. 50) may
be used. This is introduced on the flat, and passed as far as
the centre of the pupil ; it is then half rotated
downwards and withdraw^n so as to catch the
edge of the pupil, by which means the iris is
extracted, and cut ofi'as before.
The accidents and complications of iridec-
tomy. — 1. The lens may be wounded, either
during the insertion or the withdrawal of the
keratome. This is a very serious accident, as
it is sure to be followed by partial or complete
cataract.
2, The blade of the keratome may get
be.tween the layers of the cornea, instead ot
passing directly into the anterior chamber.
This accident arises from its being held too
obliquely at the commencement of the inci-
sion. As soon as this condition is discov-
ered, the instrument should be immediately
withdrawn, and another position selected for
a fresh incision ; if, however, the blade has
finally entered the anterior chamber, so as
to cause escape of tbe aqueous, the eye had
better be bandaged up at once, and the op-
eration postponed for at least twenty-four
hours, in order that a re-secretion of aque-
ous may take place before the knife is again
allowed to enter the anterior chamber. With-
out this precaution the iris and lens are so
pushed forwards after the escape of aqueous
that they are sure to be wounded at the time
of the fresh incision.
3. When the incision is made in the scle-
rotic, there may be considerable hemorrhage into the anterior
chamber either before or after the excision of the iris. The
blood can usually be made to flow out by depressing the upper
lip of the wound with the curette. When the excision of the
12
Fig. 50.— Tyrrel's
Hook for Iridectomy.
178 DISEASES OF IRIS, CILIARY BODY, AND CHOROID.
iris is completed, no anxiety need be entertained on account
of the presence of a moderate amount of blood in the anterior
chamber, as it usually becomes absorbed within a few days.
Iridodesis (T. Critchett) consists in drawing the pupillary
edo*e of the iris through a small opening in the margin of the
cornea, and securing it by a fine silk ligature on the outside.
The incision is made immediately in front of the sclero-
corneal junction, by means of a broad needle, bent at an ob-
tuse angle. The needle is then removed, and a loop of fine
black silk is placed immediately around the wound. A Tyr-
rel's hook or a pair of iris forceps is then passed through the
loop and wound into the anterior chamber, and the pupillary
edge of the iris seized and withdrawn through the wound to
the desired extent. Whilst the iris is held in this position by
the operator, the two ends of the ligature are picked up by the
assistant, by means of broad cilia forceps; they are then tight-
ened close to the surface of the cornea, and the knot is com-
pleted. The strangulated portion of iris quickly shrinks, and
the ligature can be removed after a few days. By this means
the original pupil is shifted to one side, and a new, somewhat
pear-shaped pupil is formed.
This method is particularly useful in certain cases of conical
cornea and lamellar cataract, also where a central nebula of the
cornea is sufficient to blur the vision, though not to exclude
the light ; the original pupil being obliterated by the traction
upon the iris, the rays which formerly passed through the
nebula are now excluded, whilst the new pupil only admits
those rays which pass through the clear part of the cornea.
Iridodesis was formerly practised somewhat extensively by G.
Critchett, Bowman, and others ; but the occurrence of sympa-
thetic irritation and of sympathetic ophthalmitis in a few cases
in which the operation had been performed has caused it to be
less frequently adopted.
Iridotomy (iritomy) consists in the formation of artificial
pupil by simple incision of the iris. It can only be safely
adopted when the crystalline lens is absent, and is mostly
applied to those cases in which the iris has become tightly
drawn upwards toward the cicatrix as the result of inflamma-
tion after the extraction of cataract.
IRIDOTOMY. 179
Operation. — The eyelids being separated, and the globe
steadied, as in the previous operations, a narrow lance-shaped
keratome, Fig. 41, is plunged through the upper part of the
cornea about 2 mm. from the sclero-corneal junction, it is then
pushed onwards through the membranous exudation to the
back of the iris, and finally withdrawn. The iridotomy scis-
sors (Fig. 45) are now passed through the corneal wound, tlieir
blades being closed ; as soon as they reach the iris one blade is
passed behind and the other in front of that structure, which
is now divided by a single snip from above downwards; this
single incision is usually followed by immediate separation of
the cut edges so as to form a slit-like or triangular pupil. In
some cases it is necessary to make a second incision at an acute
angle with the first, so as to include a Y-shaped piece of iris,
which can either be left to atrophy or be removed. My col-
league, Mr. Anderson Critchett, has a dexterous method of
detaching and bringing away this triangular piece of iris with
the same iridotomy scissors,
Iridotomy is also practised by de Wecker and others for
the production of artificial pupil in certain cases of lamellar
cataract, etc. ; the advantage claimed being that the small slit-
like aperture thus obtained is better for optical purposes than
the larger opening produced by even a small iridectomy. In
such a case the incision in the cornea must be made at the
side opposite to that at which the new pupil is required ; it
should be about 4 mm. wide. De Wecker's iridotomy scis-
sors (Fig. 45) are now carefully introduced to the anterior
chamber. Having reached the pupil, the blunt-ended blade is
passed behind the iris between it and the capsule; the other
blade, which is usually gilt, is passed in front of the iris in the
direction of the desired pupil ; the iris is now divided by a
single cut, and the closed instrument is cautiously withdrawn.
CHAPTER VII.
DISEASES OF THE OPTIC NERVE AND KETINA.
ANATOMY AND PHYSIOLOGY OF THE OPTIC NERVE — ASPECT OF THE HEALTHY
DISK — PHYSIOLOGICAL CUP — SCLEROTIC RING — ANATOMY OF THE RETINA
— PHYSIOLOGY^ OF THE RETINA — ASPECT OF THE HEALTHY RETINA PUL-
SATION OF THE RETINAL VESSELS — HYPEREMIA OF TUK OPTIC DISK
OPTIC NEURITIS — OPTIC ATROPHY HEMORRHAGES OF THE OPTIC NERVE —
OPAQUE NERVE-FIBRES — RETINAL ISCHj:MIA — EMBOLISM OF THE CENTRAL
ARTERY — RETINAL HEMORRHAGES— ALBUMINURIC RETINITIS — SY'PHILITIC
RETINITIS PIGMENTARY RETINITIS DETAOHMKNT OK THE RETINA —
(iLIOMA OF THE RETINA — PSEUDO-GLIOM A
Anatomy and Physiology of the Optic Nerve. — Each optic tract
arises by two roots, of which the external takes origin from
three centres of gray matter, viz., the optic thalamus, the ex-
ternal geniculate body, and the anterior tubercles (nates) of the
corpora quadrigemina ; while the internal arises from the in-
ternal geniculate body and the posterior tubercles (testes) of
the corpora quadrigemina. These centres of gray matter are
connected with the cerebral cortex by a system of iibres con-
stituting the most posterior part of the optic thalamus (cortico-
optic-radiating fasciculi — Charcot). Recent clinical observa-
tions point to the angular gyrus, and its neighborhood in the
occipital lobe, as the cortical centre of vision. The optic tract
formed by the union of these two roots then passes forwards
along the posterior inferior surface of the optic thalamus,
crosses the crus cerebri, runs along the side of the tuber ciu-
ereum, and in front of the infundibulum unites with the optic
tract of the opposite side to form the optic commissure. In the
optic commissure the fibres of each optic tract undergo semi-
decussation (Fig. 51, p. 223). From the optic commissure the
two optic nerves arise, and pass forwards and outwards to the
two optic foramina. As they pass through these, they become
ANATOMY AND PHYSIOLOGY. 181
invested b}^ prolongations from the pia mater and the dura
mater of the brain. Each nerve is about 4 mm. in diameter,
and its orbital portion is about 28 mm. in length. The nerve
is made up of numerous bundles of nerve-tibres, with inter-
vening septa of connective tissue. The ophthalmic artery
entirely supplies the optic nerve with blood.
Near the globe (about 10 mm. behind it) the optic nerve is
])enetrated by the central artery of the retina with its vein.
These are accompanied bj- distinct lymphatic sheaths, and pass
obliquely to the centre of the nerve. The central artery of the
retina does not supply the optic nerve with blood, though it
gives oif a few minute branches immediately behind the lamina
cribrosa, which pass forwards in a parallel direction to supply
that structure and the optic papilla.
The fial sheath (see Fig. 1, opposite p. 182) is a iibro-vascular
structure, which closely invests the nerve, and sends off numer-
ous bands between the fibres of the latter, so as to form a net.
work of trabecular tissue ; the trabecul?e thus formed give off
still finer connective-tissue filaments, wdiich extend between the
nerve-fibres. The pial sheath terminates anteriorly by blend-
ing with the inner fibres of the sclerotic at the edge of the
optic disk. It is supplied ^^At\\ blood from the branches of
the ophthalmic artery, and thus, by its continuity with the pia
mater, establishes arterial communication between the intra-
cranial and orbital arteries.
The dared sheath forms a complete fibrous investment to the
nerve, and terminates anteriorly by blending with the sclerotic
at the optic nerve entrance.
The intersheath space is the space between these two mem-
branes, and is considered to be a lymph-space (Schwalbe). It
is imperfectly divided by a delicate prolongation of connective
tissue from the arachnoid membrane of the brain ; this is at-
tached partly to the dural, and partly to the pial sheath. The
intersheath space communicates posteriorly with the subarach-
noid space of the brain, and anteriorly with certain lymph-
spaces in the optic nerve at the lamina cribrosa.
The optic disk or papilla is formed by the radiating fibres of
the optic nerve immediately after their passage through the
openings in the sclerotic and choroid at the back of the eye.
182 DISEASES OF THE OPTIC NEKVE AND RETINA.
The sclerotic ojpenmg, as we have just seen, is guarded by the
lamina cribrosa. In front of this is a delicate layer of connec-
tive tissue containing capillaries, which is derived from the cho-
roid. The capillaries of the disk are supplied from three sources,
vi^., the posterior short ciliary arteries of the choroid, the cen-
tral artery of the retina, and the arterial twigs of the pial sheath.
These three sets of vessels anastomose freely at the optic disk.
As the nerve-fibres pass through the lamina cribrosa they
become divested of their medullary sheaths (white substance of
Schwann), and are reduced to axis-cylinders only, surrounded
by a little transparent gelatinous substance (neuroglia). Being
thus rendered quite transparent, they radiate toward the retina.
^Vhen examined with the ophthalmoscope the healthy optic disk
usually appears as a whitish circular area surrounded by the
orange-colored groundwork formed by the choroid. It usually
has a slight pinkish tint, such as is represented in Figs. 1 and
2, opposite p. 150, but its appearance is subject to numerous
slight variations, which can only be learned by frequent exami-
nation of healthy fundi. The white reflection is caused chiefly
by the lamina cribrosa which shines througb the transparent
nerve-fibres, partly by the white substance of the nerve-sheaths
which terminates just behind the disk ; it is usually most marked
at the outer part of the disk, where the fibres are thinnest. The
pinkish tint is due to the presence of capillaries, and is more
marked when these are distended than when they contain but
little blood. In fair persons, in whom the pigment layer of the
retina is thin, the disk often appears darker by contrast with
the rest of the fundus than in persons of dark complexion. It
occasionally happens that the disk looks quite white, although
the visual and other functions of the eye are normal.
The central artery of the retina is seen to emerge from the
depths of the optic nerve rather to the inner side of the centre
of the disk; it sometimes divides before traversing the lamina
cribrosa, but more commonly its point of bifurcation is anterior
to that structure, and can be seen from the front. The two
chief divisions thus formed pass vertically, the one upwards
and the other downwards, to the retina. (See Retina.) The
central vein accompanies the artery, and is distinguished by its
somewhat darker color and larger size.
Upti^JOlSh.
utclI Srheai'h.
HI ^W1 f^^-4.^,v;.; ;:;•; ■:::}■: . i ■ ;•■ -e;.i ■■ ■:■■■ -■■ uA: l ^M -^i « ? ^h ca u.
F,,;. 1. —Normal optic disk. X about 40 dinm.
OpHedish. ^.^ .
V: \
— 'Reiin-a,.
■ ChomolSL
J^
Fig. 2.— Optic neuritis (vertical). . about 50 diam.
J)urdl shcalTu
Jntershecdh spate.
TioJ sheath.
Tfdbeeular tiesue.
Fig. ;?.— Opti.' neuritis (transverse). X 96 diam.
To face p. 182.
ANATOMY AND PHYSIOLOGY. 183
Aloiiff the mare^in of the disk there is often seen a small
patch or line of dark pigment. It may occur at any part of
the circumference, and is of no pathological importance.
The physiological cup. — On examination by the direct method
the optic disk frequently presents an excavation at its centre,
just at the point of emergence of the central vessels. This
is due to exposure of the central part of the lamina cribrosa
by the divergence of the nerve-fibres (see Fig. 1, opposite
p. 192). The central hollow thus formed is known as the
physiological cup or pit; it is usuall}' funnel-shaped, and
varies considerably in extent, but it never extends to the ex-
treme edge of the disk, as is the case in glaucomatous cup-
ping. Moreover it does not interfere with visual acuity.
The sclerotic ring is another feature of the normal disk
which is frequently observed. It is a whitish ring situated at
the edge of the disk, which is caused by the aperture in the
choroid being somewhat larger than that in the sclerotic, so
that the eds^e of the latter is seen as a white band throusrh the
transparent nerve-fibres. It is often more visible on the outer
side of the disk than throughout the rest of its extent, owing
to the fact that the optic nerve fibres are thinner at that part.
It can generally be seen as a complete ring when the optic
nerve fibres are atrophied.
The optic disk is usually circular in form ; in some cases,
however, it appears somewhat elongated in one direction. This
may be its real condition, in which case its form will be the
same in whatever way it is examined, or the oval appearance
may be due to astigmatism. If due to astigmatism, examina-
tion by the indirect method will show that the direction of its
long axis and its length compared with the short axis vary with
the position of the lens. The average diameter of the disk is
about 1.6 mm. ; its apparent size varies with the refractive
condition of the eye. (See Refraction.)
The retina is a delicate membrane containing the terminal
end-organs of the fibres of the optic nerve, supported by a
connective-tissue framework. It lies between the choroid and
the vitreous humor, and extends from the optic disk to the
outer part of the ciliary processes, where it presents a finely
indented border, the ora serrata. At this point the nervous
elements of the retina cease, but the connective-tissue frame-
184 DISEASES OF THE OPTIC NERVE AND RETINA.
Avork is continued forwards under the name of the pars ciliaris
reiince as far as the zonula. At tlie back of the retina is a
laA'er of hexagonal pigment cells which is continuous with the
pigmentar}' laj'crs of the iris and ciliary body already described.
This layer adheres to the choroid when the latter is separated
from the retina ; it was formerly considered to belong to that
body, but the study of the development of the part shows that
it belongs to the retina. By carefully removing the anterior
portion of the globe with scissors, and clearing away the vit-
reous (immediately after an eye has been excised from the liv-
ing subject), we tind that the inner surface of the retina is
smooth, and that its substance is quite transparent. About 3
mm. to the inner side of the posterior pole of the globe is seen
a white circular disk of about 1.6 mm. diameter. This is the
opiie dish ov papilla (p. 181), from the centre of which the radi-
ating retinal vessels are plainly visible. At the posterior pole
the brown color of the pigmentary layer is observed to be in-
tensified over a small area: this is the yellow spot {macula
lu(ca), and if the segment of the globe be placed in water and
examined under a low power of the microscope, this area will
be found to be depressed at the centre; the depression is the
fovea centralis. In some cases also there will be found a yel-
lowish appearance, hence the name of yellow spot which has
been given to this, the most sensitive portion of the retina, al-
though in many cases the difference of color between this re-
gion and the remainder of the retina is extremely slight. The
yellow spot region is about 1.25 mm. in diameter, and is some-
what elliptical in shape, the long axis being horizontal.
Microscopic Anatomy. — The elementary structures of the re-
tina are arranged in several layers, the chief of which are
shown in Figs. 1, 2, and 3, on the opposite page. These may
be enumerated from before backwards, as follows :
1. The inti'rruil limiting membrane 7. The outer granular layer.
2. The nerve-fibre layer. 8. The outer limiting membrane.
3. The ganglionic layer. 0. The rods and cones.
4. The inner molecular layer. 10. The pigmentary layer.
5. The inner granular layer. 11. The connective-tissue framework.
6. The outer molecular layer.
1. The internal limiting membrane is very thin and imperfect;
its inner surface rests against the vitreous humor, while its
Fig, 1. — Section of human retina.
(Diagrammatic, Seiiultze.)
'iS^ Inner ananuiui*
:,o,
U9
"J — Outer nranvlur
Fic. 2. — Hemorrhagic retinitis. X about loO diam.
TliicXened arterii.
»,', *.
f ;:?
•lar
Outfr nrn.n
la^er.
.^_„,. ted.
-' (jiood-cor-p-ixsculis.
— __ i^ — -Lajjer of rods Sccriee.
Fir.. .".—Albuminuric retinitis. X about IfiO diam.
Til face p. 1S4.
ANATOMY AND PHYSIOLOGY. 185
outer surface is in contact with the nerve-fibre layer, and is
intimately connected with the terminal extremities of the
fibres ot Miiller.
2. The nerve-fibre layer is formed by the fibres of the optic
nerve on their way to the ganglion cells: these, as we have
seen, consist simply of the axis-cylinder surrounded by a little
neuroglia.
3. The layer of ganglion cells is composed of structures sim-
ilar to those of nerve centres. They are multipolar cells con-
taining a nucleus and a bright nucleolus; their prolongations
are directed inwards to communicate with the axis-cylinders
of the nerve-fibre layer, and outwards toward the inner mole-
cular layer.
4. The inner molecular layer is composed of fine fibrillfe ir-
regularly disposed amongst gray amorphous molecules.
5. The inner granular layer (inner nuclear laj-er) consists of
two kinds of cellular elements, and two kinds of fibres. The
larger cells are nerve-cells, and are similar to the bipolar gan-
glion cells, having a large nucleus and a small nucleolus.
Each of these cells has two tail-like processes — one passes to
the outer granular layer to anastomose with the nerve-element
of that part, the other goes inwards, and is lost in the inner
molecular layer. The other cells of this layer are connected
with the fibres of Miiller.
6. The outer molecular layer is similar to the inner mole-
cular.
7. The outer granular layer (or outer nuclear) consists of nerve-
elements and of connective-tissue elements, like the inner
granular layer. The nerve-elements consist of bipolar cells
(containing nuclei and granules), from which delicate fibres
pass inwards to the inner granular layer, and outwards to the
rods and cones. The nuclei thus connected with the cones
are situated nearer to the external limiting membrane than
those communicating with the rods, the cone-fibres l)eing
shorter than the rod-fibres.
8. The external limiting membrane is the expansion formed by
the terminal extremities of the fibres of Miiller.
9. The layer of rods and cones is the most important part of
the retina. The rods are cylindrical in form; the cones are
186 DISEASES OF THE OPTIC NERVE AND RETINA.
shorter, thicker, and bulged at the inner extremity whilst they
terminate externally by a tapering filament. The rods and
cones are placed side by side, perpendicularly to the plane of
the retina, between the external limiting membrane and the
pigmentary layer. They are divided into tM'o segments, an
outer and an inner. The outer segments present a fibrillated
structure, and have a remarkable tendency to split up spon-
taneously into higlily refractile, superposed, circular disks,
presenting the ap[tearance of a pile of coins; they are unaf-
fected by carmine, iodine, or other stains. The inner seg-
ments are singly refractile, stain with carmine, are finely
fibrillated, and are connected by fine filaments with the nuclei
in the outer granular layer.
10. The 'pigmentary layer bounds the retina externally. It
consists of a single layer of hexagonal nucleated cells. The
outer surface of each cell is smooth, flattened, and devoid of
pigment; the inner surface is loaded with pigment granules,
and is prolonged by filamentous processes into the region of
the rods and cones.
11. The connective-tissue framework is composed of fibres
called the fibres of Mullei^ which traverse the various retinal
layers from the external to the internal limiting membrane,
and which spread out on reaching each of these layers. Some
writers assert that the fibres of Miiller are epithelial structures,
and do not belong to the connective tissues, being derived from
the ectoderm, or neuro-epithelial layer of the embryo.
At the yellow spot the structures just mentioned become
greatly modified. There are no rods, and the cones which
occupy this region are elongated, and narrower than in other
parts of the fundus. All the other layers are greatl}' thinned
at the fovea centralis, but toward the margin of this they are
for the most part thicker than over the rest of the retina. The
ganglionic layer is especially increased in thickness. The
nerve-fibre layer becomes gradually thin toward the edge of
the fovea, owing to the dipping of its fibres to join the gan-
glion cells.
At the ora serrata the layers of the retina terminate almost
abruptly ; only the fibres of Miiller are continued as trans-
parent, columnar, epithelial-like cells, each with an oval nu-
cleus (Schwalbe).
ANATOMY AND PHYSIOLOGY. 187
The vascular supply of the retina is derived entirely from
the central artery of the retina, with the exception of a slight
anastomosis with the choroidal vessels at the optic disk. There
is no anastomosis with the ciliary vessels at the ora serrata. The
artery breaks up into an upper and lower branch on the disk.
These branches then bend outwards, giving off twigs in their
course, and describe a large ellipse around the yellow spot.
A great number of capillary meshes are formed around the
latter, and in its outer margin, but no vessels reach the fovea
centralis. Each artery has generally a vein accompanying it,
so that, as a rule, four chief vessels are seen upon the disk.
The larger vessels occupy the nerve-fibre layer, but the capil-
laries ramify wholly in the middle portion of the retina, and
never pass external to the inner granular layer. There are
two chief networks of capillaries, one in the inner molecular
layer, and the other in the layer of ganglion cells.
The lymphatics of the retina exist around the vessels in the
form of perivascular lymph-spaces. They can be injected from
the optic nerve beneath the pial sheath (Schwalbe).
Physiology of the Retina. — The rods and cones of the retina
may be considered as the terminal organs of the optic nerve.
Their function is to receive the waves of light which impinge
on the retina, and to convert the vibrations of these into im-
pulses which are capable of being conducted along the nerve-
fibres of the retina, the optic nerve, and optic tract, to the
brain (see Fig. 50). The effect produced in the brain is per-
ceived by the mind as the sensation of light. The organ in the
brain with which these are connected being incapable of con-
veying to the mind any other sensation than that of light, the
same sensation is produced whether the stimulation is mechan-
ical, electrical, or what not, and in whatever part of the course
of the conducting chain it is applied.
It is generally believed that the ethereal undulations which
constitute light, having traversed the retina, are reflected from
the choroid. In their passage back through the retina they
are polarized by the outer segments of the rods and cones, and
the luminous movements are changed into molecular movements
wdiich traverse the retinal layers to reach the nerve-fibres, whence
thev are conducted to the brain.
188 DISEASES OF THE OPTIC NEKVE AND KETINA.
In consequence of the optical properties of the eye and the
arrangement of the retinal elements, each of the latter receives
light from one point in the visual Held, and from no other;
this correspondence between the element which is excited and
the position of the point from which the light proceeds enables
us to judge of the relative position of the points where images
are formed in the retina. Our judgment, however, receives
much unconscious support from other senses, and many sen-
sations which seem to be simply visual — such as the sense of
size, distance, and solidity — are in reality complex, and de[)end
to a great extent on the teaching of experience, on muscular
sense which tells us the position the eyes are in, on the amount
of convergence and accommodation used, and on a comparison
with well-known objects.
For distinct y\sioi\ the image of the object must fall upon the
yellow spot, or rather its central part, the fovea centralis. This
is called direct vision, in opposition to indirect vision, which oc-
curs when the image falls on any other portion of the retina.
In order that two points may give rise to separate visual im-
pressions their images must be at least 0.002 mm. apart; for,
since this is approximately the diameter of the cones, images
which are nearer together than this will only stimulate one
cone, and therefore give rise to but one visual impressipn.
Over the optic disk there is no retina, and therefore no per-
ception of light, hence this point is called the blind spot, and
its existence is shown by the familiar experiment of making a
dot and a small circle about 5 cm. apart, the dot being placed
to the left. If, wiih the left eye shut, the right eye views the
dot steadily when held near to and in front of the eye, the circle
will usually be also in view. On moving the paper slowly away
from the eye the circle will be found to vanish, and on moving
it still further away it will again come into view. When it
vanished from sight its image fell wholly on the blind spot.
This occurs when the distance of the dot from the eye is
about four times that between the dot and the circle. The
percipient elements of the retina are the rods and cones,
especially their outer segments. This is proved by the fact,
tirst, that only cones are found over the fovea centralis;
secondly, that the vessels of the retina can be perceived en-
ANA-TOMY AND PH.YSIOLOGY. 189
toptically under certain conditions. If a thin metal disk,
having a pin-hole aperture at its centre and a piece of pale
blue glass behind it, be rapidly moved in a small circle in
front of the pupil while we steadily look through the pin-hole
at a white cloud, a complete outline of all the network of cap-
illaries around the fovea centralis can be speedily obtained.
Purkinje's experiments, as described in text-books of physi-
ology, also show the existence of the bloodvessels to be in
front of the sensitive elements of the retina.
Corresponding retinal areas. — In order that the two retinal
images of an object may give rise to a single visual impres-
sion, it is necessary that images should fall upon correspond-
ing retinal areas. Thus the upper halves of the retinae corre-
spond, and also the lower halves ; but the nasal side of one
retina corresponds to the temporal side of the other, and vice
versa. When w-e see (in indirect vision) to the left side, it is
not so much with the external part of the right as with the
internal part of the left retina, and vice versa. Now all rays
affecting the external aspect of the retina come from the nasal
visual field; and this Held, tested separatel}' for each eye, is
always found delicient in extent compared to the temporal
visual field, even wdien the influence of the projecting bridge
of the nose is eliminated (Landolt). It is probable that it is
only when the images fall near the central part of the retina
that they continue to form a single visual impression; when
one falls near the centre, and the other on a very peripheral
part, the latter image, being less intense, is disregarded.
The ophthalmoscopic appearance of the retina. — When the
healthy fundus is examined by the direct method, and with a
bright illumination, the retina is, in the majority of cases,
found to be perfectly transparent. It reflects little or no light
and offers no resistance to that reflected from the choroid, and
is therefore quite invisible — in fact, were it not for the presence
of its bloodvessels, it would be impossible by this test alone to
assert that the retina existed. When only a feeble ilkimina-
tion is used, a slight brilliant reflex can be obtained from
the region immediately surrounding the optic disk. This is
caused by reflection of the light from the curved surface,
where the flbres of the nerve are spreading out to reach the
190 DISEASES OF THE OPTIC NERVE AND RETINA.
retina. The appearance is difficult to describe ; it varies with
each tilting of the mirror, is somewhat like the reflection from
shot-silk, and is lost in the red reflex from the choroid when
the intensity of the light is increased. In certain cases, how-
ever, there is a retinal reflex of this nature whatever the in-
tensity of the illumination ; this usually obtains in young
children, and in persons of very dark complexion, in whom the
choroid is highly pigmented. Along the course of the vessels
also this may be usually observed in the form of a bright line;
it is distinguished from a pathological change by the fact that
the reflection will shift from one side of the vessel to the
other by the slightest movement of the mirror.
The yellow spot is to be sought on the outer side of the optic
disk, at a distance equal to twice the diameter of the latter.
In many cases, especially in adult fair persons, the healthy
so-called yellow spot presents the appearance shown in Fig. 1,
opposite p. 150 ; that is, it differs but little, if at all, in color
from the surrounding fundus, and can only be distinguished
from the other parts of the retina by the absence of visible
vessels, and by its position with regard to the optic disk. In
the majority of eyes, however, there is an intensification of
the color, giving an appearance similar to that shown in Fig. 2,
opposite p. 150. In some cases, more especially in young
subjects and in dark eyes, a small, yellowish, somewhat brilliant
spot is seen ; this is the fovea centralis. It is surrounded by
an ill-detined dark area, and around this again there is some-
times a grayish halo, which changes its appearance when the
mirror is tilted.
The vessels of the retina are easily distinguished from those
of the choroid by their radiating course, their dichotomous
mode of branching, their clearness of tint, and their well-
defined outline.
The peripheral as well as the central portions of the retina
should always, as far as possible, be examined ; these are
better seen when the pupil has been previously dilated. The
ophthalmoscope should be held as close to the cornea as pos-
sible (about 5 mm,), and the patient told to look successively
in the outward, inward, upward, and downward directions;
this brings into view the outer, inner, upper, and lower por-
APPEARANCE OF THE HEALTHY RETINA. 191
tions of the retina respectively. In order to see the lower por-
tion when the patient looks downwards it is necessary to elevate
the upper lid with the finger of the hand which is not holding
the ophthalmoscope. The examination of the peripheral parts
of the fundus is especially important because certain morbid
conditions — such as pigmentary retinitis, disseminated choroid-
itis, detachment of retina, and other affections, often make
their first appearance in that part, whilst the central portions
are apparently normal.
The arteries of the retina are from two-thirds to three-
fourths the size of the veins, they are lighter in color, and
their course is somewhat straighter.
Pulsation of the retinal veins is sometimes observed, even in
normal eyes. This is only seen upon the optic disk, and vari-
ous theories have been propounded as to its causation :
1. Donders considers it to be owing to the rhythmically in-
creased arterial tension communicated to the veins, the vitre-
ous body being less compressible than these. It occurs only
on the disk because here the tension of the veins is most
feeble. The pulsation thus appears in the diastolic arterial
interval.
2. Schon ascribes it to the pulsation of the artery communi-
cated to the vein as they lie together in the optic nerve.
Pulsation of the retinal arteries is very rarely found in normal
eyes, although both arterial and venous pulsation can be pro-
duced by digital pressure upon the globe during ophthalmo-
scopic examination. When it does exist it mav be due to one
of two local causes, (i) It may be nothing more than a pul-
sation communicated from a neighboring vein, in which case
the pulsation of the artery would succeed that of the vein.
(ii) It may arise from the fact that the branches at the disk
are given oft" at right angles to the main trunk immediately
after its bifurcation (Otto Becker).^ With these rare excep-
tions, therefore, the existence of arterial pulsation at the optic
disk is indicative of some pathological condition either of the
eye itself, of the orbit, or of the general circulation — e. g. :
1. Arterial pulsation may be caused by increased intraocular
1 Archiv fiir Ophth., vol. xviii., part i., p. 266.
192 DISEASES OF THE OPTIC NEKVE AND RETINA.
pressure which prevents tlie retinal arteries from becoming
filled except at the acme of the pulse-wave. It is not uncom-
mon in glaucoma; and when not occurring spontaneously in
glaucoma, it can usually be temporarily produced by very
slight pressure upon the globe, whereby the tension is still
more increased.
2. It is also occasionally seen in cases in which the trunk of
the central artery has become compressed, as in certain cases
of optic neuritis, and in tumors of the orbit where the optic
nerve is pressed upon.
3. The tension of eye being normal, arterial pulsation may
be caused by low arterial tension, arising from deficient action
of the heart. It is common in aortic regurgitation wiih hy-
pertrophy of the left ventricle in Basedow's disease, in syn-
cope following loss of blood, and it is said to be present during
the period of asphyxia in cholera.
Hypersemia of the disk is characterized by increased redness.
The large central vessels can be plainly seen, but the color of
the area of the disk is intensified; in severe cases its redness is
only with difficulty distinguished from that of the surrounding
region (see Fig. 2, on the opposite page). It is, as a rule, un-
attended by impairment of the visual function, although there
may be hypersensitiveness to light (photophobia), early fatigue
in reading, and indistinct pain in and around the globe.
Hyperemia is frequently found in the subjects of hyperme-
tropia and hypermetropic astigmatism. It is also common
amongst those who are obliged to work for long periods in &
bright light, such as gaslight. It is usually seen in the early
stage of optic neuritis.
In some cases the congestion is of a passive or venous na-
ture, resulting from obstruction to the return of blood to the
heart; under these circumstances the veins of the disk are
tortuous and distended, and its color is deeper than that which
occurs in active In'pereemia.
In trcniment the cause of this affection must be borne in
mind. Any existing error of refraction must be corrected h\
suitable glasses. Over-use of the eves must be discontinued,
and bright light avoided bv the use of neutral-tinted glasses.
Ftg. 1 . FtwswlogicaL cup of optic disc.
Fiq. Z. Comrrbenajuy optijC neLuxii-d
LEBON a> CO.
Ftg.Z. Neuro -retuiztLe -wxt/v hjduarwrrhjxges.
.rsoN ft ee
OPTIC NEURITIS. 193
Optic neuritis. Papillitis. — The optic nerve may be inflamed
in the whole of its course, or the signs of inflammation may
be most marked at one particular point, either within the
skull, within the orbit, or at the papilla within the globe.
It is with the last of these that we are chiefly concerned,
and, following the suggestion of Leber, we propose to use the
term papillitis in preference to " choked disk," " descending
neuritis," and other terms which are misleading as involving
theories of causation not yet proved.
The ophthalmoscopic signs of papillitis. — In the e<(rly stage, the
whole disk becomes swollen, and bulges forwards into the vitre-
ous, whilst its edge is blurred or invisible. Its color is at first
red, as in simple hypertemia (Fig. 2, opposite p. 192), or it
may be more livid from intense congestion ; this redness soon
becomes changed to a grayish opalescence. The veins are dis-
tended and tortuous, and are seen to bulge forwards and bend
abruptly as they leave the margin of the swelling.
At a later stage the opalescent haze may give place to a de-
cided opacity, which is of a pinkish or yellowish-white, more
or less striated appearance. Xot onl}' is the edge of the disk
now quite hidden from view, but the central vessels may be
obscured or only to be seen at some distance from the centre
of the disk (Figs. 1 and 2, on the opposite page); the veins
are now very large and tortuous, the arteries are either of
normal size, contracted, or quite hidden by the opacity of the
papilla. So great is the swelling of the disk in some cases,
that when examined by the direct method it can be seen with
a convex lens as high as 6 D. In many cases small hemor-
rhages may be distinguished in the form of elongated patches
running parallel to the directions of the chief vessels.
This aftection is seldom confined to the papilla; it can usually
be observed to invade more or less of the surrounding retina.
Fig. 1, on the opposite page, represents a case of this kind.
It was taken from a patient with a tumor in the left cerebral
hemisphere. The papilla is immensely swollen, and its out-
line is lost, the vessels are quite obscure at the centre of the
disk, the veins are tortuous, and the retina is aflected with a
general haziness which obscures the vessels at certain points.
(See Retinitis.)
13
194 DISEASES OF THE OPTIC NEKVE AND RETINA.
At a later stage still (post-papillitic) these changes in the ap-
pearance of the disk undergo gradual subsidence. At the end
of some weeks or months the opacity begins to disappear, and
the edge of the disk may be seen as through a mist ("wooll}'
disk"), which gradually becomes less and less. The edge of
the disk is thus again brought into view, and may present the
same appearance as it did before the papillitis, or its outline
may be somewhat irregular. The vessels gradually become
less tortuous, and may undergo permanent contraction. The
area of the disk may resume its normal pinkish tint, or may
be more or less blanched. (See Atrophy.)
Other si/mpto)ns of papillitis. — It is remarkable that consider-
able swelling and haze of the optic disk may exist before the
patient experiences any serious interference with vision. Thus,
there may be unimpaired visual acuity, good color-perception,
and an unrestricted visual field.
Vision is seldom much impaired until papillitis has existed
for some time. If resolution take place quickly, that is, be-
fore the inflammation has given rise to atrophy of the nerve-
fibres, there ma}- be no failure of vision at all, or the sight
having become affected even to a serious degree, may quite re-
cover. As a rule, however, it is common to find papillitis at-
tended with considerable derangement of vision. 1. Visual
acuity may be much impaired, or may even be reduced to
mere perception of light. 2. Color-vision, more especially for
green and red, may be considerably interfered with. 3. The
visual field may be found to differ from the normal in various
ways. The blind spot, that is, the scotoma corresponding to
the optic disk, is usually enlarged. The field for white may
be but slightly if at all contracted, Avhilst the field for green
may be nmch diminished or entirely lost. The field for red
may also be diminished. These changes in the visual field
become more marked as the atrophic changes set in.
Both eyes are usually affected, but the vision is generally
worse in one eye than in the other at the same time. The
appearance of a central scotoma for colors (such as is found in
tobacco amaurosis) is rare. Failure of vision usually comes
on gradually ; in some cases, however, it has been known to
be very considerable in the course of a few days.
OPTIC XEURITIS PATHOLOGY. 195
When blindness supervenes, as it unfortunately often does,
it generally does so gradually.
Pathology of paplllUis. — If we examine the optic nerve micro-
scopically, l)y making horizontal and vertical sections through
the region of the optic disk of an eye removed during the
acute stage of papillitis, we find all the trabecular tissue, the
neuroglia, and the bloodvessels infiltrated, with freely staining
nuclei. There is often, also, considerable oedema of the trabe-
cular tissue. The intersheath space of the optic nerve is also
affected ; it may be distended with fluid, and contain only a
few inflammatory nuclei, or there may be little or no fluid, but
many nuclei. The intraocular portion of the nerve (papilla)
is found to be swollen, and to bulge forwards into the vitreous
cavity. In thus starting forwards, it often causes separation
of the retina from the choroid near the edge of the disk, so as
to give to the section of the inflamed papilla a pedunculated
appearance. Figs. 2 and 3, opposite p. 182, are drawn from
well-marked specimens of optic neuritis occurring in a case of
acute meningitis. These were hardened in Miiller's fluid and
stained with logwood. On comparing them with Fig 1, which
represents a vertical section of the normal disk, similarly pre-
pared, the greatly increased number of nuclei is evident both
in the vertical and transverse sections. In the latter, it will
also be observed that the intersheath space is crowded with
these structures.
This condition of hypernucleation of the nerve, nerve-sheath,
and papilla is more marked in cases of meningitis than in pa-
pillitis arising from other causes. Recent observations,^ how-
ever, tend to prove that in all cases of papillitis there can usu-
ally be found more or less hypernucleation in the optic nerve-
trunk, as well as in the papilla; this may be more al)undant
at the disk than in the nerve-trunk, or vice versa.
The causes of papillitis. — 1. Intracranial diseases are by far the
most frequent ; they are said to give rise to at least four-fifths
of the cases of papillitis (Mauthner). Of these the most com-
mon is cerebral tumor. Next in frequency come meningitis
1 Vide Gowers on Medical Ophthalmoscopy, 1882; also Brailey, Walter Ed-
munds, Stephen Mackenzie, and Leher, in the Trans. Internat. Med. Cong., 1881,
and the Trans, of Ophthalm. Soc, 1881 and 1882.
196 DISEASES OF THE OPTIC NERVE AND RETINA.
and other inflaiiiniaton- atfoctioiis. Then follow abscess of
the brain, hydatid diseai>e of the brain, and cerebral softening
from vascular obstruction. 2. Be.nal disease — albuminuria,
glycosuria. 3. Local lesions of the eye — e. g.^ ulcer of the cor-
nea. 4. Lead foisoning. 5. Errors of refraction, more espe-
cially hypermetropia and astigmatism. 6. Amenorrhcea, aneeinia,
and other morbid states. 7. Local lesions in the orbit may cause the
unilateral form. 8. Syphilis.
The theories as to the cause of papillitis in cerel)ral disease
are chiefly as follows :
1. T/ie mechcuuail theory of von Graefe assumed venous obstruction from in-
creased intracraniiil pressure affecting the cavernous sinus. This view is now
abandoned, because free anastomosis has been demonstrated between the orbital
and facial veins, and because large tumoi-s of the brain may exist with verv
little papillitis ; while, on the other hand, tumors too small to increase appre-
ciably the cranial contents frequenth' produce papillitis.
2. Manz^ assigned dropsy of the intersheath space of the optic nerve to be the
cause. This he considered to be due to admission of the cerebro-spinal fluid in
cases of intracranial pressure, or increase of subarachnoid fluid. This theory is
supported by Dr. Broadbent'^ and others.
3. Schmidt, however, found that a colored injection passed from the sheath-
space into the lymphatics of the papilla at the lamina cribrosa ; and he consid-
ered the inflammation to be produced not alone by the pressure of the fluid in
the intersheath space, but by its pressure in these lymphatic spaces.
4. Leier" considers the inflammation to be caused not at all by the ^wesswre
of the fluid in the sheath, but by the conveyance of pathogenic material in that
fluid to the optic nerve at the back of the eye.
•5. Dr. Hughlings Jackson considers the most plausible hypothesis to be that
first proposed by Schweller, viz., that a cerebral tumor acts as a source of irritation
which has a refle.v influence through the raso-tnotor nerxes upon the optic disk,
leading to its inflammation. This theory is rejected, however, by most writers,
on the ground that we possess no anatomical knowledge of such nerves.
6. Galezowski believes that the inflammation is in all cases propagated by
continuity of tissue. This theory is strongly supported by Dr. Bailey, Dr.
Walter Edmunds, and others, including myself, who have had opportunities of
examining a large number of cases microscopically.
Treatment must be directed, as far as possible, to the removal
of the cause of the affection. The various intracranial diseases
must therefore be treated by appropriate measures indepen-
dently of the papillitis, which, although serious on account of
1 Deutsch. Arch. f. klin. Med., vol. ix., 1871.
- Trans. Oph. Soc, vol. i. p. 108.
•' Discussion at International Medical Congress, London, 1881.
Fx^ -1 Atrophy of Cptzc Nerve.
Flo. 2. Atrcphy ctf Optw Nerve OTui Retuva.
LISON ft CO
ATROPHY OF THE OPTIC DISK. 197
its pernicious eft'ects upon the vision, is still only a symptom.
The same rule applies to other causes. The eyes should be
protected from bright light by the use of neutral tinted glasses.
When no satisfactory cause can be found for the existence oi
papillitis, the use of mercurials, short of salivation, and ot
iodide of potassium, is advisable.
Optic neuritis is occasionalism met with in young girls from
fifteen to twenty, and the cause usually assigned is some ir-
regularity of the menstrual function; often, however, careful
inquiry fails to elicit any history of this. The neuritis is gen-
erally preceded by severe headaches, and the prognosis as re-
gards sight is extremely unfavorable.
Atrophy of the optic nerve, Symptoms. — 1. Pallor of the optic
disk is one of the lirst signs of atrophy of the optic nerve (see
Figs 1 and 2, on the opposite page) ; the usual slight rose or
jiink tint has become diminished or is altogether lost. The
direct method of examining with the ophthalmoscope is the
best here, and the details of the papilla can often be best seen
when a leeble illumination is used. The various appearances
of the healthy eye (see p. 182) should be borne in mind when
making the examination ; and it must not be forgotten that, as
before mentioned, a very white-looking disk occasionally occurs
in a perfectly normal eye. As a rule, however, the pallor of
the disk is in proportion to the amount of atrophy present.
2. Diminution of visual acuity almost invariably takes place
from the onset of the affection. Its rate of progress is also
subject to variation ; as a rule, it proceeds slowly toward total
blindness, but it may become more rapid and lead to this
result in a comparatively short time ; on the other hand, it
occasionally becomes stationary.
3. Impaired color-vision is an almost constant symptom. The
patient at lirst finds a difficulty in recognizing green, and- if
asked to match a pure green with the confusion-colors for
green (see Color-vision) he will be unable to do so. Green
appears to him to be a gray or yellow. Further than this, the
progress of the disease is marked by gradually increasing
trouble in the perception of colors. Next the red, and then
the yellow, can no longer be recognized with any degree of
certaint}', thus leaving onl}' the power of discerning blue.
198 DISEASES OF THE OPTIC NERVE AXL) RETINA.
Finally, this also disappears, and the color-blindness is
complete.
4. Alterations in the visual field. — The failure of visual acuity,
already mentioned, is usually accompanied by more or less con-
traction of the visual field for white; this generally consists in a
regular contraction, the outline of which is concentric with the
macula ; it may, however, take the form of a sector-like defect,
or one-half of the lield (apart Irom the hemiopia of cerebral
disease) may be lost; lastly, the alteration may consist in an
irregular scotoma in the middle of the field. Again, it is fre-
quently found that the limits of the field for colors are also contracted.
By the method of testing indicated in the chapter on Perimetry
we tind that the tield for green becomes smaller by degrees,
and finally disappears. With the progress of the atrophy this
contraction of the field for green is followed by a similar limi-
tation for red, then for yellow, and finally for blue. Fig. 2,
opposite p. 232, shows the commencing concentric contraction
of the field for colors. Fig. 1, opposite p. 222, shows a more
advanced condition of atrophy, in which only the field for blue
is left, and even that is less than normal in extent. The con-
traction of the field for colors is, in fact, more constantly found
than that for white.
Causes. — Atrophy of the optic nerve may be a jprimary
change, it may be secondary to some previous lesion, or it
may be consecutive to papillitis.
Primary atrophy often comes on without any apparent
cause. It is more common in males than in females. It is
often associated with spinal diseases, of which the most im-
portant class is that connected with tabes dorsalis. It is also
caused by other diseases, as syphilis, diabetes, intermittent
fever, cold, and menstrual irregularity. It is sometimes con-
genital and hereditary. Lastly, certain toxic agents, as alco-
hol, tobacco, and lead, often cause amblyopia, and may cause
partial or complete atrophy.
Secondary atrophy is the result of some lesion, either of a
portion of the brain (cerebral centre), from which the optic
nerves arise, or of some part of the optic nerve-fibres. (See
Hemiopia.) Pressure on the chiasma from various causes,
ATROPHY OF THE OPTIC DISK. 199
lesions aftecting the optic nerve in the skull and in the orbit,
and blows upon the head, may all induce secondary atrophy.
Consecutive atrophy is that form which results from papillitis
(post-papillitic).
Mici^oscopic examination of the atrophied nerves shows that
the atrophy is not confined to the optic disk. The fibres and
the connective-tissue elements of the nerve-trunk present va-
rious degrees of wasting. As a rule, these elements are in-
creased, and the nerve-fibres partiall}" or totally destroyed.
In some cases the latter appear to be partially replaced by
particles of fatty matter.
Prognosis is always unfavorable, especially in cases in which
the cause of the aftection is beyond control. Progressive
atrophy usually attacks both eyes, and terminates very often
in complete blindness. Perimetric observation of the visual
field at stated intervals gives the best indication of the progress
of the disease. Those forms in which the visual field is not
concentrically contracted, but diminished in one part more
than another, are the least pernicious.
Treatment is frequently of no benefit.
The continuous voltaic current has been tried by Remak, Bene-
dict, Pye-Smith, Gunn and others, wnth the eftect of some res-
toration of vision. The current must be varied in strength
according to the susceptibilities of the patient. About six or
eight cells of a Stohrer's battery can usually be borne ; but it
is well to be very cautious in the application of this remedy,
as a comparatively weak current sometimes produces vertigo
and other symptoms, which are very alarming to the patient.
The positive pole is placed over the mastoid process, and the
negative pole upon the closed eyelids. The current is con-
tinued for five minutes at each sitting, and is repeated daily.
Dr. Gowers states that he has tried this treatment in many
cases, but without results which could reasonably be ascribed
to the treatment.
The hypodermic Injection of strychnine is advocated by iSTagel
and others. He injects about 1 milligramme of the sulphate
of strychnine dissolved in 10 mimims of distilled water, every
second day. If there is no improvement by the end of six
weeks, the treatment can be discontinued as useless.
200 DISEASES OF THE OPTIC N E K V E AND RETINA
General treatment is according to the evident or probable
cause of the affection — e. g., the removal of toxic influences,
abstinence from excesses of all kinds, etc. Where syphilis is
suspected, the appropriate treatment for this disease should
be carried out. Counter-irritation, as bv setons and blisters,
local leeching, and aperients, are occasionally beneficial.
Hemorrhages of the optic nerve are considered to take place
occasionally, (1) into the intersheath space,^ and (2) into the
interstices of the nerve behind the disk. They are very rare.
Their chief characteristic is the occurrence of sudden blindness,
which is unaccompanied by any immediate physical signs of
disease, either of the fundus oculi or of the brain. They are
occasionally recovered from, but are generally followed by
optic nerve atrophy.
Opaque nerve-fibres. — As we have seen (p. 182), the normal
optic nerve-fibres, having passed through the lamina cribrosa,
become, as a rule, entirely deprived of their medullary sheath,
and are quite transparent both in the papilla a;nd in the retina.
In some cases, however, it is found that the medullary sheaths
are persistent, and may be seen with the ophthalmoscope as
opaque, brilliant, white patches, occupying more or less of the
area and circumference of the disk, and extending toward the
periphery of the fundus in comet-like processes. Sometimes
onl}- a single patch exists, forming a snowy-white spot on the
edge of the disk; in other cases there are several of these ; more
usually, however, the opaque nerve-fibres are most visible where
the fibres are naturally most abundant, that is, in the directions
of the chief divisions of the retinal artery. In many cases
they have a distinctly fibrillated appearance, more especially'
toward their free edges. They can be distinguished from
morbid products by their brush-like extremities and the fact
that thet/ are in front of the retinal vessels, and some part of the
retinal artery can be seen to be embedded, as it were, in the
midst of the opaque fibres. They hardly ever occupy the re-
gion of the yellow spot.
> Knapp, Archiv fiir Ophth.. vol xiv., part i. p. 252; Abadie, Union Medicale,
Nos. 15 and 16, 1874. See also an interesting ease by Dr. Sllcock, Trans. Ophth.
.Soc. vol. iv.
:Uf.2. Opauqas' rtei-t-f fwr-es.
LCaOM k c».
OPAQUE NERVE -FIBRES. 201
Visual acuity may be quite normal as far as the opaque iibres
are concerned, although this aft'ection is often accompanied by
other abnormal conditions, ashypermetropia, astigmatism, etc.,
which may cause deterioration of vision. The visual field also
is normal, with the exception of the blind spot, which is gen-
erally^ large and irregular in proportion to the extent of the
patch or patches of opacity. Figs. 1 and 2, on the opposite
page, represent two unusually well-marked examples of opaque
nerve-fibres.
Ischsemia of the retina signifies a sudden, often total, arrest
of the retinial blood-current, accompanied by entire loss of
sight. It is unattended by any tissue-change of the retina
and optic nerve. Both eyes are usually affected.
Symptoms. — The optic disk is pale or white. The arteries
are either completely empt}' and reduced to fine white threads,
or they may contain a delicate continuous column of bloody
which is seen as a red line in the axis of each vessel, or they
may be empty in certain parts and contain a little blood in
other parts. The veins are generally smaller than normal,
and may be. more contracted in one part than another. The
affection is very rare. It is said sometimes to be present dur-
ing an epileptic seizure.
Embolism of the central artery of the retina maj- occur in the
trunk or its branches, and may be complete or partial. The
clot is usually just behind the lamina cribrosa.
Symptoms. — Sudden unilateral blindness, which may have
been preceded by temporary obscurations. Supposing the
trunk of the artery to be affected, we find by the ophthalmo-
scope that the arteries are extremely shrunken, and their
smaller branches invisible. The veins also are reduced in size,
but more so at the optic disk than in the rest of their course.
Sometimes a broken column of blood can be seen in the veins,
and then during the first few days an oscillatory movement of
the blood can sometimes be observed. Pressure upon the globe
will not produce pulsation either of the arteries or the veins.
Hemorrhages are few and slight. The characteristic feature is
a grayish-white opacity surrounding the region of the macula;
this is several times the diameter of the optic disk in breadth,
and is marked at its centre by a cherry-red spot corresponding to
202 DISEASES OF THE OPTIC NEKVE AND RETINA.
the position of the fovea centralis. A similar white haze often
surrounds the papilla. The brilliancy of the red spot at the
fovea is not of equal intensity in all cases; sometimes it is
speckled with gra}'; usually, however, it is of a bright cherry-
red color, and is either circular or oval. Its red hue is not due
to elfused blood, but is produced by contrast between the
white haze of the surrounding retina and the red color of the
blood in the choroid, seen through the thin fovea centralis.
After some weeks the retina becomes again clear, and the
optic nerve takes on the white appearance of atrophy. The
cherry- red spot at the fovea is then less marked ; there are
generally a few specks and traces of deposit in the retina.
As a rule there is no sight at any time, although a few cases
are recorded in which some perception of light has reappeared
after a sliort time in the outer part of the iield.
Fig. 1, on the opposite page, copied from Liebreich's atlas,
represents the appearance of this affection. In one or two cases
that I have seen, however, the opacity of the retina in the re-
gion of the macula and of the optic disk was decidedly more
marked than this, and the veins were less visible. If a branch
only of the retinal artery is obstructed, the cloudy opacity is
localized, and only the corresponding part of the retina suffers.
This is indicated by a scotoma, which may vary in extent from
a mere spot to half the visual field.
The causes are chiefly cardiac valvular diseases. It is also,
more rarely, caused by albuminuria and advanced pregnancy.
It is probable that, in many cases, as suggested by Mr. Priestley
Smith ( Ophth. Review, 1884), the clot is formed in the artery,
and would therefore be more correctly termed thrombosis.
The prognosis is very bad.
Retinal hemorrhages may occur without inflammation. The
number, aspect, and extent of these extravasations vary indefi-
nitely ; they may be divided into superficial and deep varieties.
The superficial naturally occur in the course of the vessels in
the nerve-fibre layer, and hence present a striated aspect. The
deeper extravasations of blood pass backwards between the
fibres of Miiller; they are not striated, but are seen as irregular
rounded masses; they vary in volume and depth, but usually
occupy only the intergranular layer. (Occasionally the blood
Fig 1 ■ Emiobbsrw of CmtraL artery of retincu (ofterLiebrebdu)
Rq 2 RaptMre at' Uw ckoroui
RETINAL HEMORRHAGES. 203
passes forwards into the vitreous body, or backwards between
the retina and choroid. Hemorrhage in the region of the yellow
spot deserves special mention on account of its frequency and
importance. This is a rounded or elliptical patch of varied
extent; it is usually about three or four times the size of the
optic disk. Smaller hemorrhagic points are often seen in its
neighborhood. The retina is never raised, and the extravasa-
tion is never deep. The absence of nerve-fibres, and of any
considerable vessels in this region, explains these peculiarities.
The frequency of return of visual acuity also shows the slight-
ness of the lesion as regards the cones and the ganglion-cells ;
indeed, it is possible that the blood has not extravasated within
the yellow spot, but from some marginal vessel, and that it has
filtered between the retina and the vitreous body. If resorp-
tion occurs, the clot becomes decolorized centripetally. If the
resorption be incomplete, white patches remain, mixed with
more or less pigmented matter. This is after large or re-
peated hemorrhages. When the macula is affected the cen-
tral vision is suddenly impaired or lost. This may not be an
absolute central scotoma, but is often a uniform cloud, cover-
ing objects in front of the eye. If into the periphery, the
visual field is affected accordingly.
The causes of retinal hemorrhages ma}' be classified as fol-
lows :
i. Injuries, such as blows, wounds of the eye, causing sud-
den alteration of the intraocular tension, as when there is
escape of aqueous or vitreous humor.
2. Derangements of the vascular si/sfem.
General arterial sclerosis.
Heart disease, especially mitral.
Embolism and thrombosis of small arteries.
Miliary aneurisms.
Fatty degeneration (after endarteritis).
3. Alteration in the quality of the blood.
Diabetes.
Albuminuria.
Leucocythfemia.
Pernicious anaMiiia.
Purpura and scurvy.
Hemorrhagic diathesis.
204 DISEASES OF THE OPTIC NERVE AND RETINA.
Some of these conditions also give rise to intiammatorj
changes, and will be referred to again later on. Retinal
hemorrhage occasionally occurs in young persons. It is
usually central, extensive, and relapsing. The subjects of it
are generally feeble or anremic; they are also frequently
myopic.
Retinitis. — Inflammation of the retina seldom occurs idio-
pathically ; it is usually the result of some constitutional dys-
crasia, as albuminuria, glycosuria, syphilis ; or else it is caused
by extension of an inflammation from the neighboring cho-
roid or ciliary processes. We shall consider retinitis under
three chief headings :
1. Albwnoiuric retinitis and its allied forms occurring in gly-
cosuria, leucocytheemia, etc.
2. Syphilitic retinitis.
3. Pigmentary retinitis.
Albuminuric retinitis. Ophthalmoscopic signs. — In the early
stage of the afl:ection we find a dull gray haze all over the
central region of the fundus. The papilla is somewhat
swollen and its outline blurred. There are generally some
hemorrhages in the region of the disk, and a few soft-edged
white patches can be seen in various parts of the retina.
After a few weeks, when the ati^ection is established, we find :
(1) White spots or patches, sometimes as small as a pin's head,
more or less collected into groups around the yellow spot (see
Fig. 1, opposite p. 206). Sometimes they assume the form of
white or yellowish-white strips, arranged in a radiating manner
around the same focus. Larger spots than these of the ma-
cular region are found scattered over the fundus ; when occur-
ring in the vicinity of a vessel, they are usually found to
cover it. (2) Hemorrhages are usually found : these may be
small and point-like, but they are usually striated and torch-
like in appearance. They vary in color according to the
length of time which may have elapsed since their extravasa-
tion, the most recent being of a bright arterial red color,
whilst the oldest are of a yellowish-white, waxy appearance.
As a rule they run parallel with the larger vessels, although
the particular vessel from which the blood is extravasated can
seldom be seen. "When large they are irregular in shape.
ALBUMINURIC RETINITIS. 205
and extend to the deeper layers of the retina. (8) The 02:)tic
papilla may be only slightly affected, but is usually swollen,
haz\-, and blurred in outline. In occasional cases there is
perivascularitis, in which the arteries or veins, or both, appear
as opaque white streaks, or present a whitish halo along their
course through which the contained blood can be dimly seen.
Detachment of the retina sometimes occurs, but it is not com-
mon. In most cases we find that one or other of these changes
predominates, and, according to the most conspicuous feature.
Dr. Gowers' proposes to distinguish four types of cases — the de-
generative, the hemorrhagic, the inflammatory, and the neuritic.
Both eyes are always affected, but the lesion is almost
always more marked in the one eye than in the other.
Functional disturbances do not always correspond with the
ophthalmoscopic signs. It is not uncommon to find considera-
ble retinal disturbance with only slight amblyopia; and on
the other hand, the retina may appear to be but slightly
affected, whilst the patient can hardly see sufficiently to find
his way about. The gravity of the functional disturbance de-
pends greatly upon the region affected : so long as the yellow
spot region remains intact the visual acuity is tolerably good,
but as soon as this part is attacked the central vision immedi-
ately suffers.
Fig, 1, opposite p. 206, is taken from a case of chronic
Bright's disease which was under my care at the Westminster
Ophthalmic Hospital. The papilla is swollen, and its outline
quite indistinguishable. The retina is hazy, and the retinal
vessels obscured in certain parts. Several recent elongated
and torch-like hemorrhages are seen running parallel to the
large vessels. The most striking feature in the case, however,
is the presence of numerous white spots occupying the region
of the macula, and of larger patches of a similar nature
toward the periphery.
Fig. 2 of the same plate was taken from a case of advanced
Bright's disease. The drawing was made hy Mr. G. L. John-
son and myself (from nature). It shows large hemorrhages
in various parts of the fundus, whitish spots in the yellow spot '
region, and, what is most remarkable, it presents opaque white
1 :Mc"dical OphibaliiKiscnpy, p. 185.
206 DISEASES OF THE OPTIC NERVE AND RETINA.
streaks in the position of tlie arteries, Tliis case was under
the care of Dr. Mules, of Manchester, who lias already pub-
lished it with drawings.'
Prognosis. — The relation between the progress of the kidney
atfection and that of the retinitis is not constant. "Witii the
improvement of the renal disease there is usually a tendency
toward subsidence of the swelling, absorption of the deposits
and extravasations, and recovery of vision. The lesion of the
kidney may remain stationary or become aggravated, whilst
that of the retina may disappear, and vision be reestablished.
Even where the retinal deposits persist there is sometimes a
very considerable improvement in vision. On the other hand,
the urine may be almost free from albumen, but the retinal
affection get worse and worse. As a rule, in the milder forms
of albuminuria the lesions of the retina disappear and the sight
is restored ; but in the severer cases, in which there have been
swelling of the optic disk, and ccdema of the retina, the loss of
vision is very great, and is not likely to improve, although
it may remain stationary. Should severe atrophic changes of
the optic nerve supervene, the sight may be permanently re-
duced to an extreme degree (V=^, J. 20, or even fingers only.)
In all cases in which albuminuric retinitis is suspected, the
urine should be repeatedly examined, the absence of albumen
on one occasion being insufficient to disprove the existence of
renal disease.
Pathology. — Albuminuric retinitis is most commonly found
in the advanced form of contracted granular kidney disease,
although it is not a ver^' frequent complication of that affec-
tion (probably not more than 8 or 10 per cent.). It occurs,
however, in other renal affections, and in the albuminuria of
pregnancy. It is rare in children, but sometimes follows scar-
latinal nephritis.
On microsropic examination of the affected optic disk and re-
tina, we find: (1) The axis-cylinders of the nerves in the retina
are swollen and opaque in parts. (2) The arteries of the retina
present thickened patches in certain parts of their course, and
sections through these nodules show a general thickening of
all their coats, especially of the subendothelial part of the in-
' Vide Trans. Ophth. Soc, vol. ii. p. 47.
Rq. 1 ■ AbumznuriC' -retinxfifi -with hAfmnrThoMeS .
Fbg. Z. Retinxxl' periarCentLS .
LEB N & CO.
ALBUMINUItlC RETINITIS. 207
tima, in consequence of which the outside diameter of each
vessel is much increased, and its lumen diminished or entirely
obliterated; indeed, according to Brailey and Edmunds,' some
impervious arteries are generally to be found in a state of fibrous
or structureless degeneration. The capillaries also present a
marked degree of structureless thickening; although thickened,
they are nevertheless disposed to rupture, and this is probably
the source of the hemorrhages. (3) Blood corpuscles are found
more abundantly in the region of these thickened patches than
in other parts of the retina; they are found not only in the
inner layers of the retina, where the capillaries exist, but also
in the intergranular layer. . After a time the hemorrhages thus
extravasated are seen as crystalline masses and fatty su//stances.
(4) Inflammatory nuclei, probably of the neuroglia, are found in
the inner layers of the retina. (5) The fibres of Miiller are greatly
thickened, and separated by sero-albuminous fluid. Fig. 3, op-
posite p. 184, is taken from a case of retinitis occurring in
chronic Bright's disease. The section shows most of the
characters above mentioned. The nerve-fibres in the inner-
most layer are thickened, and that layer is seen to contain an
abnormal number of inflammatory nuclei, in addition to nu-
merous red blood-corpuscles. In the same part one of the
arteries is seen to be greatly thickened in structure. In the
intergranular layer numerous blood corpuscles are seen, also
crystalline masses of altered blood or other exudation. Fig. 2,
in the same plate, shows a patch of hemorrhage taken from a
retina in which the signs of inflammation were less marked.
The presence of an aggregation of red blood-corpuscles is the
only abnormal sign.
Treatment. — The general treatment must be directed to the
renal afiiection. Locally, the use of smoked glasses, and rest
to the eyes, is all that can be advised.
Diabetic retinitis is very rare, and is so similar to the albu-
minuric form that it is almost impossible to distinguish the one
from the other by means of the ophthalmoscope alone. The
prognosis is very unfavorable. The treatment must be en-
tirely directed to the diabetes. Local bloodletting, byjeeching
' Vide Ophth. Trans., vol. i. p. 45.
208 DISEASES OF T H K OPTIC NEKVE AND HETINA.
or other means, blisters, scarifications, etc., are more likely to
do harm than good.
Leucocythaemic retinitis was first noticed and described by
Liebreich. It is characterized by the existence of yellowish,
rounded, hemorrhagic spots or patches; these occur in the
region of the macula, and at the periphery of the fundus;
they arc perceptibly prominent, and, when examined by the
direct method, they may be seen to project into the vitreous
cavity. In the majority of cases whitish streaks can also be
seen along the course of the retinal vessels. Various scoto-
mata, corresponding to the position of the whitish patches,
are found to exist in the visual field. The normal orange-red
color of the whole fundus is frequenth- changed to that of a
paler orange-yellow. The spots and streaks are due to accu-
mulations of leucocytes which have escaped from the walls of
the vessels by diapedesis, and the change of tint of the whole
fundus is caused by the altered condition of the blood in this
disease (0. Becker).
This aftection is by no means constant in leucocytha?mia ; it
only occurs in from 20 to 80 per cent, of the cases, and these
are mainly in the splenic form. Treatment must be general.
Syphilitic retinitis is mostly associated with, and secondary
to, choroiditis. A description of syphHUic (■horoido-retuntis will
be found on p. 154. Occasionally, however, we meet with iso-
lated syphilitic retinitis.
Symptoms. — Ophthalmoscopic examination shows a cloudy opoc it; i ;
this may be confined to the region of the yellow spot and optic
disk, or may extend over a larger area of the fundus, or it may
follow the course of the larger retinal vessels in the form of
cloudy streaks. The periphery of the retina is usually clear
and visible. Occasionally the disk is swollen. Hemorrhages
are very rare. Very often, as in choroido-retinitis, we find nu-
merous "dust-like'' opacities situated in the deeper portions
of the vitreo'is, near the posterior pole of the eye. This vitre-
ous hnzt is apt to be mistaken for optic neuritis or neuro-reti-
nitis unless care is taken to use the plane mirror in the manner
indicated on p. 151. Larger floating opacities of the vitreous
are also common, and not unfrequently we may detect the signs
of recent or old iritis in the pupil. The smallest traces of pig-
PIGMENTARY RETINITIS. 209
ment upon the front of the lens, or of adhesion of the iris to
the lens, are enough to establish this.
Failure of vision is very marked from the first, and may, if
the case is left untreated, go on to complete blindness. This
failure is often greater than the ophthalmoscopic changes would
lead us to anticipate. The patient also complains of fog before
the eyes, muscse volitantes, and of inability to see in a dull light.
There is always torpor of the retina, which often goes on to
absolute night-bUndness. This form of retinitis usually attacks
one eye at a time, but, in the absence of proper treatment, it
sooner or later comes on in the second eye. It is one of the
secondary symptoms of syphilis, and usually appears between
the sixth and eighteenth month after the primary affection.
Its course is usuallj' protracted over many months, and evinces
a tendency to relapses and exacerbations after slight temporary
improvements. When seen earl}^ and treated by mercurials,
great benefit may be effected, but with neglect of treatment,
and under bad hj^gienic conditions, it generally gets worse,
and goes on to more or less complete atrophj- of the optic
nerve and retina.
Pigmentary retinitis. — The chief symptoms are : (1) Pigmen-
tary deposits in the peripheral portions of the retina and other
ophthalmoscopic changes ; (2) Mght-blindness ; (3) Concentric
limitation of the visual field.
1. The pigmentary deposits in the retina may be easily over-
looked in the earlier stages of the affection, inasmuch as the
central portion of the fundus then appears quite normal. On
examining the periphery of the retina the appearance pre-
sented in Fig. 1, opposite p. 210, will be observed. The
masses of brownish-black pigment here shown look very sim-
ilar to the lacunae and canaliculi of bone when seen under the
microscope. They may be few in number, and scattered about
the periphery ; but more usually they are numerous, of mode-
rate size, and their arrangement corresponds more or less to
the direction of the smaller retinal arteries. In the later stages
of the affection the pigmentary deposits approach nearer to the
central portions of the fundus; they also become larger, and
are more isolated.
In the early stages the ophthalmoscope reveals no change in
14
210 DISEASES OF THE OPTIC NERVE AND RETINA.
the optic disk and yellow spot regions, nor iire the bloodves-
sels perceptihly altered; but, as the disease advances, the disk
becomes gradually pale, and finally assumes a yellowish waxy
appearance ; the bloodvessels also undergo gradual diminution
in calibre, and are finally reduced to mere threads, or become
altogether invisible. In this last stage the pigmentary layer
of the retina often disappears altogether, by which the vessels
and intervascular spaces of the choroid are rendered plainly
visible. Fig. 2, on the opposite page, represents an advanced
case of this kind, in which there are waxy pallor of the disk,
reduction of the retinal vessels to mere threads, and total dis-
appearance of the pigment layer of the retina. The stroma of
the choroid is visible in the form of yellowish wav}' streaks,
and the large masses of pigment are plainly seen. Posterior
polar cataract and opacities of the vitreous are frequently pre-
sent in the later stages.
2. Night-blindness constitutes a marked and very early symp-
tom of retinitis pigmentosa. Visual acuity is usually good in
liright daylight ; but directly the sun sets, or if the patient is
placed in a dimly lighted room, he is more or less completely
deprived of the power of vision.
3. Contraction of the cisaaljieldis iihydys present; it consists
in concentric limitation of the fields for white and for colors
around the central region. This contraction also bears a defi-
nite relation to the intensity of the illumination employed in
the use of the perimeter; the feebler the illumination the
more contracted does the field become. Fig. 2, opposite p. 238,
represents a tracing taken from a case of moderately advanced
retinitis pigmentosa in broad daylight. The central vision was
fairly good (V = ~y, but the patient could only distinguish
objects situated close to the visual axis.
These functional derangements — night-blindness and con-
traction of the visual field — are extremely distressing. From
the earliest date of the disease it becomes most difficult for
the patients to see their way about after dark, or even in the
twilight; and with the advance of contraction of the visual
field, there is proportionate difficulty in indirect vision. The
patient can then only see the object directly looked at; his
freedom of movement is consequently much impaired, because
B^. 2 . Bjetmiiie FLgrrLaztoscw. (cidA/arwed' stage.)
PIGMENTARY RETINITIS. 211
he is compelled constantly to turn his head or his eyes in dif-
ferent directions in order to acquaint himself with surround-
ing objects. After a time central vision, even with good light,
becomes affected, and in the end total blindness ensues.
The symptoms usually begin in early life, while in a few
cases no trouble is noticed until the age of fifteen or twenty
years. The consummation of the disease generally comes
after the age of twenty or thirty years. Both eyes are simi-
larly and simultaneously attacked.
Histologically the affected portions of the retina show com-
plete atrophy of the nerve-elements (rods, cones, and fibres).
There is interstitial development of connective tissue. The
walls of the vessels are found to have undergone hyaline
thickening, by which their lumen is greatly diminished; the
finer arterioles of the periphery being completely transformed
into tracts of connective tissue. In the tissues surrounding
the vessels and in the substance of their walls are found
numerous pigment cells. The choroid appears to be unaf-
fected in true pigmentary retinitis, although it often presents
lesions in syphilitic choroido-retinitis.
The causes are unknown. Heredity has a great influence.
It is frequently found in several members of the same family.
Consanguinity in the parents has been proved to exist in about
25 per cent, of the cases (Leber, Hutchinson), and congenital
syphilis has been put forwards as a cause (Galezowski), but is
not generally accepted.
The diagnosis is easy in ordinary cases. Difficulty sometimes
arises in cases of advanced syphilitic choroiditis in which there
is much pigment. In true retinitis pigmentosa there should
be no patches of choroidal atrophy.
Prognosis is unfavorable, but the rate of progress is usually
slow, and the patient may go on to the age of fifty or sixty
before he is absolutely blind.
Treatment is unavailing. A few cases have been somewhat
improved in visual acuity and in visual field by galvanism.'
Beyond this a tonic regimen and a proper care of what sight
remains are the only means in our powder.
' Giinn, Oph. Hosp. Reports, vol. x. p. 161.
212 DISEASES OF THE OPTIC NERVE AND RETINA.
Detachment of the retina. Si/mptoms. — By direct ophthalmo-
scopic examination various appearances are presented, according
to the nature and quantity of the eftused subretinal fluid, and
the length of time the detachment has existed. The detach-
ment may be slight or extensive, it may involve the whole or a
part of the retina, it may occur at any part of the fundus, but
is usually situated near the equator at the lower part. When-
ever the retina is separated from the choroid, that part of the
fundus is changed in appearance, "^"hen the detachment is
recent and the retina retains its transparency, the alteration in
focus, the dark color and the wavy outline of the vessels, are
the only signs. "When the detachment has existed for some
time the normal orange-red aspect of the corresponding part
of the fundus is generally found to assume a grayish, semi-
transparent, or opaque appearance. When the subretinal eftu-
sion is slight, and the retina transparent, there is still some
red reflex from the choroid. When the detached portion of
the retina is opaque this reflex is altogether absent. When
the detachment has existed for a considerable period it is
usually found to float up and down in the vitreous with quick
movement of the globe. When a considerable portion of the
retina is separated its surface is found to present an undulating,
rippled appearance. (See Figs. 1 and 2, on the opposite page.)
The line of demarcation from the rest of the fundus is usually
distinct. The retinal vessels are seen to follow the undulations;
their color is usually darker than normal, and they appear to
be diminished in size ; at the posterior edge of the detach-
ment they suddenly dip and disappear. In thus examining
the detached portion of the retina by the direct method it
must be remembered that whilst this is in focus, and can be
best seen b}' a strong convex lens, the rest of the fundus is out
of focus, and may require even a concave lens in order to be
properly examined. By the indirect method the grayish or
bluisb-gray aspect of the detachment is less apparent than by
the direct; and unless the media are very clear and the de-
tachment sharply limited it becomes difficult to ascertain the
extent of the lesion by this method. In all cases the pupil
should be dilated by atropine or horaatropine. Sometimes
the detachment extends as far as the edge of the disk, so that
Fig.Z. SUght sub-rduzai ef/wston/.
LEBON a CO.
DETACHMENT OF THE RETINA. 213
a part of the latter is obscured, whilst the remainder can be
seen. Occasionally the detachment extends to the whole
retina, which is then pushed forwards in a funnel-shaped
manner, so that all fundus reflex is destroyed.
The functional troubles of this lesion are severe and charac-
teristic. The onset is usually sudden, but only one eye maybe
aftected, so that the patient is not always aware of the change,
and may not discover it until some time afterwards. Gener-
ally, however, the patient notices a sort of cloud appear before
the eye, which obscures the sight. The visual field (see p. 229)
is found to present a scotoma corresponding to the detached
portion of the retina. A careful examination in this direc-
tion should be made, inasmuch as the scotoma often extends
over a greater area than the corresponding apparent detach-
ment; we may thus learn that the adjacent parts are threat-
ened with further separation, which indeed has already com-
menced. Objects sometimes appear to be distorted in indif-
ferent ways (metamorphopsia).
Premonitory symptoms, as muscse volitantes, are sometimes
observed ; patients also complain of subjective sensations ot
flashes of light. The fluid beneath the retina is albuminous
in nature ; it usually contains blood, lymph, fat, pigment, and
epithelial cells. The vitreous is often more fluid than normal,
and usually contains floating opacities. After prolonged sepa-
ration, but not at first, the structure of the retina becomes
altered.
The causes of detachment are various. The most common
is the posterior sclero-choroiditis, which is allied with pro-
gressicc myopia. Traumatism may produce detachment either
immediately or at a remote period. Inflammation of orbital
tissues, , intraocular tumors, or inflammatory products in the
vitreous, also not unfrequently cause detachment at some
period of their existence.
The progress is generally unfavorable. Even in the best
cases, in which the disease remains stationary, the vision is
always defective, and we are never certain that the affection
may not extend to the rest of the retina. A few cases of spon-
taneous recovery are on record, and some good has been effected
by treatment. It must be borne in mind that w^here one eye
214 DISEASES OF THE OPTIC NEKVE AND RETINA.
only is aiFected, the second eye is generally in danger of a
similar attack.
The Trcaiment — The eyes should be rested, and protected
from the light by means of a large shade, or by smoked
glasses. The general health should be supported by a tonic
regimen. The hypodermic injection of hydrochlorate of pilo-
carpine (F. 32) has been recently tried in some cases with good
results, in others, without benefit. Operative procedures of
various kinds have been performed by Sichel, Bowman, de
Wecker, von Graefe, Hirschberg, and others, but without very
satisfactory results. Simple puncture is easily performed. Hav-
ing ascertained by ophthalmoscopic examination the exact po-
sition of the detachment, the eyelids are separated by a spec-
ulum, and the globe is held firmly by the fixation forceps in
such a position that the detached portion is brought toward
the front ; a broad needle or a Sichel's cataract knife is then
plunged through the conjunctiva and the tunics of the globe
into the middle of the detachment; in doing this the point of
the instrument should be directed toward the centre of the
globe — that is, away from the lens. In the act of slowltj with-
drawing the instrument, its blade may be half rotated whilst
between the lips of the wound ; this will fiicilitate the escape
of the subretinal fluid. After the operation a light compress
is applied and the patient kept quietly in bed. This method
has in a few instances been attended by partial replacement of
the retina, considerable improvement in visual acuity, and
diminution of the visual scotoma. In the majority of cases,
however, it has been of no perceptible benefit, and in a few
the eye has become much worse after the puncture.
De "Wecker introduces a gold wire suture through the scle-
rotic and choroid with the view of establishing a continuous
drainage. This method has not been generally adopted, and
some cases of destructive irido-choroiditis have been caused by
it ( Noyes).
Prophylactic measures would appear to be most strongly in-
dicated in this affection. In the case of high myopia, for ex-
ample, it is of the greatest importance that the error of refrac-
tion should be corrected by the use of proper spectacles.
GLIOMA OF TIJK RETINA. 215
Glioma of the retina. Symptoms. — It usually (3ccurs in earl\-
life, either intrauterine, or during the first three or four years;
occasional cases have been recorded up to ten years. In the
early stage the ophthalmoscope reveals one or more brilliant
white patches in some part of the retina. These patches
differ considerably from those of retinitis in being of a
brighter, more metallic lustre. The tension is normal (Tn)
or slightly diminished (Brailey). There are no external changes
in the appearance of the eye, no pain is complained of; the eye
is quite blind, but this is not discovered owing to the youth of
the patient; hence the disease is rarely seen at this early period;
it usually passes unnoticed until the growth has become suffi-
ciently large to be visible through the pupil; it is then detected
by the parents, and, sooner or later, the patient is brought for
advice. In this, the second stage, the pupil of the affected eye
usually becomes considerably dilated. The tension is increased
(T + (?), T + 1). The pupil no longer has its normal black
appearance, but presents a white, pink, or yellowish lustrous
look, ^y focal illamination the tumor may be observed to pro-
ject into the vitreous cavity; the surface may be smooth or
nodulated; and some bloodvessels can generally be seen upon
the white background. By the ophthalmoscope a similar condi-
tion is observed. The lens and vitreous are usualh' clear. In
this stage there is often pain in the e3'e, and inflammatory
symptoms are liable to supervene in the form of congestion
of the scleral vessels. As the growth increases the lens is
pushed forwards, the anterior chamber becomes shallow, the
cornea becomes dull and opaque, and loses its sensitiveness ;
the eye, in fact, becomes glaucomatous. As the growth con-
tinues to increase in volume the tunics of the globe can no
longer sustain the intraocular pressure, and usually become
ruptured in the region of the sclero-corneal junction. In this,
the third stage, the tension is suddenly decreased, and the disease
rapidly extends to the surrounding parts, and backwards along
the course of the optic nerve to the brain.
Pathology. — When an eye with glioma is opened during the
second stage the tumor presents a yellowish-white appearance;
it contains bloodvessels, hemorrhages are seen, and in some
parts there are calcareous particles. Histologically this new
216 DISEASES OF THE OPTIC NKRVE AND RETINA.
growth consists of small round cells (Fig. 4, on the opposite
page), exactly similar to those found in the granular lavers of
the normal retina. Each cell is a rounded body about ,^^5-^^
mm. in diameter, and contains a large, freely staining nucleus,
in the centre of which are a few granules. Bloodvessels are
found in the tumor; they are not in actual contact with the
cells, but usually have a distinct sheath, probably a lymph-
space ; outside this clear space is found a zone of cells which
stain freely ; bej'ond these the staining becomes more feeble,
and the cells are found to have undergone either fatty or cal-
careous degeneration. Finally the vessels become destroyed,
and the whole glioma degenerates from absence of blood sup-
ply. If we examine the free or spreading edge of the tumor,
we find that the granular layers and the layer of nerve-cells
are the parts first attacked (see Figs. 2 and 3, on the opposite
page). Two chief kinds of glioma are recognized, viz., G. exo-
phyiwn and G. endoph)/tuiii. Glioma exoph/tum commences
in the inner granular layer, which becomes thickened to join
the outer ; a diti^use thickening of the whole retina is formed,
with nebular bulging on its outer side, from which the disease
extends to the choroid. Glioma endophytum commences in the
nuclear and nerve-fibre layers of the retina, whence it usually
extends along the optic nerve. The parts of the retina which
are not at first attacked would seem to be the rods and cones,
the molecular layers, the system of Midler's fibres, the base-
ment or limiting membranes, and the pars ciliaris retinae.
The structures which are attacked appear to be the nerve-ele-
ments and the very delicate neuroglia. The mode of extension
of glioma is important. Its chief direction is along the fibres of the
optic nerve. Here the cells first plug up the optic disk so as to
push back the lamina cribrosa; after a time they appear on the
outside of the latter, and appear in clusters occupying the bun-
dles of nerve-fibres ; the coarse trabecular tissue is but little
affected, even in advanced cases. The central arterj' and vein
are not attacked. From the optic nerve the cells sometimes
get into the nerve-sheath, and thence extend to the intracranial
meninges, occasionally also to the diploe of the cranial hones.
Sometimes the child has glioma in the other eye, but we have
-Lcrtt
Hetachei ittinu^.
Fif:. T. — Pseudoglioraa.
Ill
- Cn-mmcneemerit of TTfaueun
mr
Fia. 2. -Glioma of retina. X about 60 di
Fig. 3. — Glioma of retina.
X about 60 (liam.
Igp-
Fig. 4.— Cells of glioma.
X about IfiO (liam.
To face p. 216.
GLIOMA OF THE RETINA 217
110 evidence to prove that the disease spreads from one eye to
the other.
Another mode of extension is by way of the choroid ; glioma exo-
phjtum usually spreads in this way. The part of the choroid
first invaded is that nearest to the optic disk. When the cells
get into the choroid itself they immediateh^ increase by multi-
plication, and the tissue of the choroid is destroyed, its place
being occupied by a thicker layer of glioma cells. These cells
then extend to the sclerotic, which is attacked in the direction
of its component fibres. They then pass forwards along the
supra-choroidal lymph-space, through the fibres of the liga-
mentura pectinatum into the anterior chamber. They may
thus push back the lens ; sometimes they cause necrosis of 'the
cornea. When not in the anterior chamber they may cause for-
ward bulging of the lens. The vitreous undergoes atrophy, and
causes a peculiar wavy appearance of the retina (detachment).
Metastatic gliomatous tumors are said to occur in the liver
and other parts, but these are very rare, if they occur at all.
No new growth similar to glioma is found in any other part of
the body except the nervous system. Glioma was formerly
called carcinoma, fungus ha3matode8, etc. At present it is
considered to grow from the delicate connective tissue of the
neuroglia, and ought therefore to be called a sarcoma. He-
redity seems to play an important role in the existence of these
tumors ; two or more children of the same parents may suffer,
and a history of cancer of the eye during the early part of the
parent's life may sometimes be elicited.
Diagnosis is usually quite easy. Given a lustrous white, or
yellowish-white tumor, occurring in a young child, in whom
there have been no perceptible inflammatory symptoms, and
in whom the intraocular tension is increased, we can have no
hesitation in pronouncing this to be glioma.
In suppurative hyalitis, which may have disappeared leaving
the retina detached, in exudative cyclitis, and in exudative
choroiditis, a condition not unfrequently presents which is
somewhat similar to glioma; such cases are known by the
vague term pseudo-glioma. Fig. 1, opposite p. 216, shows a
section of such a case; there had been exudative inflammation
of the ciliary region and choroid, the vitreous had shrunk,
218 DISEASES OF THE OPTIC XKRVE AXD RETINA.
and the retina was pushed forwards nearly up to the lens,
where it a[)peared as a dull yellowish mass. In such cases
(pseudo-glioma) the reflex is seldom bright, the tension is
usually reduced, and there is generally a history or some other
symptom of previous inflammation in the eye. The chief dif-
ference, however, consists in the appearance of the iris ; in
glioma the whole of this is pushed forwards toward the cor-
nea, but in the so-called pseudo-glioma the contraction of the
inflammatory products in the vitreous causes retraction of the
ciliary edge of the iris, so that the latter presents the appear-
ance of an inclined plane as seen in Fig. 1, opposite p. 216.
The treatment of glioma consists in the immediate removal of
the whole of the affected globe and as much of its optic nerve
as possible. By this means the disease is prevented from
spreading backwards to the brain and in other directions, so
that although the eye is lost the patient's life may be saved.
After excision of the globe in this manner, the cut end of the
optic nerve should be examined microscopically. If this be of
normal size, and contains no glioma cells, we may hope for a
good result. If slightly swollen, and a few of the nuclear
bodies are found, the result is doubtful. If much swollen,
and numerous nuclear bodies are found, there will probably be
a return of the disease in the optic nerve in the course of a few
months.
When the disease has perforated the ocular tunics and af-
fected the surrounding parts, the whole of the contents of the
orbit must be extirpated, although the prognosis is extremely
s:rave.
CHAPTER VIII.
AMAUROSIS, AMBLYOPIA, AND SOME FUNCTIONAL
DISORDERS OF VISION.
Amaurosis signifies loss of sight without perceptible ocular
lesions; with the advance of knowledge in ophthalmology
that term is becoming less and less required, and is gradually
falling into disuse. Several grades of amaurosis are recognized.
In the first grade, which is generally called Amblyopia, there
is merely diminution of visual acuity; the patient is not able
to read small print with the amblyopic eye, but he can distin-
guish large objects and find his way about.
In tke second grade there is only quantitative perception of
light. The patient can only distinguish light from darkness.
In the third grade, usually called complete or absolute amau-
rosis, both qualitative and quantitative perception of light
have disappeared.
Tobacco amblyopia (Tobacco amaurosis). Symp)toms. — This
afifection is characterized by diminished acuity of central vision,
one of the earliest symptoms of which is the inability to distin-
guish colors over a small central portion of the field. There
is progressive failure in both eyes, which, in the course of a few
weeks or months, may have become so marked that the patient
can only distinguish -i^ or «\, or '^o. 6 or 9 of the Snellen
reading types. The periphery of the visual field is not affected
either for white or for colors, but the central portion always pre-
sents a scotoma in which the power of distinguishing green
and red is very defective. If the extent of this scotoma is
measured by testing the patient with the perimeter (see p.
231), it will be generally found to be of oval shape, with its long
diameter transverse, and to include the central portion of the
•220 AMAUROSIS, AMBLYOPIA, ETC.
visual field. The subjects of this affection are most troubled
by bright light and by distant objects; they can generally
see better in twilight than in open day, and they find some
help for this defect in the use of neutral tinted glasses, by
which the brighter rays are cut off. The peripheral portions
of the field being good, they experience no difficulty in seeing
surrounding objects; they therefore differ somewhat in manner
from patients who are suffering from diseases in which con-
traction of the visual field forms a prominent feature, such as
advanced retinitis pigmentosa, optic atrophy, and chronic
glaucoma.
The ophthalmoscope reveals nothing of importance in the
condition of the fundus. Occasionally we find hypersemia of
the optic disk, and some enlargement of the retinal veins. In
advanced cases there is sometimes a pale (atrophic) condition
of the optic disk.
The onset of the disease is verj' insidious; in some cases
hardly any other symptoms beyond the visual derangements
are to be found, in others there may be frontal headache,
nervousness, insomnia, and loss of appetite.
Causes. — This form of amblyopia is now generally admitted
to be produced chief!}', if not entirely, by tobacco intoxication.
The subjects of it are generally males, at or beyond middle
life, who have long been in the habit of smoking large
quantities of strong tobacco. T'nfortunately many excessive
smokers are also accustomed to free indulgence in alcoholic
liquors, so that it is difficult to make out how far the defective
vision may be due to the direct influence of alcohol. Macken-
zie and Sichel long ago pointed out the deleterious effect upon
vision of the excessive use of tobacco ; the latter believed that
any person smoking more than half an ounce of tobacco daily
would experience considerable defect both of sight and of
memory. He mentions a case' of a man who, not content
with smoking throughout the entire day, assumed the pipe at
intervals during the night to soothe his wakeful hours. He
became completely blind, but recovered his sight after total
abstinence from smoking, combined with antiphlogistic treat-
ment. In speaking of this affection Xettleship- says, "My
1 Aiinales d'Ociilistique, vol. liii. p. 122.
2 Diseases of the Eye, 1882, p. 217.
AMAUROSIS IN INFANCY. 221
own opinion, based on the examination of a large number of
cases, is that tobacco is the essential agent, and that the disuse
or diminished use of tobacco is the one essential measure of
treatment." it is but fair to add, however, that competent
observers are far from unanimous on this subject.
The treatment consists in the removal of the cause and the
improvement of the general condition of the patient. Total
and unconditional abstinence from all forms of tobacco and alcoholic
liquors should • be insisted on. The patient will be greatly
chagrined at the sudden cessation of these, to him poisonous,
habits ; he will beg hard to be allowed just one cigar and one
gla;ss of wine per diem ; but he must not be humored. Total
abstinence is by far the most certain and speedy mode of cure;
it should of course be combined with a tonic regimen. I^utri-
tious food, plenty of exercise in the open air, sedatives at night
if necessary to produce sleep, strychnine and iron internally,
and similar remedies, are essentiall}' helpful, and will generally
restore the visual acuity, disperse the central scotoma for colors,
and greatly improve the patient's general physique in the course
of from six to twelve weeks. As a rule, the results of treatment
are more pronounced in proportion to the rapidity of failure, and
to the shortness of the duration of the disease. In old-stand-
ing chronic cases, and especially where there is some pallor of
the optic disk, the improvement is less marked, and perfect
vision (V = |) may not be reestablished.
Some practitioners are doubtful as to the propriety of sud-
denly cutting o^cdl alcoholic stimulants from habitual drinkers,
I was for some years associated with Mr. Gibson in the treat-
ment of prisoners at ISTewgate, where we had a constant influx
of smokers and drinkers of the heaviest kind : our treatment
in every case was similar to that above indicated, and the result
was invariably beneficial.
Amaurosis is occasionallj- seen in young infants. The aimless
movements of the eyes (nystagmus) generally tirst attract the
mother's attention, and it is then observed that the child takes
no notice of a light. In such cases the fundus is sometimes
normal, not unfrequently the disks have a grayish appearance,
and their edges are a little blurred ; later on they usually become
222 A M A I' R O S I S . A -M B L Y O P I A . E T C .
atrophic. In these cases there is sometimes a history of con-
vulsions, and often there is evidence of inherited syphilis. The
prognosis is absolutely unfavorable.
Awhlijopia, from suppression of fhe image in one e^je, is often
fiHind in cases of strabismus. (See Strabismus.)
Hemiopia or Hemianopsia is characterized by the loss of one-
half of the visual held. It usually occurs in both eyes, and is
then indicative of some lesion at or beyond the optic commis-
sure. When only one eye is affected the line of separation
between the part of the visual field which is lost and that which
is retained is generally irregular ; the affection is then the result
of some lesion of the optic nerve in front of the commissure,
or of the retina itself.
The majority of cases of hemiopia affecting both eyes are
either right or left lateral — that is, there is (homonymous) loss
of the right or of the left half of the visual field in each eye.
The right half of each visual field of course corresponds to the
left half of each retina, and vice versa. As a rule, the point of
fixation lies in the part which retains its functions in both eyes,
but occasionally the line of demarcation seems accurately to bi-
sect it. Occasionally both temporal halves, and, very rarely, in-
deed, both the nasal halves, are lost.
Jlie sgmpfoms of lateral hemiopia. — The patient usually com-
plains of sudden diminution or disturbance of vision. He only
sees half of an object placed immediately in front of him. In
right lateral hemiopia there is marked inconvenience in read-
ing. This is because, in order to read with fluency, it is neces-
sary that words should be seen which are a little in advance of
those which are being pronounced ; when the right half of each
visual field is lost the words cannot be seen until their image
falls on the yellow spot of the corresponding half of each visual
field. The line of demarcation between the sensitive and the
inactive portions of the retina is usually vertical, either at, or
just internal to, the 3'ellow spot. The transition from the one
part to the other may be quite aljrupt, or it may be gradual.
Fig. 2 on the opposite page represents a chart of the visual
field for white, blue, red, and green, which was taken from the
right eye of a patient suffering from left lateral (homonymous)
hemiopia. By comparing this with the normal visual field rep-
Tig 1. Lefh visual AeLcL\ Advarvoedb^ optio atrophy.
Fig. 2. Bight/ viswaL M/i/ Hemzopiw
H E M 1 P 1 A .
223
resented in Fig 1, opposite p. 232, it will be observed that the
whole of the inner part of the field is lost.
The exact situation of the intracranial lesion giving rise to
hemiopia is still somewhat uncertain. Professor Charcot^ con-
siders the optic tract of the opposite side to be always involved ;
that is, the left optic tract is either diseased or pressed upon in
right lateral hemiopia, and vice versa. Dr. Ferrier" believes
hemiopia may result from lesion aftecting the occipital lobe
and angular gyrus, apart from any implication of the optic
tract or corpora geniculata. This conclusion is supported
both experimental!}' and clinically.
Fig. 51.
The above diagram (Fig. 51) is that used by Charcot to ex-
plain the above-mentioned phenomena of lateral hemiopia, and
crossed ambylopia.
•■ Localization of Cerebral and Spinal Disea.ses. New Sydenham Society, 1888.
* See Brain, vol. iii. p. 410.
224 AMAUROSIS, AMBLYOPIA, ETC.
The fibres of the optic nerves undergo a partial decussation
at the chiasma t ; the left optic tract, b h' receiving fibres b b
from the temporal half of the left retina, and others // b' from
the nasal half of the right, /. £•., from the right half of each
visual field. In the same way the right optic tract receives im-
pressions from the left half of each visual field.
The fibres corresponding to the optic tracts proceed to the
corpora geniculata, c g, and it is supposed that the fibres which
do not decussate in the commissure x do so beyond the corpora
geniculata in t t^.
So that the centre log in the left hemisphere receives fibres
from the right eye only, those from the right half of the visual
field coming through the left tract, and those from the left
half of the visual field coming through the right tract. In
the same way the centre l o u in the right hemisphere receives
fibres from the left eye only.
A lesion, therefore, at t would produce loss of the temporal
half of each visual field. One at n on one side would produce
loss of the nasal half of the field in the eye of the same side as
the lesion. One at k in the left optic tract would cause loss
of the right half of each visual field. One at x q would cause
loss of the nasal half of each field, a condition which is very
rare. Finally, destruction of l o a or l o d would cause total
blindness in the eye of the opposite side.*
In hysterical hemianaesthesia and in cerebral hemianaesthesia the
unilateral defect is not confined to common sensibility; it in-
volves also the special senses on the same side of the body as
the cutaneous anaesthesia ; these are the nerves of taste, hear-
ing, smell, and sight. Attention has been particularly called
to the condition of vision by the observations of M. Landolt
' But this scheme of Charcot's, though explaining the binocular heniiopia in
disease of the optic tract, and the crossed amblyopia in disease of the optic thal-
amus and internal capsule, does not explain the hemiopia met with in some cases
of disease of the cerebral cortex (about the angular gyrus). To meet this, Grasset
has recently supposed that there is a second decussation of the nerve-fibres from
the external half of each eye beyond the iniernal capsule. According to this
each occipital lobe holds : a. The external nerve-fibres of the eye on the side of
the lesion, b. The internal nerve-fibres of the opposite eye, like the optic tract
ot the same side.
XIGHT- BLINDNESS. 225
in certain cases of Professor Charcot's at La Salpetriere. He
found —
(1) ISTormal ophtlialmoscopic appearance of the fundus.
(2) Reduction of visual acuity to one-half or more in the eye
on the same side as the hemianaesthesia (crossed amblyopia).
(3) Concentric and general contraction of the visual field
for white and for colors.
Night-blindness' has already been referred to as a symptom
of pigmentary retinitis and other lesions of the fundus. Under
certain circumstances, however, this aft'ection is found to exist
as a functional disorder. The characteristic symptom of func-
tional night-blindness is that visual acuity, which is perfectly
good in a bright solar or artificial light, becomes suddenly re-
duced when the sun gets below the horizon, or when the arti-
ficial light is reduced. The patient can see perfectly well
during the day, but immediately after sunset, or when placed
in a moderately dark room, the sight is so impaired that he
has to grope about, and in some cases cannot find his way
without the help of a guide. The visual field is not con-
tracted. The fundus is normal in appearance. The pupil is
sometimes half dilated, and th^'e is generally some reduction
in the range of accommodation.
The most common cause of night-blindness is the prolongd
exposure of the retina to the action of strong brilliant light.
It is common among sailors who have made long voyages
under a tropical sun, and soldiers after prolonged marches ;
painters and masons who have been employed on white build-
ings are also sometimes aflected. This trouble is more prone
to occur in persons whose vitality is lowered from insufficient or
improper food, excessive work, and other causes. It is often
associated with scurvy. A paper by Dr. Forster [Rec. d'Ophth.,
Oct. 1882, p. 577) would seem to prove that the affection often
makes its appearance in hot climates without exposure to
bright light, especially in districts where ague is common.
' Until recently the term hemeralopia was used to indicate this symptom,
•AW(\ nyctalopia i\\Q opposite condition of "night-sight," or day-blindness. An
article, however, by Dr. Greenhill (Ophth. Hosp. Eeports, X. ii. p. 284) shows
that the true meaning of the words according to their derivation and classical
use is the exact reverse of this. Under these circumstances it would create con-
fusion to retain either term.
15
226 AMAUROSIS, AMBLYOPIA. ETC.
Prognosis and treatment. — Night-blindness always improves
under favorable conditions, although it sometimes evinces a
tendenc}' to recurrence. The first indication is to protect the
eyes from all bright light. This may be done by keeping the
patient in a feebly illuminated room, or by the use of very
dark smoked glasses. The use of eserine drops (F. 31) is also
advisable. A nourishing diet, and the use of iron, quinine,
and other tonics, are valuable adjuncts. Cod-liver oil is also
strongly recommended in this affection.
Snow-blindness, which is sometimes experienced by persons
■who have travelled over extensive tracts of snow, presents the
same functional derangements as the night-blindness just men-
tioned, but there is usually congestion of the conjunctiva with
pain and photophobia. It is prevented by the use of deeply
tinted glasses.
Micropsia signifies a condition of sight in which oljjects look
too small. Its occurrence is indicative of the rods and cones
being pressed asunder, so that images formed on the retina
coincide with fewer retinal elements. It is sometimes found
in syphilitic retinitis. 3Iegalops(a, the apparent enlargement
of objects, and micropsia are Sometimes found in hysterical
amblyopia. Metamorphopsia means the apparent distortion of
objects.
Malingering. — Simulated amblyopia, or complete amaurosis
of one or both eyes, is occasionally met with, but is less
common in Great Britain than in countries where conscription
is in force. It is found among those who wish to escape
service; after injur}-, also, it is sometimes feigned with the
hope of receiving compensation for damages. Amongst chil-
dren the desire to avoid school and lessons is sometimes the
chief motive. It also occurs amongst nervous and hysterical
young women.
One eye usually the right, is generally complained of as
being defective, the other eye being declared normal. Under
such circumstances the distant vision of each eye should be
carefully tested, and the first statement as to the vision of the
supposed amblyopic eye carefully noted. The deception may
then be discovered in various wavs.
SIMULATED AMBLYOPIA. 227
1. Von Graefe's ineihod. — Place a prism of 10° before the
sound eye. If the patient be reall}- using both ej^es, this will
produce diplopia, and he will be observed to squint in order
to correct this.
2. By means of Snellen's colored test-types suspended in
front of a window^ The alternate letters are red and bluish-
green — the exact complement of the red. The patient is told to
read these with the good eye. Thus, suppose he reads the word
FRIEND,^ of which FIN" are green and RED are red; then,
by placing a bluish-green pane of glass in front of the good
eye he will only see the letters FI]^ if the other eye be ambly-
opic — for the red letters cut off all rays of light except the
red, while these are cut ofl* by the green glass, which transmits
none but green rays, therefore no light can pass through both
glasses. If the patient is malingering, he will still see the
whole word FRIEND with the observed ej-e.
3. Two very weak lenses may be alternately placed in front
of the affected eye ; if the patient believes that a succession of
lenses is being tried, he will sometimes admit to a gradual im-
provement, often up to normal vision.
4. By paralyzing the accommodation of the good eye, or by
placing a strong concave lens ( — 20 D) in front of this, and
then directing the patient to read, we know^ that he can only
do so with the affected eye.
5. The stereoscope and other methods are also useful in the
discovery of this kind of deception.
When amblyopia in both eyes is complained of, the mode of
detection is more complicated, and requires greater tact on the
part of the surgeon.
The refraction of each eye and the ophthalmoscopic ap-
pearance of the fundus being ascertained, the visual acuity of
each eye should then be carefully recorded; then by placing
feeble convex or concave glasses in front of either eye the
patient will often betray himself by inconsistent replies. The
visual field for white and for colors (p. 229) should then be
tested. The nature of the answers to questions will here be
also useful.
1 These colored types may be obtained from Mr. Pillischer, S8 New Bond
Street, "\V.
228 AMAUROSIS, AMBLYOPIA, ETC.
AVheii complete amaurosis of one eye is asserted, it must be
remembered that in such an eye the pupil would be dilated if
the amaurosis had existed for a long time, and Avould not eon-
tract by the projection of a cone of light upon the cornea,
supposing the opposite eye to be completely shaded from the
light. In order to distinguish between dilatation of the pupil
from blindness, and that from atropine, we must bear in mind
that the dilatation from atropine is usually greater than from
amaurosis; again, while in amaurosis a cone of light thrown
upon the retina of the good eye would produce contraction of
the sphincter pupill» of the other, this would not be the case
with dilatation from atropine.
CHAPTER IX.
THE VISUAL FIELD, AND THE USE OF THE PERIMETEPt.
The visual field is the extent of a plane at right angles to
the visual axis, over Avhich the eye can recognize objects.
Thus the eye being fixed on an}' point, " the fixation point," its
image will fall on the yellow spot (direct vision) ; at the same
time other objects will be less distinctly seen by the peripheral
portions of the retina (indirect vision). The objects most dis-
tant from the fixation point will represent the limits of the
visual field, and the latter may be considered as subtending a
cone-shaped space whose apex is situated at the eye, and whose
base becomes larger in proportion to its distance from the
eye.
If the yellow spot were the only portion of the retina used
for visual purposes, we should sufi^er the greatest inconvenience
from being able to see nothing but the object to which the
visual axis was directed; all side objects, such as passers-by
in the street, the ground on which we walk, and the thou-
sands of other objects which we see indirectly with the peri-
pheral portions of the retina, could then only be observed by
constant turning of the eyes or head.
The limits of the visual field may be roughly ascertained in
various ways.
1. Place the patient with his back to the window or gas-
light ; let him close one eye, and with the other look straight
at your nose at a distance of about two feet; then hold up
your two hands on opposite sides of your nose in the plane of
the face, and ascertain to what extent they can be separated in
the vertical, horizontal, and oblique directions before they dis-
appear from his indirect vision.
230 THE VISUAL FIELD. AND USE OF PERIMETER.
2. By the Cainp'niutre of de Wccker. — This instrument (Fig.
52) consists of a blackboard, in the centre of which is a white
cross, to which the patient is told to direct his visual axis.
The head is kept in position by a chin-rest, and in front of the
blackboard there are radii of wire, upon which white balls can
be raade to slide from the circumference to the centre. While
the patient looks sseadily at the cross with the eye to be ex-
amined, the white balls are passed inwards until the patient
can just see them by indirect vision. They are thus found to
describe an outline of the visual field
Fig.
-De Weckei's Catupimetre.
The projection of the visual field on a plane surface has,
however, the disadvantage that the peripheral parts are further
removed from the eye than the central ; and indeed, for points
which are so far removed from the centre that lines drawn from
them to the eye make angles of more than 45° with the visual
axis, this method is almost impracticable. To obviate this the
THE PERIMETER. 231
perimeter is used, which enables the field to be projected on a
hemisphere of which the eye is the centre, so that every point
of the field is at an equal distance.
3. The Perimeter consists of the arc or quadrant of a circle
which in turning on a point describes a hemisphere, at the
centre of which the eye of the patient is placed. The hemi-
sphere thus described must be amply illuminated by diftused
white light. At the pole of the hemisphere which is opposite
to the patient's eye is a white spot, which the patient can fix
by direct vision. The arc is divided into degrees, starting
from 0°, which marks the white spot, up to 90°. These divi-
sions are marked upon the arc. The test-objects should con-
sist of small disks of white and colored paper, of 3 to 10 mm.
diameter. In order to ascertain the limits of the visual field
we proceed as follows :
The head being fixed, and the eye to be examined being
placed at the centre of the hemisphere, the other eye is cov-
ered with a shade. The patient is then told to look steadily
at the white spot above mentioned, while the surgeon, placing
himself behind the perimeter, keeps a watch on the patient's
eye, so as to be able to check its least deviation from the
centre. Then, the arc of the perimeter being held in a cer-
tain plane, the vertical for example, the test-object is advanced
from the periphery toward the centre of the arc until it is just
recognized by the eye under examination. This point corre-
sponds to the limit of the visual field for that meridian.
The horizontal and oblique meridians are then similarly
ascertained, and the data are transcribed on to a diagram or
" chart," such as is shown in Fig. 1, opposite p. 232, which
represents the projection of a hemishere upon a plane surface.
In that diagram we have a series of concentric circles cut by
numerous radii or diameters. The centre corresponds to 0° or
the point of fixation, and the diameters to the different planes
in which the measurements have been made. At the ex-
tremity of each radius a number shows the inclination of the
corresponding meridian to the vertical. The radii themselves
are also divided into equal parts, each corresponding to 10°
of the divisions upon the arc of the perimeter.
Thus, supposing the right eye to be under examination for
232 THE VISUAL FIELD, AND USE OF PERIMETER.
white, and we fiiul the hmits of indirect vision in the hori-
zontal meridian to extend to 90° on the onter side, 70° on the
inner: we proceed to mark these by dots or pricks upon the
horizontal line of the chart at the points corresponding to 90°
and 70° on the outer and inner parts respectively. The other
meridians are similarly measured and marked off; and the
dots are finally joined together by a continuous line, in the
manner represented in Fig. 1, on the opposite page.
In this way we find that the normal visual field is not cir-
cular, but that it is more extensive in the outer and lower than
in the inner and upper portions. This is due partly to the
fact that the retina extends slightly further forwards on the
inner side (which of course corresponds to the outer side of
the visual field), but chiefly to the circumstance that the outer
part is less used than the inner, in consequence of the projec-
tion of the nose s'hutting off* peripheral rays coming from the
inner side.
Visual field for colors. — In testing the limits of the field for
colors, Landolt' found that when colors of great intensity,
such as those of the solar spectrum, are used the}' can be
recognized quite up to the limits of the field for white. When,
however, ordinary disks of colored paper of about 2 cm. diam-
eter are used in the manner above indicated for white, it is
found that the peripheral portions of the retina are less easily
excited by colored than by white disks, and that each color
has its own limits, beyond which it ceases to bo perceived by
the retina. Thus, if we test the normal eye with the funda-
mental colors, blue, red, and green, in ordinary bright, well-
diffused daylight, we find that on passing the test-object from
the periphery toward the centre, the blue is the first to be re-
cognized, after that the red, and next the green. If the fields
for each of these colors are respectively taken, and their out-
lines marked with cojored pencils, we obtain a chart similar to
that represented in Fig. 1 on the opposite page. Thus we find
that the field for blue is almost as large as that for white, that
it is larger than that for red, whilst the field for green is con-
siderably smaller than that for red.
' Examination of the Eves, 1870. Bv Dr. E. Landolt.
Fig 1 Normal/ vvsumI' fveLdb of' ngJU, Eye .
Fig-2. Bighi/ vimxdj rield . Cbnunenang of±u: airophy.
L£80N & Co.
VISUAL FIELD FOR COLORS. 233
Of the other colors of the spectrum, the field for yellow is
very similar to that for blue ; the field for orange exists be-
tween the limits of the yellow and the red. Violet is a difli-
cult color to test; it appears for a considerable distance as blue
before its color is really recognized as violet. The three fun-
damental colors, red, green, and blue, are really all that are
required in practice.
The limits of the normal fields for color are necessarily
difiicult to fix with accuracy, because, as we have seen, the
sensibility of the retina varies with the intensity of the color
and the brightness of the illumination, and the acuteness of
vision for color is much less marked at the periphery than
toward the centre of the field.
From a number of experiments on this subject, Landolt is
of opinion that the following should represent the minimum
extent of the normal visual field for colors :
Blue.
Red.
Green
Upper
. .50°
35°
30°
Outer
. 80°
70°
55°
Lower
. 55°
45°
35°
Inner
. 50°
40°
30°
Other observers, however, consider that the normal limits
are considerably less than this. This difference of opinion is
doubtless owing to difterent conditions in experimenting.
Scotomata. — Having ascertained the limits of the visual field,
it is necessary to examine its area in order to ascertain if there
exist any blind spots (scotomata). These may be complete or
partial. AVhen complete, the test-object entirely disappears
from view as it passes over the affected area. When partial,
the object is only obscurely seen. This is effected by passing
the test-object from the peripherj^ of the field toward its
centre in the difierent meridians. The patient fixes the white
spot on the perimeter as before, and is instructed to give a
sign the moment that the object becomes obscure or entirely
disappears, and when it again becomes clearly visible. These
points are then recorded on the chart.
The blind spot. — There is one part of the field in which a
scotoma is alwa3-s present ; this corresponds to the optic disk,
where, as we have seen, the retina does not exist. In emme-
234 THE VISUAL FIELD. AND USE OF PERIMETER.
tropic eyes the position of this, the blind spot, is about 15° to
the outer side, and 3° below the centre of the field. In hyper-
niotrojtia this distance is greater, and may be as much as 19° ;
whilst in myopic eyes it is less, and seldom exceeds 11°. The
form of the blind spot is usually round, and its diameter sub-
tends an angle of from 5° to 6°.
Scotoiitaiafor colors are tested for in the same way as those
for white.
Numerous forms of the perimeter have been introduced
since this instrument was first used by Aubert. For a long
time I was in the habit of using the instrument known as
Forster's perimeter; this is, however, an exceedingly cumber-
some apparatus, consisting of a broad semicircle of wood,
which can be rotated about its centre ; the test-object is moved
along this by a system of pulleys. There is, however, no
advantage in using a semicircle, and most modern instruments
have a quadrant only.
The self-registering machine recently invented by Mr. Mc-
Hardy, and that still more recentl}' introduced b}' Mr. Priest-
ley Smith, are very excellent for the rapidity, accuracy, and
facilit}' with which they can be employed.
In Mr. McHardy's perimeter (Fig. 53) there is a chin-rest (e)
and a biting fixation l)ar (m). The height of the rest and of
the stem which supports the quadrant can be regulated to suit
different patients.
The test-object — a disk of white and colored paper — is fixed
on a traveller, which is moved by an endless band worked by
rotating the milled head (j). The hand of the surgeon can be
concealed while rotating this by atfixing the shield shown de-
tached in the figure (n).
The chief novelt}* in the instrument is the mechanism by
which the registering of the field is accomplished. The milled
head (j), in addition to moving the traveller (?), rotates two
toothed wheels, which cause two slips of metal to move in the
same direction as tlie traveller, and at ^ and \ of its speed
respectively ; from each of these there projects backwards a
sharp pointer (/>); these are so placed that when the traveller
is at the fixation point (zero) their extremities lie exactly be-
hind the fixation point.
PKIESTLEY S:\[ITH S PERIMETER,
235
The chart is placed in a frame supported on a hinged limb
(/•), in such a position that when the traveller is at zero the
pointers correspond to the centre of the chart.
The quadrant can be rotated to, and tixed in any position ;
and as the plates supporting the pointers move with it, their
|ltilill,lli,iiiifii»'iiw'i!''iii.ii!'.i'"'='^
Fig. 53. — McHardj's Perimeter.'
line of movement always corresponds with the position of the
quadrant.
In using the instrument the slow-travelling pointer is usually
employed, and the other (which is intended for mapping out
limited areas on an enlarged scale) is removed.
Mr. Priestley Smith's perimeter.- — The general arrangement of
the instrument will be understood from Fis:. 54: the followins:
1 This instrument (with charts) is sold by Messrs. Pickard & Curry, of l'.i.5
Great Portland Street, W. Its price is 8^. 10s.
^ This instrument (with charts) is sold by Messrs. Pickard & Curry, of 195
Great Portland .Street, AV. Its price is 41. 4s.
236 THE VISUAL FIELD. AND USE OF PERIMETER.
points only, need be particularly described. AViien the travel-
ler has reached the limit of the visual field the chart is pressed
against the pointer; the position of the test-object is thus
recorded on the chart by a puncture.
1. The patient rests his cheek against the wooden pillar, so
that the eye is about an inch and a half above the knob, and
Fic. J4. — Priestley tiniiLi't Peiiiiieler.
vertically over it. The height of the instrument is regulated
by movable blocks.
2. The quadrant, which is a flat strip of metal engraved
upon its two sides, is rotated by a wooden hand-wheel, at-
tached to the axis; it is balanced by a weight upon the hand-
Avheel, 80 that it will stand in any position without being fixed.
3. The test-object is a square of paper gummed upon a
light vulcanite wand, which the operator holds in the left hand.
With the right hand he rotates the hand-wheel, and pricks
the chart.
4. The chart is placed upon the hinder surface of the hand-
wheel, and rotates with it. There is a mark on the hand-
wheel to show whicli way the chart is to be placed. This
PRIESTLEY smith's PERIxMETER. 237
mark is brought to the top, and the chart is then slipped in
from above downwards and in the upright position.
5. Immediately behind the hand-wheel is lixed a horizontal
scale, the divisions of which correspond with the circles on
the chart. As the quadrant rotates the chart rotates with it,
and in whatever position the quadrant stands, the correspond-
ing meridian of the chart stands against the scale. This
arrangement enables the operator to prick oif his observations
with the greatest ease, and has the further advantage that the
chart is constantly' under inspection, and that an}- portion of
the tield can be immediatel}' brought under examination at
any time.
6. The charts are of two kinds, A and B. The A charts
correspond to the entire field, and are divided by circles from
0° to 90°, the limits of the average normal field being shown
by a dotted line. The B charts are for mapping the central
part of the field on a larger scale, and are divided from 0° to
45°. The scale of the perimeter is graduated accordingly on
its two sides ; the A side is to be used with the A charts, and
the B side with the B charts.
7. There are many cases in which it is better to sweep the
field, or parts of it, in circles rather than in meridians — e. g.,
hemiopic and sector-like defects, in which the boundary line of
the field runs in a meridional direction. In cases of this kind,
the test-object may be placed in the clip which slides upon the
quadrant, and carried round the field in successive circles.
(Vide Ophthalmic Review, November, 1882.)
The importance of systematic observation by means of the
perimeter is paramount. There is scarcel}' a lesion ot the in-
terior of the eye which is not accompanied by perimetric
symptoms. iSTot only does it frequently assist in establishing
a diagnosis which without its aid would have been doubtful,
but a prognosis of the case can often be effected by this means
which would otherwise have been impossible. Thus, in atrophy
of the optic nerve there is always found to be a contraction of
the visual field at least for colors, and although this affection
is easily recognized in the advanced condition, yet there are
many cases occurring in practice in which, at the onset of the
disease, the disks are not particularly pale, nor are the vessels
238 T H K VISUAL FlKhV, AND USE OF PERIMETER.
contracted. Under sucli circumstances the discovery of con-
traction of the visual field for colors is of great assistance, both
in the diagnosis and in the prognosis of the affection. Fig. 2,
opposite p. 232, shows such a case, in which a man aged 40
was suffering from gradual failure of vision in both eyes. The
vision in each eye was only -£j^. The disks were not remark-
ably pale, nor was the visual field for white greatly contracted;
but on carefully testing his field for colors it was found that
the color-sense of the peripheral portions of the retina was
considerably diminished. In advancing optic atrophy the con-
traction of the visual field is almost as constant a symptom as
the failure of acuteness of vision.
In glaucoma the contraction of the visual field is quite char-
acteristic of the disease. First the inner, and then the upper
and lower portions of the field, begin to contract, and this
gradually extends toward the centre of the field, the central
and outer parts alone remaining unaffected. At a later period
even the central vision is abolished, leaving only a portion of
the outer, part of the field intact. Finally even this is lost.
The remarkable feature of this diminution is, that the contrac-
tion of the fields for colors appears to advance at the same rate
as that for white, and so retain throughout a concentric arrange-
ment simihir to that existing in health. Fig. 1, on the opposite
page, shows the usual condition of concentric limitation of the
field. It was taken from a case of moderate!}- advanced chronic
glaucoma. There is sometimes a difficulty in distinguishing
between chronic glaucoma and partial atrophy of the optic
nerve. The cupping of the disk may be slight, and there may
be pallor in both affections ; but in the case of glaucoma the
fields for color are only limited in proportion to the contrac-
tion for white, whilst in atroph}' the color-sense, more espe-
cially for green and red, may be almost abolished. Compare
tlie charts of optic nerve atrophy and glaucoma opposite pp.
232 and 238.
In pigmentary retinitis there is also contraction of the field,
which is alone almost characteristic of the disease. Here we
find concentric limitation of the field, which involves all the
peripheral portions, and leaves a small circular area around the
centre in which the vision for colors is comparatively good.
Rg.1 ■ Bzgkt/ vl6iuj2/ ftdd' Xhrvrdc Giaacona/.
Rg Z Blghb vLsumJ/ fieLtL . Ptgrweniwy RetimUe.
THE INDICATIONS OF THE PERIMETER. 239
Fig. 2, on the opposite page, shows the chart of a man suffer-
ing from this affection.
In detachment of the retina, also, the use of the perimeter is
often of service. Thus, having found by the ophthahiioscope
that a portion of the retina is detached, we proceed to ascer-
tain the limits of the field for white. Finding a limited por-
tion in, say, the upper half of the field, destroyed, we know
from this that the corresponding lower half of the retina is
separated from the choroid. Now, by further testing the lower
half of this field for colors we may still learn something as to
prognosis. If we find the limits of the fields for color extend-
ing quite up to the edge of the detachment, this maj- be re-
garded as a favorable indication ; if, on the contrary, the color-
sense is defective at some distance from the detachment, a fur-
ther separation of the retina is to be feared.
In the various forms of heviiojna, again, it is advisable to keep
a record of the limits of the persistent part of the field both
for white and for colors. It is not at all uncommon, especially
in hompnymous hemiopia, to find the persistent half of the
visual field in a state of perfect visual acuitj^ both for white
and for colors. A chart of such a field is shown in Fig'. 2,
opposite p. 222. ISTow, it is possible for the central cause of
this affection, such as a small hemorrhage in the correspond-
ing hemisphere, or the pressure of a gumma upon the optic
tract, to recede and so allow the hemiopia to disappear; and,
on the other hand, the central lesion may so increase as to ex-
tend to the opposite optic tract. By careful perimetric obser-
vation we may, to a great extent, ascertain the condition of
things going on within.
In the various forms of toxic amaurosis — of which those due
to tobacco and alcohol (vide p. 219) are the most common —
the perimeter is a valuable instrument of diagnosis, for by it
we are enabled to discern a central scotoma for colors, wdiich
is pathognomonic of these afiFections.
Other forms of scotoma are sometimes found. That known
as the ring scotoma forms a band round the point of fixation,
while the adjacent portion of the field is unafl:ected, and may
easily be overlooked unless the field be very carefully tested.
^Vhat the sic:nificance of this and other rare forms of scotoma
240 THE VISUAL FIELD. AND USE OF PERIMETER.
is we are not at present in a position to state ; but there can
be no doubt that the perimeter will in the future be of consid-
erable help in tlie differential diagnosis of many of the cases
of amblyopia without ophthalmoscopic signs, tlie pathology of
which is at present obscure.
The field of fixation is a term used to express the amount of
angular deviation from a line at right angles to the plane of
the face which can be given to the eye by its muscles. This
can also be measured by means of the perimeter. The patient
is placed in the same position as for testing the visual tield.
Instead of employing disks as test-objects, we substitute a let-
ter of the alphabet, which is of such a size that its form can
only be recognized when its image falls on the yellow spot.
The slide of the perimeter, with the letter attached, is now
passed from the centre toward the periphery of the arc, and
the patient is told to follow it with his eye, and to give a sign
as soon as he can no longer distinguish its form. The angle
at which the form of the letter is lost is then marked upon a
chart similar to those used for the visual field. The process is
repeated for the remainder of the horizontal, the vertical, and
the intermediate meridians. The points thus obtained are
then connected by a continuous line, which maps out the
limits of the field of fixation for that eye.
From a large number of experiments made in this way
upon healthy eyes, Landolt has found that the average limita-
tions of the normal field of fixation are as follows :
Outwards ..... 4.5° Inwards ..... 45°
Outwards and downward- . 47° Inwards and upwards 45°
Downwards .... 50° Upwards 43°
Downwards and inwards . 38° Upwards and outwards . 47°
It is evident that this method of testing the movements of the
eye produced by the action of the ocular nmscles would be of
great help in recording any deficiency in the action of these
muscles. Thus, supposing the external ractus to be paralyzed,
we should find that the limits of the field of fixation would
not extend to 45°, but would be nearer to zero in proportion
to the completeness of the paralysis. Similarly for all the
ocular muscles.
THE FIELD OF FIXATION
241
In the chapter on Strabismus it will be found that the use
of the perimeter in tracing the field of fixation is not only
useful in this way, but also in distinguishing the paralytic
from other forms of squint.
The Jield of fixation can also be ascertained ohjectively. To
efifect this a lighted taper is passed along the arc of the
perimeter instead of the letter just mentioned. The positions
of the patient and the observer are the same as before. The
Fig. 55.
patient is then told to direct the eye as^far as possible in the
direction of the periphery of the~arc. Having done this, the
observer passes the light along the arc until, by keeping his
own eye just behind it, he is able to see its image in the centre
of the patient's cornea. Since the'reflected pencil of rays only
16
242 THE VISUAL FIELD, AND USE OF PERIMETER.
coincides with the incident rays when it lies on the principal
axis of the cornea, this test gives the position of the latter, and
although this does not exactly coincide with the visual axis, the
diiference is unimportant. ]Ie then reads upon the arc (a a,
Fig. 55) the position (x) of the taper, and then proceeds to
register the other meridians in a similar manner (Javal).
The angle " alpha," or the angle formed by the intersection
of the visual line and the optic axis, can also be determined
by the perimeter. The patient must be madetolix the lighted
taper placed at zero ; the observer then moves his eye along
the arc until the reflection of the flame is seen in the cornea ;
he then reads the angle between this point and the flame,
which is double that of the angle alpha. (This experiment is
accurate only when the principal axis of the cornea coincides
with that of the whole eye.)
A recent writer (de Wecker and Landolt, p. 110) has em-
ployed the terra angle " alpha " to express the angle formed
by the visual line and the axis of the cornea; it has, however,
been thoui^ht better to retain the original sense of the term.
CHAPTER X.
COLOR-YISIOX AND ITS DEFECTS.
By W. Adams Frost, F.E.C.S.
Normal color- vision. — Light is transmitted by means of trans-
verse waves of ether ; the waves, however, in white or color-
less light are not of one uniform type, but vary in height and
rapidity of vibration. The waves of greatest height and
slowest vibration are less easily refracted than the lesser waves
with more rapid vibration; hence, when a beam of solar light
passes through a prism, it undergoes dispersion, or a separation
into waves of different rates of vibration. Such of these waves
as are cajDable of exciting the retina give rise to the sensation
of color, and the series of colors caused by the- decomposition
of light is called a spectrum. The largest waves which are
capable of exciting the retina give rise to the sensation of red,
the smallest to that of violet; between these extremes are
waves of gradually decreasing size and increasing rates of
vibration from the red to the violet, and these give rise to
various colors.
The colors of the spectrum, and their order, are as follows :
{Heat rays), Red, Orange, Yellow, Green, Prussian Blue,
Indigo, Violet {chemical rays).
These are the only ether waves capable of exciting the
retina ; but at each end of the visible spectrum there are in-
visible waves. Those beyond the red are of still greater
height, and are called heat rays ; and beyond the violet are
smaller waves, which are called chemical rays. The differ-
ence, however, is of degree, and not of kind, for all the rays
possess heat and chemical action, and the visible portion of
the spectrum owes its visibility, not to any difference in its
244 COLOR-VISION AND ITS DEFECTS.
physical character, but to the construction of our visual ap-
paratus.
Light is reflected from objects in various ways. A surface
reflecting light perfectly — a perfect mirror — would be colorless
and invisible. A surface which reflects all the waves in the
same proportion as they exist in white light, but reflects the
waves irregularl}', appears ich'de. A surface reflecting no light,
but quenching or absorbing all, would be invisible; if it re-
flected only suflicient light to render it visible, it would appear
black ; so that a black surface is visible only in consequence of
the imperfection of its blackness. A colored surface quenches
some waves of colorless light, and reflects others; it is from
the latter that we judge of the color of the surface.
For the sake of clearness, the following terms in relation to
colors should always be used in the same sense. Difterences
in hue or tone are those which exist between the diflerent colors
of the spectrum, as red, yellow, blue, etc. Fulness or satura-
tion depends on the amount of colored light reflected; the
more white light is reflected with a color the less the degree
of saturation. Brightness depends on the total amount of light
reflected. A color which is much diluted with white we speak
of as pale or light. The term fall or deep should mean that a
large quantity of the colored light is reflected, and very little
white; while rf«/'A- means that a comparatively small quantity
of colored light is reflected, but none of any other kind — in
other words, it is mixed with black.
Additional proof that white light is composite is aflforded by
the fact that the colors of the spectrum can be recombined, so
as to form white, by condensing them by means of a lens, aod
that if the colors be painted on a disk (Maxwell's disk) in the
same proportions as they exist in the spectrum, and the disk
be rotated rapidly, a gray is produced, which approaches white
in proportion to the purity of the pigments used and the ac-
curacy with which the relative quantity of each color has been
measured.
In order to produce white, however, it is not necessary to
employ all the colors of the spectrum; a mixture of red, green,
and violet will suffice. These colors are the only ones that
cannot be produced by a mixture of others, hence they are
THE COMPLEMENTARY COLORS. 245
called fundamental or primary. Any other color of the spec-
trum (or a color indistinguishable from it by the eye) can be
produced by a combination of the primary colors on either
side of it. In speaking thus of the mixture of colors, it must
be understood that colored light is meant; the effect of mixing
pigments is different, because the pigments are impure ; thus a
mixture of blue and yellow light produces white, but if blue
and j-ellow pigments be mixed, green is produced ; this is be-
cause each of the pigments reflects some green light in addi-
tion to its own color, so that by their union a green, more or
less mixed with white, is produced.
Since white can be made by mixing the three primary colors,
it follows that to each one of these there corresponds a com-
plernentary color [i. e., a color whose addition is required to make
white), which is formed by a combination of the other two.
Thus the complement of 7'ed is green -\- violet = bluish-green.
" " green is red -f- violet = purple.
" " violet is red -|- green = yellowifsh-green.
In the same way, to each color in the spectrum there is an-
other, which, added to it, produces white, and which is there-
fore said to ])e complementary to it. The relative positions of
a color and its complement are the same throughout the spec-
trum. Thus, if a color be taken which lies to the right of red —
e. g., orange, its complement will lie to the right of bluish-
green, viz., blue, and so throughout the spectrum.
But here we must guard against an error. Each color in
the spectrum has a definite wave-length, and rapidity of vibra-
tion peculiar to itself; and, though the visual sensation pro-
duced b}' the mixture of two of the so-called fundamental
colors is indistinguishable from that produced by the spectral
color that lies between them, this resemblance is probably only
due to the imperfection of our color-sense. Viewed in this
light, the separation of the colors of the spectrum into funda-
mental and non-fundamental has a great value in relation to
our perception of colors, but none in relation to their physical
properties ; in other words, its value is physiological rather
than physical.
Purple seems to occupy an anomalous position in the scale
246 COLOR-VISION AND ITS DEFECTS.
of colors, for it is formed by the union of red and violet; yet
these do not lie on either side of it, but at opposite ends of the
spectrum. We have seen that beyond either end of the visible
spectrum there are waves the rates of whose vibrations form a
continuous series with those of the visible spectrum ; so that
from the large, slowly vibrating, ultra-red waves the rate of
vibration gradually increases through all the spectral colors to
the invisible ultra-violet rays ; how far they extend in either
direction we have no means of knowing, but there is no ground
for supposing that they stop short at the point where we cease
to be able to follow them. If we assume that beyond the vio-
let these waves extend ad injinitum, their rate of vibration in-
creasing at the same rate as in the visible spectrum, it is evi-
dent that at some distance beyond the violet they would form
a series of waves which would stand in the same relation to
the colors of the visible spectrum as a series of musical notes
to their octaves. On this hypothesis purple would take its
proper place between the violet of the visible spectrum and
the octave of the visible red, and the light of the sun would
consist of an infinite series of waves, of which only a single
octave would be capable of exciting any visual sensation.
The relation of the color-sensations to each other and to
white may be conveniently represented by a circle formed by
all the colors of the spectrum, the red and violet being united
by various shades of purple, and white being placed in the
middle. Each color and its complement would then lie at
opposite extremities of the same diameter, while white, which
is formed by their union, would lie between them. Such a
diagram, however, would give no indication of the proportion
of each color necessary; this can be done by altering the circle
to a triangle, and placing the fundamental colors at the angles;
a color formed by the combination of any two will then be
found on the line between them (Fig. 56). We shall presently
see that the purest primary colors do not give rise to the purest
possible sensation of those colors, so that the sensations which
we call red, green, and violet are indicated by a position a little
removed from the angles. The position of the various colors,
and of white, is so chosen that the latter always lies on the
line connecting the complementary colors, and proportionately
THE COLOR-SENSE. 247
nearer to that one of which it contains most; and in the same
way, any componnd color lies on the line between its compo-
nents, and proportionately nearer to the one of which it con-
tains most.
There is reason to believe that our sense of color is very
defective. In the first place we know that there are waves on
each side of the visible spectrum, which, although they possess
Fig. 56. — (From Hermann : modified.)
no other difference, as far as we can ascertain, from those of
the visible spectrum, yet excite no visual sensation. In the
second place, the same visual impression is caused by colors
that have no other claim to be considered as identical. Thus,
a mixture of red and bluish-green, and one of yellowish-green
and violet, alike produce the sensation of white ; yet a surface
illuminated by the first would in a photograph come out black,
while the second, under the same conditions, would appear
very bright ; by means of a prism, too, the mixtures could be
resolved into their component colors. Helmholtz has com-
pared our color and musical senses, and shown how much
more highly developed the latter is ; for a good musical ear
can not only assign to every note heard singly its true value,
but can resolve a chord into the notes of which it is com-
pounded, and even in the combined effect of an orchestra can
recognize each component sound.
We shall presently see that the visual sensations produced
248 COLOK-VISIOX AND ITS DEFECTS.
by the fundamental spectral colors, although the purest ever
experienced, are under the ordinary conditions of vision less
pure than certain subjective sensations of these same colors.
AVe must first glance at the physiological relation that ex-
ists between complementary color-sensations. If any bright
color be looked at steadily for about half a minute, and the
eye be then directed to some white or gray surface, an aftei--
image is seen, whose color is complementary to that of the sur-
face originally looked at. If the comi)lement to one of the
spectral colors is looked at in this manner, the hue in the
after-image is brighter than the corresponding hue in the spec-
trum, and gives rise to a purer sensation of that color than can
be obtained in any other way.
To construct a theory of the mode in which colors are per-
ceived, which should explain the relation of the fundamental
to the other colors, the physiological relation of the comple-
mentary colors, and the mistakes made by those who are color-
blind, was a problem which occupied physicists and physiolo-
gists during the first half of this century. In 1800, however,
the mighty intellect of Thomas Young had already formulated
such a theory ; but as it was about half a century in advance
of the. accepted physiology of his day, it lay dormant and for-
gotten, until revived and slightly modified by Ilelmholtz, when
it was found not only to explain nearly all the phenomena as-
sociated with our ])erception of colors, but to be in strict accord-
ance with facts which have been discovered and theories which
have been accepted since it was first constructed.
Young's theory was, that in the eye there existed three sets
of fibres, each of which was excited by one of the fundamental
colors and by the non-fundamental colors near it in the spec-
trum, so that each fundamental color excited onl}' one set of
fibres, but a non-fundamental color excited the fibres corre-
sponding to the fundamental colors on each side of it. Thus
red and green would each excite one set of fibres only, while
yellow, which lies between them in the spectrum, would excite
both the red and green fibres ; this explains why the same
visual sensation is produced b}' a pure spectral yellow, and a
yellow is produced by mixing red and green. This theory, how-
ever, although capable of accounting for most of the facts
Y O U X G - H E L :\I H O L T Z THEORY.
249
connected with color-vision, leaves a few unexplained — for in-
stance, the fact of the subjective sensation of the after-image
of bluish-o^reen (the complement of red) being more intense
than that caused by the primary sensation of the purest red
in nature, namely, that of the spectrum; it fails to explain,
also, why those who are blind to red confuse certain shades of
red and green, for according to it pure red would excite no
visual sensation at all. To meet these difficulties Helmholtz
modified the theory somewhat.
Young-Helmholtz theory. — This modified theory is as follows:
That there exist, as assumed by Young, three sets of fibres,
corresponding to the three fundamental colors, but that each
of these colors, in addition to exciting its own special fibres,
excites also, but in a much less degree, the other two. The
efi:ect of the various colors of the spectrum in difierent sets of
fibres can be conveniently shown b}- the accompanying dia-
gram (Fig. 57). The curves 1, 2, and 3 rei)rcsent respectively
Fig. 57. — (From Holmgren.)
the fibres corresponding to red, green, and violet; the height
of the curve at any point is in proportion to the degree in
which it is stimulated by the color indicated below by a letter.
The sensation of white is produced by the maximum stimula-
tion of all three.
According to this view, red not only stimulates strongly the
red fibres, but also to a slight extent those for green and violet.
If, then, we could eliminate the action of the two latter fibres,
we should get a purer sensation of red ; this can be done by
gazing at a color formed by the union of green and violet,
viz., bluish-green ; the fibres corresponding to green and violet
then become fatigued, and the complementary red of the after-
250 COLOR-VISION AND ITS DEFECTS.
image consequently appears more vivid than the purest red
with the eye in its natural condition. The Young-IIelniholtz
theory is now very generally accepted; there are, however,
several rival theories, most of which arc merely modifications
of it, and need not detain us; l)ut what may be termed the
photo-chemical theory of Ilering must be briefly noticed.
Hering's theory, — It was discovered a few years ago that
there existed in the retina a substance which received the name
of visaal purple., upon which light under certain conditions
acted chemicall}', producing a kind of photograph of external
objects. Hering assumed that there are three substances, each
of which is acted on chemically by two colors but in opposite
ways, the one color causing disintegration of the substance,
the other building up ; and he accordingly designated each as
an assimilation or a dissimilation color ; these substances he con-
siders as corresponding to the following pairs : (1) Red and
green, of which red is the dissimilation and green the assimi-
lation color ; (2) Blue and yellow — of these he is uncertain
which to consider as dissimilation and which assimilation ; (3)
White and black, of which white is the dissimilation color.
According to this view, white and black are considered as
specific color-sensations, and not as expressing the combined
effect of all colors or the absence of lio^ht.
The foundation for Hering's theory is the assumption that
the visual purple plays an essential part in vision, but this is
by no means proved. That prolonged exposure to light of a
delicate membrane like the retina, should produce some
changes, is not surprising; but if such changes were essential
to vision they would surely be most marked where vision was
most acute, viz., at the yellow spot, but here the visual purple
is absent. This theory, however, does explain a fact that the
Young-IIelmholtz theory does not account for, viz., that a
complementary after-image is seen when the eyes are closed.
The retinal elements which are essential to color-vision are
probably the cones, for they are most abundant at the yellow
spot, where color-vision is most acute, and more sparsely scat-
tered at the periphery, where color-vision is very defective, and
in animals whose habits are nocturnal the cones are absent.
(Schultze.)
C0L0R-15LINDXESS. 251
The periphery of the visual field is blind to all colors, the
field for green being the smallest. It has, however, been said
(Landolt) that if colors of great intensity be employed they
can be recognized quite up to the periphery of the field. Since
the color of objects depends on the light reflected from them,
it will necessarily vary with the incident light; if the amount
of light reflected is sufficiently bright to stimulate all the three
sets of fibres to their maximum extent, the sensation of white
is produced whatever may be the color of the reflecting
surface by a feebler illumination. A color which has the
greatest intrinsic brightness, i. e., reflects the most light, most
easily passes into white ; in this respect yellow takes the lead.
For the same reason colors of a low degree of saturation, i. e.,
containing much white light, differ less from each other in ap-
pearance than more saturated colors; this fact has an impor-
tant practical bearing in testing the color-vision.
Congenital defects of color-vision. — It has long been known
that persons are occasionally met with who, although possess-
ing normal sight in all other respects, fail to see any difference
between colors which to other people are totally distinct ;
they are therefore said to be color-blind. The earliest published
case of color-blindness is that of a shoemaker in Cumberland
named Harris {Phil. Trans, of Roy. Soc, 1777). In 1794 Dal-
ton discovered his own defect, and mentioned other cases.
But it is only within the present decade that any attempt has
been made to ascertain the frequency of color-blindness ; and
the result of the examination of large numbers of persons, in
this country, on the Continent, and in America, lias been to
establish the fact that, although it is a rare defect among
females, the proportion of color-blind persons among males
vs-hose sight is otherwise normal is not less than 4 per cent.
That the percentage should be so high seems at first sight
almost incredible, but the defect is one that cannot only easilj^
be concealed by the subject of it, but one of which he may be
himself entirely unconscious. In early life we learn to asso-
ciate the names of certain colors with the names of common
objects ; thus we learn very early that grass is green, the clear
sky blue, and that a soldier wears a red coat; a child who has
normal color-sense soon learns to recognize similar qualities in
252 COLOR-VISION AND ITS DEFECTS.
other objects and to call them by the same name, whilst one
whose color-vision is defective learns l)y heart the colors of
common objects, without recoo^nizino^the true distinctions. As
he grows older he is puzzled to tind other objects designated
by the same epithet; if he attempts to name the color of un-
familiar objects he makes mistakes, for which he is laughed at,
and he probably thinks no more about the matter, but does not
again commit himself to giving a name to a color. Except in
certain employments, it is very seldom that one is called upon
to name a color or to match two colored objects; and it must,
moreover, be borne in mind that the color-blind do not con-
fuse all colors, but only a few, and not all shades of those ; so
that a man may easily reach adult life without suspecting his
defect himself, and still more easily without exciting any sus-
picion of it among his friends. The case of a woman is some-
what different. Except in the lowest grades of society, it
would hardly be possible for a woman who was color-blind
long to conceal her defect; but among women the defect is,
as we shall see later on, extremely rare.
Throughout this chapter it must be understood that we are
speaking of a congenital, not of an acquired defect; in many
morbid conditions the loss or impairment of color-sense is an
important symptom, and in some toxic forms of amaurosis —
notably those due to tobacco and alcohol — the loss of color-
vision over a limited area of the visual field is a characteristic
s^^mptom. Tliese acquired defects will, however, be more ap-
propriately considered under the diseases in the course of
which they occur.
Defective color-vision may present several varieties and de-
grees, and these have been variously classified. The mistakes
made by the color-blind can, however, be most conveniently
explained by means of the Young-Helmholtz theor}', and this
therefore serves as the best basis for a classification. As the
essence of this theory is the existence of separate nerve-fibres
for each of the three fundamental colors, so defective color-
vision is explained by the absence, or impaired function, of one
or more of these sets of fibres. Thus we may have —
A. Total color-blindness (achromatopsia), in which there would
be only one set of fibres capable of excitation, and therefore
VARIETIES OF CO LO E-BLIX DN ESS . 253
all dift'erences of color would only make themselves known
according to the degree of excitation they caused, and would
be perceived only as various degrees of brightness. Total
color-blindness is, however, extremely rare, and need not be
further considered here.
B. Complete blindness for one of the fundamental colors (par-
tial achromatopsia). Thus we maj' liav^e —
i. Complete red-blindness.
ii. Complete green-blindness,
iii. Complete violet-blindness (or blue, according to ]Maxwell).
C. Incomplete blindness for one of the fundamental colors.
D. Incomplete blindness for all three.
The two latter may be conveniently classed together as
feeble chromatic sense.
Among pronounced cases of color-blindness — Group B —
red-blindn-ess is the most common, while violet-blindness is
very rare.
The red- and the green-blind possess, as we shall presently
see, many points of resemblance, and are equally important in
cases where the competence of the subject to distinguish sig-
nals is in question. For these reasons those coming under
B i and B ii are sometimes classed together as " red-green-
blind."
We have seen that, according to the Young-Helmholtz the-
ory, each fundamental color, in addition to exciting the special
fibres corresponding to it, excites also, but in a less degree, the
other fibres ; it is evident, therefore, that the absence of one
set of fibres must alter the perception not only of the funda-
mental color which most powerfully excites it, but also of those
Avhich excite it in a less degree. This will be made clearer by
a reference to the annexed diagram (Fig. 58), which is a repro-
duction of Fig. 57 with the curve 1 omitted, and therefore
represents the color-vision of the red-blind. The sensation of
white is now produced by the excitation of two instead of three
sets of fibres. Hed will excite the fibres for green, and very
slightly indeed those for violet ; therefore, the sensation of
green will be produced. Since the amount of excitation of
each set of fibres is comparatively slight, the color will appear
to be lacking in brightness; but as the stimulation is confined
254
COLOR-VISION AND ITS DEFECTS.
almost entirely to the one set of iibres, there will be little ap-
pearance of admixture with white: therefore the red will
appear as a saturated green of low intensity.
Fi<i. 58. — (Huluigreu.)
Red, orange, yellow, and green will obviously i)roduce very
similar sensations, but the green will be the most intense — i. e.,
the brightest, and at the same time the least saturated — that
is, will contain the greatest amount of white. A red-blind
person, therefore, would distinguish red and green only by
their difference in brightness; if the two appeared of the
same intensity to the normal eye, the green would appear the
Fig. o'J. — (Holmgren.)
brightest to the red-blind ; and if given several shades of red
and green, and told to find two — one of each color — which
appeared to him alike, he would match a dark saturated red
with a bright green. It is evident, however, that yellow and
blue would give rise to totally different sensations, and would
therefore not be confounded by him.
In the same way, for the green-blind curve 2 is omitted
(Fig. 59).
Red will be a saturated color of low intensity: yellow will
be slightlv more intense, and whiter.
METHODS OF TESTING. 255
Green is composed of nearly equal parts of the two funda-
mental sensations which in the green-blind produce white by
their combination, but being of low intensity is equivalent to
gray. The impression produced by a yellowish-green, how-
ever (between yellow and green), would not be easily distin
guished from a yellowish-red (scarlet) between red and orange,
except that the latter would appear brighter. Hence the
green-blind will not unfrequently match a scarlet with a yel-
lowish-green, which to the normal sight is much brighter,
Yiolet-blindness is extremely rare, and not of so much prac-
tical interest as the preceding varieties, as it produces no con-
fusion between red and green, which are the colors used in
signalling.
Methods of testing color-vision. — The practical importance of
being able with certainty to detect defective color-vision lies
in the fact that the lives of man}^ may be sacrificed by one
man mistaking a red for a green signal. Hence it would seem
at first sight that the best test would be to show the examinee
red and green signals in succession, and ask him to name the
color. Such a test would, however, be inefiicient for several
reasons. We have seen that the red- and green-blind do not
confound red and green, but only certain shades of these
colors; given a red and green, which to the normal eye appear
of equal brightness, the red will appear the brighter to the
green-blind, and the green to the red-blind. Seeing the two
lights in quick succession, a man who is red- or green-blind
may recognize the difference between them, and name them
correctly ; possibly he is unaware of his defect, and believes
that he recognizes the true difference between them. But
this is not sufficient; he may in clear weather, and at a known
distance, recognize a signal correctly ; but if that which is to
him the brighter light is obscured by steam or mist, how is he
then, with no standard of comparison, to recognize it? At
sea, too, a fresh difficulty is interposed by the fact that the
distance of the light is unknown. The use of colored lanterns,
or a lamp with colored glasses and diaphragms, so that signal
lamps at different distances can be represented, is interesting
as a confirmation of other tests, but is utterly unreliable as a
first test.
256 COLOK-VISIOX AND ITS DEFECTS.
A good test should be quite independent of the names of the
colors — many uneducated persons are wonderfully ignorant of
color-nomenclature, and yet have perfect color-vision — and it
should be sufficiently rapid to enable a large number of
persons to be examined in a short space of time. It is, of
course, essential that it should be a real test, ('. e., that it should
allow no one with defective color-vision to pass, or condemn
any with normal color-sense.
Holmgren's wools constitute a test which fulfils these require-
ments better than any other. This method consists in making
the observer pick out from a heap of wools those which seem
to him to be the same color as one given to him. Skeins of
wool have been chosen as the test-objects, for the following
reasons amongst others. The colors are purer, and the sur-
face reflects less white light than pieces of paper, glass, or
other stiff material. They can be obtained in any variety of
color, and are uniformly colored throughout.
The tests are three in number : the first will detect all those
who have any defect of color-vision; the others will determine
the nature of the defect.
The wools must be placed on a flat surface, on a white cloth,
in good daylight.
Test I. — In the first test a skein is taken as the color, which
is a pure green rather freel}' mixed with white; it is repre-
sented very accurately in the color-plate on the opposite page.^
The heap of wools should consist of: (1) A variety of shades
of green of the same character as the test-color ; the other
greens also liiay be added, such as blue-green, but they make
the test longer, and do not add to its efficiency. (2) Various
shades of the confusion-colors (1-5, in the opposite plate), con-
sisting of grays, drabs, yellows, rose, and salmon colors, all
freely diluted with white.
The test-color is shown to the examinee, and he is told to
' Great puins have been taken by Messrs. Lebon «& Co. to reproduce the colors
of the wools in the plate, but it is diflScult or impossible to do so accurately. As,
however, several shades of each color have to be used, the errors are of little
consequence. The plate is onh' intended to represent the wools, and must on
no account be itself used as a test, as some of the compound. colors are composed
ditlerentlv to the dves used for the wools.
TESTS for COLOUR-BLINDNESS.
I.
Ila.
6 7
II
8. a
II
lib
10. n.
II
X2. 13.
Lebon*,Co
METHODS OF TESTING. 257
look at the heap and to pick out from it those skeins which
appear to him to be the same color as it, it being explained
that they may be of lighter or darker shades.
With people of low intelligence, and with children, it is a
good plan for the examiner to go through the test himself to
show how simple a matter it is; if the number of wools be
sufficient, and they are properly mixed afterwards, this gives
no unfair assistance to those whose color- vision is defective.
The directions may be given to a large number — as many
as can conveniently see — at the same time, and then each one
is told to step forward in turn and go through the test. Those
with normal color-sense, as a rule, pick out the correct wools
quickly and without hesitation ; those who have any defect
choose their wools in a slow, hesitating manner, and with
them select one or more of the confusion-colors, and miss
some of the greens. Any who choose a confusion-color, or
show a genuine doubt as to whether they should choose one
— even though they reject it — should be subjected to the
second test. Those who pick out all the correct wools and
no confusion-colors may be considered to possess normal color-
sense. After a little experience, one learns to recognize those
who suspect their own deficiency, by their general behaviour;
they generally hang back, and watch the performance of
others with great care, when their turn comes they are most
laboriously careful, taking up each skein and looking at it
minutely. The inexperienced examiner ma}-, however, if he
trusts to general behavior, occasionally mistake nervousness
or stupidity for defective color-sense; the difficulties arising
from the former can always be overcome by tact and patience.
The object of Test I. is to separate those whose color-vision
is normal from those in whom it is defective ; the nature of the
defect is determined by the following test.
Test II. — A rather pale but bright shade of purple (rose) is
taken as the test (ii, (a) represents it fairly well, but is a little
too dull). The heap of wools consists of (1) various shades of
purple, (2) various shades of the confusion-colors (6-9) — blues,
violets, grays, and greens.
Purple, being composed of red and violet or blue, is to the
red-blind identical with the two latter colors. For the green-
17
258 COLOR-VISION AND ITS DEFECTS.
l)lind a combination of red and violet produces white or gra}',
and green (vide g, Fig. 59) produces a similar effect, but less
intense.
Therefore —
The red-blind chooses blue and violet (6 and 7) ;
The gray-blind chooses grag and bright green (8 and 9).
He who, having failed in Test I., chooses only purples, has
a weak chromatic sense — /. e., he may have any of the defects
enumerated under C and D on p. 253. There is no practical
advantage in endeavoring to distinguish between these. The
examination may close here, but the following may be used to
confirm the result in those who have failed in the preceding
tests.
Test III. — A bright red, such as is employed in signal flags
(ir. b), is used as the test-skein. The confusion-colors are dark
and light shades of green and brown (10-13), which should be
rather darker than 10, or olive color.
The red-blind chooses a green and a dark brown (10 and 11),
the latter being a combination of greenish-yellow with black.
The green-blind chooses a green, brighter to the normal eye
than the red, or lighter brown (12 and 13).
A convenient arrangement of Holmgren's wools has been
adopted by Dr. Thomson, of Philadelphia, and is shown in the
annexed wood-cut (Fig. 60). The skeins, instead of being
thrown promiscuously on the table, are hung by one extremity
from a bar, and to each skein is attached a number, which is,
however, concealed from view while the instrument is in use.
The skeins, of which there are forty, are numbered in the
following manner: The test-colors are Nos. 1, 21, and 31.
Nos. 1 to 20 consist alternately of colors matching the test-
color and the confusion-colors. In the same way with Nos.
21 to 30 in the second test, and with Nos. 31 to 40 in the third
test. The wools should be arranged in an irregular order on
the bar (not as they are shown in the figure), and the numbers
of the skeins which the examinee chooses in each test are
noted ; if his color-vision is normal, these will of course con-
sist onl}' of odd numbers.
The frequency of color-blindness. — It has been ascertained by
the examination of large numbers of people, chiefly by Conti-
THE FKEQUEXCY OF COLO R-BLI XDNESS.
259
nental and American observers, that the number of color-blind
persons is on an average a little over 4 per cent, of the male
population. In consequence of this discovery the Govern-
ments of various countries have been urged to make compul-
sory the testing of the color-vision of railway employes and
seamen; and in this respect Professor Holmgren, in Sweden,
and Dr. Joy JefJries, in America, have been equally active.
AS) rt A r^ ft A * A
Fig. 60. — Dr. Thomson's Arrangement of Holmgren's Wools.
It was felt that it was exiremely important to ascertain
whether the frequency of color-blindness was as great in this
country; and the Ophthalmological Society of Great Britain
accordingly, in 1880, appointed a committee, of which the
writer was a member, to investigate the subject. The following
are some of the results.'
The total number examined was 18,088 ; of these, 16,431
were males, and 1657 were females.
Of the males, 1785 were taken from classes which it was
suspected might contain an exceptionallv high percentage of
color-blind — these were imbeciles, deaf-mutes, members of the
Society of Friends, and Jews — all, except the iirst, gave a
percentage above the average.
Deducting these, there remain 14,846 males, and of these
4.16 per cent, had defective color-vision, in 3.5 per cent, the
^ The report of the committee is published in the Transactions of tlie Ophthal-
mokigical Society, voL i. p. 191.
260 COLOR-VISION AND ITS DEFECTS.
defect being of the pronounced character classified under B on
p. 252. Comparing difterent classes of society together, color-
blindness would seem to diminish in proportion as education
improves. Thus, among the schools of the poorer classes in
Dublin^ the average of pronounced cases was 4.2 per cent.
Among the (London) metropolitan police and schools of the
same rank, it was 3.7 per cent. In middle-class schools it was
3.5 per cent. Among medical students and the sons of medical
men, it was 2.5 per cent. Among the boys at Eton it was
only 2.46 per cent.
Although, however, the frequency of the defect diminishes
wnth the education of the class, the education of the individual
has no tendency to remove the defect ; this is shown by the
fact that there was no appreciable dift'erence between the
children and adults in the same class, and is consistent with
the history of individuals who have known themselves to be
color-blind. Thus, Dalton discovered his defect in early life,
and always took great interest in comparing his ideas of colors
with those of other people ; yet he remained color-blind to the
same extent throughout his life; and the same has been re-
corded of others. Indeed, there is no case on record in which
a person proved to have had congenital color-blindness has
succeeded in removing the defect.
There can be little doubt that practice in distinguishing
between colors, continued through several generations, would
have a tendency to produce higher development of the per-
cipient elements, while want of practice continued in the same
way would lead to their degeneration. In this way may proba-
bly be explained the great rarity of color-blindness among
women (only 0.4 per cent, of the number examined, and those
for the most part slight cases), and its comparative frequency
among the Society of Friends (5.9 per cent, of males and 5.5
of females).
The defect having once appeared, w^ould have a tendency to
be handed down to posterity, especially if intermarriage took
place within a class in which color-blindness was especially
1 These are not included in the grand total, which is for England only.
The results were obtained by Mr. Swanzy from an examination of 2859 male
children.
THE FREQUENCY OF COLOR-BLINDNESS. 261
frequent. In connection with this.it is interesting to note,
that the daughters of a color-blind parent, although not ex-
hibiting the defect themselves, may yet transmit it to their
children. Thus, in an instance which came under the writer's
own observation : a color-blind parent had seven sons, all of
whom were color-blind except the youngest, and three daugh-
ters, none of whom %Vere color-blind, but the son of the only
daughter who married was color-blind.
In order to demonstrate the importance of excluding color-
blind persons from any emploj'ment in which the recognition
of signal lights is called for, Mr. Nettleship has constructed a
lantern by means of which two lights similar to signal lights
can be seen, either separately or side b}' side. In experi-
ments which he made in conjunction with Dr. Brailey on color-
blind persons, the following conclusions were arrived at.^
1. When red and green are shown together, they are often
correctly distinguished if well within the maximum distance.
2. If w'hite and red, or white and green, are shown, they are
always seen to be different, but are often wrongly named.
3. By using various shades of smoked glass it is possible to
make the white light undistinguishable from either red or
green to the color-blind.
4. When only one light is shown, whether white, red, or
green, it is often, but by no means always, wrongly named.
^ Appendix G. to Report on Color-Blindness, loc. cit. p. 206.
CHAPTER XI.
THE CRYSTALLINE LENS.
ANATOMY — VARIETIES OF CATARACT — ETIOLOGY — SYMPTOMS — TREATMENT —
NEEDLE OPERATION — LINEAR EXTRACTION SUCTION — FLAP OPERATION
VON GRAEFE'S linear and ALLIED OPERATIONS — EXTRACTION IN CAPSULE
— AFTER-TREATMENT — COMPLICATIONS DISLOCATION OF THE LENS.
The crystalline lens is a transparent, biconvex, solid body,
enclosed in a transparent elastic membrane — the lens capsule.
In front of the lens is the iris. When the pupil is contracted
the iris rests on the anterior surface of the lens, and is pushed
somewhat forwards by it ; when the pupil is fully dilated, no
part of the lens is in contact with the iris ; while in interme-
diate conditions a corresponding extent of the surface of the
iris is in contact with the lens. Behind, the lens rests entirely
against the vitreous humor.
When the accommodation is relaxed, the convexity of the
lens is greatest posteriorly; during the act of accommodation,
the convexity of the anterior surface is greatly increased, and
that of the posterior very slightly, if at all, so that the curva-
ture of the two surfaces is then very nearly equal.
The measurements of the lens in adult life are from 8 to 9
mm. across, and 4 to 5 mm. from before backwards.
By a series of admirably conducted experiments made upon
lenses in each decade of adult life, Priestley Smith' has found
that the average weight of the lens continually increases, the
increase being at the rate of about 1.5 milligramme each year;
also that the volume of the lens increases continually, at the
rate of about 1.6 cubic mm. each year.
Histology. — The capsule is thickest in front, and diminishes
toward the posterior pole. The part which covers the front of
' Trans. Uph. iSoc, voi. iii.
ANATOMY. 263
the lens (anterior capsule) is lined with a single layer of hex-
agonal, transparent, granular-looking epithelial cells, each
having an oval or a spherical nucleus. This layer of cells is
of great physiological importance; from it the lens fibres are
probably derived. It governs the nutrition of the lens by pro-
moting proper osmosis between the lens tissue and the lymph
in the anterior chamber (Leber). In this nutritive function it
is probably greatly assisted by the ciliary processes, which are
in close contact with the suspensory ligament just before it
reaches the capsule.
The part which is behind the lens (posterior capsule) has no
epithelial lining of this kind ; it is in close contact with the
lens substance in front and with the vitreous humor posteriorly.
The substance of the lens is made up of lens fibres and inter-
stitial substance. The fibres are band-like structures, each
containing an oval nucleus; they extend between the anterior
and posterior surfaces of the lens, and are arranged in con-
centric lamellse parallel to the surface. Each lamella consists
of a single layer of lens fibres joined at their broad surfaces.
Their extremities are slightly enlarged. At the two surfaces
of the lens these extremities are united together by three ray-
like structures, which in the early stage of cataract can often
be seen by focal illumination, in the form of white lines di-
verging from the poles to the circumference at equal angles.
In the natural state these sutures contain a semi-fluid, homo-
geneous, interstitial cement substance. A similar substance
is contained between the lamellse, and, in smaller quantity,
between the fibres of each lamella (Klein). In this cement
substance there exist certain channels, from which fine canals
extend between the fibres of the lamellse. These probably
have an important bearing on the changes in the shape of the
lens during accommodation, and in the nutrition of the organ
(Otto Becker). The central portion of the lens is of firmer
consistence than that of the periphery, hence the central por-
tion of the lens is called the nucleus and the peripheral portion
the cortex. This distinction is, however, entirely arbitrary,
there being no distinct line of demarcation between the two
portions. In young subjects the lens substance is soft and
easily broken down ; with age it becomes gradually firmer,
and its form less convex.
264 THE CRYSTALLINE LENS.
The suspensory ligament of the crystalline lens (zonule of
Zinn) is a Hbrilluted elastic membrane, extending from the
region of the ora serrata of the retina to the equator of the
crystalline lens. It was formerly considered to be formed by
the anterior division of a hyaloid membrane which enclosed
the vitreous humor; the researches of Iwanoff,' however, have
shown that this membrane is identical with the membrana
limitans of the retina, and that the suspensory ligament is
formed from three chief sources: (1) from the continuation of
the membrana limitans interna of the retina; (2) from tine
fibrils derived from just below the surface of the vitreous in
ihe region of the ora serrata; (3) from tine filaments arising
from the rod-like cells of the pars ciliaris retinse. The mem-
brane thus formed follows the sinuosities of the ciliary pro-
cesses, and is continued forwards to the anterior part of the
equator of the capsule of the lens, to which it is firmly attached
in a tortuous line. Before it reaches the equator of the lens
the suspensorj' ligament is separated from the vitreous by a
space — the canal of Petit — which is probably occupied by lymph
during life. The relation of the suspensory ligament to the
surrounding structures is of great practical importance, more
especially with regard to accommodation, to the extraction of
cataract, and to dislocation of the lens. The function of the
suspensory ligament is probably that of maintaining the lens
in situ, and of controlling its accommodative changes. It
offers no obstacle to the interchange of fluids between the
aqueous and vitreous chambers.
Cataract is an opaque condition of the crystalline lens,
which is due to structural changes of its component fibres.
The opacity varies so mucli in the portion of the lens which
is first aftected, in its rate of progress, in the time of life at
which it occurs, in its color and consistency, and in its causes,
that it is difiicult to construct a good classification. The
following arrangement of the different forms of cataract may
be found useful :
1. Nuclear; 2. Cortical; 3. Lamellar; 4. Pyramidal; 5. Pos-
ierior polar ; 0. General or mixed.
' Strieker's Handbook of Histolosrv.
VARIETIES OF CATARACT. 265
1. Nuclear or central cataract. — In this form the opacity
commences in tlie central portion of the lens, and gradually
shades oif toward the periphery (see Figs. 9 and 10, opposite
p. 266). Its rate of increase varies considerably, the whole
lens in some cases becoming opaque in the course of a few
months, whilst in others the cortex ma}- remain clear for
years. Its color is usually that of amber; sometimes it is
almost white, or brown, and occasionally quite black. It
mostly occurs after the age of fifty — very frequently from fifty
to fifty-five. It ma}', however, come on at any age, or be
present at birth.
2. Cortical cataract commences on both surfaces of the lens
in the form of pyramidal streaks, having their bases at the
equator of the lens, and their apices directed toward its antero-
posterior axis (see Figs. 7 and 8, opposite p. 266) ; these are
usually irregular in length and breadth. They are at first
quite covered by the iris, and can then only be seen by dilat-
ing the pupil. After a time, however, the}- encroach upon
the central portion of the lens, and can be seen within the
normal pupillary area. These streaks finally become united
into a mass of cortical opacity ; the central portion also be-
comes opaque, and the whole lens is thus rendered cataractous.
This form of opacity is of frequent occurrence in old people,
and is but rarely seen before the age of fifty. When progres-
sive, as it usually is, cortical cataract shows great variation in
its rate of increase.
3. Lamellar cataract (Zonular). — In this form both the cen-
tral and the peripheral portions are unaftected, but a shell-like
layer of opacity exists between the centre and the surface of
the lens (see Figs. 5 and 6, opposite p. 266). The exact posi-
tion of this lamina is variable, but it is usuallj- between the
inner and outer fourths of the substance of the lens. It is
generally very thin and delicate in structure, and has a faint
bluish-white semi-transparent appearance ; its surface is smooth,
or only slightly granular; and if this condition continues it
appears to remain stationary; occasionally, however, there
appear dots of denser opacity upon its surface, which increase
at the expense of the peripheral portion of the lens, and ma}'
often be seen as delicate radial projections directed toward the
DESCRIPTION OF PLATE.
Fig. 1.' — Partial Dislocation of Lens (backwards and outwards).
" 2. — Dislocation of Lens (forwards).
" 3.— Pyramidal Cataract.
" 4. — PjTamidal Cataract.
" 5. — Lamellar Cataract.
" 6. — Lamellar Cataract.
" 7. — Cortical Cataract.
" 8.— Cortical Cataract.
" 9. — Nuclear Cataract.
" 10. — Nuclear Cataract.
" 11. — Posterior Polar Cataract.
" 12. — Posterior Polar Cataract.
' The figures in which the pupil is red represent the eye as seen by using the
ophthalmoscope mirror, others as seen by the oblique focal illumination.
-'^'
f^
"^^
J 1
^^. ^*Vif*'
12.
.:^
Le'^orvi, Co.
VARIETIES OF CATARACT. 267
surface. As a rule, lamellar cataract remains stationary ; occa-
sionallj, however, it gradually extends, and involves the whole
lens. This form of cataract generally comes on a few months
after birth; but as' the opacity is not usually sufficiently dense
to be conspicuous, the condition is often not discerned until
the child learns to read.^
4. Pyramidal cataract consists in a dense, chalky-white, cir-
cular patch of opacity at the anterior pole of the lens, on and
immediately beneath its capsule (see Figs. 3 and 4, opposite
p. 266); it is usually about 1 or 2 mm. in diameter, and when
viewed from the side, it is seen to stand out in front of the
lens in a pyramidal form. The opacity only extends for a
short distance into the lens substance; that portion of the
capsule which is in front of the cataract is often somewhat
puckered, and may contain deposits of organized lymph upon
its anterior surface.
This condition is sometimes congenital; more often, how-
ever, it is the result of an attack of ophthalmia neonatorum,
which has caused a central perforating ulcer of the cornea; on
the escape of the aqueous humor, the lens has been pressed
forwards against the cornea, the perforation becoming closed
by lymph ; the aqueous has then re-collected, and the lens,
being thus pressed back to its normal position, has carried
with it a little mass of lymph. In such cases, a central opacity
of the cornea can usually be seen by focal illumination ; occa-
sionall}', however, cases are met with in which there are a
faint central nebula of the cornea and pyramidal cataract
without any history of purulent conjunctivitis. Pyramidal
cataract is always stationary.
1 Since the growth of the lens takes place by means of new material formed
on its surface, the occurrence of a layer of cloudy lens substance at a certain
depth would seem to indicate that, at some period during its growth, there had
been an interference with the general health, which had led to the deposit dur-
ing that period of imperfect lens material. This is supported by the fact that in
children with lamellar cataract a history of convulsions in infancy can generally
be obtained, while there is usually a peculiar appearance of the permanent teeth,
consisting in a defect in the enamel which renders them of a bad color; they
generally present a constriction a little below the summit of the teeth, and the
surface has a corrugated appearance. These changes are generally most marked
in the molars. It will often be found that mercurial powders have been admin-
istered for the convulsions, and it is thought by some that the condition of the
teeth, and possibly also that of the lens, is due to this circumstance.
268 THE CRYSTALLINE LENS.
5. Posterior polar cataract is the term applied to any opacity
situated on the posterior pole of the lens or its capsule. The
opacity is usually small, round, and white; it not unfre-
quently has minute streaks radiating from it. Sometimes,
although appearing to be on the posterior capsule, it is in
reality in the forepart of the vitreous (see Figs. 11 and 12,
opposite p. 2(3(3). Posterior polar cataract may be congenital
or acquired. The congenital form is probably in some way
connected with imperfect absorption of the fietal hyaloid
artery ; and cases have been recorded in which a minute thread,
corresponding in position and size to that structure, has been
visible jiassing back from the opacity toward the optic disk.
The acquired form is generally progressive, and is nearly
always secondary to disease of the vitreous or choroid.
6. General or mixed cataracts include all those in which the
opacity occurs both in the cortex and nucleus, whether these
are completely opaque or merely dotted throughout with spots
or strife of opacity. Such cataracts are met with in endless
variety, and no useful purpose would be served b^' a more
detailed classification of them.
Many of the congenital cataracts would come under this
heading. These may occur in one or both eyes. Usually the
whole lens is opaque; but exceptional forms occur, such as the
anterior and posterior polar, and cataracts in which the opacity
is distributed irregularly. Not unfrequently, in congenital
cataracts the pupil acts very imperfectly to atropine, and the
eye is often defective in other respects, so that, even after a
successful oi)eration, the vision is not good.
Cataracts are generally classed as being either hard (senile)
or soft ; and althougli all intermediate degrees of consistency
are met with, the distinction has a ]»ractical importance, as the
two classes are amenable to different modes of treatment.
The soft, if broken up, are readily dissolved by the aqueous,
and can be absorbed with that fluid, while it is impossible to
extract the lens from its capsule en masse. The hard cataracts,
on the contrary, when broken up imbibe the aqueous humor,
and undergo much swelling, but show little tendency to be-
come absorbed; on the other hand, when \\\qj have reached a
certain stage of maturity, they can be shelled out entire from
CAUSES OF CATARACT. 269
the capsule. One may say that, as a rule (to which there are
many exceptions), cataracts which occur before the age of
thirty or thirtj'-tive are soft, and tliose occurring after that age
are hard.
A hard cataract which has reached its full development may
undergo pathological softening; this usually begins in the cor-
tical portion of the lens, which becomes more or less milk}- in
appearance. Sometimes the fluiditj' of the cortical structure
is such that the harder central portion (nucleus) floats about;
this constitutes what is known as the cataract of Morgagni.
The causes of cataract are still very obscure. The opacity
appears to be due to atrophic degeneration of the lens fibres.
This is probably the result of defective nutrition, although it
is frequently developed without any perceptible local or gen-
eral cause.
1. Semlity. — In many cases the disease appears to be due to
the decline of vitality in the tissues of the body, either from
age, anxiety, or dissipated habits.
2. Diabetes. — A large proportion (about 6 per cent.) of dia-
betic patients suffer from cataract. This is usually of the soft
variety, and matures slowly. It is well to bear in mind that
.other ocular aft'ections are common in this disease, such as
•paresis of accommodation, arnhbjopia, hemiopia, retinitis, and optic
nerve atrophy. Nevertheless, diabetic cataracts may be oper-
ated upon successfully; in fact, many surgeons are of opinion
that the eye recovers from the effect of the operation as readily
as in health.
3. Ergotism has been observed to produce cataract ; it is
supposed to act by causing spasmodic contraction of the ves-
sels of the ciliary body.
4. Local diseases of the iris, choroid, or ciliary body, as in
the secondary cataract of glaucoma, and of sympathetic dis-
ease.
5. Injury. — This may consist in a blow upon the globe, by
which the capsule is ruptured, or the lens is entirely or par-
tially dislocated ; it may be wounded by a sharp instrument,
or a foreign body may have entered or passed through it.
Opacity may follow a perforation caused by an ulcer of the
cornea, as, for example, the pyramidal cataract.
270 THE CRYSTALMNE LEXS.
6. Convulsions. — The possibility of convulsions being a cause
of lamellar cataract has already been referred to (p. 267).
7. Inherited syphilis is considered to be an occasional cause
of congenital cataract (Hutchinson).
The symptoms and diagnosis of cataract.
1. Gradual failure of vision, and an inability to obtain suit-
able glasses, are usually the lirst symptoms complained of by
elderly patients. The vision is generally worse in one eye
than in the other. In the early stage of those forms of cata-
ract where the opacity commences within the central portion
of the lens, the patient can always see better when placed in
any condition that favors the dilatation of the pupil ; he will
therefore prefer a dull day or the twilight, and his vision will
be improved by wearing a shade, or by standing with his back
to the light; his distant vision will bo better after the use of
atropine.
With the progress of the cataract toward maturity, all useful
vision disappears. First, all distant test-types and objects are
lost to sight ; then the reading power, even for the largest
type, gradually goes; lastly, the patient is unable to count
lingers when held up within from 20 to 40 cm. of the aftected
eye. In no case of cataract, however, is the opacity so dense
as to prevent the patient from distinguishing between light
and darkness. In the broad daylight, when placed with his
face toward the window, he perceives a shadow when the hand
is passed in front of the eyes; and in a dark room he can
localize the position of the flame of a lamp or candle. This
perception of light should always be present in mature cataract ;
its absence indicates the existence of disease in the fundus
oculi. Of course, in such a case, no operation could be of any
possible benefit.
Owing to the changes which occur in the various sectors of
the lens during the development of cataract, it sometimes
happens that monocular diplopia and irregular astigmatism
are developed.
In children there is generally a history of " near-sighted-
ness," which is usually noticed as soon as the child begins to
read. This is due to the fact that the book is held close to
the face in order to obtain larger retinal images, and it is
SYMPTOMS OF CATARACT. 271
more particularly noticeable in lamellar cataracts. When the
opacity is denser, as is usually the case in congenital cataracts,
the white reflex from the pupil is often noticed within a few
days after birth.
2. Changes in the appearances of the p^upH. — In young subjects
the normal pupil looks quite black, whether seen by difl:used
light or by focal illumination ; after the age of thirty-live,
however, it often happens that a gray, hazy appearance is
presented, which may easily be mistaken for cataract. A
diagnosis should therefore never be given on the strength of
this appearance only. When, on account of gradual failure of
sight or other symptoms, the presence of opacity of the lens
is suspected, the pupil should be dilated by the use of some
mydriatic (F. 17, 20, or 22), and the patient examined in a
dark room by means of the ophthalmoscope, and by the oblique
focal illumination. By using a concave or a plane mirror at a
distance of about one metre (40 inches) in front of the eye,
any opacity of the transparent media can be at once detected.
In the normal fundus, as already described (p. 150), there is a
homogeneous, bright, orange-red reflection lighting up the
whole area of the dilated pupil. Any opacity existing in the
vitreous, the crystalline lens, or the cornea, would intercept
the rays reflected from the fundus, and so would appear dark
(black) in proportion to its densit}'.
To ascertain the position of the opacity, oblique focal illumina-
tion (p. 86) should be employed; by this means opacities of
the cornea or lens can be at once recognized. If the opacity
cannot be thus detected, recourse should be had to direct
ophthalmoscopic examination, when an opacity in the vitreous
will at once be recognized, and its depth approximately mea-
sured by finding what is the strongest convex lens with which
it can be distinctly seen. In many cases the vitreous is fluid,
and the opacities are seen to float about as the affected eye is
quickly moved in any direction. As seen by the oblique focal
illumination, the opacity of the lens appears in its true color,
and the transparent portions no longer present a red reflex.
The characters presented by the various immature and partial
cataracts when examined by these methods, are given in the
figures opposite p. 266 ; it will be observed that in the nuclear
272 THE CRYSTALLINE LENS.
form the opacity is most dense at the centre, and gradually
fades away at the outer part. When the cortical or central
portion of the lens is sufficiently clear for an ophthalmoscopic
examination to be made, advantage should be taken of this
opportunity to ascertain the condition of the fundus ; such
knowledge will be useful with regard to the probable results
of a future operation, and cannot be obtained later on when
the cataract has become more general.
In the lamellar form, if the pupil is widely dilated, the peri-
phery of the lens is seen to be clear, while in the centre of the
pupil the shell of opacity forms a regular circular area of
darker color, which is often sufficiently thin to allow of the
fundus being seen through it; the edge of this often appears
darker, owing to the opaque shell being viewed " end-on ; "
occasionally minute striae can be seen radiating from the
opacity into the. otherwise clear periphery.
The treatment of cataract. — In no case can the opacity of the
crystalline lens be made to recede by the use of therapeutic
agents ; the question of treatment therefore resolves itself into
the best means of restoring vision by operative measures.
1. By artificial pupil. — When the cataract is non-progressive,
and the extent of the opacity is such that its area is equal to,
or very slightly greater than that of the normal pupil, much
benefit is sometimes derived from the formation of an artificial
pupil. In such cases the patient may be able to see tolerably
well in the twilight with deeply tinted glasses, by shading the
eyes, or by other conditions which favor the dilatation of the
pupil ; but is quite incapacitated for useful vision by the pres-
ence of diffused bright light, which causes contraction of the
pupil. In order to ascertain the probable result of an artificial
pupil in a case of this description, the pupil should be thoroughly
dilated with atropine ; the vision for distant types should then
be carefully tested, any existing error of refraction being at the
same time neutralized by means of the correcting glasses. If
this dilatation of the pupil is found to improve materially the
distant vision, so that the patient is enabled to see the letters
corresponding to -j^, y^g-, or even /^ of Snellen, it may be antici-
pated that the vision will be still more improved by the forma-
tion of a small artificial pupil in the downward and inward
TREATMENT OF CATARACT. 273
direction ; and that after the operation, when the accommo-
dating power of the eye is no longer paralyzed by atropine, he
will also possess good near vision. The size of the artificial
pnpil must vary according to the extent of the opacity ; so long
as it is brought opposite to the clear portion of the lens, the
smaller it is, the better Avill it be for distinctness of vision.
It may be made by iridectomy, by iridotomy, or by iridodesis.
The method I prefer in these cases is that of iridectomy by
means of the hook, as described on p. 177. The artificial
pupil made in this manner is narrow, especially at its peri-
phery, and there is not so much spherical aberration as occurs
in larger iridectomies in which a considerable extent of the
lens margin is exposed.
In suitable cases this operation possesses at least two advan-
tages over the removal of the lens — namely, that the opera-
tion itself is practically free from risk; and, secondly, that the
power of accommodation is retained.
Wfmi the distant vision is not improved by full dilatation of the
pupil, it may be concluded that an artificial pupil would be of
no service, and recourse had better be had to one of the opera-
tions to be presently described for the absorption, or the re-
moval of the lens itself.
2. By solution and absorption. — Any kind of cataract, whether
nuclear, lamellar, cortical, or general, occurring in subjects
under thirty-five years of age is, as we have mentioned, soft in
structure. By lacerating the anterior capsule, and breaking
up the laminse of such a lens, the aqueous humor is brought
into immediate contact with its fibres, and has the efitect of
causing them to become opaque and swollen. This efiect is
produced within the first twenty-four hours after the opera-
tion, and is immediately followed by a process of gradual dis-
integration, solution, and absorption. This method is called
discission, or the needle operation. It may be employed in
any soft cataract which is not amenable to treatment by the
formation of an artificial pupil. The younger the subject the
more quickly do solution and absorption take place, and the
less liable is the eye to severe inflammation after the opera-
tion. After the age of thirty-five the nuclear portion of the
lens is so hard that the number of operations, and the time
required for solution, are beyond endurance, while the larger
18
274
THE CnYSTALLINE LENS.
size of the lens, and the greater intolerance of the eye to in-
creased intraocular tension, render this operation more dan-
gerous than in younger subjects.
The needle operation (Discission, Solution) gives so little pain
that, except in young children and in persons of nervous tem-
perament, anresthesia is not necessary. The pupil must be
dilated by the previous use of a mydriatic (F.
19, 21, 22). The positions of the operator and
the patient are the same as for iridectomy (p.
174). The lids being separated by a speculum,
and the globe held steady by fixation forceps,
or with the fingers, a cataract needle (Fig. 61)
is passed obliquely through the outer part of
the cornea into the anterior chamber. Its
point is then made to perforate the anterior
capsule of the lens within the area of the di-
lated pupil (see Fig. 62). By gentle to-and-fro
movements the capsule is now lacerated, and
the lens matter having been broken up to the
extent desired, the needle is gradually with-
drawn. The best part of the cornea at which
to insert the needle is that at from 2 to 3 mm.
from the outer extremity of its horizontal di-
ameter. The extent to which the capsule
should be lacerated, and the lens matter stirred
up, depends upon the nature of the case. Care
should be taken not to wound the posterior
capsule of the lens, as the vitreous is then
liable to come forwards, and so to interfere
with the action of the aqueous upon the lens.
To prevent this accident, needles are often
made with a shoulder or " stop," as the left
one in Fig. 61 ; this, however, is not a suffi-
cient safeguard for a clumsy operator, and is
quite unnecessary for anyone of average dex-
terity ; it is, however, a slight advantage, as it
gives firmness to the needle. In a properly
constructed cataract needle the shaft should
exactly fit the puncture : if it tits too loosely, aqueous will leak
out; if too tightly, its movements will be impeded. The com-
FiG. 61.
Cataract Needles
TREATMENT OF CATARACT SOLUTION.
275
plete solution of a lens by this process usually requires the
performance of three or four needle operations, and occupies
a period varying from four to eight weeks. At the first
needling it is best not to do more than lacerate the capsule
and the most anterior layers of the lens substance by a slight
vertical or crucial incision. This is usually followed by in-
FiG. 62.— The Needle Operation.
creased opacity of the lens substance, which swells up and
bulges forwards through the pupil, so that it may be seen pro-
jecting into the anterior chamber. After the operation the
pupil must be kept dilated by the use of a 1 per cent, solution
of atropine every three hours; the patient should be kept in
bed, the room darkened, and the closed lids kept constantly
cool by means of lint dipped in cold or iced water during the
first forty-eight hours ; after that time, if the case is doing
well, the wet dressing may be replaced by a single layer of
dry lint and a bandage ; both the eyes should still be screened
from the light, either by means of a dark shade over the
bandage, or by remaining in the dark room.
Complications. — Although a simple and easy operation, several
precautions are necessary.
(i) The laceration of the capsule and the lens must not be
too extensive, especially at the first needling, otherwise the
masses of crystalline lens become so rapidly swollen by im-
bibition of the aqueous as to set up increased intraocular tension.
For similar reasons the iris and ciliary' body are liable to be-
come irritated by the swollen lens to such an extent as to cause
iritis or irido-cyclitis.
276 THE CRYSTALLINE LENS.
(ii) J)uriiig- the throe days succeeding the operation the eye
requires careful watching and treatment. The occurrence of
slight ciliary congestion, without pain, need cause no anxiety;
but if the redness around the circumference of the cornea in-
crease, and be accompanied by pain, and by symptoms of com-
mencing iritis, a few leeches should be at once applied to the
lower lid, the atropine repeated more frequently, and the iced-
water dressing continued.
(iii) If these remedies do not cut short the inflammatory
symptoms, but are followed by increasing pain, congestion,
and symptoms of irido-cyclitis, or glaucomatous tension, the
soft lens matter must be immediately removed, either by the
method of linear extraction or b}^ suction.
The exact period at which to perform the second needling
must be decided by the condition of the eye. In no case
should it be undertaken until all the inflammatory symptoms
which may have been produced by the first operation have
entirely subsided, leaving the ej'e perfectly quiet, free from
all pain, and without a trace of redness in the circumcorueal
zone. As a rule, it is well to wait until the process of absorp-
tion seems to be at a standstill ; if, however, it is wished to
hasten the process, there is no objection to repeating the
needling as soon as all irritation has ceased.
In the second and third operations the needle may be used
more freely than in the first, as there is less risk of setting up
inflammatory mischief When absorption progresses slowly,
some surgeons perform repeated paracentesis of the anterior
chamber in order to evacuate the aqueous humor, which is
saturated with the substance of the lens.
The needle operation is often required after the extraction
of cataract, when a portion of the capsule lies in the pupil.
A single needle may suffice for this purpose, but when the
capsule is tough it is always better to use two, otherwise the
attachment of this membrane in the region of the ciliary bod}-
is necessarily dragged upon, and cyclitis is very likely to be
set up; if, on the other hand, two needles are used, the rent
can be made by tearing from the centre, without the least
traction on the ciliary attachment.
The needle operation is often supplemented by the subse-
TREATMENT OF CATARACT LINEAR OPERATION. 277
quent removal of the soft lens matter, either by linear extrac-
tion or bj suction. These operations save a good deal of time,
and are sometimes necessary, as we have seen, to counteract
inflammatory symptoms after a simple needling.
The linear operation (Gibson) consists in the removal of a
soft lens through a small incision in the cornea. It is espe-
cially indicated in cases of traumatic cataract, whether pro-
duced b}^ the needle operation or by any other injury, in which
the eye has become painful and inflamed. When employed
for the removal of other forms of soft partial cataract, as the
lamellar, the linear extraction should be preceded by the needle
operation (p. 274), the anterior capsule of the lens being freelt/
lacerated, in order that the lens matter may be rendered more
soft and so escape more freely from the corneal wound. Some
surgeons, however, prefer to complete the operation at one
sitting, and in order to do this they lacerate the anterior cap-
sule of the lens by means of a cystitome (Fig. 78) introduced
on the flat, through the corneal wound.
When the needle operation is performed as the first stage
of the operation, the interval of time which should elapse
between this and the extraction of the softened lens matter
must vary with the condition of the eye. Should the latter
remain quiet, and free from any marked pain or redness, it
may with advantage be left until the sixth or eighth day. But
should there be considerable pain, and especially if this is
combined with inflammatory or glaucomatous symptoms, the
extraction should be efl^ected without further delay.
Operation. — The pupil being widely dilated b}' atropine, the
patient thoroughly anaesthetized, the ej'elids separated by a
speculum, and the globe held steady by fixation forceps, a bent
broad needle (Fig. 48) is passed through the cornea into the
anterior chamber in a direction parallel to the plane of the
iris. The incision should be about 2 mm. within the margin
of the cornea on irs temporal side; its width should be about
5 or 6 mm. If the greater part of the lens substance still lies
within the capsule, the latter should be freely incised before
the needle is withdrawn. The broad needle is then withdrawn
and laid aside, and the curette (Fig. 63) taken up. Gentle
pressure is first made with this upon the outer lip of the
278 THE CRYSTALLINE LENS.
wound, and is usually followed by the exit of a considerable
quantity of aqueous humor and soft lens matter ; the curette
may then be carefully introduced through the wound into the
area of the pupil, when any remaining lens matter will usually
Fig. 63.— Curette.
be found to escape along its groove. Should any fragments
of lens still remain, they may be followed by the curette, and
the point of the latter dipped beneath them so as to scoop
them out.
Accidents and complications. — (i) Care must be taken in using
the curette not to rupture the posterior capsule; this accident
is liable to be followed by protrusion of the '^itreous forwards
into the anterior chamber and through the corneal wound.
If this should occur, no further attempt should be made to
remove the lens matter.
(ii) Unless the curette be gently manipulated the iris may
be contused; a slight injury of this structure is liable to be
followed by inflammation and plastic exudation.
(iii) At the time of the first escape of the aqueous, after
the incision of the cornea, the iris is occasionally found to pro-
trude between the lips of the wound. This can often be re-
turned by gentle pressure with the curette or spatula. Should
it be found impossible to do this, the protruding portion must
be seized with forceps and excised with the iridectomy scissors.
Some surgeons prefer to remove a small piece of iris in all cases.
The after-treatment is the same as for the needle operation.
The suction operation is similar in principle to that just de-
scribed, and, like it, may be performed all at one sitting, but
is generally more successful when preceded by the needle
operation. It consists in the removal of the soft lens matter
by means of an aspirator i>assed through a small wound in the
cornea. The same interval of time, etc., between the needling
and the removal of lens matter are necessarj^ here as in the
linear operation.
Operation. — The patient being anfesthetized, and the eye
tixed as betbie, an incision is made in the cornea bv means of
TREATMENT OF CATARACT — SUCTION OPERATION. 279
an angular broad needle (Fig. 48, p. 175); the wound should
be just large enough to admit easily the nozzle of the aspi-
rator; it should be on the temporal side of the cornea, about
2 or 3 mm. from the sclerotic. The aspirator consists of a
small, flattened canula, having a free opening on one side
(6, Fig. 64), and connected with a glass tube [d d). This is
attached either to a metal piston-syringe (Bowman's) or to an
India-rubber tube and mouthpiece (e) (Teale's). The nozzle of
Fig. 64. — Teale's Suction Apparatus for Cataract.
this instrument is passed into the anterior chamber with its
concavity upwards, and placed in the most favorable position
for withdrawing the lens matter without injuring the iris.
Gentle suction is then made, and as much lens matter removed
as possible. The nozzle must, however, not be passed behind
the iris in search of fragments.
The after-treatment is the same as for the needle and the
linear operations.
This operation requires great care and delicacy in manipu-
lation ; when successful it gives very satisfactory results, more
especially in the saving of time which it effects by the early
removal of the lens matter.
Unfortunately it is occasionally followed by inflammatory
trouble, which sometimes leads to loss of the eye by suppura-
tion. The flrst symptom of this is a continuance of the con-
junctival injection and pain beyond the third day; signs of
iritis then supervene — dulness of the iris and incomplete dila-
tation with atropine ; a day or two later hypopyon may make
its appearance. A good-sized iridectomy downwards will
sometimes do good in this state of aftairs, and ocx-asionally
280 THE CRYSTALLINE LENS.
the pus will be absorbed and a good result obtained; the sup-
puration may, however, extend to the vitreous, and shrinking
of the globe ensue.
3. By the extraction of the entire cataract. — After the age of
thirty -five the structure of the lens is so dense, and its nucleus
so large, that its removal requires a larger incision than that
just mentioned for the linear operation.
It is usually advisable to avoid operating until the opacity
has extended to the greater part of the lens, otherwise the
unaffected cortical substance remains adherent to the capsule,
and although, owing to its transparency, it is difficult or im-
possible to see it at the time of the operation, it afterwards
becomes swollen and opaque, and gives rise to the trouble to be
presently described. When the whole of the lens has become
opaque, the cataract is said to be "mature" or "ripe;" the
sio-ns of this condition are, that no red reflex can be obtained
from the choroid by the use of the ophthalmoscope, and no
shadow is thrown by the iris upon the lens when light is pro-
jected upon the eye by oblique focal illumination. If the
cataract is removed before it has reached the condition of
maturity, it does not so readily shell out from the capsule, and
is liable to leave behind it more or less of the transparent por-
tion either adherent to the capsule or within the pupillary area.
These remains, however, can often be evacuated at the time of
the operation ; when left in the eye the}^ are apt to swell up
and to cause iritis. In such cases lymph is often thrown out in
considerable quantity, and, becoming organized, may form a
dense membrane completely occluding the pupil. As a rule,
these fragments of cortical matter are eventually absorbed,
but in the meantime irreparable mischief may have been set
up by their presence.
There are, however, many circumstances which sometimes
render it highly inconvenient, if not altogether impossible, to
wait for the complete maturity of a cataract. There may be
commencing, or equally advanced, cataract in the second eye,
by which the patient is deprived of all useful vision, and is
consequently debarred from following his usual occupation.
The patient's place of residence may be beyond the reach of
surgical skill, and he may be unable to present himself for
TREATMENT OF CATARACT EXTRACTION. 281
periodical examination. In such cases the extraction of the
immature cataract at the earliest possible date is imperative.
Under such circumstances it is best to perform an iridectomy
upwards as a preliminary operation, and after the lapse of six
or eight weeks to extract the cataraf't from one eye at a time.
This preliminary iridectomy does not interfere with what little
vision the patient may possess — indeed, the enlargement of the
pupil may improve this, and it has the effect of lessening the
danger of iritis after the extraction ; it also enables the cataract
to be removed before it is quite mature without much risk, and
in some cases seems to hasten the maturing of the cataract.
When one eye only is ajfected, or when the second eye is still
serviceable, the removal of the lens is less urgent; if, how^ever,
the cataract is quite complete, it is better that it should be ex-
tracted without further delay. The result of the operation will
not be so satisfactory to the patient as it would be if the second
eye were blind, on account of the difference of refraction between
the operated and the sound eye, but delay in extraction might
cause the eye to become amblyopic from disuse. The in-
creased visual field which is obtained by the use of both ej'es
is of considerable advantage, while the operated eye will
be ready for use in case of the other becoming cataractous.
Finally the removal of a disfigurement, which is often very
marked, is of importance from an aesthetic point of view.
When both eyes are affected at the same time, and both the
cataracts mature, it is well that the tw^o extractions should
not be performed at the same sitting, but that they should be
separated by an interval of some weeks. If both eyes were
done together, and one of them should progress badly, it
would complicate the management of its fellow ; whilst in
two separate operations, the failure of the first eye, during or
after extraction, may enable us to take special precautions
with the second; thus it might be considered better to make
the incision more or less peripheral, to perform preliminary
iridectomy, to extract the lens in its capsule, or to use the
scoop instead of pressing upon the cornea in the removal of
the lens.
The flap operation. — It ^\as not until toward the middle of
the last century that the operation of extracting a cataractous
282 THE CRYSTALLINE LENS.
lens became a regular surgical proceeding. Previous to that
date, the recognized treatment of cataract was that of reclina-
tton or couching, which consisted in dislocating the lens into
the vitreous. The immediate effect of this was of course
satisfactory as regards the improvement in vision, but subse-
quent trouble nearly always arose from the irritation set up
by the displaced lens, and the eye was generally eventually
lost from irido-choroiditis or glaucoma.
During the first half of the eighteenth century, extraction
was occasionally performed, but to Daviel certainly
O belongs the credit of having definitely established
the superiority of extraction over reclination.
\ ^ >: DaiieVs method was to make in the cornea near
Fig 65 ^^^ lower margin an incision with a lance-shaped
knife, and to enlarge this in both directions with
scissors, so that he obtained an incision concentric with the
lower margin of the cornea, and extending a little above the
horizontal meridian (Fig. 65).
The Hap having been raised, the capsule was lacerated, and
the lens expressed through the pupil.
Beer modified the operation by using the triangular knife
Fk;. t')6. — Beer's Knife.
which bears his name. The point of this was introduced into
the cornea level with its horizontal meridian, and, while ihe
point of the knife was carried across the anterior
O chamber to make its exit at a corresponding point
on the other side, the edge cut its way out at the
sclero-corneal junction, thus forming a flap which
Fig r.7 <'orresponded almost exactly with the lower half of
the cornea (Fig. 67). The flap thus formed was
slightly smaller than Daviel's, and, being made by a simple
cut, allowed of more perfect adaptation of the parts.
There is no doubt that the above method was a very great
advance on former proceedings, and that many most excellent
TREATMENT OF CATARACT EXTRACTION. 2^3
results were obtained by it; indeed, nothing could be more
perfect than a flap operation which succeeded well ; after the
wound had healed there was hardly a trace of its existence
left upon the cornea, and the pupil retained its natural size,
form, and function ; but the percentage of failure was very
high, and this was in great part due to fiiults inherent in the
method.
In the tirst place, the nutrition of the cornea was seriously
imperilled by a section including half its circumference; in
the second, the large size of the wound predisposed to pro-
lapse of the iris, which not only delayed the union of the
wound, but by its adhesion gave rise to subsequent inflamma-
tory trouble, such as iritis and irido-cj'clitis. The iris itself
was, moreover, necessarily contused by the passage of the lens
through the pupil, and this was often followed by iritis, which
led to closure of the pupil by lymph.
Some of these dangers were lessened b}' Jacobson, who
made the section in the sclerotic concentric with
the cornea, thus carrying it through vascular y' >v
tissue, while owing to the larger circumference ( J
of the globe here, the same length of incision was X:^^.^^
obtained without carrying its extremities as high p^^ gg
as the horizontal meridian (Fig. 68). It is doubt-
ful whether to Mooren or to Jacobson should be ascribed the
credit of adding an iridectomy, thus obviating the eft'ects of
contusion of the iris and preventing its prolapse.
Undoubtedly the most important moditication since the intro-
duction of the operation of extraction is that which constitutes
von Graefe's operation. The principle of his operation is, that
the section should be as near an approach to a line as possible,
since a linear wound allows of a more perfect coaptation than
a flap; that the wound should by preference be entirely in
the sclerotic; and that an iridectomy should form part of the
operation. Since the wound must have a minimum extent of
10 nmi., and the ciliary body must be avoided, the direction of a
"linear" section which is to be wholly in the sclerotic allows of
comparatively little variation.
Von Graefe's linear operation. — 1. The mcision is made with
the right hand for the right eye, and the left hand for the left
eye, the surgeon standing behind the patient's head.
284
THE CRYSTALLIXE LENS.
The eyelids are ke})t open by means of a stop-speculum.
There are several varieties of this instrument. The form I
prefer for this operation is that shown in Fig. 69. It is curved
in such a manner as not to impede the movement of the in-
struments used, and its outer end, being well behind the plane
of the eye, can, if necessary, be held by an assistant without
interfering with the operator.
Fig. 69. — Spring Stop-sjieculum.
Noyes's specula (Fig. 70) are also admirably adapted for
cataract extraction.
Fig. 70. — Noyes's Specula (right and left).
The globe must be held steady, and kept under the control
of the operator by some fixation instrument. The conjunctiva
ma\' be seized just below the position of the counter-puncture
with the fixation forceps (Fig. 71), or when the conjunctiva is
extremely brittle the sclerotic may be held by means of a
forceps with sharper and longer teeth (Fig. .72').
An extremely useful instrument is the double fixation hook
(Fig. 73); it consists of two minute hooks on a single stem
placed back to back, each, however, having a twist to the
vox GRAEFKS LINEAR OPERATION.
285
right; when the instrument is placed perpendicularly upon the
conjunctiva and rotated to the right, it takes firm hold and
rolls up a little screw of conjunctiva, which gives a good grip,
Fig, 71. — Fixation
Forceps.
Fig. 72.— Forceps
for seizing the
Sclerotic.
Fig. 73. — The
Double Fixa-
tion Hook.
Fig. 74. — Von Graefe's
Linear Cataract Knife.
and which seldom gives way; to release the globe, it is only
necessary to rotate the instrument to the left.
Yon Graefe's linear knife (Fig. 74), held with its cutting edge
2b6
THE CRYSTALLINE LENS,
upwarils, is then made to enter the sclerotic at a point 2 mm.
below the upper tangent of the vertical meridian, and lying
on the tangent of the transverse meridian of the cornea (a,
Fig. 75), and to penetrate the anterior chamber; the direction
of this penetration should be downwards and inwards toward
c (Fig. 75); the knife having reached the middle of the ante-
rior chamber, its handle is slightly depressed, and its point
pushed steadily onwards in front of the plane of the iris, so
that a counter-puncture may be made in the scle-
rotic on the opposite side; in a position which
should correspond to that of the puncture (b.
Fig. 75). The knife is now made to cut its way
upwards through the sclerotic, and to come out
at the junction of this with the upper part of the
cornea; this is etiected by pushing the knife steadily onwards
as far as its heel, and then withdrawing it if necessary.
Fig.
'•"»,
Fig. 70. — The Incision.
The above incision, which ordinarily i^oes by the name of von Graefe's, has
been slightly modified by different operators, and von Graefe himself at one
time made th^ puncture and counter-puncture somewhat higher, so that the
height of the flap was less than a millimetre.^ In nearly all modern operations
1 Vide letter fif von Graefe in de Wecker's Chirurgie Oculairc, p. 30. Paris,
1879.
OPERATIONS FOR CATARACT EXTRACTION. zS t
the puncture and counter-puncture are made a little beyond the sclero-corneal
junction, and from 2 to 4 mm. from the horizontal tangent of the cornea ; the
line of incision in some in.-itances traverses the cornea, in others the sclero-corneal
junction or the sclerotic.
Fisj. 76 represents the modification of this incision which, in suitable cases, is
always made by my colleague, Anderson Critchett,' and which I usually
adopt in mj- own practice. The puncture and counter-puncture are made in the
sclerotic at 1 mm. from the edge of the cornea and 3 mm. below its upper tan-
gent, the knife is brought out through the sclerotic immediately below the cornea
— a little nearer to this than is represented by the dotted line.
De Wecker makes a section exactly at the sclero-corneal junction of such
an extent that its height is about 3 mm.
Streatfeild. makes an incision corresponding to the corneal margin, but
makes a puncture with a Sichel's knife, and enlarges the wound to the required
extent by a gentle sawing movement, no counter-puncture being made.
Taylor makes the incision with a bent broad needle (Fig. 48), and enlarges
the wound as in the preceding operation. The capsule is lacerated before the
iriilectomy is made ; and in performing the latter, a bridge of iris is left at the
pupillary edge, and the lens extracted through the artificial pupil.
In Warlomont's operation the puncture and counter-puncture are made as
in von Graefe's, but the incision lies in the upper part of the cornea.
Liiebreich's is similar t(j the preceding, but is performed downwards. In
neither is an iridectomy performed.
2. The iridectomy. — The Hxation forceps are now entrusted
to the assistant, who, if necessary, will seize the ocular con-
junctiva below the cornea, and gently rotate the globe down-
wards. The iris is now to be seized with the iris forceps near
its pupillary edge, and drawn just outside one angle of the
wound; whilst slight traction is made upon it in this position,
a snip is made through its outer part with the iris scissors in
the manner shown in Fig. 77 ; the portion of the iris held in
the forceps is then gently drawn across to the other angle, and
the excision completed as near to the periphery as possible.
In doing this, if the anterior conjunctival flap should be long,
it must be turned forwards on the cornea, otherwise it may be
caught in the forceps with the iris, and so interfere with the
excision of the latter.
3. The laceration of the anterior capsule of the lens is the next
step in the operation. The operator again takes the fixation
forceps in order to steady the globe with his left hand. The
cystitome (Fig. 78) is now to be gently passed, on the flat, into
1 Vide Lecture on Eclecticism in Operations for Cataract. By Anderson
Critchett, Brit. Med. Journal, November 17, 1883.
THE CRVSTALLIXE LENS,
the anterior cluimber: when it has reached the lower edge of
the pupil its point is rotated toward the capsule, and the latter
is freely lacerated from below upwards, and from side to side.
In doing this it should be remembered that the capsule tears
Fig.
-The Iridectomy.
very readily, and that any undue pressure on the lens may
cause it to sink back into the vitreous. The elasticity of the
Fig "8. — Cvstitotue and Curette.
capsule causes the rent made by the cystitome to gape widely,
so that if properly incised a large triangular gap is left after
the lens has been removed.
The removal of the lens. — By the exercise of gentle pressure
with the back of the curette upon the sclerotic and on the
lower part of the cornea, the edges of the wound are seen to
become separated, and the upper edge of the lens presents
itself between them ; b}' the continuation of this pressure in a
direction backwards, and slightly upwards, the lens is presently
expelled (Fig. 79). In immature cataracts there will still re-
main a certain amount of soft cortical matter within the pu-
pillary area. This should, as far as possible, be evacuated at
once. Its removal may be attempted before the speculum is
taken out, by gently stroking the cornea with the back of the
curette from below upwards toward the wound; or, the spec-
OPERATIONS FOR CATARACT EXTRACTION,
289
Ilium being removed, a similar pressure may be made upon
the cornea through the lower lid, either with the finger or the
back of the curette. Either one or other of these methods
of coaxing out the soft matter should be repeated until the
pupil looks quite black and clear.
Fig. 79. — The Removal of the Lens.
A patch of soft linen is then applied to the closed eyelids,
and slight pressure made by means of layers of cotton-wool
and a light bandage. The patient may remain for a few hours
upon the operating couch, or may be at once placed in bed.
The room must be darkened.
Accidents and immediate complications. 1. Wrong position of
the knife. — The operator may find that he has introduced the
blade of the knife with its cutting edge downwards instead of
upwards. In case of this awkward occurrence, the knife must
be cautiously withdrawn on the flat, so as to avoid the escape
of aqueous ; if only a little aqueous is lost, the knife may be
again introduced, either at the same place or by making a fresh
puncture ; if much aqueous has escaped, so that the iris is bulg-
ing forwards against the cornea, the operation had better be
postponed for a day or two, in order to allow time for re-se-
19
290 THE CRYSTALLINE LENS,
cretion of the aqueous ; without this, the reintroduction of the
knife and the upward section would cause an irregular wound
of the iris,
2. Early escape of the aqueous. — Having completed the punc-
ture and the counter-puncture, the section must not be made
too slowly, or the aqueous escapes, and the iris bulges forwards
in contact with the edge of the knife before the section is tin-
ished. Such an accident is not very serious, as the iris has to
be excised in the second stage of the operation ; it is, never-
theless, much better to avoid its occurrence, because the out-
line of the excised portion of iris is likely to be jagged, and
less regular than when the iridectomy is made with scissors,
and the hemorrhage is likely to be troublesome in the succeed-
ing steps of the operation.
As the counter-puncture is being made, there is sometimes
a rush of aqueous into the subconjunctival tissue, which causes
the conjunctiva in its vicinity to start forwards in the form of
a bladder, which obscures the point of the knife. This should
be disregarded, and the blade of the knife pushed on in the
horizontal direction until its point has passed through the
conjunctiva,
3. Hemorrhage into the anterior chamber. — The iridectomy is
liable to be followed by hemorrhage into the anterior chamber.
The extravasated blood in this case comes partly from the iris
and partly from the vessels in the neighborhood of the canal
of Schlemm ; it usually ceases to flow after a few seconds, ^in-d
should, if possible, be evacuated from the anterior chamber
l)efore the operation is proceeded with. This can usually be
elfected by gentle pressure \yith the end of the curette upon
the posterior flap of the wound, or by gently stroking the
cornea from below upwards with the back of the same instru-
ment. If the bleeding cannot be stopped by these means, the
operation must be proceeded with. Although the capsule is
now rendered invisible by the existing blood in the anterior
chamber, it must still be lacerated with the cystitome, and the
lens removed in the ordinary way. It usually happens that
the blood escapes, and the hemorrhage ceases with the re-
moval of the lens.
CATARACT EXTRACTION — COMPLICATIONS. 291
4. Difficulty in removing the cataract.
a. Dislocation of the lens. — If too great pressure is made on
the lens in lacerating the capsule, and occasionally without
any fault of the operator, the suspensory ligament is ruptured;
the lens may then immediatel}' sink back into the vitreous, or
this may not occur until pressure is made with the view of
causing it to present; vitreous at the same time often appears
in the wound. This backward dislocation of the lens is one
of the most serious accidents that can occur during a cataract
operation ; not a moment should be lost in passing the larsre
scoop (Fig. 80) into the eye well behind the presumed position
of the lens, and attempting to extract it in its capsule. A
good deal of vitreous is generally lost, but if the lens is ex-
tracted, a very good result may be obtained.
b. The iDOund may he too small. — When this is the case the
edge of the cataract may be seen to present between the lips
of the wound, whilst the remainder refuses to come through.
Under such circumstances, the section had better be enlarged
at one or both extremities with small blunt-ended scissors ;
by making extreme pressure on the globe, the contusion of the
iris and cornea in the region of the wound is liable to be fol-
lowed by inflammatory trouble ; while the cortical portion is
likely to be scraped oif and remain in the eye by endeavoring
to squeeze the lens through too small an opening. Sometimes
when the lens appears in the wound during the pressure with
the curette, its exit may be facilitated by gentle leverage.
The assistant may be able to make traction upon it by means
of the cystitome, or a small hook.
c. The capsule may be incompletely lacerated. — Here the lens does
not present at all. The use of the cystitome must be repeated.
5. Escape of vitreous. — This is always a serious complication,
but the consequences of its occurrence will depend in a great
measure on whether it occurs before or after the extraction of
the lens. The presence of vitreous in the wound is indicated
by the appearance of a perfect!}' transparent viscid fluid.
a. If it occurs before the extraction of the lens, it is generally
due either to the counter-puncture having been made too far
from the cornea, or to too great pressure having been em-
ployed, either with the cystitome or with the curette in the
292 THE CKYSTALLINE LENS.
fourth Stage. If the vitreous is abnormally fluid, this acts as a
predisposing cause. However the escape is caused, all pressure
must be at once abandoned, the speculum removed, and a lid
retractor (Fig. 22) substituted for it, the lens should then be
immediately removed with the scoop ; if it still lies in its
capsule, the latter must be removed with it.
The scoop (Fig. 80) is introduced through the wound, and,
with slight lateral movements, directed downwards and slightly
backwards, so as to insinuate it behind the
ylens; when it has reached the lower edge
of the latter, its handle is slightly depressed,
and it is then gradually withdrawn, with
the hope of bringing out the cataract at
the same time. In case of failure in this
method of traction, further attempts must
be made so long as the cataract can be seen
through the cornea.
b. If vitreous follows the escape of the
lens, it is due either to the latter having
been expressed too suddenly, to a weak
Fig. 80.— Critchett's , . *^ , '' . „ ,
Catarnct Scoop posterior capsulc, or to compressiou or the
globe b}- contraction of the ocular muscles.
Very slight spasm of these muscles is liable to cause evacuation
of the greater part of the vitreous humor. In order to pre-
vent this accident, the patient should be kept thoroughly
under the influence of the antesthetic; the retractor should
either be held forwards by the assistant or removed altogether,
and the lids then separated by the surgeon's fingers. If
vomiting occur at this period, the e^'elids must be closed, and
supported by a compress of cotton-wool during its continuance.
The treatment to be followed will depend on the amount of
vitreous which escapes. If this is considerable, not a moment
should be lost in removing the speculum, closing the eyelids,
and applying the pad. If only a small bead presents in the
wound separating its lips, the projecting part may be cut aw ay
with scissors; many operators, however, prefer to close the
eye at once and trust to the vitreous falling back.
The loss of a small quantity of vitreous is not a serious
accident, in fact a considerable portion may escape without
OPERATIONS FOR CATARACT EXTRACTION. 293
any immediate ill-effects, but this is often followed at a later
date by detachment of the retina, and consequent loss of
vision.
Extraction in the capsule. — Some surgeons advocate the re-
moval of the lens in its capsule, on the ground that by doing
so no particles of lens matter can remain behind to set up
irritation.
Pagenstecher, who is the chief supporter of this operation,
makes a large incision, either upwards or downwards, entirely
in the sclerotic about 1 mm. from the cornea; he then excises
a large piece of the iris, and finally introduces a scoop behind
the capsule of the lens, and removes the latter by traction.
Macnamara extracts the lens in the capsule without per-
forming an iridectomy ; he uses a large, straight, triangular
keratome ; with this he makes a large incision just within the
margin of the cornea on the outer side, A scoop is then in-
serted through the wound as far as the outer edge of the
pupil ; having reached this, its handle is raised so as to bring
the lower end into contact with the capsule of the lens. The
scoop is now slightly withdrawn, still keeping its extremity
on the lens, but so as to draw open the pupil far enough for
pressure to be made on the edge of the lens with the rounded
extremity of the scoop. This pressure causes the lens to tilt
over, and the scoop being thrust onwards, the lens comes in
front of it, and is withdrawn through the pupil and through
the wound.
Extraction in the capsule would seem to be most suitable
for such cataracts as are sufficiently advanced to interfere
seriously with vision, but remain for many 3'ears in an imma-
ture condition. In old people the suspensory ligament is very
weak, and the lens can consequently often be extracted in its
capsule without the introduction of the scoop.
The after-treatment and remote complications of cataract extrac-
tion. — No food or drink should be given during the three hours
following the operation;, should thirst be complained of, the
patient may be allowed to suck a small lump of ice. After
that time a light diet of beef tea, fish, and farinaceous food
may be given. After the first day ordinary nourishing diet
may be ordered. Alcoholic drinks are not necessary, but a
•204 THE CRYSTALLINE LENS.
small allowance may be made if the patient cannot sleep with-
out it.
The dressings are carefully removed twice daily ; the out-
sides of the eyelids are gently moistened with a line sponge or
cotton-wool and tepid water; the lower lid may also be slightly
depressed with the finger, in order to give vent to any pent-up
tears.
On the third day, under favorable circumstances, the patient
may be dressed and allowed to rest for a few hours on a couch,
or on the outside of his bed, the eyes being still bandaged, and
the room darkened. After the flap operation, no examination
of the wound should be made before the eighth day ; and after
the peripheral linear method, the eye is better when left alone
until the third or fourth day. On the twelfth day the bandage
may be replaced by a large black shade covering both the eyes,
so that the latter may be well protected from direct rays of
bright light.
About the eighteenth day the shade may be substituted by
the use of protective spectacles of dark neutral tint. About
the sixtieth day the eyes will have reached the maximum of
visual acuteness; they may then be tested for correcting
glasses. The removal of the crystalline lens has rendered
the eye exceedingly hypermetropic, and has destroyed the
power of accommodation. The patient will therefore require
two pairs of convex spectacles for the purposes of distinct
vision — the one to render the eye emmetropic, which Avill
enable him to see all distant objects clearly, and the other to
render him myopic, so that he may be able to read small
print, or to do fine work at 20 to 40 cm. from the eyes. The
strength of the lenses required for these purposes is usually
about 10 D. and 14 D. respectively ; but this will, of course,
vary with the refraction of the eye. (See Refraction.)
The use of the spectacles should be gradually acquired,
commencing with about half an hour's practice dail}'.
The slight pain arising from the operation usually ceases in
the course of a few hours; its disappearance is always a favor-
able sign. On removing the dressings during the first few
days succeeding the operation, the absence of pain in and
around the eye, of any swelling of the lids, and of any muco-
CATARACT EXTRACTION AFTER-TREATMENT. 295
pus, is always a guarantee that the eye is progressing favor-
ably. If the pain should reappear toward night, and become
continuous so as to render the patient restless and uncomfort-
able, some sedative (F. 28 or 29) should be given, in order to
procure sleep.
The occurrence of severe and increasing -pain during the first
few days after the operation is always an indication of some
complication in the process of healing, and is sufficient to
justify an immediate examination of the eye. The lids should
be carefully separated, and the wound and other parts exam-
ined by means of focal illumination from the light of a single
candle. We may thus find that the pain is simply due to
accumulated tears, to an inverted lower lid, to the presence
of eyelashes within the palpebral aperture, or to the com-
mencement of inflammation.
Iritis is an extremely common complication of cataract ex-
traction : if an iridectomy has formed part of the operation,
its effects are less injurious than in the old flap operation,
where it was the cause of a large percentage of failures. The
most usual time for it to come on is about the fifth day after
the operation. Its presence is indicated by photophobia,
oedema of the lids, pain, and chemosis ; there is also copious
lachrymation, but not muco-purulent discharge; the cornea
may be clear, but the aqueous is turbid, and the iris somewhat
changed in color. In such a case a few leeches should be ap-
plied to the temple, a 1 per cent, solution of atropine dropped
into the eye three or four times daily, and the eyes kept con-
stantly warm by a large pad of cotton-wool over the closed
eyelids. The extent of the damage the iritis may bring about
will chiefly depend upon the amount of plastic exudation thrown
out into the pupillary area; the amount of this exudation may
be so great as to cause occlusion of the old pupil and of the
new one formed by the iridectomy ; the thick membrane thus
established may also contract and draw the iris upwards to-
ward the cicatrix, so as to diminish and displace the pupil.
The inflammation may also extend to the rest of the uveal
tract, setting up cyclitis or choroiditis, which may lead to
complete loss of vision.
Entanglement of the iris in the angles of the wound is not
296 * THE CRYSTALLINE LEXS.
uncommon where iridectomy has been performed. It is indi-
cated by the presence of black nodules in the wound ; these
are of variable magnitude, and may be so extensive as to im-
pede union, and even to form small cysts within the cicatrix.
The entangled iris may also cause serious trouble by dragging
upon the wound during contraction ; this, again, may retard
the healing process, and is often the cause of recurrent iritis.
It may further be the means of setting up plastic irido-cyclitis in
the operated eye; and this, as we have seen (p. 159), may extend
to the second eye, and so set up sympathetic ophthalmitis.
The means of preventing this entanglement of iris at the
time of operation have already been pointed out (p. 175);
sometimes, however, this condition supervenes on' the second
or third day. If the knuckle of iris does not exceed 2 mm. in
diameter, and give no pain, it may be disregarded; when larger
than this — and especially when it evinces a tendency to increase
in size, and to cause irritation of the eye — an attempt must be
made to remove the prolapsed portion. This must be seized
with forceps, and cut otf level with the globe by means of iris
scissors. The eye must be kept closed with a light compress
for at least a week after this, in order to favor the consolida-
tion of the cicatrix. Should there be a recurrence of the pro-
lapse after the operation, it can be lightly touched from time
to time with nitrate of silver.
Suppuration is attended by violent and increasing pain in
and around the eye, by swelling of the eyelids, chemosis, and
a copious muco-purulent discharge. It may commence at any
time during the first few days follov/ing the extraction. When
the lids are separated, and the eye examined during the early
stage, the ocular conjunctiva is found to be distended with
serum, the cornea is hazy, and the edges of the wound present
a grayish-yellow appearance, indicating the formation of pus.
Unless this process can be immediately checked, it will extend
to the whole of the cornea, to the tunica vasculosa, and to the
vitreous, thus constituting severe panophthalmitis, wliich must
terminate in the destruction of the globe. 'So time must,
therefore, be lost in endeavoring to reduce the inflammation.
The eyelids should be widely separated, and the discharge well
washed away with warm water four or five times daily ; after
OPAQUE CAPSULE — SECONDARY MEMBRANE. 297
each ablution the outsides of the eyelids and surrounding parts
should be well fomented with hot water for at least an hour ;
between the fomentations the lids should be closed, and com-
pressed with a disk of linen, layers of absorbent cotton-wool,
and a bandaire. Good nourishins: diet, port wine or brand}',
quinine, or bark and ammonia, should be given internally,
^vith opiates if necessary. By these means the affection may
take on a less destructive form, and may occasionally be
arrested before total destruction of the eye has taken place.
Intraocular hemorrhage from the choroidal or retinal vessels
may come on immediately or shortly after the operation. Its
advent is marked by severe pain ; the globe is seen to be filled
with blood, which escapes through the wound and oozes
through the dressings. Such an eye is sure to be lost, and
may require immediate excision on account of the pain and
the bleeding.
Spasmodic eiUropion is a troublesome complication which is
apt to come on a few days after the operation. The lax state
of the tissues acts as a predisposing condition, while the
operation wound, and possibly the compressing bandage, excite
contraction of the orbicularis muscle. Unless this condition
is quickly remedied, the irritation set up by the inverted lashes
of the lower lid brushing against the cornea is very likely to
lead to loss of the eye.
Treatmerd. — Sometimes it is sufficient to substitute a large
shade for the bandage; if this is ineffectual or undesirable, the
lid should be drawn down, and the face just below the eye
well covered with a film of contractile collodion. If this fails
— and it seldom does if properly applied — a fold of skin must
be at once excised, as described on p. 34.
Cystoid degeneration of the cicatrix ma}' occur after the peri-
pheral operation with iridectomy. The iris is usually more
or less entangled in the wound. It is usually due to a glauco-
matous condition of the eye.
Opaque capsule. Secondary pupillary membrane.
If the anterior layer of the capsule of the lens has been
properly lacerated, a large triangular gap generally remains;
sometimes, however, owing either to the laceration having
298 THE CRYSTALLINE LEXS.
been insufficient, or to the capsule floating back over the pupil,
a layer is left which interferes with vision ; sometimes the
cappule is so transparent tliat it can only be seen by very
careful focal illumination ; but even in these cases it causes
considerable interference with vision, probably because it is
always slightly wrinkled. In other cases the capsule forms an
opaque membrane, which can be distinctly seen with the naked
eye. Occasionally, a pupil which was quite clear at the time
of the operation and some weeks later, subsequently presents
a capsular opacity ; in such cases it is probably always the
posterior capsule that is in fault.
The membranes which form in the pupil as a consequence
of iritis, are of much more serious importance. They are
generally thick and tough; they adhere by their margins to
the iris, and by their contraction tend to narrow the area of
the pupil.
Treatment. — No operative measures must be had recourse to
until all active signs of inflammation have subsided.
The flue membranous opacities formed of capsule only, can
be readily torn through with cataract needles ; for this purpose
two needles should always be used, and the opening made by
tearing from the centre. When it was the custom only to
employ a single needle, some traction was necessarily made
upon the ciliary attachment of the capsule, and, as a conse-
quence of this, inflammatory symptoms frequently followed.
To Sir William Bowman is due the credit of having suggested
the simple expedient of using two needles, and thus avoiding
this risk.
For the tougher membranes formed by lymph, or lymph
and capsule, needling is not sufficient; in the first place, it is
difficult in such a case, even with two needles, to avoid making
some traction, and if inflammatory symptoms follow, the open-
ing made generally gets closed by fresh lymph. By far the
most ettectual proceeding is to divide the membrane and the
iris with scissors. This operation is called iridotoiny, and is
described on p. 179.
Dislocation of the crystalline lens may be congenital, spon-
taneous, or traumatic. When congenital it is due to irregular
or imperfect closure of the choroidal fissure, and to deficient
SYMPTOMS OF DISLOCATION. ^99
formation of the suspensory ligament; the hixation is usually
partial, in the upward and outward direction, and generally
occurs in both eyes. When spontaneous it is usually the result
of pathological degeneration of the vitreous humor, and of the
suspensory ligament. It is more commonly found amongst
diseases in which these structures are known to be afiVcted, as
in sparkling synchisis, high degrees of myopia, staphyloma of
the ciliary region, etc. When traumatic it is usually the result
of a contusion of the globe, which has caused rupture of the
suspensory ligament.
The symptoms vary with the extent of the displacement.
In partial dislocation^ by using the ophthalmoscope mirror
(p. 271), the edge of the lens can be seen as a narrow dark
line, slightly curved, crossing the peripheral part of the pupil.
The appearance presented by the lens margin is quite unmis-
takable, and is diagnostic of dislocation of the lens, as, even
in extreme dilatation of the pupil, it can never be seen when
the lens is in situ (vide Figs. 1 and 2, opposite p. 266). With
focal illumination (p. 86) the lens can often be distinguished by
a sort of grayish opalescence. When the displacement is such
that the edge of the lens extends to the visual field, the symp-
toms are more numerous and pronounced. The surface of the
iris is seen to be irregular, one part being more or less bulged
forwards toward the cornea, whilst the remainder is depressed ;
this depressed portion may also be tremulous when the eye is
moved. The patient often complains of monocular diplopia.
The visual acuteness is also greatly impaired, the oblique posi-
tion of the lens having produced irregular astigmatism, which
cannot be corrected by s])ectacles. The power of accommoda-
tion is very defective. When the pupil is fully dilated with
atropine it is often found that by using a stenopaic disk the
double vision of the eye is dispersed, and that the vision is
different when the slit is held in front of the partly dislocated
lens from that which is obtained when it is held in front of the
part where the lens is absent; in the latter position the eye is
found to be highly hypermetropic. On examining the fundus
with the ophthalmoscope, either by the direct or indirect
method, two images of the optic disk and retinal vessels are
seen; this phenomenon, as well as that of the monocular di-
300 THE CRYSTALLINE LENS.
plopia, is explained by the fact that the rays passing through
the lens and those passing outside it have different foci.
In complete dishcation the lens falls either backwards into the
vitreous or forwards into tlie anterior chamber. In dislocation
into the vitreous this substance, being more liquid than normal,
allows the lens to sink to the bottom of the chamber. In this
new position it gradually becomes opaque ; by focal illumina-
tion it may sometimes be seen, and with the ophthalmoscope
it appears as a dark floating mass at the bottom of the cavity
when the eye is moved. The iris, having lost the support of
ihe lens, falls somewhat backwards, and undergoes a tremu-
lous motion \vhen the eye is moved. The refractive condition
of the eye is the same here as it is after cataract extraction.
In dislocation into the anterior chamber the lens in its capsule
passes forwards through the pupil and becomes wedged be-
tween the iris and the back of the cornea. The appearance
presented by the transparent lens in the anterior chamber is
that of a drop of oil. The iris is pushed backwards, the pupil
somewhat dilated; the refraction is myopic (unless the lens
sinks to'the bottom of the chamber, when the refraction will
be the same as after cataract extraction), and the power ot
accommodation abolished. The lens may remain for some
time in the anterior chamber without becoming opaque, and
without causing pain ; as a rule, however, it gradually be-
comes opaque, is attended with pain in and around the eye,
and with more or less severe plastic inflammation of the iris.
When dislocation arises from an injury it is frequently ac-
companied by other lesions, such as rupture of the choroid
and of the sclerotic; hemorrhage may also take place either
into the fundus, or into the anterior chamber, or both. Some-
times the lens escapes from the globe altogether through a
wound in the sclerotic, and may be discovered beneath the
ocular conjunctiva.
Treatment. — 1. When tlie luxation is partial the treatment
which should be adopted will depend on the amount of dis-
placement and the interference with vision. When vision is
not much impaired, and the lens always remains in the same
position, no treatment is advisable. These partial luxations,
DISLOCATIOX— TREATMENT. 301
however, often become complete, the lens fulling forwards into
the anterior chamber or backwards into the vitreous.
When the displaced lens is transparent and its position per-
manent, but vision is seriously interfered with, some improve-
ment may sometimes be obtained by making an artificial pupil
in the direction toward which the lens is displaced ; the re-
sults, however, are uncertain, and apt to be disappointing.
"When the lens is opaque, and in a young subject, an attempt
may be made to get rid of it by needling; but in a person
over thirty-five it had better be extracted by the method
of von Graefe (p. 283).
2. When the dislocation is complete the lens is useless, and its
presence is liable to cause an attack of glaucoma ; hence its
removal should be undertaken when this can be done without
much risk. The removal of the lens is especially indicated in
cases in which inflammatory symptoms have already appeared.
Unfortunately, the removal of the lens from the vitreous in-
volves so great a loss of that fluid, while the difliculty in
extracting the lens is so great, that the operation can hardly be
said at present to come within the sphere of practical surgery,
and it is better in such a case to enucleate the eye.
When the lens lies in the anterior chamber it may be re-
moved either by needling and solution or b}' linear extraction ;
the former methods are only adapted for children. It may be
necessary to remove the capsule later; this can be done by
seizing it with fine forceps, introduced through a small wound.
In performing linear extraction in these cases, it should be
remembered that there is usually no separation between the
aqueous and vitreous. One serious diflicultj' of the operation
is the liability of the lens to slip back into the vitreous chamber;
hence it is generally desirable to have the pupil contracted by
eserine, and to fix the lens, by a needle passed through the
cornea, while making the incision.
CHAPTER XII.
THE VITREOUS HUMOR.
The vitreous body or humor is the transparent jelly-like
substance which occupies the whole of that part of the globe
which lies behind the lens and its suspensory ligament. The
crystalline lens rests in a depression on its anterior surface, and
the attachment of the vitreous to the posterior capsule is firmer
than elsewhere. Traversing the vitreous, from the optic nerve
to the middle of the posterior capsule, is a canal of about 2 mm.
diameter — the hyaloid canal. The consistence of the vitreous
gradually becomes less firm as age advances; in adult life it i^^
a viscid tiuid, somewhat more tenacious than the uncoagulated
white of egg. Its index of refraction is 1..337, and therefore
identical with that of the aqueous humor.
The vitreous is considered by some authorities (Klein) to be
enclosed in a distinct hyaloid membrane; but, according to
Iwanott",' this is identical with the membrana limitans interna
of the retina, and is consequently in relation with the vitreous
only so far as the retina extends — that is, as far as tlie ora
serrata. From this point it is continuous with the pars ciliaris
retinje, and here meridionally running fibres are found between
it and the vitreous, which form the zonule of Zinn, or sus-
pensory -ligament.
iStrudure. — When hardened in chromic acid, or by freezing,
the vitreous shows a tendency to split into concentric layers
in its peripheral portions, while the central part shows a less
marked radial striation. The lamellte thus formed do not,
however, as far as is known, correspond with any structural
arrangement of the solid constituents, although it was formerly
thought that such was the case. In the recent state we find a
' Strieker's Handbook of Histology, vol. iil. p. 346. New. Syd. Soc.
MUSC^ VOLITANTES' — VITREOUS OPACITIES. 303
perfectly clear homogeneous matrix containing a few charac-
teristic vitreous cells; these are of a roundish shape, somewhat
larger than white blood-corpuscles, and contain one, two, or
three perfectly transparent vesicles which nearly till up the
cavity. In the peripheral portions of the vitreous, stellate
and fusiform cells are also found, which contain similar round
transparent vesicles. The outline of the cells can be made
more apparent if a portion of recent vitreous is stained in a
weak solution of logwood. If examined on the warm stage,
these vitreous cells are found to undergo amoebiform move-
ments.
Muscae volitantes. — Under ordinary conditions the cells which
float in the vitreous do not give rise to any visual sensation,
although shadows must be thrown by them upon the retina.
This is probably because, in the tirst place, the mind is accus-
tomed to disregard them ; and, secondly, the shadows are
much less detined than the images of external olrjects. If,
however, the light enter the eye in an unaccustomed manner,
as when a strongl}' diverging pencil of rays is employed, as is
the case in looking through a pinhole aperture held close to
the eye, they be<3ome visible, especially if the eye be directed
to a large white surface, such as a white cloud, so that there
are no other retinal images with which to compare them.
Occasionally, owing either to hyperesthesia of the retina, or
to an error of refraction which impairs the deiinition of the
retinal images of all objects, the shadows of the vitreous cells
become visible by ordinary light, and then constitute the
troublesome symptom known as muscoe volitantes. In this
condition the vision is unimpaired, but the patient is often
much alarmed by the muscse, which he looks upon as an indi-
cation of impending blindness. In reality they are of no
importance whatever, except in so far as they indicate the
necessity of examining for any errors of refraction, and im-
proving the general condition.
Opacities in the vitreous may be floating or fixed. The free
opacities are usually multiple and of small size, while the fixed,
which are less common, are more often single, and assume the
form of a membrane. Both forms are usually due to the
exudation of inflammatory material, and are generally second-
304 THE VITREOUS UUMOR.
ary to disease of the ciliary body or choroid. Cases, however,
are frecjuently seen in which no cause whatever can be found
• for the opacities.
In order to ascertain if there are any opacities in the vitreous
the pUme mirror should be employed ; if this be held at a
distance of 8 or JO inches from the eye, and the patient moves
the latter successively in different directions, any opacities in
the vitreous, unless they are extremely minute, will come into
view ; if not seen by this method, the mirror should be held
quite close to the eye, and convex lenses of gradually increasing
strength be placed behind it, so that different parts of the
vitreous are successively brought into view, from the deeper to
the more superficial layers. If the examination be conducted
in this manner, the presence of vitreous opacities can hardly
be overlooked.
Floating opacities. — These are usually of very small size, but
occasionally there are mixed with the smaller ones a few of
larger size, which are probably formed by their coalescence;
the latter always appear black when viewed with the ophthal-
moscope, because they intercept the light reflected from the
fundus ; but if, as occasionally happens, an opacity is sufficiently
far forwards to be seen by focal illumination, it appears white
or grayish.
The fixed membranous opacities usually present sufficient sur-
face to reflect light thrown into the eye, and so appear white ;
they are much rarer than the small floating opacities, of which
they are probably in many instances a further development.
Occasionally vessels can be seen running on them for a short
distance.
Opacities of the vitreous are met with in the following con-
ditions. In myopia of high degree complicated icith posterior sclero-
choroiditis we frequently And flocculi floating about in the
unnaturally fluid vitreous; they are usually few in numljer;
as a rule, they do not interfere greatly with vision, and need
not give rise to much anxiety ; but should they be numerous
and the vision much impaired, a guarded prognosis must be
given, as this condition may be the forerunner of detachment
of the retina. In choroiditis where the pigmentary layer of the
retina is thick, the appearance of numerous floating opacities
SYNCHISIS SCINTILLANS — FOREIGN BODIES. 305
ill tte vitreous is sometimes the only symptom of the inflam-
mation. In severe choroiditis and cyclitis membranous opaci-
ties occasionally form, which completely prevent any reflex
being obtained from the fundus. Syphilitic retino-choroiditis
has already been mentioned (p. 15 i) as being accompanied by
flne " dust-like '" opacities in the vitreous.
Degenerative changes. Abnormal fluidity. — Occasionally, in
old persons, the vitreous becomes unnaturally fluid without
any other morbid change being apparent in it; unless there
are floating opacities also, this condition cannot be diagnos-
ticated, but its presence may complicate the operation of cat-
aract extraction by predisposing to an escape of vitreous.
Synchisis scintillans is the term applied to a variety of soft-
ening of the vitreous, in which a number of brilliant floating
particles are observed. When the ophthalmoscope is used
they look like floating spheres or disks of gold moving in all
directions. They are extremely numerous in the anterior
layers of the vitreous. When the pupil is dilated they can be
seen by the oblique focal illumination, as well as by the oph-
thalmoscope. On careful examination two kinds of particles
may be seen ; the one, small and white, composed of tyrosin ;
the other, larger and more lustrous, consisting of cholesterin.
The vitreous is usually rendered so opaque by the existence of
these bodies that no detail of the fundus beyond can be ob-
tained. The aft'ectioii is mostly observed in old people. It
may exist for some time without causing great visual trouble.
Foreign bodies occasionally lodge in the vitreous, although
more often they are either arrested in the lens, or pass right
through the vitreous chamber. The crystalline lens also may
be dislocated backwards, and so act as a foreign body. When
penetrating the e^-e from without, the foreign body is usually
surrounded in a few hours by cloudy opacity, which may be-
come organized into a cyst-like casing; when thus encysted it
may be tolerated for an indetinite period without pain, and
even the vision may to a great extent be restored. As a rule,
however, no such favorable condition is arrived at, but we find
one of the following conditions : (1) Inflammation and abscess
of the vitreous; (2) localized inflammation, followed by con-
traction of the vitreous and detachment of the retina, with
20
306 THE VITREOUS HUMOR.
final atrophy of the whole globe; (3) acute iiiflammation'of
the vitreous may spread to the surrounding parts, causing
panophthalmitis ; (J) the foreign body may not be fixed or
encysted, but may remain for some time visible and movable
in the vitreous cavity, and whilst in this condition it may
bring on a glaucomatous attack in this eye, or it may produce
sympathetic intlanimation in that of the opposite side.
The treatment must vary with the position of the wound, and
the presence of other comjdications, such as hemorrhage,
wound of the lens, etc. The danger of sympathetic trouble
in the other eye is of such magnitude that it is imperative,
either to remove the ofiending particle, or to enucleate the eye
containing it.
The electro-magnet. — When the foreign body consists of a
portion of iron or steel, the electro-magnet is frequent!}' found
to be of great service in its removal from the vitreous cavity
as well as from the crystalline lens, the iris, and other parts of
the eye. The practical utility of this instrument has been
amply proved during the last few years in the practice of
Snell,' Hirschberg, McHardy, Bradford, and others. The in-
strument (Fig. 81) consists of a core of soft iron, around which
is placed a coil of insulated copper wire ; the whole being en-
FiG. SI. — Snell's Electro-magnet.'*
closed in an ebonite case. At one end are two screws to re-
ceive batter}- connections, at the other end the core of the
magnet projects in such a manner that either of the needles
represented in the figure can be screwed into it. The cases in
which the electro-magnet has been employed most successfully
are recent accidents, but several are recorded in which a good
1 See The Electro-magnet in Ophthalmic Surgery, by Simeon Snell, London,
1883.
* Made by Messrs. Cubley and Preston, High Street. Sheffield.
FOREIGN BODIES — HEMOERHAGES. 307
result was obtained even after the lapse of a considerable in-
terval. In recent cases it will generally be well to introduce
the point of the instrument through the original wound, but
it will sometimes be advisable to make a fresh incision, as
being more convenienly situated for reaching and removing
the fragment; in the older cases a new puncture will be re-
quired.
If the particle be visible, either with the ophthalmoscope or
by focal illumination, the needle of the electro-magnet may be
advanced up to the chip, and the circuit completed when the
point of the instrument is in close proximity to it. For diag-
nostic purposes, also, the electro-magnet is of service. For
instance, if a body be detected, but its nature uncertain, and
on the approach of the electro-magnet to the outside of the
eye, it is noticed to quiver or alter its position, its character is
thus rendered evident. The electro-magnet may for this pur-
pose be used without a needle attached, employing in this
manner an instrument of considerable power. A delicate
suspended magnetic needle also, held over the eye, in some
cases in which the presence of a foreign body in the interior
of the globe is doubtful, by its movements sometimes affords
aid in diagnosis. The contained particle should previously be
magnetized by holding an electro-magnet in contact with the
globe for a time.
"When the object can be seen to occupy the floor of the
fundus at some distance behind the lens, an attempt may be
made to remove it by an incision through the sclerotic, choroid,
and retina at the lowest part of the globe ; after the incision
the foreign body may present in the wound, and can then be
removed with forceps. When the particle is in the anterior
part of the vitreous, near the lens, the latter had better be
removed in the manner recommended for the extraction of
cataract (p. 283) ; the foreign body may then follow the lens
in the direction of the wound, and so come within reach of the
forceps.
Cystieercus is occasionally found in the vitreous in Germany,
but in this country it is almost unknown. It is generally
developed beneath the retina, and, after having perforated that
membrane, projects into the vitreous. When the media are
308 THE VITREOUS HUMOR.
clear, the parasite can be seen with the ophthahnoscope as a
bluish-white semi-transparent cyst; it moves about with the
slightest deviation of the eye, and possesses certain undulating
movements of its own. Its presence is usually followed by
loss of the eye, which becomes disorganized and atrophied.
Pseudo-glioma has been already referred to (p. 218).
Hemorrhages into the vitreous are usually caused by injury,
as a direct blow or wound of the eye, or by concussion propa-
gated through the skull. Occasionally they are idiopathic,
and then the extravasation is from the choroidal or retinal
vessels.
Symptoms. — The hemorrhages announce themselves by
partial or total darkening of the field of vision ; this may come
on gradually, or occur suddenly. The extravasations can
usually be seen with the ophthalmoscope, and frequently also
by the oblique focal illumination.
They often disappear in the course of a few weeks, but more
frequently are followed by pigmented floating opacities.
CHAPTER XIII.
GLAUCOMA.
Glaucoma is the name given to the group of sj^mptoms
caused bj an excess of intraocular tension. It is essentially a
disease of advanced life, seventy per cent, of the cases occur-
ring in those who are over fifty. A large proportion of glau-
comatous eyes (fifty to seventy-five per cent.) are found to be
hypermetropic. When it occurs independently of any other
aflfection of the eye, it is called primary ; when it is caused by
preexisting eye disease, it is known as secondary glaucoma.
Primary glaucoma occurs in every degree of severity, and
varies exceedingly in its rate of progress ; it may be so acute
as to terminate in total blindness in the course of twenty-four
hours, or so chronic as to go on for months, and even years,
before arriving at this condition. It is, how^ever, always pro-
gressive, unless checked by remedial measures.
The symptoms may be divided into :
1. Those which are premonitor3^
2. Those which accompany the actual attack.
Premonitory symptoms are seldom wanting, although they are
frequently unheeded by the patient until the true onset of the
attack. One of the earliest is the rapid impairment of accom-
modation — rapidly increasing presbyopia. The patient has
been unable to read small print (No. 0.5 Snellen) without spec-
tacles of greater strength than should be required at his age
(see Refraction), and has found it necessary to increase the
strength of the latter perhaps several times in the course of a
few months. All artificial lights, such as the gas or candle
flame, have at times been surrounded by a halo of brightness,
or by colored rainbow-like rings. In some cases the patient
310 PRIMARY GLAUCOMA.
complains of cloudiness of sight, which he describes as " fog,"
or " mist," before the eyes. This is not always present, but
comes and goes at intervals; it is more likely to supervene
after prolonged use of the eyes, and is therefore more common
at night than in the morning. Occasionally the patient maj'
find himself in total darkness for several seconds from sudden
failure of vision.
Of the symptoms which accompany the actual attack, the
most important are :
1. Increased intraocular tension.
2. Cupping of the optic disk.
3. Limitation of the visual field.
4. Dilatation of the pupil.
5. Pain and other symptoms.
1. Intraocular tension is always increased; in fact, this symp-
tom is pathognomonic of the disease. In order to ascertain the
degree of tension, the patient should be directed to look toward
the floor, whilst the head is retained erect ; the upper part of
the globe is thus brought well forwards, so that it can be
reached by the tips of the surgeon's two index fingers, and so
examined by gentle pressure through the upper lid. Consid-
erable practice in this palpation is necessary before the tactus
eruditus can be acquired; the affected e^'c should be compared
with the other, and with the normal eye of another person.
The following method of indicating the amount of intraocular
tension (Bowman) is now almost universally adopted :
Tw, normal tension.
T + ? tension probably increased.
T + 1 tension perceptibly increased.
T + 2 " increased, but the globe can be dimpled.
T + 3 " increased so much that the globe cannot be
dimpled (stony hardness).
T — ? " probably diminished.
T — 1 " certainlj- diminished.
T — 2 " much diminished.
T — 3 " very much diminished (globe flaccid).
The increase of tension is almost in direct proportion to the
severity of the disease; in the most acute cases it is usually
very high (T = + 2 or + 3) ; in the subacute forms it is less
3g.Z. Beep GUmoomcju (hppmjg .
SYMPTOMS. 311
increased (T = + 1 or -\-2); and in the chronic varieties, it
may be only slightly augmented (T = + ? + 1 or + 2).
2. Cupping of the optic disk is not present in the early stage
of glaucoma, but is always found where increased intraocular
tension has existed for some time. The depth of the cup is
verj' variable ; it is more marked in persons under fifty than
in those above that age. Its floor presents a bluish-white
appearance; this is most pronounced in advanced cases.
The cupping can be best seen by the direct method of oph-
thalmoscopic examination ; but atropine must on no account
be used to dilate the pupil, as this invariably aggravates the
symptoms. Examined in this way the cupped disk presents
the appearance represented in Figs. 1 and 2, on the opposite
page ; they are taken from two cases of chronic primary glau-
coma, Fig. 1 being moderately, and Fig. 2 considerably ad-
vanced. In both cases it will be seen that the vessels situated
at the edges of the disk, which is now in focus, are quite clear,
and appear to make a distinct curve on to the retina, whilst
those situated within the area of the disk are somewhat
blurred and indistinct; in order to bring the latter into view,
it will be necessary to interpose one of the concave lenses of
the ophthalmoscope, the strength of the lens thus required to
bring the lamina cribrosa into focus being proportionate to the
depth of the cup. In fact we have only to allow 0.3 mm. for
each dioptre of the lens used, in order to obtain an approximate
estimate of this. Thus, suppose the edge of the disk and the
vessels there to be in focus without any lens being interposed
between the two eyes, and that a lens of 4 D. is required to
bring the lamina cribrosa into focus, then (0.3 X 4 = 1.2) the
approximate depth of the cup will be 1.2 mm. If the head be
moved from side to side, the bottom of the cup being farther
away appears to move in the same direction as the observer's
head ; this parallax or change in the relative positions of the
floor and edge of the cup is quite diagnostic.
The parallax can also be seen by the indirect method ; in this
case, if the lens which is used b}^ the observer be moved
through a small space in front of the eye, the images of the
vessels at the edge of the cup, and those of the vessels at the
bottom of the cup, appear to change their relative positions;
312 PRIMARY GLAUCOMA.
those of the former seem to move more quickly than those of
the latter. This phenomenon is easily explained. In Fig. 82,
let o be the position of the vessel at the edge of the disk, and
that of a vessel at its bottom. Let i and i be the respective
images of these vessels. Then the distance l i is greater than
Fig. S2.— Optical Parallax.
L ('. If the lens be moved from l to l', the image i', being
farther from the centre l' than the image i, will have to de-
scribe a greater space in the same time, and so i' will be dis-
placed more quickly than i'.
It is important to distinguish between the cupping of the
optic disk which is due to increased intraocular pressure, and
the physiological cupping already described in p. 183. By
comparing Fig. 1, opposite p. 192, with Figs. 1 and 2, opposite
p. 310, it will be seen that the physiological excavation only
occupies a part of the area of the disk, whilst in glaucoma the
whole disk is depressed.
Pulsation of the veins of the optic disk is always produced by
increased tension, but, as it is very frequently present in
healthy eyes, it is of little value as a symptom unless it can be
proved that it did not previously exist. Arterial pulsation at
the optic disk is occasionally seen, and when present is an
important diagnostic sign. It is " the expression of the con-
tention between the pressures in the arteries and in the ocular
chambers, and the alternate supremacy of each " (Priestley
SYMPTOMS. 313
Smith). With the exceptions mentioned on p. 191, it is
always due to increased intraocular tension or to aortic re-
gurgitation. It may be present before the onset of an acute
attack, and at any stage in the course of chronic glaucoma.
3. Contraction of the field of vision is always present in glau-
coma. The field for white first commences to contract on the
inner part, and then over the upper and lower portions of the
periphery; from these inner, upper, and lower portions the
obliteration gradual!}^ proceeds toward the point of fixation,
which is ultimately destroyed, leaving o\\\y a contracted space
in the outer jjart of the field in which vision still remains,
although its acuity is necessarily much diminished.
It is an interesting fact, and one which is almost peculiar
to glaucoma, that the limits of vision for colors follow the
same kind of contraction as those for white. (See Perimetry.)
rig. 1, opposite p. 238, is a chart showing the visual field for
white, blue, red, and green respectively, which was taken from
a case of moderately advanced primary glaucoma. On com-
paring this with the normal visual field (Fig. 1, opposite p. 232)
it will be seen that all the areas for colors are contracted
almost concentrically with that for white. So long as the
central part of the field of vision, that is, the part which cor-
responds to the yellow spot region of the retina, is not en-
croached upon, the patient may enjoy very good central vision
both for white and for colors; he will, however, be unable to
perceive other objects than those toward which his eye is
directed ; his vision is similar to that of a person looking
through a tube. After the obliteration has passed the central
region the vision becomes very defective, and finally is lost
altogether.
4. Dilatation of the loupil. — In the early staqe of primary
glaucoma the pupil is always somewhat dilated; it is usually
oval, and is moderately active. As the disease advances, the
dilatation becomes greater, the activity is lost, the periphery
of the iris adheres to the back of the cornea near the circum-
ference of the latter. In very advanced cases the edge of the
pupil forsakes its normal position against the capsule of the
lens and becomes everted (ectropion iridis), so that a ring of
brown pigment (uvea) is now seen to encircle the pupil in
314 PRIMARY GLAUCOMA.
front. Finally, the iris becomes reduced to a narrow band of
atrophied tissue.
5. Other important symptoms present themselves in glau-
coma, but are less constant than those just mentioned.
Pain is sometimes a premonitory s3'mptom. The actual
onset of acute glauconux is nearly always marked by intense
pain in the eye and in surrounding parts, as the side of the
nose, the temple, and the back of the head. The sudden
appearance and extreme violence of the pain are important
features in acute cases. Similar but less severe pain is some-
times present in subacute glaucoma, and occasionally in the
chronic forms; but the majority of the last are free from this
symptom.
Injlmnmatory symptoms are alwaj-s present in the acute and
subacute forms, but are absent in chronic glaucoma. In the
most acute cases there is intense congestion of the circum-
corneal zone of vessels, and often of the whole conjunctiva;
there may be considerable chemosis of the ocular conjunctiva;
and oedema of the eyelids. The iris loses its brilliancy, the
aqueous and vitreous humors become turbid, and the cornea
may be steamy. In subacute cases there is dusky redness of
the vessels in the circumcorneal zone.
Shallowness of the anterior chamber is frequently found in
cases of increased tension, but it is not a constant symptom;
the iris appears to be pushed forwards by advancement of the
lens. In acute and subacute cases this forward bulging of the
iris and lens is sometimes so pronounced that these structures
appear to be in actual contact with the back of the cornea.
Impaired sensation of the cornea is a common symptom.
"When the tension is greatly increased, and especially where it
has been of long duration, the cornea maybe touched without
exciting reflex contraction of the orbicularis, and without
discomfort to the patient.
Opacities of the media are nearly always present in the acute
and subacute, but are rare in the chronic forms of glaucoma.
The cornea often becomes dull and " steamy" in appearance;
the aqueous is turbid, and may contain small hemorrhages;
the vitreous frequently presents floating opacities. In old-
standing cases the lens becomes opaque.
SYMPTOMS. 315
From what has been said of the symptoms of primary
glaucoma it will be evident that an extensive range of cases
is met with, and that, according to the nature of their promi-
nent symptoms, they may be conveniently divided into three
or four groups — viz., the acute ^ the subacute^ the chronic, and the
hemorrhagic. The first three differ rather in degree than in
kind, for intermediate forms occur, and a case belonging to
one group may at any time assume the characters of the other.
The hemorrhagic, however, presents marked diflerences in its
cause, and in the effect of treatment.
In acute cases the actual attack is generally ushered in by
severe pain in and around the eye, often extending over the
whole side of the head; vomiting is not unfrequently present,
and this, with the pain in the head, may cause the local trouble
to be overlooked. The conjunctiva is usually intensely injected
and covered by large tortuous veins. The pupil is inactive,
semidilated, and oval. The cornea and media are always
turbid; so that the iris looks muddy and the fundus cannot
be seen. Tension is greatly increased, and vision becomes
rapidly impaired, so that in the worst cases (glaucoma fulminans)
total blindness may ensue in twenty-four hours or less.
The subacute cases resemble in man}- respects those just de-
scribed, but the premonitory symptoms extend over a longer
time, and those which mark the actual onset of the attack are
less severe. The injection of the conjunctiva in this case is
often confined to the circumcorneal zone, a fact which, com-
bined with the immobility of the pupil, not unfrequently leads
to a diagnosis of iritis — a mistake which may have most dis-
astrous consequences, for, while atropine does good in iritis, it
invariably does harm in glaucoma.
Chronic glaucoma differs from the preceding forms in the ab-
sence of conjunctival injection, and of opacities in the media.
The absence of inflammatory symptoms led to these cases
being formerly classed as simple or non-injiammatory glaucoma,
but the distinction is probably not a sound one. Cases of
chronic glaucoma often extend over many years, there being
very slight increase of tension, but progressive failure of vision,
with contraction of the visual field, cupping of the optic nerve,
and atrophy of its fibres.
316 PRIMARY GLAUCOMA.
Hemorrhagic glaucoma is characterized l)y hemorrhages from
the retinal vessels in addition to the other symptoms of glau-
coma.
When the media will allow of ophthalmoscopic examina-
tion, it is found that these hemorrhages do not materially
differ from those of other diseases ; they appear in dark red
somewhat elongated patches, running in the direction of the
retinal vessels, which they sometimes render obscure; the
veins appear dilated and tortuous, the arteries are of more
normal calibre; the optic disk is hazy and congested.
"When retinal hemorrhages exist, the other symptoms of
glaucoma are less evident than in ordinary cases.
The tension is sometimes only slightly- augmented. The
visual field does not present the typical concentric limitation,
but contains various irregular ijlind spots (scotomata) corre-
sponding to the positions of the blood extravasations; and
should these be situated near the yellow spot region, the cen-
tral vision will be destroyed. Sooner or later, however, all
doubt as to the nature of the case is dispelled by the onset of
markedly increased tension, and of violent pains in and around
the eye. Any sudden diminution of tension, such as takes
place in performing an iridectomy, is liable to be followed by
fresh hemorrhage.
Primary glaucoma usually attacks both eyes, but rarel}'' at
the same time ; the afitection of the second eye may set in at
any time from a few hours to several years after the first.
Pathology. — As we have already seen (p. 139), the intra-
ocular fluid is mainlv secreted by the ciliary processes, al-
though a small portion may be given ofll: by the iris. Part of
this fluid passes directly into the aqueous chamber ; another
portion passes into the vitreous chamber, and from the vitreous
chamber through the suspensory ligament into the posterior
part of the aqueous chamber. The aqueous humor thus formed
flows forwards from behind the iris, mainly through the aper-
ture of the pupil, but a portion of it passes through the tissues
at the periphery of the iris ; having thus reached the anterior
part of the aqueous chamber, it flows between the fibres of the
ligamentum pectinatum at the angle of the anterior chamber
(iritic angle) and reaches the canal of Schlemm; from this it
PATHOLOGY. 317
passes into the venous plexus, situated in the vicinity of the
canal ; it either enters directly into these veins by means of
valvular apertures, and so enters the blood current, or it passes
into the perivascular lymph spaces surrounding the veins, and
is carried by these to the capsule of Tenon. The increased
tension of glaucoma is undoubtedly due to an excess of this
fluid within the globe, but ophthalmologists are somewhat at
variance as to the exact cause of this phenomenon.
Priestley Smith believes^ that the comparatively large size of
the lens in advanced life (see p. 262) accounts for the special
liability of elderly people to primary glaucoma. He found
by experiment that if the vitreous chamber be overfilled v^ ith
fluid, so that the lens and suspensory ligament move slightly
forwards, the ciliary processes are pressed against the base of
the iris, and this, in turn, against the cornea, so that the fil-
tration channels at the angle of the anterior chamber are
shut up in a manner closely resembling what is found in the
early stage of primary glaucoma. He is of opinion that
primary glaucoma is the consequence of a shutting up of the
angle of the anterior chamber, arising precisely in this way.
In the normal state of the eye the waste fluid of the vitreous
body passes forwards through the suspensory ligament to
mingle with the aqueous fluid ; but in glaucoma this escape
of the vitreous fluid appears to be checked by closing up the
space between the ciliary body and the lens, and so the vitreous
chamber gets overfilled. The immediate cause of the obstruc-
tion appears in most cases to be a swelling up of the ciliary
processes, but it is obvious that the large size of the senile
lens will act as ?i predisposing cause of glaucoma wherever such
swelling occurs. This opinion as to the participation of the
lens is supported by the fact that swelling of the lens as the
result of injury is very apt to induce glaucoma in elderly
people, in whom the lens is already of large size, and less so
in young people, in whom it is small. It is, however, insuffi-
cient to account for certain forms of glaucoma, such as some-
times occur in eyes from which the lens had been removed,
and in eyes in which the lens has been dislocated backwards.
Dr. Brailey^ believes glaucoma to be primarily due to a
1 Glaucoma. London, 1879. ''■ Lend. Oph. Hosp. Eeports, vol. x. part ii.
318 PRIMARY GLAUCOMA.
vascular change ; he considers that before the development of
the increased tension there is ahviiys inflammation of the ciliar^y
body, iris, and optic nerve; that this is most [)ronounced in the
ciliary body, especially in and around its muscular libres ; that
the inflamed condition gives rise in the first instance to hyper-
secretion of fluid from the ciliai-y body and iris; that the en-
largement of the ciliary folds, due to tlieir vascular turges-
cence causes the advancement of the periphery of the iris
toward the cornea, by which tbe outflow of fluid from the
globe through the angles of the aqueous chamber and the
canal of Schlemm is impeded.
Dr. Weber, of Darmstadt,^ does not believe in the theory of
hypersecretion of fluid, but in a diminished outflow. He does
not consider that the hindrance to the outflow is limited to the
iritic angle of the anterior chamber, but that impediments may
exist in the vitreous, in the suspensory ligament, the anterior
chamber, the canal of Schlemm, or in the superficial layers of
the sclerotic. He also is of opinion that a higher " condition
of albuminosity " of the intraocular fluid may tend to prevent
its outflow.
"Whatever may be the wHial cause of primary glaucoma,
whether from (i) hypersecretion of the inflamed ciliary body,
(ii) impeded outflow caused by pressure of the enlarged ciliary
body upon the periphery of the iris, (iii) impeded outflow from
the vitreous chamber by enlargement of the lens, or from all
these causes combined, there are certain pathological condi-
tions which are pretty constantly found in glaucomatous eyes.
These will now be considered.
The ciliary bod//. — In the early stage there is always inflamma-
tion of the ciliary muscle, and enlargement of the ciliary folds
(cyclitis). This condition of capillary distention of the ciliary
body is believed by Dr. Brailey to cause increased secretion,
which may of itself be sufiicient to cause glaucomatous ten-
sion. Its appearance at this early stage is very similar to that
of serous iritis (see Fig. 1, opposite p. 143). It difters from
that affection in becoming rapidly atrophic, the atrophy being
accompanied by great dilatation of the bloodvessels. In the
advanced stage of primary glaucoma the ciliary body is always
' Trans. Int. Med. Congress, vol. iii., 1881.
SeUniic.
_— 5«nwl«w*"»^'
'rr^i^ -essib
Fic. I. — Primary glancoma. X about 50 diaiii.
Sclero-corncal ju-nciiorv.
CiectiriJP
(hliaiy hodj.
^ ?A N»i* Remains of iri a.
Fig. 2. — Upper ciliary region. •. about 50 diam.
Teriphery at' ir^a aci/iet-ent U tornfc-
Iri*
Fig. 3. — Lower ciliary region. X about 50 diaiu.
'iippeH SuslC
-BeiirieC,
Choroid.
^ZiUTmna, erllvosa..
Wieuth. gpofC.
.Jtural sheath.
Fii.. 4, — OptK- uifR region. X about 50 diam.
ADVANCED PRIMAKY GLAUCOMA.
To /ate jK. 31J.
PATHOLOGY. 319
found to be atrophied (see Figs. 1, 2, and 3, on the opposite
page); not only the muscle but the ciliary folds are found to
be shrunken and the vessels widely dilated. In old people
this atrophy is accompanied by the formation of dense con-
nective tissue, whilst in the more rare attacks in young people
the part becomes stretched, owing to the elasticity of the tis-
sues, thus forming a general bulging of the anterior part of the
eye, and giving rise to the condition known as huphthalmos.
The iris is also slightly inflamed, and the pupil somewhat
dilated and sluggish in the earli/ stage. Its periphery is ap-
proximated to the back of the cornea at the iritic angle so as
to diminish the size of that outlet ; the fibres of the liga-
mentum pectinatum as they pass from Descemet's membrane
to the base of the iris are found to be swollen by hypernuclea-
tion of their epithelioid covering, and, by being thus increased
in calibre, the spaces between them (spaces of Fontana) are
considerably diminished, thus forming a further obstruction to
the outflow of the fluid from the anterior chamber to the canal
of Schlemm. In the advanced stage the periphery of the iris is
found to be in actual contact with the cornea, and adherent to
it (see Figs. 1, 2, and 3, on the opposite page), so that the
iritic angle is more or less completed blocked. Under these
circumstances the edges of the pupil are sometimes everted,
as in Fig. 3, and the pupillary margin of the iris no longer
rests upon the capsule of the lens. Finally, the iris may be-
come atrophied and reduced to a mere baud of slate-colored
tissue around the widely dilated pupil.
The suspensory ligament is put upon the stretch by the accu-
mulated intraocular fluid. This is probably an important
factor in the impairment of accommodation which is always
present in glaucoma.
The optic nerve is always found to be somewhat inflamed in
the very early stage (Brailey). In the advanced stages there are
always changes in this structure. On transverse section the
nerve-flbres are found to be shrunken, and the intervening
connective tissue considerably hypertrophied. The same
hypertrophy is found to afl:ect the pial sheath of the optic
nerve and the lamina cribrosa. This latter structure, which
forms the floor of the optic disk, is the weakest part of the
320 PRIMARY GLAUCOMA.
fibrous capsule of the globe, and is therefore the first to yield
to glaucomatous tension. In cupping of the optic disk the fibres
of the lamina are pushed backwards in the manner shown in
Fig. 4, opposite p. 319, and the nerve-fibres as they radiate
toward the retina are pressed back with it. The depth of the
cup depends chiefly upon the amount and duration of increased
tension and the age of the patient. In a person of middle
age, in whom the tension has been considerable and of long
standing, the cup is generally deep with overhanging edges,
but in an older person (over sixty) it is less deep, owing to the
unyielding nature of the fibrous tissue.
The choroid. — It was formerly considered (von Graefe) that
choroiditis serosa was one of the chief causes of glaucoma, but
it is found that this structure is not affected in the early stage,
and only evinces a tendency to atrophy in the later period of
glaucoma, when the optic disk is often seen surrounded by a
ring of choroidal atrophy.
The retina sutlers from prolonged pressure in several ways.
In the first place, the compression of so delicate a structure is
alone sufficient to impair its function; then we have seen that
the fibres of the optic nerve are compressed and atrophied at
or near the optic disk ; finally, the flow of arterial blood to the
retina is impeded, and the etflux of venous blood is retarded.
The want of arterial blood is probably the cause of the charac-
teristic limitation of the visual fluid; the course of the vessels
to the periphery being longer, and so having greater resistance
to overcome than those at the centre. The vessels of the
retina are frequently found to be degenerated. The walls of
the arteries are often thick, and present a hyaline appearance ;
sometimes aneurismal dilatations may be seen, and hemor-
rhages are frequently found.
Treatment. — In the year 1856 Alfred von Graefe, having dis-
covered that iridectomy was eftectual in reducing intraocular
tension, employed this operation in the treatment of glaucoma;
his attempts in this direction were followed by the most bril-
liant success. The operation of iridectomy has been, and is
almost universally adopted for this disease, and is the means
of rescuing hundreds of persons from blindness every year.
Before the time of von Graefe's discovery, glaucoma held a
TREATMENT. 321
prominent place in the category of incurable diseases. Since
the introduction of iridectomy other operative measures, as
sclerotomy and paracentesis of the vitreous and anterior cham-
bers, have been introduced, but up to the present time they
have in no way proved themselves superior to the original
operation, although in certain cases their adoption may be
advisable.
Of late years also the local action of certain myotic drugs,
such as the extract of calabar bean, eserine, and pilocarpine,
has been found effectual in reducing and, in a few cases, even
abolishing the excess of tension in glaucomatous eyes.
During the premonitory stage, which is probably the expression
of successive transient attacks of increased tension, recurring
after variable intervals of time, eserine (F. 31) may be em-
ployed with great benefit.
In acute and subacute cases, a large iridectomy (see p. 171) in
the upward direction should be immediately performed. The
omission or postponement of this, or an equivalent operation,
is liable to be attended with the most disastrous consequences;
by allowing the continuance of the great intraocular pressure
which accompanies these affections, the function of the retina
will become permanently deteriorated, if not absolutely de-
stroyed. On the other hand, the performance of the opera-
tion is usually attended, not only with a cessation of the
symptoms and progress of the disease, but with marked im-
provement of the vision ; an eye thus affected may have been
recently deprived of all useful vision, and even, it has been
said, for a short time, of perception of light, and may yet re-
cover very good sight from a prompt and well-performed
iridectomy. Whatever defect of vision may have existed in
the eye before the operation, the after-improvement will almost
entirely depend upon the previous duration of the pressure.
In the event of unavoidable delay, from want of proper in-
struments, objections on the part of the patient, or from other
causes, a solution of eserine (F. 31) should be dropped into the
palpebral aperture every hour ; this may to some extent reduce
the intraocular pressure, and so stave off its pernicious effects
until the operation can be performed. In fact, it is well in all
cases to commence the use of eserine as soon as possible after
21
322 PRIMARY GLAUCOMA.
the diagnosis is completed, and to continue its use both before
and after any operation that may be performed.
In chronic glaucoma, the improvement produced by iridec-
tomy and the use of eserine or other myotics, is not so marked
as in the cases just mentioned. In the majority of cases the
operation is sufficient to arrest the progress of the disease, but
it seldom restores much of the vision that has been lost by
continued pressure. The use of eserine alone is generally
helpful in reducing tension, which in some cases will almost
entirely disappear after a few days' use of that drug. The
general experience, however, is that the relief thus obtained
is not permanent ; the tension returns soon after, or even be-
fore, the discontinuance of the drug, with the effect of gradual
deterioration and final loss of vision.
In a small proportion of cases, mostly of the chronic kind,
iridectomy is not followed by improvement; the tension re-
mains elevated, and the vision continues to decrease. In a few
cases of the same class this operation is succeeded by exagger-
ation of the symptoms; the vision rapidly fails, and it may be
followed by shrinking of the globe.
There are no definite signs by which we are able to foretell
these conditions ; it is, therefore, well to give a guarded prog-
nosis in all cases, and to forewarn the patient of this possible
termination.
In hemorrhagic glaucoma, when the condition of the media
will admit of the detection of hemorrhages in the retina, the
vitreous, or the anterior chamber, iridectomy is contraindi-
cated. Owing to the diseased condition of the bloodvessels,
an iridectomy is certain to aggravate the mischief, the sudden
lowering of the intraocular pressure causing further hemor-
rhage. The operation of sclerotomj', in which the diminution
of tension is more gradual, has not so far been followed by
these untoward results.
In very old people the probable duration of life must be
considered : where the disease is of the mild and chronic form
the central vision may continue fairly good until the end.
In advanced disease, where the vision is perhaps totally
gone from one eye, and greatly impaired in the other, the
iris is usually atrophied, and sclerotomy would be more easily
TREATMENT. 323
performed than iridectomy, although but little benelit, beyond
the relief of tension and consequent cessation of pain, could
be expected.
Sclerotomy has of late years been extensively tried as a sub-
stitute for iridectomy in glaucoma; this is owing to the wide-
spread conviction that the latter operation owes its eificacy to
the incision in the sclerotic rather than to the excision of a
portion of the iris. Various methods of performing sclerotomy
are in use ; the following plan, as recommended by de Wecker,
is the one I usually adopt.
Operation. — A von Graefe's linear knife (Fig. 42, p. 172), or
one of de Wecker's sclerotomes, is introduced into the scle-
rotic at 1 or 2 mm. from the margin of the cornea, in the same
way as for iridectomy in the extraction of cataract (see p. 286),
except that the incision is slightly more posterior than in the
iridectomy ; its point is carried across the anterior chamber in
front of the iris, ^nd the counter-puncture made in the oppo-
site corresponding position. The knife is now carried upwards
by a sawing movement until its edge is just covered by the
sclero-corneal junction, that is, until its edge forms a tangent
with the highest point of the cornea; the incision is then
stopped without cutting through the remaining bridge of scle-
rotic above, and the knife is slowly withdrawn. Great care
should be taken not to wound the iris, also to prevent a sudden
rush of the aqueous from the wound, whereby the iris might be
caused to protrude, and so become entangled in the wound.
By sclerotomy performed in this manner all the tissues at
the iritic angle are divided, except the bridge of sclerotic tissue
which is left. The operation is " subconjunctival." The line
of incision which it is desirable to obtain in sclerotomy is
shown in Fig. 83, where it is seen to be somewhat posterior to
that of iridectomy. It is evident that in this operation, if the
incision is too far removed from the cornea, there is danger of
wounding the ciliary body, and consequent hemorrhage into
the vitreous chamber, also of possible plastic cyclitis, and con-
sequent sympathetic inflammation in the other eye.
With the view of preventing the prolapse of the iris through
the wound in the sclerotic, as well as for the continued reduc-
tion of tension, the use of eserine (F. 31) is advisable both
before and after the operation.
324 PRIMARY GLAUCOMA.
Sclerotomy, although generally admitted to be theoretically
equivalent to iridectomy, has not yet gained the universal
coniidence of ophthalmic surgeons. Speaking on this subject
Fig. 83. — Lines of Incision.
/, in iridectomy; S, in sclerotomy.
in 1878, de Wecker,^ one of the strongest supporters of scle-
rotomy, says : " Although I shall, probably, during the whole
course of my career continue to give preference to excision of
the iris as being the surest operation against glaucoma, I hold
the conviction that our progressive science will substitute for
it a simpler and more logical proceeding. . . . Under two
circumstances only do I strongly recommend you to renounce
iridectomy and to resort to my operative procedure; first,
when you recognize that you are dealing with hemorrhagic
glaucoma, for here the double section with the narrow scle-
rotome (2 mm.) enables you to avoid the danger of the section
for iridectomy; and secondly, in cases of absolute glaucoma;
in these sclerotomy ought always to be preferred to iridectomy,
the operation being undertaken only with the object of freeing
the patient from severe pain."
Paracentesis of the vitreous chamber is practised by Cowell for
the relief of certain forms of chronic and secondary glaucoma ;
he plunges the point of a Beer's cataract knife to the extent
of 5 mm. through the conjunctiva, sclerotic, choroid, and
retina, as near as possible to the space between the insertions
of the superior and external recti. The incision is sometimes
attended with excellent results, not only in relieving tension,
but in the improvement of vision, etc.
1 Th^rapeutiqu4 Oculaire, part i. p. 378. 1878.
SECONDARY GLAUCOMA. 325
When an eje is lost from glaucoma and continues to be
painful after sclerotomy or any other operation, excision of the
globe is the only remedy.
Secondary glaucoma signifies a condition of increased intra-
ocular tension, occurring as a complication of some other aflt'ec-
tion of the eye. It is most common amongst those maladies
which interfere with the normal movements and position of
the iris.
Perforating ulcer of the cornea with protrusion of the iris is a
common example of this. The whole or part of the pupillary
edge of the iris becomes entangled in the wound, where it
appears as a black point ; if this be carefully examined, the
protruding portion of the iris will be found to act as a filter,
and for a certain period to give rise to a constant leakage ;
finally, this black point becomes covered over by a layer ol
lymph which cicatrizes and the leak is closed. Increased ten-
sion is the immediate result ; the fluid can no longer pass
through the cicatrix; the periphery of the iris is jammed
against the cornea by the fluid pressure behind it, and so the
entrance to the canal of Schlemm is closed. Unless the ten-
sion is relieved by iridectomy, or an equivalent operation, the
iris becomes atrophied and adherent to the cornea; anterior
staphyloma or bulging of the whole anterior part of the eye
may occur; the iris is greatly stretched, and tension is made
upon the ciliary processes ; the lens is carried forwards as well
as the iris ; the zonula is stretched, and so traction is made
upon the pars ciliaris retinse. The vitreous undergoes degen-
eration, and becomes more fluid than normal.
Complete posterior synechia is another common cause of secon-
dary glaucoma ; the pupil being bound to the anterior capsule
of the lens, the passage of fluid forwards through this is ar-
rested; pressure is thus made upon the iris from behind, and
its peripheral portion is bulged forwards, thus closing the angle
of the anterior chamber, while the attachment of its pupillary
edge to the lens gives n funnel-shaped appearance to the pupil.
Wound of the lens, as in the needle operation or by accident,
often gives rise to increased tension, probably by causing swell-
ing of the lens structure within its capsule. The remains of
326 SECONDARY GLAUCOMA.
soft lens matter after cataract extraction is also a cause of in-
creased tension.
Dislocation of the lens either forwards or backwards, and par-
tial dislocation of the lens, sometimes give rise to glaucoma.
Foreign bodies in the globe may cause glaucomatous tension;
this, again, is probably generally by wound of the lens and
iris or ciliary body.
Sarcoma of the choroid and glioma of the retina are usually at-
tended at some period of their history by a rise of tension.
Symptoms. — Increased tension is the chief sign of secondary
glaucoma. The other symptoms of contracted field, halos,
impaired visual acuity, and changes in the refractive condi-
tion, are seldom to be made out on account of the lesions of
the cornea, iris, lens, etc.
The treatment of secondary glaucoma must vary with the
cause. In the case of a dislocated lens being the cause of the
trouble, an attempt should be made to remove it. (See p.
301). Where the iris is adherent, either anteriorly or poste-
riorly, iridectomy (see p. 171) should be performed. When the
eye is quite blind and the media opaque, if it is painful, and
especially if the other eye remains unaffected, it probably con-
tains a tumor, and should therefore be excised.
The after-treatment of iridectomy or sclerotomy for glaucoma
is simple enough. After iridectomy, the eyelids are closed
and covered with a piece of wet lint and a light bandage.
After sclerotomy, the bandage is generally dispensed with alto-
gether, and the eyes shaded from the light. On the second or
third day the use of eseriue (F. 31) should be resumed. The
general health should be supported by tonics ; any excess in
diet, and especially in alcoholic drinks, being avoided. Any
constitutional dyscrasia, as gout or rheumatism, should be com-
bated by suitable remedies. For the first few days the patient
had better be kept in bed, and should not leave the darkened
room for at least a week. After that time he should wear
spectacles of the darkest neutral tint; he should avoid over-
use of the eyes, and be as far as possible removed from over-
work and worry.
CHAPTER XIV.
ERRORS OF REFRACTION.
By W. Adams Frost, F.R.C.S. Eng. ; and Henry Juler, F.R.C.S. Eng.
i. optical principles. — ii. the eye considered as an optical instru-
ment. iii. errors of refraction. — iv. lenses. the ophthalmo-
scope. — v. methods of estimating refraction. — vi. general con-
siderations.
Section I. — Optical Principles.
From every point on the surface of an illuminated or lumi-
nous object light is given off in every direction in a straight
line. Hence the light from any such point may be considered,
and represented diagrammatically, as fine radiating lines;
such imaginary lines are called rays. Adjacent rays coming
from the same point constitute a pencil of light. Rays of light
therefore coming from any point must necessarily be divergent ;
the greater, however, the distance of the source of the light,
the more nearly will they approach to parallelism. Thus, in
the case of rays from the sun, it is impossible by the most
accurate measurement to demonstrate that they are not paral-
lel. Here we shall be chiefly concerned with rays which
enter the eye through the pupil, and of these we may, for all
practical purposes, consider as parallel those which come from
a point distant not less than six metres (20 feet).
As long as a ray travels in the same medium it continues
its original direction ; if it passes into a medium of different
density it changes its direction at the surface which separates
the two media. The direction and amount of the change
depend on two factors — the difference in the refracting power
of the two media, and the form of the surface of separation.
328
ERRORS OF REFRACTION
As a rule, the refracting power of a medium is in proportion
to its density ; thus glass is more refracting than water, and
water than air, while air, as compared with a vacuum, has a
deiinite power of refraction. The following are the laws of
refraction : (1) A ray- in passing from a less into a more refracting
medium is refracted toward the normal. (2) In passing from a
more into a less refracting medium a ray is refracted away from the
normal. A ray, whose course coincides with the normal,
undergoes no change of direction. The normal, in the case
of a plane surface, is the perpendicular to the surface drawn
from the point of contact of the ray ; in the case of a spherical
surface it is identical with the radius of curvature.
It is evident that if a ray pass right through the more re-
fracting medium into the same medium which it traversed be-
fore, it will be refracted at the surfaces both of entry and of
exit.
We wi\\ consider first the case of a ray passing through a
piece of glass whose surfaces are parallel, as in an ordinary
plate-glass window. Let a b (Fig. 84) be such a ray passing
Fig. 84.
through n' ; then at h it is refracted toward the perpendicular
p h, and at h' it is again refracted away from the perpendicular
p' h' to the same extent — i. e., the amount of refraction is the
same, but its direction is opposite to that which it underwent
on entering the glass — hence its ultimate direction is parallel
OPTICAL PEINCIPLES. 329
to that which it originally had, and it has merely undergone
jparallel displacement. The amount of this displacement ob-
viously depends on the obliquity with which the ray strikes
the glass, and on the thickness of the latter. In all the cases
with which we shall be concerned the parallel displacement
may be disregarded, and rays which pass through a body
whose surfaces are parallel or concentric may be considered to
be unchanged in their course, provided that the media on each
side of the body have the same power of refraction.
If, instead of being parallel, the surfaces of the glass con-
verge as in a prism (Fig. 85), the prolongations of the normals,
p h and p' h\ are no longer parallel, but are directed toward
the base of the prism ; hence the ray a b, following the laws
Fig. So.
of refraction, will also be refracted toward the base both on
entering and leaving the glass. Therefore, rai/s passing through
a prism are refracted toward its base.
By refraction at a plane surface the actual direction of rays
is changed, but not their relative direction ; thus rays which
were parallel or divergent before remain parallel or divergent
after refraction. This results from the fact that the normals
to a plane surface are parallel to each other.
If the separating surface is curved (Fig. 86), the normals are
no longer parallel, but, in the case of a spherical surface, meet
at the centre of curvature ; hence rays by refraction at such a
surface are rendered more or less divergent, according as they
are made to approach or recede from the normals.
"We will consider tirst refraction at a single spherical surface.
330
ERRORS OF REFRACTION,
Let c D (Fig. 86) be a portion of such a surface separating
the media n and n', of which ii' is the more refracting, and let
k be its centre of curvature. Then lines drawn from k to any
points in c d will constitute normals to the surface c d, and,
since rays which coincide with the normal are unrefracted, any
ray which is directed to k is unrefracted — hence k is called the
Fig. S(j.
optical centre (it coincides in this case with the centre of curva-
ture). A line, a b, joining the centre of c d (A) with k, is called
the principal axis of. the surface ; all other rays which pass
through k are called secondary axes.
Let a h' be a ray parallel in n to the principal axis a b. Draw
the normal h' k; then at the point h' the ray a h' will be re-
fracted toward h' k, and would intersect the principal axis a b
at F. In the same way any other ray parallel in n to the prin-
cipal axis would intersect it at F. The point at which the rays
of a pencil meet after refraction is called a, focus. The focus
for parallel rays is called the principal focus. The distance
(A F) of the principal focus from the refracting surface is
called the principal focal distance. Rays parallel to any secon-
dary axis are focusscd on that axis in the same vertical plane
as the principal focus ; this plane [F F') is called the principal
focal plane. ^
The radius of curvature (r) of the refracting surface, and
the relative refracting power of the two media (n and n') being
^ It would be more accurately represented by the arc of a circle having k as
centre, and k F as radius.
OPTICAL PRINCIPLES.
331
known, the principal focal distance i^can be found by the
formula —
(1)
F =
iv r
n'
Rays coming from n' and passing into n are of course subject to the same
laws, so that rays which are parallel to the principal axis in n' will have their
focus on it in n ; this is called the anterior focus (F"). Its distance from the
refracting surface can be found by the formula —
(la)
F"
n r
Now let a ray/ A' (Fig. 87), instead of being parallel to the
principal axis a b, come from some point,/, on it; since /A'
diverges from a b it nieets the normal h' k at a. greater angle
than if it were parallel to a b, so that the same change in its
direction will not cause it to intersect a b at -F, but at some
greater distance,/' ; and any other rays from /would meet at
/'. Conversely, if we considered the rays as starting from/'
they would be focussed at/, hence the two points /and/' are
said to be conjugate foci. Conjugate foci are situated on the
same axis. The principal focal distance {F) being known, the
conjugate focus (/') of any point (/) can be found by the
formula —
(2)
provided that the foci are on opposite sides of the refracting
surface ; the case in which they are both on one side will be
considered presently.
Fig. 87.
If the positions of Ic and i^ are known, the conjugate focus of/ can also be
found by construction. Draw/^ k (Fig. 87) parallel to/ A''; prolong it to meet
332
ERRORS OF REFRACTION,
the principal focal ^'plane at F^ ; then /^ F^ forms a secondary axis. Since/ h'
is parallel in n to the secondary axis,/^ F^^ it will after refraction intersect the
latter at the principal focal plane F F^, i. e., at Fy, but the conjugate focus of/
must lie on A B, prolong h^ Fy until it intersects A B, and the point of inter-
eection,/'', will be the conjugate focus of/.
Both from the formula (2) and from Fig. 87 it is evident
that the nearer/ is brought to the refracting surface the fur-
ther will/' recede; when the distance of/ from the surface is
equal to twice the principal focal distance (/= 2F),f' will be
at the same distance on the other side ; so we get this rule :
When conjugate foci are at equal distances from the refracting
surface^ that distance is double that of the principal focus.
Fig. 88.
If/ coincides with F", the rays in n' will be parallel ; if it
is brought still nearer to the refracting surface, as in Fig. 88,
the rays will diverge in n'^ and therefore would only meet if
prolonged backwards, so that the conjugate focus of / would
now be on the same side of the refracting surface (/', Fig. 88).
The conjugate focus of/ is now said to be negative, and is
a virtual, as distinguished from a real, focus — i. e., it is not
formed bj' a meeting of the actual rays, but of their imaginary
prolongations; and formula (2) must now be altered by giving
the minus sign to/', so that it becomes ;
(2a)
1
F
1
1'
So far we have considered refraction at one spherical surface
only ; if, however, a ray passes through the more refracting
medium, and again emerges into the less refracting, it is re-
fracted again at the second surface.
OPTICAL PRINCIPLES.
333
Lenses are portions of a highly refracting substance, gen-
erally glass, having one or both surfaces curved. Those with
which we shall deal at present are biconvex and biconcave,
and their surfaces are portions of a sphere ; they are therefore
called spherical lenses ; later on we shall have to deal with
cylindrical lenses.
A biconvex lens renders rays less divergent, and a biconcave ren-
ders them more divergent, at both surfaces.
If parallel before refraction, the convex lens will render
them convergent, and the concave divergent.
The above rule as to the action of lenses only applies if, as is usually the case,
the material of the lens is more refracting than the medium in which it is placed ;
if these conditions are reversed, the convex lens becomes a diverging and the
concave a converging lens. Divers sometimes use spectacles in which the lenses
are formed of air, i. e., they are composed of two curved plates of glass enclosing
a cavity which is the shape of a concave lens and contains air. A. concave air-
lens of this nature, when used in water, has the same effect as a convex glass
lens in air. In air it would have no action.
In a bispherical lens, the principal axis is the line joining
the centres of curvature of the two surfaces (c c', Fig. 89).
Fig. 89,
In considering refraction at a single surface, we saw that
rays which passed through the optical centre (which, in that
case, coincided with the centre of curvature) underwent no
change of direction; in double refraction, the only ray whose
course remains absolutely unchanged is the one which coin-
384 ERRORS OF REFKACTIOX.
cities with the principal axis ; for every bispherical lens, how-
ever, there are two " nodal points " {k\ k-, Fig. 89), whose
relation to each other is such that a ray which is directed to
the one before refraction is directed to the other after refrac-
tion, and its course is then parallel to its previous direction.
The ray a b (Fig. 89) therefore undergoes parallel displace-
ment ; it is evident, however, that, except in very thick lenses,
or with great obliquity of the incident ray, a very trifling
dift'erence would be made by drawing the ray through a point
between the nodal points. Such a point constitutes the
Optical Centre, and rays which pass through it may, for all
practical purposes, be considered to undergo no change in
their direction, and to constitute secondary axes.
The principal focus of a bispherical lens is found by the
following formula, /• being the radius of the first surface and
r' that of the second, and n' and n the refractive indices^ of the
material of which the lens is made, and of the medium in
which it is placed, respectively :
(8) • • • ^=(«'-«)(i-^.).
In most bispherical lenses, the curvature of both surfaces is
the same ; and, as the index of refraction of glass is approxi-
mately 1.5, and that of air is 1.0, the formula becomes :
1 (1.5 — ]) 2 -r,
that is to say, in bispherical lenses with similar surfaces the
principal focal distance is equal to the radius of curvature.
Conjugate foci are found by formulae (2) and (2a), as in
single refraction.
At the conjugate focus of any point an exact image of the
point is formed. When the image is formed by the actual
meeting of the rays it is said to be real, when it is only formed
by an imaginary prolongation of the rays it is said to be
tnrtual.
' The index of refraction of any substance is its refractive power as compared
with that of air, the latter being expressed by unity.
OPTICAL PRINCIPLES.
335
The image of an object is the sum of the images of all
points of the object. The position and size of the image can
therefore be found hy finding the position of the conjugate
focus of the extreme points of the object. For the images of
all the other points of the object will lie between these, and in
the same focal plane.
As rays coming from any point on an axial ray are focussed
on the same axis, and as the course of the latter is not changed,
it follows that the size of the image in relation to that of the
object is the same as the relation of their distances from the
optical centre.^
Fig. 90.
Examples. — If the object {a b, Fig. 90) be situated at more
than twice the principal focal distance, the image {b' a') is
smaller than the object, real, and inverted.
If situated at twice the principal focal distance, it is of the
same size, real, and inverted.
Fig. 91.
If the object is beyond the principal focal distance, but at
less than twice that distance, the image is larger than the
1 Strictly speaking, as the distance of the image and the object respectively
from'the nodal point which is situated on the same side the optical centre.
336
ERRORS OF REFRACTION.
object, real, and inverted. This will be seen if, in Fig. 90, a' h'
is considered as the object, and a b as the image.
If situated at the principal focus (Fig. 91), the rays would
be parallel, and, as they would never meet, no image would
be formed.
If nearer still (Fig. 92), the rays would be divergent, and
would therefore only meet when prolonged backwards; the
Fig. 92.
image is, therefore, larger than the object, virtual, and erect.
Such an image could on\y be seen b}^ looking through the lens.
With a concave lens (Fig. 93) the image is always smaller
than the object, virtual, and erect.
Fui. 93.
"When the image is real it can be projected on to a screen,
but this cannot of course be done with virtual images, which
can only be seen by looking through the lens.
Spherical aberration. — We have hitherto assumed that rays coming from any
point are accurately focussed in a point; this is, however, only true of those
which fall upon the refracting surface at no great distance from its principal
axis. As long as the aperture of a lens (i. e., the angle formed by lines drawn
OPTICAL PRINCIPLES. 337
from its edges to the principal focus) does not exceed 12°, the erroi- from this
source may be disregarded. But rays which fall upon the refracting surface
beyond this limit are refracted more powerfully than the more central rays ;
this, which is called spherical aberration, causes slight loss of definition in an
image ; it can be overcome in optical instruments by the use of diaphragms, by
employing refracting surfaces whose curves are parabolic, and by a combination
of lenses.
Chromatic aberratio7i. — Impaired definition of the image also arises from the
fact that all the constituents of colorless light are not equally refracted ; thus
the red waves are the least, the violet the most refractile. (See Chapter X.)
If an image of a brightly illuminated white spot be formed on a screen by a
lens, the central part will be white because there all the rays are combined, but
the edge will be fringed with color ; this is called chromatic aberration, and
is overcome in optical instruments by using a combination of lenses composed
of different materials.
Section II. — The Eye considered as an Optical Instrument.
For distinct vision three factors must be associated: (1)
well-delined images of external objects must be formed on the
retina at the posterior pole of the eye.
(2) The nervous elements of the retina which correspond
to this image must be stimulated, and the effect be conducted
to the brain.
(3) The mind must be able to interpret correctly the impres-
sions thus received. The first is the result of the optical prop-
erties of the eye, and with it alone we are here concerned.
The eye is a closed, nearly spherical, chamber, measuring
22.2 mm. in its antero-posterior diameter. It is almost imper-
vious to light except in front, where it is closed in by a trans-
parent membrane, the cornea, which is more sharply curved
than the opaque portion of the investing tunic, having a radius
of curvature of nearly 8 mm.
The opaque portion of the sphere is formed by a firm fibrous
membrane, the sclerotic, whose structure is continuous with
that of the cornea. This is lined by an extremely vascular
membrane, the choroid, and this again by a layer of nervous
tissue, the retina, which is an expansion of the optic nerve.
The latter enters the eye a little to the inner side of its poste-
rior pole through an aperture in the sclerotic and choroid.
The eye contains a transparent fluid, the aqueous humor,
and a transparent gelatinous substance, the vitreous ; the re-
fractive indices of these are, however, almost the same, and
22
338 ERRORS OF REFRACTION.
for optical purposes they may be considered as a single me-
dium, having an index of refraction of 1.337.
Since the surfaces of the cornea are parallel, rays passing
through it alone, from air on the one side into air on the other,
would merely undergo parallel displacement. Its thickness
may therefore be disregarded, and it may be looked upon as
the surface of separation between the air and the intraocular
fluids. If this constituted the whole of the refracting system
of the eye, as it does after the operation of cataract extraction,
it principal focal distance calculated by formula (1) would be
about 31.5 mm. ; but suspended in the eye, between the aqueous
and the vitreous, is a biconvex lens of still more highly refract-
ing substance ; this is placed in the eye in such a position that
its optical centre is 5.8 mm. behind the anterior surface of the
cornea. The effect of this combination is such that the prin-
cipal focus for the whole eye is 22.2 mm. from the cornea, that
is, on the retina. The following are the optical constants of
the normal eye which are the most important (Helmholtz) :
mm.
Radius of curvature of cornea ...... 8
Radius of anterior surface of lens . . . . . .10
Radius of posterior surface of lens. . . . . . 6
Distance from anterior surface of cornea :
To anterior surface of lens ....... 3.6
To posterior surface of lens ....... 7.2
To principal focal point 22.2
The nodal points are only 0.4 mm. apart, and may be re-
placed by an optical centre situated at the posterior surface of
the lens.
The part of the retina which is most sensitive is that known
as the " yellow spot," and for accurate vision it is necessary
thai the retinal image should be formed on this. This spot is
situated a little to the outer side of the point where the optic
axis — a line drawn through the centre of cornea and the
optical centre to the posterior pole of the eye — cuts the re-
tina (a b. Fig. 94).
The line which passes from the yellow spot through the
optical centre is called the visual line (v v), because an object
must be situated on it for its image to fall on the yellow spot.
The angle which the visual line makes with the optic axis is
SCHEMATIC EYE — ARTIFICIAL EYE.
339
called the angle a ; it varies somewhat, but in normal eyes its
average magnitude is 3° or 4°.
The dioptric system of the eye consists, then, of three re-
fracting surfaces — the cornea, and the anterior and the poste-
FiG. 94.
rior surfaces of the lens — and of three refracting media — the
aqueous, lens, and vitreous ; the first and third, however, have
the same index of refraction.
liays entering the eye are re-
fracted at each of the three
refracting surfaces, each re-
fraction rendering them more
convergent. In front of the
lens is the iris, which forms
a diaphragm whose aperture
can be varied.
Schematic Eye. — It is essential fur
diagrammatic purposes to simplify
these changes in the direction of the
rays without altering the final result
of the refraction. For this purpose
the reduced eye of Prof. Bonders is
extremely useful (Fig. 94). It is
supposed to contain only one refract-
ing medium, whose index of refrac-
tion is to that of air as 4 to 3, and to
have only one refracting surface —
the cornea. Its dimensions are as
follows. The radius of curvature of
the cornea is 5 mm., and its centre of
curvature, ^-j of course coincides with
the optical centre of the eye. The
length of the eye from cornea to posterior pole is 20 mm. By formulae I and la
(p. 330) F=20 mm. and F''= 15 mm. The size of retinal images formed in
Fig. 95. — Frost's Artificial Eye.
340 ERRORS OF REFRACTION.
such an eye does not differ much from that of those formed in the natural eye —
being ^\ less.
Artificial Eye. — For practical experiments in connection with refraction it is
often necessary to use an artificial eye, and several elaborate and expensive
instruments have been constructed for this purpose. In many instances a con-
vex lens to replace the dioptric system of the eye, and a screen with some
arrangement by which its distance from the lens can be altered, answers the
purpose. For experiments in which greater accuracy is required, the simple
and inexpensive artificial eye shown in Fig. 95 will be found very useful.
The dioptric system of the eye is represented by a biconvex lens of 40 mm.
focus. Immediately in front of this is a disk containing diaphragms of several
sizes, to represent different-sized pupils. By means of a rack and pinion the
length of the eye can be varied between 30 and 65 mm., the distance of the
retina from the posterior nodal point being shown by an index on a scale.
There are two surfaces to represent the retina ; the one, a ground glass, divided
into millimetres — so that the formation of images can be seen and their size
measured ; the other painted to represent a normal fundus. In front of the lens
are two fixed clips a and b, placed respectively at 5 and 10 mm. from the ante-
rior nodal point, while a third (c) clip travels on a graduated bar which can
itself be lengthened, shortened, or removed, and is constructed to hold a lens,
test-object, or a ground-glass screen.
Accommodatioii. Presbyopia. — So far the eye has been de-
scribed as a passive instrument in which images of distant
objects only can be formed with any clearness on the retina,
for the latter is placed at the principal focus of its dioptric
system. The eye, however, possesses the means of increasing
its refractive power, and so adapting itself for near objects.
The crystalline lens is composed of a somewhat elastic sub-
stance, and it is suspended in its position by a membrane —
the suspensory ligament — which is stretched tightly across the
eye near the junction of the cornea and sclerotic, and attached
to the capsule of the lens. By the tension of this membrane
the lens is made to assume a flatter shape than it would if left
to itself. By the action of the ciliary muscle (see p, 135), the
suspensory ligament is relaxed, and the natural elasticity of
the lens then causes it to become more convex, the greatest
change taking place in the form of its anterior surface. This
muscular act, which is called accommodation, because by it the
eye is accommodated for near objects, has always associated
with it a contraction of the pupil, which prevents the most
divergent rays from entering the eye.
As age advances, the substance of the lens becomes less
ACCOMMODATION. PRESBYOPIA.
341
elastic, and the same muscular effort does not then produce so
great an increase in its convexity. At the age of ten the
accommodation is sufficiently powerful for an object to be
clearly seen at 2f in. (7 cm.), but after this its gets gradually
weaker, so that the nearest point of distinct vision (often
written p. 'p., punctum proximum) recedes further and further
from the eye, until, at the age of seventy-five, all accommoda-
tion is lost.
A knowledge of the strength of accommodation proper to
each period of life is necessary in order that any departure
from the normal condition of this function may be recognized.
In the following table, opposite each age, is placed in the
first column the strength of the lens, in dioptres, which is
equivalent to the maximum amount of accommodation which
can be used, and which therefore expresses the amplitude of
accommodation, or the difference between the refractive power
of the eye when adapted for its "far-" and "near-points."
In the last two columns are given the distances of the " near-
point " in centimetres and inches. It w^ill be seen that the
position of the latter coincides in each case with the focus of
lens which represents the amplitude of accommodation.
Table of Amplitude of Accommodation {from Landolt),
Age.
10
15
20
25
30
35
40
45
50
55
60
65
70
75
Amplitude
of
Distance of
Accommodation.
"near
point."
D.
cm.
ins.
. 14
/
2|
12
8
3
10
10
4
8.5
11.7
Ah
1
14
H
5.5
18
7
4.5
22
81
3.5
28. G
II2
2.5
40.5
16
1.75
57
23
1
100
39.5
0.75
0.25
. .
. 0.0
When the near-point recedes farther than 10 in. (25 cm.)
reading, etc., becomes difficult, because, at the distance at
342 ERRORS OF REFRACTION.
which the book is ordinarily held, the whole accommodation
available has to be used, and hence fatigue is soon experi-
enced ; while if the book is held further away, only large
print can be read, because of the diminution in the size of the
retinal images.
When, owing to the failure of accommodation, the " near-
point " has receded beyond 9 in. (22 cm.), the condition is
called preshyopia (aged sight), and its effects are obviated by
supplementing the accommodation by convex spectacles of
such a strength as to bring the near-point back to 9 in. (22 cm).
If the refraction of the eye is normal, the lens which will be
required to do this will depend on the age of the patient.
The presbyopic correction proper to any age can be found by
ascertaining the diiFerence between the amplitude of accom-
modation which corresponds to that age and ^ (4.5 D.), which is
the amount required to bring the near-point to 9 in. (22 cm). A
useful practical rule to remember is to add ^V (1 D.) for every five
years, beginning at forty-five ; beyond the age of sixty, how-
ever, this does not hold good. If the refraction is not normal,
it must be corrected first, and then the presbyopic correction
added to the glass which is required for this purpose. In
cases where the patient requires to see his work at a greater
distance than that at which a book is generally held, glasses
slightly weaker than would correct the presbyopia must be
given ; in such cases, however, the patient is generally the
best judge. This subject will be referred to again in a later
section.
Optical Defects of the Normal Eye. — The eye is sometimes spoken of as if it
•were a perfect optical instrument ; this, however, is very far from being the
case. It is, it is true, wonderfully well adapted to its purpose, for the range of
its vision extends in a straight line from a few inches from the eye to an infinite
distance, whilst, with the eyes directed forwards, objects can be seen, although
indistinctlj-, which lie as much as 90° on both sides of the head, and this lateral
range can be increased still further on either side by a movement of the eyes —
the head remaining fixed, and of course to a much greater extent by movement
of the latter. The perfect adaptation of the ej^e to all the requirements of
vision does not depend so much on its perfection as an optical instrument as on
its free mobility, the great sensibility of the retina, and the readiness with which
the mind mterprets the impressions conveyed to it.
Spherical aberration is to a great extent, but not entirely, obviated by the
iris, and chromatic aberration is considerable. The cornea is not a perfectly
DEFECTS OF THE NORMAL EYE. 343
spherical surface,^ for its vertical meridian generally has a shorter radius of cur-
vature than the horizontal. In consequence of this, few people see vertical and
horizontal lines with quite equal clearness. The media of the eye, moreover,
are not perfectly clear, for in the lens are numerous strise and spots, besides the
regularly radiating stri;e which mark its division into sectors, and in the vitreous
are a large number of floating cells and fibres. All these structures can be
brought into view by throwing light into the eye in an unusual manner, so that
their shadows are formed on a part of the retina unaccustomed to them. The
retina, too, does not form a continuous surface for the reception of visual im-
pression, for besides the large hiatus formed by the entrance of the optic nerve
— the "blind spot" — the bloodvessels of the retina itself pass in front of its
sensitive elements and cause linear gaps in the visual field.
The sensibility of the retina varies very greatly at dift'erent parts. So great
is it at the centre — the fovea centralis — that the average eye can distinguish two
points if they are separated by an angular measurement of only one minute,
while many eyes can do the same with a somewhat smaller angle ; but from this
point toward the periphery its sensibility rapidly diminishes, owing to the
greater scarcity of the cones, so that as an object is moved toward the peripheral
part of the visual field, its color is first lost and then its form, although a visual
impression, sufficient to indicate the presence of the object and its position,
remains longer.
The eye can be so readily directed toward an object, so that its image falls on
the fovea centralis, that this indistinct lateral vision is all that is reallj^ required
for practical purposes ; while, owing to our visual impressions being formed as
the result of experience, we notice the defects in the visual field so little that
most people are quite unaware that they have in each field a gap sulficient to
include a man's head at a distance of seven feet.
Visual angle. — It will be seen from what has preceded, that
the distance between the retinal images of any two points will
depend, not only on the distance of the two points from each
other, but also on their distance from the eye.
Thus, in Fig. 96, the retinal image b' a' would occupy the
same position at whatever points on the lines a a' and b // the
points a and b were situated; and if a and b were the terminal
points of an object a b, the retinal image of the object would
be of the same size as long as it subtended the angle a k b.
The angle made by the axial rays from the terminal points
of an object at the optical centre is called the visual angle.
The size of the retinal image of an object is in direct propor-
tion to the visual angle under which it is seen; therefore,
^ Strictly speaking, the cornea is not a portion of a spherical surface at all,
but forms the extremity of an ellipse. A small circle described on the butt end
of an egg would give a good idea of its form.
344
ERRORS OF REFRACTION.
objects which are seen under the same visual angle have
retinal images of the same size.
Visual acuteness. — It is essential to have a standard of normal
vision, and some method of expressing numerically departures
from it. This is very conveniently supplied by Snellen's test-
FiG. 96.
types, which are those in ordinary use in this country, and of
which a copy will be found at the end of this book. These
consist of letters of various sizes, the strokes of which the
letters are formed being in every case a fifth of the diameter
of the letter. The smallest letters are about seven-eighths of
an inch in diameter, and at twenty feet are therefore seen
under a visual angle of five minutes (5"); while each compo-
nent stroke is seen under an angle of one minute. This has
been found to be the smallest visual angle under which the
majority of healthy eyes can recognize an object. If, there-
fore, the row of smallest letters can be distinctly seen at
twenty feet, the visual acuteness is said to be normal, or it
may be expressed as V= 1.
Each row of letters has a number indicating the distance at
which it must be placed in order to be seen under a visual
angle of 5", and the visual acuteness may be conveniently
expressed by a fraction, the numerator of which is the distance
in feet at which the letters are situated, and the denominator
the distance at which the smallest letters which can be read
would make a visual angle of 5 minutes.
For example : (1) Standing at twenty feet, the smallest
20
letters are read, V= --• (2) But, if at twenty feet the smallest
letters which can be read are those which Avould make a
VISUAL ACUTENESS. 345
visual angle of 5", if removed to forty feet, it is evident that
the visual acuteness is only half that of the normal eye,
20
"7= ---. (3) The letters which should be seen at two hun-
40 ^ '
dred feet cannot be read until they are brought as near as
9
nine feet, F= -— ,, and so on.
' 200
As has been shown, in this country the distance is often ex-
pressed in feet instead of in metres.
The following table shows the relation between the two
systems of notation :
6 _2_0
"e'O' — 2
_6_ 20
36 12
_6_. 10.
2 4 8
6_ 2.0
18 G'ff
G_ 2.0
12 4Tr
6 20
¥ — FC
6 2.0
6 217
r 20 \
*■ 7 0^
*.50/
The types used, however, often do not correspond exactly with
those of Snellen, and letters which correspond more closely to
the figures in brackets in the third column are more generally
employed.
Besides the test-types just described, there are others which
form a continuous series with them, and which are adapted for
distances ranging from fifteen feet to eighteen inches. These,
for distinction, are called Reading Types. They are not so
well adapted for testing the visual acuteness as the distance
types, as for near objects the accommodation must be used,
and a defect due to weakness of the latter might be mis-
taken for diminished acuteness of vision. Objects, on the other
hand, held near the eye are rather more easily recognized than
more distant ones which are seen under the same visual angle,
because the amount of light entering the eye in the former
case is proportionately greater ; for, while the size of the re-
tinal image varies directly as the distance, the amount of illu-
mination varies as the square of the distance. Notwithstand-
ing this source of error, the reading types often form a very
346 ERRORS OF REFRACTION.
convenient rough test of the visual acuteness. In this country
Snellen's reading types are less used than those of Jaeger,
which are not arranged on any scientific plan, but are simply
ordinary printers' types of various sizes from " Brilliant " to
" 8-line Koman," numbered consecutively. Selections from
both Snellen and Jaeger will be found at the end of the book.
Section III. — Errors of Refraction.
AVe have seen that in the normal eye the retina is placed at
the principal focus of the dioptric system; it is evident that
this condition may be departed from in either of two direc-
tions, and that the retina may be either beyond the principal
focus of the dioptric system — Myopia (m, Fig, 97), or in front
Fig. 97.
of it — Hypermetropic (h). The normal, or mean, condition is
called Emmetropia, while any departure from this is called
Ametropia.
It must be understood that in speaking of the refraction of
an eye the accommodation is always assumed to be relaxed.
Fig. 9S.
(i) Myopia (m. Figs. 97 and 98), being the condition in which
the retina lies beyond the principal focus of the dioptric sys-
MYOPIA,
347
tem, may be due (1) to the antero-posterior axis of the e3'e
being too long, or (2) to the refraction of the eye being too
great. The first, which is called axial ynyopia, is by far the
most common ; the second, refractive myopia, may be due to an
increase in the refractive power of the nucleus of the crystal-
line lens, and is sometimes met with in the early stages of
nuclear cataract.
Owing to tonic spasm of the ciliary muscle, an eye is some-
times maintained in a state of accommodation for a near point.
This condition is not myopia, although often difficult to distin-
guish from it, for the refraction of an eye must be estimated
from its condition when the accommodation is relaxed.
Since the retina lies beyond the principal focus of the diop-
tric system of the eye, rays from any point (a. Fig. 99) on the
retina do not leave the eye parallel, as in emmetropia, but
Fig. 99.
converging (compare Fig. 90 on p. 335), and they will there-
fore meet at a focus [a') in front of the eye. Conversely, the
only rays which can come to a focus on the retina, while
the accommodation is at rest, are diverging rays from points
which lie in the same plane as a', as, for instance, b'. Since
rays coming from a' and // come to a focus at a and b respec-
tively, it follows that a retinal image would be formed of anj^
object of which a and h were the terminal points.
If the accommodation were used, rays which were more
divergent — i. e., coming from a nearer point than a' — could
be brought to a focus on the retina; but under no circum-
stances could this occur with those which are less divergent,
i e., coming from a greater distance than a'. For this reason
a' is called the ^^ far-point " of the eye, as it is the farthest point
of distinct vision. The far-point (often written p. r., puncium
348
ERRORS OF REFRACTION.
remohim) may be defined as the conjugate focus of the yellow
spot ; in emnietropia it is at infinity, for the rays, being parallel,
would never meet ; in myopia, as we have just seen, it is posi-
tive and finite.
Not only is an image of an object, which is situated at the
far-point of a myopic eye, formed on the retina, but a real in-
verted image of the fundus is formed at the far-point (see p.
331).
The reader will do well to verify the preceding statements by experiments
with the artificial eye (p. 339). Affix the glass retina and render the eye myopic
by lengthening it ; its far-point can tlien be found by formula (2) : -^=^ -\—z
P J J
(page 331), and it will be seen that a clear image of any object is only formed
on the glass retina when that object is situated at the "^ far-point." Next, place
a light behind the eye and a ground-glass screen on the movable clip (c) ; it
will be found that, when the ground glass is at the far-point, a distinct inverted
image of the markings on the glass retina is formed on it. If the screen be
now removed, the image is formed, and can be seen, in the air.
We have seen that, to the emmetrope, distance alone forms
no limit to vision ; the myope, on the contrary, has clear vision
of no objects situated beyond his far-point; hence the popular
name for myopia — " short-sightedness'" — is a good one.
Rays, coming from a point beyond the far-point of a myopic
eye, can be focussed on the retina by rendering them as diver-
Fii;. lOU.
gent as they would be if they came from the " far-point;" for
parallel rays this would be accomplished by a concave lens of
such a strength, and- placed in such a position, that its prin-
cipal focus would coincide with the " far-point." Thus, in
Fig. 100 the far-point is atp r; rays, therefore, which diverged
from this point would be focussed on the retina ; if, now, a
MYOPIA. 349
concave lens be placed in front of the eye, its focus being at
p r, it renders parallel rajs as divergent as if they came from
that point, and so enables them to be focussed on the retina.
With the artificial eye lengthened to 50 mm. the/), r. by formula (2) (page
331) would be 200 mm., and a concave lens of 195 mm. focal length (5.13 D.),
placed 5 mm. in front of the eye, would render the images of distant objects on
the retina sharp and distinct as in emmetropia, or in other words would correct
the myopia.
Myopia is, as we have seen, usually the result of an elonga-
tion of the antero-posterior diameter. The eye is generally
also enlarged in other directions, but to a less extent. Although
the tendenc}'^ to myopia is frequently inherited, that condition
is itself seldom present at birth, but comes on during child-
hood. The essential condition for the production of myopia
would seem to be a diminished power of resistance in the
ocular tunics ; it is, however, a disputed point what the ana-
tomical lesion is which causes the weakening. There are cer-
tain conditions which accelerate the appearance of myopia in
those who are predisposed to it, and may even induce it in
cases in which there is no reason to suspect the existence of
any such tendency. The most potent of these is the employ-
ment of the eyes in childhood for near work in a defective
light. To compensate for the paucity of light an attempt is
made to obtain larger retinal images. The head is held down
close to the book; this necessitates a strong effort of con-
vergence in order that binocular vision may be maintained,
and a corresponding effort of accommodation is made by each
eye. The action of the recti muscles on the globe tends, if its
tissues are weak, to cause it to bulge at the posterior pole,
where it is unsupported by muscles. The eye has not attained
its full growth, and its circulation, like that of all growing
organs, is active and easily influenced by causes which would
not affect a fully developed organ. The obstruction to the
return of blood by the compression of the cervical veins pro-
duced by the position of the head, and the action of the recti
and ciliary muscles, induces a state of chronic congestion
which weakens the investing tunics. There is possibly also
combined with this, in some cases, an increased activity in the
350 ERRORS OF REFRACTIOX.
secretion of the intraocular fluid, so that, while on the one
hand the power of resistance of the eye is diminished, on the
other the forces tending to its distention are increased.
In the worst cases a chronic inflammatory process is set up
in the sclerotic and choroid at the posterior pole, and the
elongation of the eye rapidly increases {progressive myopia),
while the choroid becomes thinned and atrophied, the changes
usually commencing in the portion adjacent to, and on the
outer side of, the optic disk.
The atrophy of the choroid exposes the sclerotic to view,
and so produces the appearance of a Avhite or yellowish-white
area extending to a variable extent from the optic disk. At
first it is crescentic in shape, and confined to the outer border
of the disk, as in Fig. 1, opposite p. 158; generally its border
presents several patches of pigment, which did not exist in the
case from which the plate was taken. Later on, this crescent
may become irregular in shape, increase in size,- and so extend
further toward the yellow spot, and may surround the disk;
very frequently associated with this condition are isolated
patches of choroiditis and atrophy (see Fig. 2, opposite p. 158).
In its early stage it is generally called a myopic crescent, although
the same appearance is occasionally seen in emmetropic or
hypermetropic eyes ; in its more fully developed condition it
always indicates that a considerable bulging {posterior staphy-
loma) has taken place at the posterior pole of the eye.
A myopic eye presents other peculiarities besides those already mentioned ;
thus the anterior chamber is freqiientlj' of great depth, the ciliary muscle is
elongated, its transverse fibres being defective. The optic nerve enters the
sclerotic obliquely, and the white matter of Schwann often extends to the level
of the retina over the whole disk, so that the physiological cupping is absent.
The nerve sheath, instead of ceasing at the point where the nerve enters the
sclerotic, is prolonged a short distance into its substance, a condition which
must still further weaken this part of the eye. The angle made by the visual
line and the optic axis is smaller than in emmetropia, indeed in some cases the
visual lies on the outer side of the optic axis, and the angle a (see page 338) is
then said to be negative.
"When myopia has once become established, some of the
conditions which combined to produce it are removed; thus
the accommodation is used less, or not at all, and, since accom-
HYPER METROPIA. 351
moclation and convergence are associated acts, the mj'ope iinds
it easier to give up convergence, and to use one eye only at a
time for near vision. The elliptical shape assumed by the eye-
ball is less adapted for rotation within Tenon's capsule than
the more spherical form of the emmetropic eye, and this also
renders convergence difficult. In a short time the power of
convergence becomes so impaired that it can be maintained,
■even by an effort, only for a fe\v seconds, and before long may
be altogether lost, and one eye remain in a state of divergence.
(See Divergent Strabismus.)
The action of the ciliary muscle and internal recti having
been in this way annulled, the myopia may in favorable cases
remain stationary ; such eyes are, however, liable to suffer
from an increase of their myopia if the general health is in
any way impaired ; and patients — mostly women — are not
unfrequently met with who," having had a high degree of
myopia since childhood, suffer after middle life without any
obvious cause from its rapid increase, with atrophic changes
in the choroid, the appearance of opacities in the vitreous,
which is unduly fluid, and in the lens.
The importance of preventing myopia by the removal of all
conditions likely to cause it, cannot be too forcibly impressed
on all who have to do with the education of the young. It is
most important that the light should be good; it should on no
account be facing the pupils, and b}' preference should come
from the left side for writing, while the desks and seats should
be so arranged that no stooping is necessary. For reading, the
type should be clear, and not too small.
The treatment of myopia by glasses will be considered in a
later section.
(ii) Hypermetropia (h. Fig. 97, and Fig. 101) is the condi-
tion in which the retina lies in front of the principal focus of
the dioptric system of the eye. It may be due to the antero-
posterior axis of the eye being too short — axial hypermetropia
— and this is the common form, or to the refractive power of
the eye being diminished by flattening of the cornea, dimin-
ished refractive power in the lens, or absence of the lens —
aphakia.
Since the retina lies in front of the principal focus, rays
352
ERRORS OF REFRACTION
from any point on it will be divergent on leaving the eye
(Fig. 101)/ and the conjugate focus of any such point will
therefore be behind the eye, at the point where the rays would
Fig. 101.
meet if prolonged, the puncfum remotum (Fig. 102) is therefore
negative and virtual. As in Myopia, an image of the fundus is
formed at the far-point, but in this case the image is erect and
virtual.
Since the rays from the retina are divergent on leaving the
eye, it is evident that only convergent rays can be focussed on
Fig. 102.
the retina, but in nature there are no such rays, hence a hyper-
metrope, with his accommodation relaxed, has no distinct
vision of any objects, but by means of the accommodation
the refractive power of the eye can be increased, and parallel,
and even divergent rays, be brought to a focus on the retina if
the ciliary muscle is sufficiently powerful. The muscular effort
required will, however, be great in proportion to the nearness
of the object, so that such eyes tire comparatively soon, if con-
tinuously iixed on near objects, while more distant ones may
1 Compare also Figs. 88 and 92.
HYPER METROPIA. 353
be viewed for a considerable time without fatigue ; hence the
popular term " long-sightedness." This condition must not
be confounded with that of presbyopia, in which the refrac-
tion may be normal, but the accommodation having become
weakened from age, near vision is impaired.
We have seen that converging rays are the only ones which
can be focussed by a hypermetropic eye with its accommoda-
tion at rest, and that there are in nature no such nijs ; parallel
or divergent rays may, however, be rendered convergent by a
convex lens. Thus, if an eye were hypermetropic to such an
extent that its far-point was 28 cm. behind the cornea, a lens
of such a strength, and so placed, that its principal focus coin-
cided with this point would give to parallel rays the required
amount of convergence, and cause them to come to a focus on
the retina without any accommodation being used, so that
such an eye, with its hypermetropia corrected in this way,
would see distant objects under the same conditions as the
emmetropic eye (Fig. 102).
If the artificial eye (p. 339) were shortened to 30 mm., its far-point, calcu-
lated from formula 2a (page 332), would be — 120 mm. A convex lens, placed
5 mm. in front of the eye, would require to have a focus of 125 mm. in order to
bring parallel rays to a focus on the retina. It will be found that such a lens
(-|-8 D.) will give a clear image of distant objects on the ground-glass retina,
and will therefore correct the hypermetropia.
Since the defective vision due to hypermetropia can be
obviated by the use of the accommodation, a small amount
may exist without causing any symptoms ; if, however, a
hypermetrope is called upon to use the eyes much for near
objects, trouble, varying in degree and kind in different indi-
viduals, is experienced. In slight cases the eyes become tired
and bloodshot after being used for some hours. In others the
work or book has to be laid aside after a few minutes, owino-
to the sight becoming dim, or the eyes filling with tears — a
group of symptoms often classed under the name of asthenopia,
or " weak sight." In others, again, reading is always followed
by headache, which occasionally is so severe that it is attributed
to cerebral causes, and the subject of it condemned to spend
his or her time in idleness, when the whole trouble might be
removed by correcting the hypermetropia with suitable glasses.
23
354 ERRORS OF REFRACTION,
The defect is a congenital one, and due to an imperfect
development of the eyeball, but it is seldom discovered until the
child iDcgins to learn to read. The symptoms in children
differ somewhat from those met with in the adult. Often one
of the first indications of there being anything wrong is that
the child holds the book very close to the face, and is therefore
supposed to be shortsighted. Myopia, however, in young
children is rare, and the presence of hypermetropia under
these circumstances should always be suspected. The myope
obtains clear images of the minutest objects if held within his
range of vision, and therefore reads the smallest type with
ease ; the hypermetrope, on the other hand, can only obtain
clear retinal images by using his accommodation, and the
nearer the object, the greater is the effort required, but the
size of the retinal image increases in proportion as the dis-
tance is decreased, and increases at a greater ratio than the
circles of diffusion caused b}' imperfect focussing; hence the
child will sometimes prefer to hold the book so near that the
ciliary muscle is unequal to the exertion necessarj^ to focus
the ra3's on the retina, because by that means he obtains
a large image with less muscular effort than if he held it at a
distance for which his accommodation was sufficient.
In other cases the efforts made by the ciliary muscle to
respond to the call made upon it result in the production of a
tonic contraction by which the eye is maintained in a condition
of accommodation for a near point. This spasmodic contrac-
tion is involuntary, and therefore cannot be relaxed ; hence
distant vision is defective and near vision good, and the former
is improved by concave lenses. The mode of distinguishing
between this condition and myopia will be considered later on.
In many instances of hypermetropia generally of moderate
degree, the accommodation is only equal to the necessary
effort when it has convergence associated with it; hence the
child (these cases mostly occur in children) suffers from no
defect of vision, but develops a concergent sirabismus. This
subject will be considered more fully in a subsequent chapter;
it is sufficient here to note the fact that a greater amount of
accommodation can be used if convergence is associated with
ASTIGMATISM,
355
it than if used alone; and that convergent strabismus in a
child is an almost certain sign of hj' permetropia.
(iii) Astigmatism. — In considering optical principles and the
laws of refraction we saw that rays from any point being re-
fracted at a spherical surface again came to a focus, and formed
an image of the point. If, however, one meridian of the re-
fracting surface had a different curvature to the others it is
evident that the focal distance would also be different, and that
the rays would therefore no longer all be focussed at one
point. Such a surface is therefore said to be astigmatic (a,
privative; onyua, a point). A familiar example of an astig-
matic surface is the bowl of a spoon.
In surfaces which are regularly astigmatic — which the bowl
of a spoon is not — the various meridians have the same curve
throughout. Those having the longest and shortest radius of
curvature are called the principal meridians, and are always at
right angles to each other.
It will be necessary to consider in detail the action of an
astigmatic surface. In Fig. 103 let rays from a point/ fall on
Fig. 103.
an astigmatic surface ac b d, and let the conjugate focus of/ be
at/'j for rays which pass through the vertical meridian a b,
and at/'i for those which pass through the horizontal meri-
dian c d; it is evident that ■ the section of the cone of rays
after refraction will vary in shape according to the position at
which it is made ; thus, between the refracting surface andf\
it will be an oval diminishing in size toward /'j, the horizontal
meridian shortening more rapidly than the vertical ; so that as
we approach /'i we get an oval gradually becoming narrower,
until at/'j the section is indistinguishable from a vertical line;
between f\ and f'^ the vertical diameter will continue to
356
ERROKS OF REFRACTION.
diminish, while the transverse will increase, so that we obtain
successively an oval with a long vertical diameter, a circle, an
oval with long transverse diameter, and at/'j a transverse line.
Hence we get this rule :
If rays from a point are refracted by an astigmatic surface, a
linear image of the point is formed at the focus of each principal
mei'idian ; and the direction of the line is at right angles to that of
the meridian at whose focus it is formed.
If the above rule be kept in mind, all the phenomena of
refraction which occur in an astigmatic eye will be readily
understood.
Although we have spoken of the cornea as a spherical sur-
face, it is rarely strictly so ; usually its vertical meridian has a
somewhat shorter radius of curvature, and therefore a greater
power of refraction than the horizontal, so that most eyes are
astigmatic in a very slight degree ; it is only, however, when
the difference between the principal meridians is sufficient to
interfere with vision that the defect comes under the notice of
the surgeon. Astigmatism of the cornea may be increased,
diminished, or neutralized by a similar condition in the crys-
talline lens.
Astigmatism is, then, the condition in which the eye refracts
differently in its different meridians. It is usual to classify it
into five varieties, which are enumerated in the accompanying
table, and this arrangement is a convenient one : it should be
borne in mind, however, that the difference between these
does not really consist in a difference in the nature of the
astigmatism, but in the difference in the refraction of the eye
when the astigmatism has been corrected by rendering the
principal meridians equal by an alteration in the refraction of
one of them.
Variety of astigmatism
1. Simple myopic
2. Simple hypermetropic
3. Compound myopic .
4. Compound hypermetropic
5. Mixed ....
Refraction of the
principal meridians
f Emmetropic
\ ilyopic
f Emmetropic
\ Hypermetropic
Both myopic
Both hypermetropic
f Myopic
Hypermetropic
Condition to which the eye
may be brought by correct-
ing the astigmatism.
• Emmelropia
Myopia
Hypermetropia
MN'opia or hyperme-
tropia, according to
which meridian is
altered.
LENSES. 357
In simple astigmatism the retina lies at the focus of one of
the principal meridians, and the retinal image of a point will
therefore be a line at right angles to that meridian. This can
be impressed on the memory by a simple experiment. Let the
reader render his own eye astigmatic by placing a cylindrical
lens in front of it ; the axis of the cylinder, shown by marks
on the glass, will then be the direction of the unaltered, or
emmetropic, n:ieridian ; if, now, a point of light be looked at,
obtained by looking at a pinhole aperture in a card held close
to a flame, the point will be seen as a line of light, and in
whatever position the lens is held, the direction of the line
will alway be at right angles to the axis of the cylinder — /. e.,
to the emmetropic meridian.
If now, under the same conditions, a straight line be looked
at, it will be found that it is only seen clearly when its direc-
tion is at right angles to the emmetropic meridian ; this is
because every point of the line is seen as a minute line.
When the direction of all these linear images corresponds
with that of the line, the latter appears dark and clear ; but
when the direction of the linear images is at right angles to the
line, the latter is widened out and its edges blurred; this is
better seen if two parallel lines, separated by onlv a small
interval, be looked at, then, when the lines are held in the
direction of the emmetropic meridian, the space between them
becomes indistinguishable.
Hence the following rule :
An eye with simple astigmatism- {one of the principal meridians
emmetropic) can only see clearly lines ivhose direction is at right
angles to its emmetropic meridian.
Section IV. — Lenses Used in Testing Refraction.
The Ophthalmoscope.
(i) Trial lenses. — Before describing the various methods of
ascertaining the refraction of an eye, it will be necessary to
make a digression in order to explain the principles on which
the lenses used for this purpose are numbered, and to explain
the nature and use of the ophthalmoscope, which is also used
for the same purpose. •
358 ERRORS OF REFRACTION.
In this country there are two modes in use of numbering
lenses.
The one is to give to each lens a number expressing its focal
length in inches; thus, we speak of a 3-in. or 6-in. lens. There
are several objections to this method; in the first place, since
the strength of the lens is in inverse proportion to its focal
length, it is necessary to invert the numbers, in order to make
them represent the relative power of the lenses; so that in
calculating the power of a lens we should speak of it as a Jd
or lih ; this becomes inconvenient when several have to be
added or subtracted. Then, in the higher powers the intervals
between the lenses are necessarily unequal. Another great
drawback to the system lies in the fact that the inch has a
different value in different countries, and as many opticians
use foreign glasses, it is not always clear what is meant by a
particular number.'
The other system of numbering lenses is based on the
metrical system of measurement, and is now in very general
use. The unit is a glass of a metre focal length, and this is
termed a dioptre (1 D.) ; all other lenses are enumerated as
fractions or multiples of this ; thus, a lens having a focus of
two metres would be half this strength, and would therefore
be 0.5 D,, while one having a focus of half a metre would be
2.0 D., a third of a metre 3.0 D., and so on The focal length
of any lens numbered on this system is found by dividing a
metre b}' the number of the lens; thus, 4.0 D. would have a
focal length of 25 cm., or ten English inches.^
A case of trial lenses should contain pairs of convex and
concave spherical lenses running from an one one-hundredth
and forty-fourth of an inch focus lens to an one-half inch focus
lens (0.25 D. to 20.0 D.), and convex and concave cylindrical
lenses from an one one-hundred and forty-fourth of an inch
focus lens to a six inches focus lens (0.25 to 6.0 D.)
Spherical lenses have been already sufficiently described,
but a few words of explanation are necessary as to the nature
of the cylindrical. One surface of such a lens is, as the name
' 1 English inch = 25.3 mm. 1 Paris inch = 27.07 mm.
•^ The relation of centimetres to inches is approximately as 5 to 2.
LENSES. 359
implies, a portion of a cylindrical surface; the other is usually
plane. If, on the outside of an upright glass cylinder, a circle
of an inch and a half diameter is described, the included por-
tion represents very well the surface of a convex cylindrical
lens; the vertical meridian, corresponding to the axis of the
cylinder, is plane, while the transverse is the most convex.
In the same way a circular portion on the inner surface of a
hollow cylinder would represent a concave cylindrical lens;
the plane meridian would still coincide with the axis of the
cylinder, while the most concave would be the transverse.
The direction of the axis of the cylinder is marked on the
glass either by two lines, one at each side, or by a portion of
the lens on each side being ground with the edges of the
ground portions parallel to the axis; this meridian, being
plane, has no refractive power. The lens is numbered in
accordance with the refraction of the meridian of greatest
curvature — i. e., the one which is at right angles to the axis;
thus, a cylindrical lens of six inches focus (6 D. cyl.) means
that the refracting power of the meridian of greatest curva-
ture is equal to that of a lens of six inches.
From the nature of a cylindrical lens, it follows that the
addition of one to an eye which is not astigmatic would render
it so, and that by one of suitable strength the difference between
the principal meridians of an astigmatic eye could be neutral-
ized and the astigmatism corrected.
Besides lenses, a trial case should contain a set of prisms, an
adjustable trial frame (Fig. 104), a block of the same size as
the lenses to occlude one eye; a slit one millimetre wide, also
mounted like a lens; and a few diaphragms and colored glasses.
(ii) The ophthalmoscope. — As the ophthalmoscope affords one
of the most useful means which we possess of testing refrac-
tion, it is necessary to say a few words here concerning its
construction and use. The rays which come from any point
on the retina of an emmetropic eye leave the eye in a state of
parallelism (Fig. 97), and could therefore be focussed on the
retina of another emmetropic eye. But the only light which
comes from an eye is the reflected portion of that which has
entered it through the pupil ; and, since the emerging pencil
follows the same course as that which entered the eye, it
360
ERRORS OF REFRACTION,
follows that the observer's head cannot be placed in a position
to receive the former without at the same time intercepting
the latter. The ophthalmoscope is a contrivance for throwing
light into the eye, and allowing some of the returning rays to
Fig. 104. — Adjustable Trial Frame.
enter the observer's eye. It consists essentially of a mirror,
which, while reflecting some rays, transmits others.
The original ophthalmoscope of Helmholtz consisted of
three parallel plates of glass, separated from each other by
small intervals; by means of this, held at a suitable angle,
light from a lamp was reflected into the eye, and of the light
which returned from the fundus some was reflected from the
glass and lost, but a portion was transmitted through it to the
observer's eye; and, being focussed on its retina, produced an
image of the fundus of the eye under examination. Helm-
holtz's ophthalmoscope can be used with less discomfort to the
patient than perhaps any other form ; but the illumination of
the fundus obtained by it is much less than with the more
modern instruments, and it requires considerable practice to
use it with ease. It was soon found that the fears originally
entertained of damage being done to the eye by exposure to
THE OPHTHALMOSCOPE.
361
light were not well founded, and instruments were accordinglj^
constructed in which the mirror was made of polished metal
or silvered glass, a central perforation
allowing the passage of some of the re-
turning rays.
The modern ophthalmoscope consists
essentially of a mirror, which may be
plane or concave, having a small central
aperture ; and this is all that is necessary
for the purpose for which the instrument
was originally constructed — namely, that
of seeing the fundus of the emmetropic
eye. But for estimating refraction, it is
necessary to have an arrangement by
which different lenses can be placed behind
the sight-hole ; and it is chiefly in the
mode in which this latter requirement has
been fulfilled that the various instruments
difier from each other. The variety of
ophthalmoscopes is so great that a mere
enumeration of them would occupy a
considerable space, and serve no useful
purpose; it will suffice to indicate the
conditions which are essential to a good
instrument, and to mention a few in which
these are fulfilled.
The mirror, if there is only one, should
be concave, have a focal length of not less
than 9 inches (22 cm,), and a diameter of
not less than one inch. A second smaller
mirror set obliquely with a focal length
of about two inches is an advantage, but
not essential, and a plane mirror is often
useful. There must be a series of convex
and concave lenses, and an arrangement
by which these can be successively placed
behind the sight-hole without removing
the instrument from the eye. Much dif-
ference of opinion exists as to the number of lenses necessary.
Mr. Couper, who was one of the earliest to use the ophthal-
ii' ''
Fig. 105. — Couper's
Ophthalmoscope.
362 ERRORS OF REFRACTION.
moscope systematically for the estimation of refraction, con-
siders that every power should be obtained by a single lens,
and that combinations are inadmissible ; as he also considers
that every ophthalmoscope should possess a lens sufficiently
powerful lO correct the highest degree of myopia which is
likely to be met with, his ophthalmoscope necessarily contains
a very large number of lenses. The latest form of his instru-
ment (see Fig. 105) contains seventy-four lenses arranged on
an endless chain, and is somewhat in the shape of a paper
knife. As a specimen of mechanical ingenuity it deserves all
praise, but its cost and size render it unavailable for general
use.
An instrument of excellent workmanship and convenient
size is that invented by Mr. Lang; it contains a large number
of powers, some being made by combinations; it has two
mirrors, which can be very readil}' changed, and is exceed-
ingly neat and handy; its cost, however, is rather high, and it
is therefore not available for the majority of students.
A very good instrument for refraction and other purposes is
represented in Fig, 106. Its cost is less than one-half that of
Couper's. It consists of a disk (Fig. 2) containing two series of
spherical lenses ; one convex — 1, 2, 3, 4, 5, 6, 7, 8, 1), and 10 diop-
tres; the other concave — 1,2,3,4, 5,6, 7,8, 9, 10,andl5.dioptres.
The disk is milled at the edge, as shown at b (Fig. 1), and is
made to revolve to the right or left by means of two other milled
disks, one of which, a, is worked by the index linger of the
hand holding the instrument. A sector (Fig. 3) of a similar
disk is placed behind this for occasional use. It contains
spherical lenses of + 0.5 D., + 12 D., and — 0.5 D., —20 D.,
and can be moved to right or left by the index finger of the
hand holding the instrument by moving the knob f (Fig. 1).
The power of the lens in use belonging to the disk is shown
at c. The power of the lens belonging to the sector is shown
at D. The change of each lens is indicated by an audible
click. A small mirror (Fig. 4, and Fig. 1, e) of 8 cm. focal
length, is attached by means of a universal joint, so that it can
be placed at any angle. This can be substituted by a mirror
of larger size and greater focal length when required for the
indirect method.
THE OPHTHALMOSCOPE.
363
Fig. 106.
364 ERRORS OF REFRACTION,
There are two methods of using the ophthalmoscope — the
direct and the indirect. Each of these has advantages of its
own, and neither of them should be practised to the exclusion
of the other. Before passing to a detailed description of these,
there are certain practical points common to both of them
which must claim our attention.
In the first place, an artificial source of light is necessary;
sunlight, it is true, can be employed, but there are obvious
inconveniences which practically preclude its use. Any steady
broad flame will answer the purpose, a circular gas-burner,
such as an Argand, being the best. It is convenient to have
it attixed to a bracket, which allows of free movement both in
a vertical and in a horizontal plane; and a shade by which
lateral rays can be arrested is sometimes useful. The lamp
must be placed on the same horizontal plane as the eye, suf-
ficiently far back to prevent any direct rays falling on the
cornea, and only removed laterally a sufficient distance to
avoid discomfort from its heat. Before commencing to examine
a patient, the knack should have been acquired of so manipu-
lating the mirror as to throw the light on any required spot,
and to keep it there during any movements of the head ; this
is easily learnt with a little practice, but the want of that
practice causes much disappointment at the first trial with the
ophthalmoscope, and a considerable amount of discomfort to
the patient.
In the direct method, the surgeon sits facing the patient on
the same side as the eye which is to be examined, in such a
position that, when his fiice is brought close to the patient's,
his own eye is opposite the same eye of the patient. The
mirror, with the observer's eye close behind the sight-hole, is
held close to the patient's eye. If the relative position of
surgeon and patient are such as have been described, the
former will naturally- use the left eye for the patient's left, and
vice versa. Holding the mirror as close as he can without
losing the illumination, the surgeon looks through the sight-
hole into the patient's eye ; if this is emmetropic, the parallel
rays from it enter his own eye and are focussed on his retina ;
he accordingly sees all the details of the patient's fundus. It
is essential that neither patient nor surgeon should use any
THE OPHTHALMOSCOPE. 365
accommodatioii, for in the one case the rays would leave the
patient's eye convergent instead of parallel, and in the other,
although parallel, they would not be focussed on the retina of
the surgeon. By this method the details of the fundus are
seen in their true position, but highly magnified by the diop-
tric system of the eye. The image is therefore erect.
In the second or indirect method, the mirror is held at a dis-
tance of about 2 feet from the patient's eye, and a convex lens
close to the eye, so that the emerging rays are brought to a
focus, and an inverted image of the fundus is formed in the air.
The rays, being parallel, are brought to a focus at the prin-
cipal focus of the lens; the more distant this is, the more
magnified will the image be, but it will represent a propor-
tionately smaller area of the fundus; hence, the weaker the
lens used, the more magnified will be the image. A con-
venient lens for this purpose is one of 3 in. (13 D.), those
sold with the ophthalmoscope have usually a shorter focus
than this, and do not magnify sufficiently. The larger its
diameter, within convenient limits, the better; a good size
for the pocket is 2 in. diameter. The image obtained
by this method is inverted and real, while the direct gives
an erect and virtual image. By the indirect method a large
portion of the fundus can be seen at one time, and it is
therefore the best for obtaining a general view of the fundus,
and should be used first in every case. The direct gives more
detailed information concerning a smaller area at one time.
There are several difiiculties to be overcome in using the
direct method ; the first is that of getting sufl&ciently close to
the ej'e without losing the illumination; this is, however,
easily accomplished if the manipulation of the mirror has
been previoush' learnt. If the patient's eye be directed straight
forwards, a difficulty sometimes arises from the reflection of the
mirror being seen in the cornea; this is avoided if the eye be
directed a little to the nasal side, and this position has the
additional advantage that the posterior pole of the eye is
rotated outwards, so that the optic disk, which lies slightly to
the inner side, comes into view. We have seen that accommo-
dation on the part of either surgeon or patient prevents a clear
view being obtained of an emmetropic fundus ; on the part of
366 ERRORS OF REFRACTION.
the patient this can generally be obviated by taking care that
the other eye has no light falling on it, and that it is directed
to a distant object. The surgeon's own accommodation is a
more difficult matter to control ; some idea of the difhculty,
and of the kind of eftbrt required to overcome it, can be ob-
tained by attempting to read through a convex lens a page of
print placed at its focal distance; at first this will be found to
be difficult, but the knack can be acquired with a little practice.
When using the ophthalmoscope, it is well to try to imagine
that one is looking at a distant object, and this is facilitated by
the other eye being kept open. The small size of the pupil
will not often prove an obstacle to the examination of the optic
disk if the above precautions be adopted, but it frequently pre-
vents a view being obtained of other parts of the fundus. The
pupil contracts less if a plane mirror be used, and still less
with an ophthalmoscope on the principle of Helmholtz's. The
use of a mydriatic is, however, often necessary or advisable.
The small size of the pupil is a more serious obstacle to the
indirect method, owing to the greater concentration of the
light ; and here the use of a mydriatic is more frequently
necessar}'. The chief difficulty in this method lies in manipu-
lating the lens and mirror at the same time. The best plan is
to throw the light on the eye first with the mirror alone, then
to interpose the lens, holding it at a little less than its own
focal distance from the patient's eye ; the head must then be
moved backwards and forwards, care beiiig taken not to lose
the red reflex, until the details of the fundus are clearly seen.
If any trouble arises from an image of the flame or mirror
being seen reflected in the lens, a very slight rotation of it on
its vertical axis throws the image out of the way.
In order to see any peripheral part of the fundus Avith the
direct method, the patient must be told to look in the corre-
sponding direction — e. g., upwards for the upper part of the
fundus, downwards for the lower. With the indirect method
it should be borne in mind that the image moves in the same
direction as the lens, and in the reverse direction to the sur-
geon's head ; by a combined movement, therefore, in opposite
directions, of lens and mirror, the part of the fundus which is
visible may be changed at will.
METHODS OF ESTIMATING REFRACTION. 367
Section V. — Methods of Estimating Eefraction.
We are now in a position to consider the various modes of
estimating the exact refraction of the eye ; these are very
numerous, but they mostly come under one of two heads ;
either they are subjective in character — that is, they depend on
the visual sensations of the patient — or they are objective, and
depend on what the surgeon himself observes. The subjec-
tive methods for the most part, though not entirely, are founded
on changes made in the patient's vision by glasses. Such a
method has the obvious disadvantage that the results depend
on the statements of the patient, who may be stupid or igno-
rant; on the other hand, with an intelligent subject it is often
the quickest, and as the object of the examination is usually
to ascertain what is the most suitable glass, its results are
more appreciated by the patient. Some methods combine
both the subjective and objective principles, and few surgeons
care to rely upon either exclusively in a difficult case.
(i) Testing by trial lenses. — At the outset the reader is again
reminded that a perfectly emmetropic eye has clear retinal
images of distant objects without the use of any accommodation,
and a glass does not correct an ametropic eye (f. e., neutralize
its ametropia) unless it places it in this condition.
If the reader has followed what already has been said con-
cerning myopia and hyperraetropia, he will often be able to
form a correct opinion in a given case, from the patient's de-
scription of the symptoms, as to which of these errors is the
more likely to be present; it will be better, however, for the
present to disregard the symptoms altogether, and to suppose
the diagnosis to be made entirely by means of the test-glasses.
The patient should be placed at a distance of 20 ft. (6 m.)
from Snellen's test-types, and it should be ascertained what is
the smallest line which can be read by the eye under examina-
tion — it is, of course, essential that the other eye should be
covered — and the result should be noted in the manner de-
scribed on p. 344. It is a good plan now to test the near
vision with the reading-types, not because it is always, or even
generally, essential for ascertaining the refraction, but because
368 ERRORS OF REFRACTION.
it may be required for this or for other purposes, and if not
done at this stage is apt to be forgotten. In noting the near
vision, the smallest type should be found which the patient
can read, choosing his own distance, and then the farthest and
the nearest point at which he can see it.
Example.— R' ^-f^ (V) and Sn. l^ (0.5 Sn.)' 8"-20"
(20-50 cm.).-
If distant vision is found to be normal, it does not follow
that the eye is emmetropic, unless it can be proved that no
accommodation was used: myopia, however, is excluded.
The distant vision having been noted, a weak convex lens
-J- ^ (-j- 0.50 D.) is placed before the eye; the subsequent steps
of the test will depend on the efiect which this has on vision ;
these will therefore be considered under two separate headings.
A. Vision is not rendered worse hy a weak convex lens.
B. Vision is rendered worse by it.
A. If distant vision is not impaired by a convex lens, hyper-
metropia is present ; for the efl'ect of the lens is to render the
parallel rays convergent, and only a hypermetropic eye can
focus converging rays (vide p. 352). The strength of the lens
should now be gradually increased until the strongest is found
which the patient can bear without vision being made any
worse ; an amount of hypermetropia corresponding at the
least to this must be present. The error thus discovered is
called the manifest hypermetropia (Mh.).
20 /^6X
Example. — Supposing that vision of -- I q I is changed to
90 V A J ^•^' ^^^^ addition of + ^4 ( + 1-^^ ^•)^ and that a
stronger glass impairs vision, the result is written thus :
1 The letters R and L are used throughout to indicate the right and left eye
respectively. Sn. indicates Snellen's reading-types, and J. those of Jaeger.
* It is to be strictly understood that these quantities are merely approximate
values. The English inch has been used.
HYPERMETROPIA. 369
therefore -^ = the manifest hypermetropia. In the same way,
if vision remained the same with the addition of a convex
glass, the glass would be the measure of the manifest hyper-
metropia, and the result might be written thus :
-^'''=2-0 (I) +A(+2D.) = Hm.
We 8aw% however, on page 353 that hypermetropia may be
concealed by the action of the accommodation ; and having
found the manifest hypermetropia by the above method, we
have no guarantee that a further amount does not still remain
concealed by the accommodation. As a matter of fact, in
young subjects this is usually the case, for having constantly
to accommodate in order to see, the act is performed instinc-
tively as soon as an effort is made to look attentively at an
object; and although, by a very gradual transition from the
weaker to the stronger glasses, the accommodation can be
coaxed to relax to a certain extent, some frequently remains in
use concealing some hypermetropia, which is therefore said to
be latent. It is of course possible that the whole of the hyper-
metropia may be latent, so that the fact that a weak convex
lens renders vision worse does not necessarily exclude the ex-
istence of hypermetropia. But it is rare, except in children,
for all the hypermetropia to be latent; in patients over thirty,
on the other hand, it is unusual for any to be latent. If the
patient's " near-point" is further away than it should be at his
age (see table, p. 341), hypermetropia may be suspected to
exist, although none may be manifest.
Not only may the action of the ciliary muscle entirely con-
ceal the existence of hypermetropia, but it sometimes passes
into a condition of tonic contraction in excess of that required
for distant vision, so that the eye is maintained in a condition
of accommodation for a near point. As this spasmodic con-
traction cannot be voluntarily relaxed, the eye appears to be
shortsighted. This spasm, of the accommodation undergoes a
partial, and sometimes a complete relaxation in the dark, so
that by examination with the ophthalmoscope in the " dark-
24
370 ERRORS OF REFRACTION.
room/' the apparent myopia may be proved to be fictitious, or
the existence of hyperraetropia be diagnosticated.
In order to ascertain with certainty the amount of hitcnt
liypermetropia it is necessary to paralyze the accommodation.
There are several agents, called mydriatics, by which this can
be temporarily accomplished. The commonest of these is
sulphate of atropia. A solution in Avater of the strength of
one per cent, (four grains to the fluid-ounce) is. the best for the
purpose, and it should be dropped into the eye, if complete
paralj'sis of the accommodation is required, three times a day
for about three days. In 3'oung children, owing to the greater
strength of the accommodation, it is often necessary to use
it for a week or more. In addition to the paralysis of the
accommodation the pupil is widely dilated, and the efl'ect
does not fully pass oft' for a week or ten days after the last
application.
Owing to the serious inconvenience that a patient suffers from the slow recovery
of the function of accommodation after atropine, other agents have been em-
ployed as mydriatics whose action is less lasting. The sulphates of daturin and
duboisin act efficiently, but, although the efl'ect lasts only about half as long as
that of atropine, it is long enough to cause serious inconvenience. Duboisin,
moreover, has the further disadvantage that it occasionally causes vertigo and
even delirium ; lience these drugs are seldom used except when atropine, as
occasionally happens, causes conjunctival irritation.
A much more useful agent is the hydrobromate of homatropine, as its efiect
entirely passes off in twenty-four houi-s, and generally in a much shorter time.
Whether it can be relied upon in children, and in cases of spasm of the accom-
modation, to produce complete paralysis, is a point which more extended expe-
rience is needed to determine. It is, however, quite efficient, in ordinary cases,
if used of a strength of one and a half per cent, (six grains to the fluid-ounce),
and at short intervals. As the ctfcct is so transient, it is probably useless to pi-e-
scribe its use for several days; the best plan is to let the patient use it three times
on the morning of his visit, at intervals of half an hour, and for the surgeon to
apply it every ten minutes during the hour preceding examination.
[In a scries of careful investigations by Dr. Charles A.
Oliver, of Philadelphia, upon the comparative action of hydro-
bromate of homatropine and of sulphate of atropia upon the
iris and ciliary muscle, as well as a series of similar experi-
ments with the same amounts of sulphate of daturia and of
sul[>hate of hyoscyamia, the following definite observations
and conclusions, as expressed in both the tables and text, were
arrived at.
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COMPARATIVE ACTION OF MYDRIATICS. 373
Hi/drobromate of Homatropine and Sulphate of Atropia.
'■'■Observations. — 1. The mydriasis of a single instillation of
the one-fortieth of a grain of sulphate of atropia is consum-
mated in twenty-two minutes, whilst the utmost dilatation of
the pupil occasioned by a single instillation of the one-fortieth
of a grain of hydrobromate of homatropine takes thirty
minutes.
" 2. The mydriasis of a single instillation of the one-twen-
tieth of a grain of sulphate of atropia occurs in eighteen
minutes, whilst the mydriasis produced by a single instillation
of the one-twentieth of a grain of hydrobromate of homa-
tropine takes thirty -four minutes.
" 3. The ciliary paralysis of a single instillation of the one-
fortieth of a grain of sulphate of atropia is attained in forty-
six minutes, whilst the utmost intensity^ of the action of a
single instillation of the one-fortieth of a grain of hydro-
bromate of homatropine takes place in sixt3' minutes.
" 4, The ciliary paralysis of a single instillation of the one-
twentieth of a grain of sulphate of atropia is attained in
thirty-eight minutes, whilst the utmost loss of accommodation
occasioned by a single instillation of the one-twentieth of a
grain of hydrobromate of homatropine takes place in thirty-
two minutes.
" 5. The single instillation of the one-fortieth of a grain of
hydrobromate of homatropine has not in any instance pro-
duced full dilatation of the pupil, whilst, in every case, the
single instillation of the one-fortieth of a grain of sulphate of
atropia has caused maximum dilatation.
" 6. In the majority of cases examined, the single instillation
of the one-twentieth of a grain of hydrobromate of homatro-
pine caused maximum dilatation^ of the pupil, whilst in every
instance full dilatation was produced by the single instillation
of the one-twentieth of a grain of sulphate of atropia.
" 7. The utmost intensity of the action of the single instil-
lation of the one-fortieth of a grain of hydrobromate of homa-
tropine upon the ciliary muscle, is maintained for about two
1 It has not been deemed necessary to enter into the details of the actual
loss, as reference to the table will explain.
" Vide case noted in Table II.
37-1 ERRORS OF REFRACTION.
to four minutes, the same beiiiii^ true for the single instillation
of the one-twentieth of a grain of the same drug, \vhilst the
ciliary paralysis of both the one-fortieth and the one-twentieth
of a grain of sulphate of atropia is stationary for many hours.
" 8. By accurate observations made every second or third hour
after the utmost action of the single instillation of the one-
fortieth of a grain of hydrobromate of homatropine, it was
found that the diameter of the pupil became normal in about
thirty hours, and full reestablishment of the power of the
ciliary muscle in fourteen hours.
" 9. By observations made every second or third hour after
the mydriasis and utmost loss of ciliary action by the single
instillation of the one-twentieth of a grain of hydrobromate
of homatropine were established, it was found that the pupil
became normal in about fifty hours, and full accommodative
power returned in twenty-four hours.
" 10. In the mj'driasis and ciliary paralysis of the single
instillation of both the one-fortieth and the one-twentieth of a
grain of sulpliate of atropia, the pupillary diameters became
normal, and full accommodation returned in from ten to four-
teen days.
" During the course of the experiments with the homatro-
pine, it Avas noticed :
"1. After the time of its utmost action, the near-point was
exceedingly difficult to determine on account of difiusion-
circles being suddenly thrown around the test-object, due to
clonic spasm of the ciliary muscle, as shown by the table.
" 2. If after the lapse of twenty -four hours, a second instil-
lation of the one-twentieth of a grain w^as made, almost full
radiary contraction of the iris took place in from ten to twelve
minutes, whilst the utmost action of the drug on the ciliary
muscle took but ten to eighteen minutes' time,' but in no in-
stance was there total loss of accommodation.
" 3. If at the time of the utmost action of the single instil-
lation of the one-twentieth of a grain of the homatropine
upon the ciliary muscle the one-sixtieth of a grain of the same
drug was instilled, complete paralysis of the muscle was estab-
' This result not invariable, two cases requiring the same length of time as on
previous day.
COMPARATIVE ACTION OF MYDKIATICS. 375
lished in fifty-four minutes, which remained stationary more
than thirty minutes,^
" 4. In nearly every case there was conjunctival irritation
and injection, with a sense of astrin^ency and smarting.^
" 5. There was no observable appearance of constitutional
disturbance, except some dryness of fauces and a peculiar
bitter taste.^
" Conclusions. — 1. A single instillation of either the one-
fortieth or the one-twentieth of a grain of hydrobroraate of
homatropine is insufficient to paralyze accommodation, and
hence is of no value in properly estimating refractive error.
" 2. Complete paralysis of the ciliary muscle can be obtained
by a single instillation of either the one-fortieth or the one-
twentieth of a grain of sulphate of atropia.
" 3. A single instillation of the one-twentieth of a grain of
hydrobromate of homatropine is capable of producing full
dilatation of the pupil ;■* w^hilst it is impossible to produce
maximum dilatation by a single instillation of the one-fortieth
of a grain of the same drug.
" 4. Maximum dilatation of the pupil is produced by a
single instillation of either the one-fortieth or the one-twentieth
of a grain of sulphate of atropia.
"5. The utmost action of a single instillation of the one-
fortieth of a grain of hydrobromate of homatropine upon the
ciliary muscle, is attained later and lost sooner than the full
paralysis occasioned by a single instillation of an equivalent
amount of sulphate of atropia.
" 6. The utmost action of a single instillation of the one-
twentieth of a grain of hydrobromate of homatropine upon
the ciliary muscle is attained sooner and more quickly lost
' The exact length of time is not accurately known, as examination was not
continued beyond one-half hour after full jxiralysis was established; the thirty
minutes being considered sufficient time to correct any existing refractive error.
2 Thinking the preparation might not be neutral, it was submitted to the
litmus test, revealing marked acidity.
* Here it might be proper to state that many of the unpleasant constitutional
effects seen in the use of mydriatics, are dependent upon the physician; the
drugs often being used without a thought in reference to strength, quantity, and
repetition.
* This statement is given with some reserve. In the majority of cases it was
undoubtedly so, as in the case noted.
376 ERRORS OF REFRACTION.
than the full paralysis occasioned by a single instillation of an
equivalent amount of sulphate of atropia.
" 7. The mydriasis of a single instillation of either the one-
fortieth or the one-twentieth of a grain of hydrobromate of
homatropine is not so quickly produced, and is of shorter
duration than that of a single instillation of either the one-
fortieth or the one-twentieth of a grain of sulphate of atropia.
" 8. Complete ciliary paralysis can be obtained by a single in-
stillation of the one-sixtieth of a grain of hydrobromate of
homatropine at the time of the utmost action of a single instil-
lation of the one-twentieth of a grain of hydrobromate of
homatropine, thus allowing ametropia to be accurately deter-
mined.
" 9. A single instillation of either the one-fortieth or the
one-twentieth of a grain of hydrobromate of homatropine, by
reason of its transient efl'ect on the iris and ciliary muscle, is
valuable when we desire accurate ophthalmoscopic examina-
tions in cases dependent upon their use,
" 10. The conjunctival irritation of hydrobromate of homa-
tropine may be avoided by the use of an absolutely neutral
salt.
" 11. Single instillations of the amounts given, of either of
the drugs, are perfectly free from injurious constitutional
effect."
Sulphate of Daturia and Sulphate of Hyoscijahiia.
^^Observations. — 1. The mydriasis of a single instillation of
the one-fortieth of a grain of sulphate of daturia was consum-
mated in sixteen to eighteen minutes; whilst the mydriasis
produced by a single instillation of the one-fortieth of a grain
of sulphate of hyoscyamia took place in eight to ten minutes'
time.
" 2. The mydriasis of a single instillation of the one-twen-
tieth of a grain of sulphate of daturia occurred in twelve min-
utes ; whilst the mydriasis of a single instillation of the one-
twentieth of a grain of sulphate of hyoscyamia took place in
eight minutes' time.
"3. The utmost loss of accommodation occasioned by a
single instillation of the one-fortieth of a grain of sulphate of
daturia Avas attained in thirty-six minutes; whilst the utmost
intensity of the action of a single instillation of the one-for-
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COMPARATIVE ACTION OF MYDRIATICS. 379
tieth of a grain of sulphate of hjoscyamia took place in thirty
minutes' time.
"4. The utmost loss of accommodation occasioned by a
single instillation of the one-twentieth of a grain of sulphate
of daturia was attained in twenty-six minutes; whilst the
utmost intensity of the action of a single instillation of the
one-twentieth of a grain of sulphate of hyoscyamia took place
in twent}^ minutes' time.
" 5. The single instillation of the one-fortieth or the one-
twentieth of a grain each of both the sulphate of daturia and
the sulphate of hyoscyamia produced full dilatation of the
pupil,
" 6. Full ciliary paralysis was obtained in nearly every in-
stance by the single instillation of the one-fortieth or the one-
twentieth of a grain each, of both the sulphate of daturia and
the sulphate of hyoscyamia : the intensity of action seeming
to depend entirely upon the quality and degree of refraction
being greater in the normal emmetropic eye.
" 7. The dilatation of the pupil occasioned by the single in-
stillation of the one-fortieth or the one-twentieth of a grain of
sulphate of daturia, remained ad maximum- for twenty-four to
thirty-six hours; whilst that of equivalent amounts of sulphate
of hyoscyamia remained intact for thirtj'-six to forty-eight
hours : the time of the o:reater amount beino^ Ioniser in both
instances.
" 8. The total ciliary paralysis occasioned by the single in-
stillation of the one-fortieth or the one-twentieth of a grain of
sulphate of daturia is maintained for twenty-fouri to thirty-six
hours; whilst that of equivalent amounts of sulphate of hyos-
cyamia is stationary for thirtj^-six to forty-eight hours : the
time of the greater amount being longer in both instances.
" 9. By accurate observations made many times daily, after
the mydriasis and ciliary paralysis of the single instillation of
the one-fortieth of a grain of sulphate of daturia were estab-
lished, it was found that the pupil became normal in about
fifteen days, and full accommodation returned in nine to ten
days' time ; whilst with the single instillation of an equivalent
amount of sulphate of hyoscyamia, pupillarj^ diameter became
normal in about seventeen days, and full accommodation was
regained in ten days' time.
380 ERRORS OF REFRACTION.
" 10. By accurate observations made many times daily after
the mydriasis and ciliary paralysis of the single instillation of
the one-twentieth of a grain of siil[>liate of daturia were estab-
lished, it was found that the diameter of the pupil became
normal in about sixteen to seventeen days, and full accommo-
dation was restored in ten days' time ; whilst in the mydriasis
and ciliary paralysis of the single instillation of the one-twen-
tieth of a grain of sulphate of hyoscyamia, the pupil became
normal in seventeen days, and full reestablishment of the
power of the ciliary muscle occurred in twelve days' time.
" During the course of the experiments it was noticed —
" 1. AVith both drugs, a marked sense of conjunctival astrin-
gency, which in a few instances amounted to actual smarting
and pain — this being more pronounced with daturia.^
" 2. In a few instances, during the use of the daturia, there
was some constitutional disturbance — faucial dryness and bitter
taste, accompanied with flushing of the face, headache, and
giddiness, but all of such a mild and exceedingly slight char-
acter as practically to be of no moment.^
" 3. hi many instances, when the hyoscyamia was used,
constitutional disturbance manifested itself by dry throat,
flushed foce, intense giddiness, wakefulness, followed by pro-
found sleep.
" 4. A case of H. + Ah., corrected several months previously
with the use of sulphate of atropia, chose the same combina-
tion, at intervals of one month, with the use of single instilhi-
tions of the one-twentieth, one-fortieth, one-sixtieth, and the
one-eightieth of a grain each of sulphate of daturia.
" 5. During the correction of several cases of H. + Ah.,
with both the drugs, it was noticed that upon the patient's
return in twenty-four hours after the primary instillation, full
paralysis had occurred during the intervening time, and the
correct combination chosen without the use of a second instil-
lation ; proving that, through strain and irritation, the ciliary
muscle had not been paralyzed at the proper time for a normal
eye.
' In every specimen there was acidity, as shown by the litmus t«!st.
' The gravity and character of these symptoms were remarkable in being com-
parable with those of equivalent amounts of atropia.
COMPARATIVE ACTION OF MYDRIATICS. 381
" 6. In many cases of H. + Ah., in which latent hyperme-
tropia was high, the astigmatism at a comparatively rare angle,
accompanied with much retinal and choroidal disturhance, it
was impossible to obtain complete paralysis of the ciliary
muscle by single instillations of the amounts given.
" 7. Unreliability of results, dependent upon miscellaneous
selection of drugs. During the lirst series of these experi-
ments, in which it was found necessary to verify previous cal-
culation in two normal eyes, difterent results were obtained
from specimens obtained from other sources. Reliable articles
were gotten, and care taken to prepare fresh solutions, and use
new pipettes in every individual case.
" Conclusions. — 1. A single instillation of either the one-
fortieth or the one-twentieth of a grain each of both the sul-
phate of daturia and the sulphate of hyoscyamia, is sufficient
to paralyze accommodation in a normal emmetropic or a healthy
ametropic eye.
" 2, No dependence can be placed upon the action of a single
instillation of either the one-fortieth or the one-twentieth of a
grain each, of both the sulphate of daturia and the sulphate of
hyoscyamia, upon the ciliary muscle of an unhealthy ame-
tropic eye.
" 3. A single instillation of either the one-fortieth or the
one-twentieth of a grain each of both the sulphate of daturia
and the sulphate of hyoscyamia, is of no value in the estima-
tion of the degree of refraction in marked cases of asthenopic
ametropia; but may be of great service in either verifying
previous results or primarily determining errors in healthy ame-
tropic eyes.
" 4. Maximum dilatation of the pupil is produced by a single
instillation of either the one-fortieth or the one-twentieth of a
grain each of both the sulphate of daturia and the sulphate of
hyoscyamia.
" 5. The total paralysis^ of the ciliary muscle, occasioned by
a single instillation of either the one-fortieth or the one-twen-
tieth of a grain of sulphate of daturia, is attained later and
1 Complete paralysis is not necessarily meant. The use of the terms " total
paralysis" and "full action" are synonymous, and imply the utmost action of
the drug, which may be either complete or incomplete.
382 ERRORS OF REFRACTION;
lost sooner than the total paralysis occasioned by a single in-
stillation of equivalent amounts of sulphate of hyoscyamia.
" 6. The mydriasis of a single instilhition of either the one-
fortieth or the one-twentieth of a grain of sulphate of daturia
is not so quickly attained, and is of shorter duration than that
of a single instillation of equivalent amounts of sulpliate of
hyoscyamia,
" 7. The full action of a single instillation of either the one-
fortieth or the one-twentieth of a grain of sulphate of daturia
upon the iris and ciliary muscle, remains intact for a shorter
time than that of a single instillation of equivalent amounts of
sulphate of hyoscyamia ; the time of the latter being almost
double that of the former.
" 8. AVith the use of the amounts given of both the drugs,
primary calculation of refractive error may be accurately ob-
tained without second instillation, after the lapse of twenty-
four hours.
" 9. The long-continued dilatation of the pupil and the slow
return of ciliary power occasioned by the amounts given of
both the drugs, render them absolutely useless where we de-
sire accurate ophthalmoscopic examination in cases dependent
upon their use.
" 10. The astringent and irritant action of the two drugs
upon the conjunctiva may be avoided by the use of a neutral salt.
" 11. The comparatively rare and slight transient constitu-
tional eifect caused by a single instillation of the amounts
given of sulphate of daturia may be considered as perfectly
harmless, and of no consequence.
" 12. The grave constitutional disturbance sometimes seen
during the use of a single instillation of the amounts given of
sul[)hate of hyoscyamia, should render us cautious in its em-
ployment.
"These experiments were conducted in the following manner.
Young emmetropes w^ere chosen, and a few who had been pre-
viously corrected or were being corrected for H. -\- Ah. Care
was taken to obtain persons of intelligence, and to place them
under the same conditions in reference to light and time of
day. In every case, as soon as accommodation for Sn. 1^ be-
HYPERMETROPIA. 383
came impossible, a convex lens was placed one-half inch before
the eye, this in all instances being taken into account." — 0.]
The effect of a mydriatic on a hypermetrope is to render his
distant vision worse. The eye being under the influence of
atropine, the hypermetropia is again tested by convex lenses
until the one is found which gives the best result; this should
be at least as good as that obtained before the use of atropine.
Example: Date L ^= |o-(|)+ ^^ (1-50 D.) = |^ (^1).
Date (Atropa) L V= f^ (A) + (2.50 D.) = | (|).
In this case the manifest Hypermetropia is ^t (l.oO D.), and
the total Jy (2,50 D.), the amount of latent II. therefore is
^V(1D.)-
If vision is improved by convex lenses up to a certain point,
but not to the normal standard. Hypermetropic Astigmatism
(see p. 356) may be suspected to be present. If the result
obtained by convex lenses is not as good as that which was
obtained before atropine was used. Astigmatism is almost cer-
tainly present.
B. Convex lenses render vision worse, (a) Distant vision is
normal. — The condition cannot be Myopia, but may be (i)
Emmetropia; (ii) Latent Hypermetropia. Latent Hyperme-
tropia may be suspected if the patient is under thirty, if the
symptoms are those of hypermetropia (see p. 352), and if the
near-point is further away than it should be at the patient's
age. The diagnosis can generally be established by the oph-
thalmoscope (see p. 394). If these symptoms are absent, and
if the ophthalmoscope fails to discover any hypermetropia, we
may assume that the eye is Emmetropic. If, however, symp-
toms are present and persist, it is often advisable to paralyze
the accommodation; if distant vision is then still normal, the
eye is emmetropic ; if it is impaired, hypermetropia is present ;
and the amount must be ascertained in the manner already
described.
(b) Distant vision is subnormal. — The condition is either (i)
Myopia (or spasm of the accommodation) or (ii) Astigmatism
384 E K R O R S OF REFRACTION.
(i) Distant cision i^ improved by concave lenses. — ^env vision is
good — i. €., Sn. IJ (0.50 Sn.) can be read fluently; the near-
point is nearer than corresponds with the patient's age. My-
opia is present.
Spasm of the accommodation may cause an eye to resemble
myopia in all respects; indeed, an eye under such circum-
stances is to all intents and purposes myopic for the time ;
spasm sufficient to produce this condition rarely occurs, how-
ever, in children, and if the accommodation be paralyzed by
the use of atropine — and in children it is always safer to do
this — the true refraction of the eye can be ascertained.
If concave lenses bring distance up to the normal standard,
the case is one of myopia only. If vision is improved, but not
to the normal standard, the case is one of Compound Myopic
Astigmatism' (see below, under ii).
Before endeavoring to find the lens which corrects the my-
opia, the /ar-pom^ should be ascertained; this is done by find-
ing the smallest of the reading-types which the patient can
read (which in uncomplicated myopia is Sn. Ii(0.o0 Sn.)), and
then ascertaining what is the greatest distance at which he can
read it. For example :
F^= less than -— ^-^tcV & Sn. li (0.50 Sn.) at eight inches
(20 cm.) (pr.)
In high degrees of myopia, however, the " far-point " cannot
be accurately determined in this manner. For, owing both to
the nearness of the type, and the length of the eye, the retinal
images are so large that their form can be recognized, even
when they are not accurately focussed. Hence the letters of
Sn. li (0.50 Sn.) can sometimes be read, even when placed
beyond the patient's far-point. On the other hand, if, as is fre-
quently the case, there are morbid changes in the fundus,
which have lowered the visual acuity, the patient may find it
necessary to hold the type at a shorter distance than the true
" far-point " of the eye.
' Assuming, of course, that the defective vision is due to an error of refrac-
tion ; it must be remembered, however, that morbid changes in the fundus are
very frequently met with in Myopia.
TESTING BY TRIAL GLASSES,
385
The focus of the correcting lens should coincide with the
far-point of the eye, so that parallel rays will be rendered aa
divergent as they would be if they came from the far-point.
(See Fig. 107.) They will therefore be focussed on the retina
Fig. lOT.
without any accommodation being used, and distant objects
will therefore be seen under the same conditions as in emme-
tropia. A stronger lens will render the rays more divergent;
but, as they can still be focussed on the retina if the accom-
modation is called into play, vision is not necessarily rendered
worse. Hence the weakest concave lens which gives the best
vision is the glass to be chosen.
Example.— L V= less than ---- (--), & Sn. l.V (0.50 Sn.)
zOO VoO/ " ^
at eight inches (20 cm.) (pr.) c-J (-5 D.), V = -^- Q).
If a concave lens improves vision, but does not bring it up to
the normal standard, and there are no other morbid conditions,
the case is one of Compound Myopic Astigmatism.
(ii) Distant vision is not improved by concave lenses. — The case
is probably one of Simple, or Mixed Astigmatism, Astigma-
tism is also present when the distant vision cannot be brought
up to the normal standard by spherical lenses. (See above,
under i.)
If vision is at all improved by spherical lenses, the one
which produces the greatest improvement should be put in the
trial frame in front of the eye. The patient should then be tested
with a revolving line; for this purpose Carter's, Astigmatic Clock
is extremely useful. It consists of a clock-dial, in which the
hands are replaced by three parallel lines revolving about a
25
386 ERRORS OF REFRACTION.
centre. The lines should be of the thickness of the strokes of
the lowest letters of the distance-t^'pes, and should be repeated
by spaces of the same width. It is convenient to have, in
addition to the dial with one set of lines, another dial with
two sets at right angles to each other in the form of a cross.
If the lines, when revolved, are seen equally clearly in all
positions, there is no astigmatism present. If there is a differ-
ence, the position in which they are best seen, and the position
at right angles to this, will indicate the direction of the prin-
cipal meridians. The meridian in which they are most clearly
seen, indicates the one in which there is the greatest error (see
p. 357), while the meridian at right angles to this is either
emmetropic or requires the least correction.
The " principal meridians" having been found in this way,
the one in which the error of refraction is least should be
tested alone, by shutting off the others by means of the
etenopaic slit. This having been placed in front of the eye
in the best meridian, the spherical lens is found which gives
the best vision, and which may therefore be assumed to correct
this meridian. To make the other meridian equal to it, the slit
must be removed, and cylinders added to the spherical lens,
with their axes in the direction of the corrected meridian,
until the lines on the dial are seen with equal clearness in
both positions. It is here that the crossed lines are useful, as
the patient is the better able to compare them when seeing
them both at the same moment. The crossing also obviates
a difficulty which sometimes arises from the patient using a
different amount of accommodation for the two positions, and
thus seeing the lines equallj' well, although the refraction of
the corresponding meridians of his eye may be different. In
most cases of astigmatism, however, it is advisable to paralyze
the accommodation.
As soon as the lines have been made to appear equal, the
astigmatism — i. e., the difference between the refraction of the
principal meridians — has been corrected, it only remains to see
if vision is improved by a slight alteration in the spherical lens.
A convenient way of noting tlie result is as follows: the slit
is indicated by the letter S, and its direction by the line drawn
through it. The three parallel lines indicate that they were
TESTING BY TRIAL GLASSES. 387
seen best in the position depicted, while the crossed lines show-
that the difference has been corrected. (The positions of the
slit and of the axis of the cylindrical lens are noted as they
appear to the surgeon looking at the patient, and that of the
lines as they appear to the patient. This apparent discrepancy
is not a real inconvenience, and it will be found on the whole
the most satisfactory notation.)
Example :
^c. + A(2D.)=|«(6).
20 /6
+ i^ (2 D.) sp. ^- + i, (1.5 D.) cyl. | =f^Q) and
Occasionally cases are met with in which the astigmatism
appears to be corrected by every test, and vision is brought up
almost to the normal standard, and yet the lines are not seen
equally well, and no glass makes them equal. Such cases
show the importance of not trusting to one test alone.
For the vision of an astigmatic eye to be improved by
spherical lenses, it is essential that the nature of the error of
the refraction in the two principal meridians should be the
same (Compound Hj-perraetropic or Compound Myopic Astig-
matism). If spherical lenses do not improve vision, the astig-
matism is Simple (myopic or hypermetropic) or Mixed. In
either case, the lens which tends to correct the one meridian
renders the other worse.
If — the accommodation being paralyzed — the revolving lines
are seen quite clearly in one direction, while vision is normal
when the stenopiiic slit is placed in the meridian at right angles
to this, the astigmatism is Simple, and all that is necessary is
to place cylindrical lenses in front of the eye, with their axes
in the direction of the emmetropic meridian, until the lines
are seen equally well.
If the lines are not clearly seen in any position, and near
and distant vision are both defective, while the latter is not
388
ERRORS OF REFRACTION.
improved by spherical lenses, the defect is due to Mixed
Astigmatism, if to any error of refraction at all. It is ver\'
tedious to work out mixed astigmatism by the aid of the trial
lenses alone; and it can be so quickly and accurately done by
the " shadow test," that it will be better to postpone its further
consideration till we treat of that test.
ii. Other subjective tests. — There are other subjective tests
for astigmatism, some of which it will be well to mention
briefly. [One of the latest is that of a revolving astigmatic
disk, by Charles A. Oliver, M.D.
[Fig. 108. — Oliver's Revolving Astigmatic»Disk.]
" This instrument consists of three distinct parts : A flat brass
rod, thirteen millimetres wide and fifty centimetres long, per-
forated at each end by a small hole. The rod is immovably
fastened at its centre to a circular disk thirty-three centimetres
in diameter, bearing on its face three concentric series of short
test-lines, similar to those of Becker, each being representatives
of a certain distance, width, and angle. Upon the periphery
of this card, are numbers representing five degree dififerences
of angle, commencing at 0° on the left-hand side of the hori-
zontal meridian, running on the under half up to 180° at the
Oliver's revolving astigmatic disk. 389
right-hand side of the same meridian. This is repeated in the
opposite direction upon the upper semicircle, thus making the
angles correspond, similar to the ordinary test-glass frame.
Between the front card and the retaining rod there is a rotating
disk forty-seven centimetres in diameter, having two of Pray's
letters placed at a quarter angle to each other (ninety degrees
apart), each having a small arrow so fixed as to meet the
number of degrees on the outer card, showing the exact angle
reached.
" The disk is to be fastened to a wall by the retaining rod, in
a good light coming over the head of the observer placed at
twenty feet distance, and at a height so arranged as to bring
the centre of the card on a level with the patient's eye.
" If we find the patient able to see the twenty-foot type with the
eye under examination, he is to have his attention confined to the
lines of the inner circle. If the sight of the eye be more defective,
he is to look at the outer circles. By now making him closely
watch, we ask him to designate the clearest, sharpest, and
blackest radius; after this has been chosen, we wheel the
striped letter Z to the angle named, or to a point between, and
ask which letter is the darker and clearer. He will then
answer that the Z appears the plainer; now wheel the A into
the place occupied by Z, and if it becomes the darker and the
clearer, he will have verified his assertion, and the angles of
astigmatism be obtained.^
" Its employment in the estimation of ametropia, whilst the
eye is under the influence of a mydriatic, is also of much
value. Experimental determinations have several times been
made without the use of any test-types whatever, when it was
found that the results were identical with those obtained during
the use of the letters. Yet it is no more than fair to state,
that it was done with subjects of more than average intel-
ligence, as really, although forming a most delicate test, it is
[' "If the patient's sight is so bad that he cannot make out any of the lines at
twenty feet distance, he must gradually appi-oach the test, and watch for the
first angle brought out. "We note the distance and angle, and place the letter
Z at the chosen place. He is then to walk nearer and nearer until the letter
A and the lines at its angle become as distinct as the letter Z and its lines.
We accurately register this new distance, and calculate the difference."]
390
ERRORS OF REFRACTION.
harder to appreciate and keep in mind the slight observable
chansces of difference in the distinctness of the lines.
"As an adjuvant in the verification of a corrected case of
ametropia, it is of incalculable advantage. It is a good plan
to endeavor, after the selection of the correcting lenses, to
have the two letters appear equally black and distinct in their
entire revolution of the primary card, and that every spoke in
the inner wheel (or those of the concentric widths, if vision
cannot be brought to normal) shall be of the same clear-
ness; by these means getting the amount and angle of astig-
matism almost to a dead certainty." — 0.]
Various instruments, called Optometers, have been devised
for the purpose of facilitating the estimation of the refraction;
most of these consist essentially in an arrangement, more or
Fio. 109. — Tweedy's Optometer.
less ingenious, by which lenses of various powers and in dif-
ferent combinations can be rapidly placed in succession in
front of the eye which is to be examined; the test object being
Snellen's types. These require no further description here.
The distinctive feature of other optometers is the nature of the
test-object; thus in Tweedy's Optometer it consists of a series of
radiating lines on a clock-dial, sliding on a graduated bar
TESTING BY OPHTHALMOSCOPE. 391
(Fig. 109). In the use of the instrument, the eye, if not
already myopic, is rendered so by a conv^ex lens, so that the
further extremity of the bar lies beyond the patient's range of
vision. The dial is then gradually approximated, and the dis-
tance noted at which one of the radiating lines is seen. By
comparing the corresponding number on the graduated bar,
and the lens in front of the eye, the refraction of the meridian
at right angles to the line seen can be calculated. In the same
way the refraction of the other principal meridian is ascer-
tained, and the glass found which renders all the lines equally
distinct.
An attempt was made a few years ago to utilize the principle
of a very old test known as Scheiner's. This depends on the
fact that an Emmetropic eye, looking at a point of light through
two minute apertures, placed close together, sees the point
singly, because the rays which pass through each aperture
meet at the same point on the retina; but an Araetropic eye
under the same circumstances sees the point reduplicated, because
the rays coming through the two apertures would meet in a
single point in front of the retina in myopia, and behind it in
h3'permetropia, and would, therefore, in either case, touch the
retina in two separate places; the test, however, is not suffi-
ciently accurate for practical use.
Thomson's ameiromeier is an ingenious instrument, but labors
under the same disadvantage as the preceding test. In it, two
small flames are looked at from a distance, and the size of the
projected images of the diffusion-circles which they form on
the retina is measured by finding the extent to which the
flames must be separated in order that their images should
appear to touch each other, but not to overlap. The two
lights can be placed in any meridian, and the calculation made
for the meridian of the eye which is at right angles to it.
Among objective tests, the use of the ophthalmoscope takes
the foremost place, and it may be employed in several ways;
each test having this feature in common, that the result depends
on the direction given by the refracting media of the eye to
the rays which are reflected from the retina, those rays being,
as we have seen, parallel in Emmetropia, convergent in Myopia,
and divergent in Hj^permetropia.
892 ERRORS OF REFRACTION.
' iii. Testing by direct ophthalmoscopic examination. — This test
was very warmly advocated by Mr. Couper some years ago,
when ol)jective tests were little used, and has been extensively
practised by liim and others. As an approximate test it is
exceedingly useful, and its employment should be practised
by everyone. To render it accurate requires considerable
experience, and even with this, it is in most hands inferior to
some other methods, especially in astigmatism.
Two things are necessary, first that the ophthalmoscope
contains a series of convex and concave lenses; and second,
that the surgeon must be able to relax his own accommodation.
We have seen that in emmetropia the rays from the fundus
are parallel on leaving the eye, and that therefore they are
focussed on the surgeon's retina (if his accommodation is re-
laxed) when his eye is placed close behind the sight-hole of the
mirror, and when the latter is held close to the eye under
examination. If the rays coming from the eye are parallel,
as in emmetropia, a convex lens will render them convergent,
and they can then be no longer focussed by the observer's eye.
Hence :
In Emmetropia the fundus is clearly seen without any lens behind
the min'or, and a convex glass renders the image blurred.
In Myopia the rays are convergent on leaving the eye, hence
the fundus cannot be seen by an emmetropic eye until they
have been rendered parallel by a concave lens. The weakest
concave lens which makes the details of the fundus clear, is
the measure of the myopia — provided, of course, that neither
the patient nor the surgeon is using his accommodation ; if a
stronger lens is used, the rays are rendered divergent, and can
then only be focussed by the surgeon using his accommoda-
tion ; this, however, is done instinctively, and by most people
unconsciously, so that the fundus is still clearly seen with a
concave lens much stronger than that required to correct the
myopia. It follows from what has been said that:
In Myopia the fundus can only be seen by rising a concave lens ;
and the weakest concave glass with which it can be seen is the measure
of the Myopia.
In Hypermetropia, if the patient's accommodation is relaxed,
the rays leave the eye diverging. Under such circumstances
a clear view of the fundus can be obtained only by the surgeon
Fig. :?. Appearanxy of disc in astujm.jjyisnh (Diredy whocfe.)
Fu7 " Optic ttiftr rn nsh/jrnaiisrn, ' incur «co unaae/.
TESTING BY OPHTHALMOSCOPE. 393
using his accommodation. Most people are unconscious of the
act of accommodation, and therefore, upon seeing the fundus
clearly, may think that the eye is emmetropic; but if a
convex glass should be placed behind the mirror, the accom-
modation will partially relax, and the fundus will be still
clearly seen. It follows therefore that :
The fundus of a Hypermetropic eye can he seen with a convex
lens ; and the strongest convex lens with ivhich it can he clearly seen
is the measure of the hypermetropia.
To recapitulate. If when the patient's accommodation, and
that of the surgeon, is relaxed, the fundus is clearly seen
without any lens behind the mirror, the case may be one of
Emmetropia or Hypermetropia, but cannot be Myopia. If a
convex lens renders the image blurred, it is Emmetropia ; if it
remains distinct, it is Hypermetropia ; if the fundus can only
be clearly seen with a concave lens, it is Myopia.
The weakest concave lens is the measure of the myopia.
The strongest convex lens is the measure of the hypermetropia.
In Astigmatism, the disk usually appears to be of an oval
shape, and the vessels which run in different directions are
viewed under difierent conditions (see Figs. 1 and 2 on the
opposite page) ; thus, if the eye is emmetropic in the horizontal
meridian, and myopic in the vertical, the vertical vessels will
be clearly seen, but the horizontal will require a concave lens
to render them distinct. This follows from what was said in
p. 355, for since the raj-s from any point on the retina which
come out through the horizontal meridian are parallel, they
are focussed on the observer's retina, and by the rule there
given, a vertical linear image of the point will be formed on the
observer's retina. If a vertical vessel be looked at, it is seen
clearly, because all its points form elongated vertical images
which overlap one another, whilst the horizontal vessel, on
the contrary, looks blurred, because the images of its points
are elongated, not in the direction of its length but across it.
If a concave lens is placed behind the mirror of such a
strength as to bring the ra^'S coming through the vertical
(myopic) meridian to a focus on the retina, the horizontal
vessels will be clearly seen.
Hence we get this rule for the estimation of astigmatism :
The refraction of either principal meridian can he ascertained hy
394 ERRORS OF REFRACTION.
finding the weakest concave or strongest convex lens with which the
vessels whose course is at right angles to that meridian, can be seen.
With practice, it is possible to estimate astigmatism with
great accuracy by this method in most cases, but there are
several difficulties. On tlie disk itself, vessels can usually be
found running in several directions, but the refraction of the
region of the yellow spot, and not that of the optic disk, is Avhat
is required, and in the region of the macula there are but few
vessels to be found, and these frequently do not lie in the
principal meridians. Mr. Tempest Anderson has endeavored
to remove this difficulty by an ingenious apparatus by which
an imacce of fine wires radiatino: from a common centre is
thrown on the retina, those of the lines which correspond to
the principal meridians of refraction being used as test-objects.
iv. Testing by the indirect method of ophthalmoscopic exam-
ination.
In Emmetropia the image remains of the same size, whatever is
the distance of the lens from the observed eye.
In Myopia the image enlarges as the lens is withdrawn from the
eye.
In Hypermetropia it diminishes.
In Astigmatism, the shape of the disk appears to change as
the lens is withdrawn. "When the lens is close to the eye, the
disk appears oval, and the long diameter corresponds to the
meridian of least refraction (which is the reverse of what
occurs in the direct method) ; as the lens is withdrawn, the
relative size of the diameters changes until the long axis of the
disk corresponds with the meridian of greatest refraction.
V. Testing with mirror alone, held at a distance, (a) Fandus-
image Test, (b) lieiinoscopy. — In addition to the methods of
using the ophthalmoscope already described, the two follow-
ing are very useful in estimating refraction. The first of these
may be called the " Fundus-image" test, the other has been
called " Retinoscopy," but would be more appropriately desig-
nated by some such term as " Shadow Test." In both, the
ophthalmoscopic mirror alone is employed, and is held at a
considerable distance from the eye.
(a) Fundus-image Test. — If the mirror be held at a consid-
erable distance from an Emmetropic eye, no image of any de-
FUNDUS-IMAGE AND SHADOW TESTS.
395
tails of the fundus is seen, but only a red reflex; this is he-
cause only the very minute point of the fundus is seen which
lies on the axis along which light is reflected into the eye, for
the rays from any other point on the fundus form a pencil of
ra3''8 parallel to the axis on which the point is situated, so that
by the time the rays from any two such points have reached
the distance at which the observer's eye is placed, the two
pencils are widely separated (Fig. 110).
Fig. 11(1.
In myopia and hypermetropia, however, a portion of the
fundus is seen whose extent is in proportion to the degree of
ametropia. In Myopia, as we have seen, a real inverted image
[a' h', Fig. Ill) of the fundus is formed in the air at the pa-
FlG. 111.
tient's "far-point," and, since this is in front of the patient's
eye, it appears to move in the opposite direction when the ob-
server's head is carried from side to side.
lu Hypermetropia, the emerging rays form divergent pencils,
hence the image of the fundus is virtual and erect, and is formed
behind the patient's eye (see Fig. 112). The image therefore
appears to move in the same direction as the observer's head.
390
ERROHS OF REFRACTION
Hence we get this rule :
If while the mirror is held two feet or more from the eye^ airy de-
tails of the fundus are seen, the eye is either hypermetropic or myopic.
If the vessels move in the same direction as the head, it is Hyperme-
tropic ; if in the opposite direction, it is Myopic.
Fig. 112.
Retinoscopy , or the Shadow Test. — When light is reflected
into an eye from a mirror held at a distance of a little over a
metre, and the mirror rotated to and fro on one of its axes, the
appearance seen through the sight-hole of the mirror varies
with the refraction of the eve.
In one position of the mirror, the whole pupil is occupied
by a red reflex, but if it be rotated slightly, this red reflex
shifts its position so that a limited area of the pupil becomes
less illuminated, and the appearance presented is that of a
shadow creeping a short distance over the pupillary area (Fig.
113).
If a concave mirror be used, the " shadow '' appears to move
in the same direction as the rotation in myopia,'
and in the opposite direction in hypermetropia.
Before considering how this fact may be utilized
as an accurate test, not only of the kind of error,
but also of its degree, it would be well to explain
the rationale of the phenomena.
When rays of light from a lamp (l. Fig. 114) fall on a con-
cave mirror (m,) they are rendered convergent, and an in-
verted image of the lamp-flame {l^) is formed in the air a little
' There is one exception to this, which will he nr)ticed presently. (See p. 400).
Fic. li;;.
THE SHADOW TEST.
397
nearer the patient than the principal focus of the mirror,
which should be about ten inches (25 cm.) If the mirror be
rotated in any direction — say downwards — as to M2, the aerial
image of the lamp-flame will move in the same direction, as
to 4. If the eye is myopic to such a degree that its "far-
point" coincides with the position of ^, or 4? a well-detined
image of one of these will be formed on the retina at l\ or l'^^
and since the relative position of external objects is inverted
on the retina, the lower the aerial image, the higher will be
that on the retina. In other words, the retinal image of the
flame will move in the opposite direction to that of the rota-
tion of the mirror.
In any other state of refraction but that just indicated, no
true retinal image of the flame will be formed, but a circular
" diff'usion-image." The size of the latter will vary with that
of the pupil, and with the refraction of the eye, but it will in
any case occupy only a comparatively small portion of the
fundus. Since the size of the dilated pupil is, practically, a
Fig. 114.
fixed quantity, that of the diffusion-image will depend on the
extent to which the refraction differs from a myopia, with the
" far-point " at the aerial image. The diffusion-image, however,
enlarges more rapidly with increasing degrees of myopia than
with increasing degrees of hypermetropia, owing to the greater
length of the eye in the former case.
It is evident that in any case, the movement of the " diffu-
398 ERRORS OF REFRACTION.
sion-iraage'' must always be in the opposite direction to that
of the rotation of the mirror.^ Therefore the difference in
the appearance in myopia and hypermetropia does not depend
on a real difference in the direction of movement of the light
on the fundus, but on a difference in the conditions under
which the fundus is seen, in the two cases. What this differ-
ence is, the reader will easily see by referring to what has been
already said when speaking of the " fundus-image" test (see p.
394). We then saw that at a distance from the eye an erect
image of the fundus is seen in hypermetropia and an inverted
image in myopia, while in emmetropia only an infinitesimal
portion of the fundus is visible. Hence in hypermetropia the
" diffusion-image" is seen to move in its true direction,/, e., oppo-
site to that of the mirror, while in myopia it appears to move in
the reverse direction to the actual one, i. e., in the same direction
as the mirror. The mode of production of the characteristic
shadow will be made plain by the following diagrams. Fig.
Fig. 115.
115 represents a hypermetropic eye, and the degree of hyper-
metropia is such that a virtual image [a' b') of a portion of the
fundus (a b) is visible.
For the sake of simplicity we will assume that, in the first
position of the mirror, the " diffusion-image" exactly coincides
with a b; therefore the whole of a' b' will be illuminated, and
the whole of the pupil appear occupied by a red reflex. ISTow
1 If a plane mirror be used, the retinal image will move in the same direction
as the mirror, and the appearance will therefore be the reverse of that described
in the text.
THE SHADOW TEST.
399
let the mirror be rotated downwards, so that the " diffusion-
image" no longer coincides with a b, but is shifted upwards
to the position indicated by the dotted line ; the lower por-
tion of a b, and therefore of a' b' , corresponding to
5, will now not be illuminated, and therefore will
appear as a " shadow," while the upper part, corre-
sponding to I, will give the red reflex. Hence the
lower part of the pupil will present a " shadow,"
while the remainder will be bright (Fig. 116). In
other words, the " shadow has moved upwards, or in the
opposite direction to the mirror.
In myopia, if the mirror is rotated downwards, a difl:erent
appearance will be produced. Let Fig. 117 represent an eye
which is myopic to such an extent that an inverted image a' b'
of a portion of the fundus, a b, is formed. If, as before, the
Fig. 116.
Fig. 117.
" diffusion-image" coincides with a 6 in the first position of the
mirror, the whole of ft' b', and therefore the whole of the pupil,
will appear of a red color. If the mirror be now rotated
downwards so that the " diffusion-image" is shifted upwards
toward a, to the position indicated by the dotted line (Fig.
117), the part of a 6 nearest to b will now not be
illumined, and therefore the portion of the image
ft' 6' nearest to b' (corresponding to 5) will be in
shadow, while the remainder (corresponding to i)
will still give the red reflex. In other words, the
shadow has appeared to move downwards, that is,
in the same direction as the mirror, and the pupil will present
the appearance as shown in Fig. 118.
Fig. 118.
400 ERRORS OF REFRACTION.
Besides the difference in tlie direction of tlie shadow, which
is due to the kind of ametropia, there are differences in the
rate of movement and the brightness of the reflex which de-
pend upoti the degree of ametropia. The higher the degree the
larger is the area of fundus seen (see p. 395), but this is pro-
portionately less magnified. Hence, with an equal amount of
real movement of the light on the fundus, the movement of
the " shadow" will ajo/?rar to be slower in high than in low
degrees.
The brightness of the reflex also varies with the degree of
ametropia. We have seen that in low myopia (about 1 D.) a
well-deflned retinal image of the flame is formed; hence in
this condition the light is most concentrated on the fundus.
In proportion as the refraction differs from this, the larger is
the area of the fundus over which the same amount of light is
spread, hence the illumination of any given point is propor-
tionately diminished.
The practical bearing of what has been said will be made
plain by a few examples.
Example 1. — The reflex is dull, the shadow moves in the
opposite direction to the mirror, but only a short distance
across the pupil. The case is one of high hypermetropia.
If convex lenses of increasing strength be now placed before
the eye, the reflex becomes brighter, the movement of the
shadow greater, but its edge less defined; finally, the shadow
becomes indistinct, and then, if still stronger lenses are used,
it reappears, moving, however, now in the same direction as
the mirror, and the eye has been rendered myopic.
We have seen that the mj-opic appearance is produced by
the inversion of the fundus image, and as this occurs at the
far-point of the eye, it can only be seen when the latter is
between the patient and observer, and not too near the latter;
for this reason a myopia of less than ^V (1 ^•) cannot therefore
be recognized at the distance at which the mirror is usually
held, but if the distance be increased, a very much smaller
amount can be recognized.
There are two ways of estimating the amount of Ametropia
by this method ; the one is to increase gradually the strength
of the lens until the myopic shadow is seen, and then to deduct
THE SHADOW TEST. 401
4V (1 I)-) from the lens used. The other is to lind the weakest
lens which renders the shadow indistinct. After a little prac-
tice, it will be found that the lens which corrects the ametropia
can be found in this way. As the tendency is rather to over-
correct hypermetropia by this test, and so render the eye
myopic, it is a good plan, as soon as the lens has been found
which appears to correct the ametropia, to hold the mirror
further away, and see if there is then a myopic shadow, if so,
a weaker lens must of course be taken.
Example 2. — The reflex is bright, and the shadow moves over
a large portion of the pupillary area, and in the opposite direc-
tion to the rotation of the mirror. Hypermetropia of low
degree. It is to be corrected as in the preceding example.
Example 3. — The reflex is very dull, and the shadow moves
very slightly, and in the same direction as the mirror. High
myopia. Concave lenses should now be placed in front of the
eye, their strength being increased until the shadow moves
in the opposite direction. A lens a little weaker than this
will give the correction.
Example 4. — The reflex is brighter, and the shadow moves in
the same direction as the mirror, and over a large portion of
the pupil. Low myopia. Correct as in preceding example.
The great advantage of this test, however, consists in the
ease with Avhich it can be applied to the estimation of astig-
matism. The refraction of any one meridian can be ascer-
tained by noting the movement of the shadow in that meridian;
this will be made plain by a few examples.
Example 1. — The mirror being rotated upon its vertical axis
(so that the light moves transversely on the retina), the emme-
tropic appearance is seen ; whilst, on rotating the mirror upon
its horizontal axis (so that the light moves vertically on the
retina), a shadow is seen to move in the same direction as the
mirror. Here the case is one of Simple Myopic Astigmatism ;
the horizontal meridian being the emmetropic, and the ver-
tical the myopic. In order to correct the error, we use a
concave cylindrical lens with its axis horizontal.
Example 2. — We will now suppose that in testing the hori-
zontal meridian (by causing the light to travel transversely) the
shadow moves in the opposite direction to that of the mirror,
26
402 ERRORS OF REFRACTION.
whilst there is no distinct shadow in the vertical meridian.
Here the case is one of Simple Hypermetropic Astigmatism,
and will be corrected by a convex c^dinder with its axis vertical.
Example 3. — If in both meridians the movement of the
shadow indicates the same kind of error, a diiference in de-
gree may be suspected if a difference in the rate of move-
ment is noticed. Spherical lenses must now be placed in
front of the eye until one is found which renders one meridian
emmetropic. If the meridian at right angles to this still
remains ametropic, the case is one of Compound Astigmatism
which has been converted by the spherical lens into one of
Simple Astigmatism. This remaining error can be corrected
by a cylindrical lens having its axis in the direction of the
corrected meridian (as in Examples 1 and 2).
Example 4. — The shadow moves in the same direction as the
mirror in one meridian, and in the opposite direction in the
other meridian. The case is one of Mixed Astigmatism.
Spherical lenses should now be placed in front of the eye, so
as to correct one meridian, thus converting the case into one
of Simple Astigmatism. For instance — a hypermetropic
shadow is seen moving in the horizontal meridian, and a
myopic shadow in the vertical. Convex lenses are used, and
it is found that + 4^ (+ 2 D.) renders the horizontal meridian
emmetropic. The vertical meridian will, however, have been
rendered more myopic, for it was myopic to begin with and
-|- ^V (+ 2 D.) has been added. To correct the error, a con-
cave cylinder of greater strength than -^-^ (2 D.) must now be
used with its axis horizontal. (The reason for the use of this
higher cylinder we have already learned.) Now, if with + ^
(+2 D.) sph. it is necessary to use a — -^ ( — 4 D.) cylinder
glass to correct the vertical meridian, the indication is that this
meridian is myopic to the extent of one-twentieth (2 D.) — (for
one-twentieth out of one-tenth has been employed in neutral-
izing the vertical meridian of the spherical lens). Another
method is to correct each principal meridian with a cj'linder.
In practice, however, this latter plan is less convenient, as it
is difficult to insure the axes of the lenses being exactly at
right angles to each other.
If the principal meridians are not exactly horizontal and
THE SHADOW TEST. 403
vertical, but slightly oblique, and if the mirror is rotated on its
horizontal or vertical axis, the edge of the shadow will coin-
cide, not with the axis of rotation of the mirror, but with the
nearest principal meridian, and will therefore indicate the di-
rection of the latter; sometimes, however, it is easier to judge
of the direction of the movement than of the exact amount of
obliquity of the shadow edge.
We have seen that the real movement of the light (and
therefore of the " shadow ") on the fundus is along a line at
right angles to the axis on which the mirror is rotated. The
motion of the light always appears to take place in a direction
at right angles to the edge of the shadow whatever may be
its real movement. This can be illustrated by the simple ex-
periment of passing a card with its edge held obliquely in a
horizontal direction across an aperture (as suggested by Dr.
Charnley^). It will then be seen that although the real move-
ment of the card is horizontal, its apparent direction is along
aline at right angles to its edge; hence the direction in
which the shadow moves across the pupil depends on the
direction of its edge, i. e., of the margin of the diffusion-
image formed on the retina.
In astigmatism (to simplify the explanation, we will here
assume that the astigmatism is Simple), the outline of the dif-
fusion-image is not exactly circular but oval, and only those
parts of its outline will be clearly seen whose directions coin-
cide with that of the emmetropic meridian. For example,
supposing the vertical meridian to be myopic and the hori-
zontal emmetropic (Simple Mj'opic Astigmatism), then, at the
"far-point'' of the myopic (vertical) meridian, there will be
formed horizontal linear images of every point on the outline
of the diffusion-figure; hence only the horizontal edges will be
clearly seen, because here alone will the linear images be super-
posed : so that the edge of the shadow will be horizontal, and
its movement will be in the vertical meridian whether the
mirror be rotated on a horizontal axis or on one which is
slightly inclined to the horizontal. By these actions it will
be known that the principal meridians are vertical and hori-
1 Oph, Hosp. Kep., X., iii. p. 364.
404 ERRORS OF REFRACTION.
zontal. In the same way if the meridians are oblique, the
amount of obliquity can be gauged by that of the " shadow-
edge,'' and the error' of refraction indicated by the direction
of its movement, while correction will be given by a cylinder
with its axis parallel to the shadow-edge.
The reader will find it helpful to verify the above statements bj' experiments
on the artificftl eye (page 339). If the ground-glass retina be used, and the eye
viewed from behind, while the light is thrown in through the pupil in the same
way as in retinoscopy, the movement of the patch of light on the retina can be
seen, and will be found to be in the opposite direction to the rotation of the
mirror, however much the eye is shortened or lengthened. (It will be noticed
that part of the light is cut oft' on the side toward which the illuminated patch
moves, but this does not aft'ect the explanation.) It will also be seen that a
well-defined image of the flame is formed when the eye is slightly myopic, so
that its far-point corresponds to the aerial image. As the artificial eye is shortened
or lengthened the image of the flame becomes circular; although increasing in
size more rapidlj' on a lengthening than upon a shortening of the apparatus.
Having seen the real movement, the apparent movement is best seen by using
the opaque retina. The appearance in the different states of refraction, and the
eflTect of correcting them by the placing of glasses in the clip, should then be ob-
served. Finally, the artificial eye should be made astigmatic by the addition of
a cylindrical lens. If there should have been made a myopic meridian in the
artificial ej'e and the ground glass retina should be used with the light placed
behind it, it will be found that the only lines on the fundus which are distinctly
seen are those which are at right angles to the myopic meridian, and that these
lines (corresponding to the edges of the shadows in the test) can be focussed on
a screen placed at the " far-point " of the myopic meridian. With the opaque
retina, the appearance seen in the natural astigmatic eye can be closely imitated.
vi. Other objective tests. — Among the objective methods ot
estimating astigmatism must be mentioned the measurement
of the curvature of the refracting surfaces of the eye by
special instruments. One of the best of these is the Ophthal-
mometer of Javal and Schiotz. It measures the refraction of
the cornea only ; and both for this reason, and because of its
cost, it is of value rather as a scientific instrument than as a
practical test. It works on the principle, which is common to
most ophthalmometers, of calculating the curvature of the cor-
neal surface from the size of the images of a given object re-
flected in it. The chief novelty of the instrument consists in
the ingenuity with which the difference in the size of the
image in the principal meridians of an astigmatic cornea is
graphically indicated, so that it can be at once seen how many
GENERAL CONSIDERATIONS. 405
dioptres of astigmatism it corresponds to. Since, however,
astigmatism of the cornea can be increased, diminished, or
neutralized by astigmatism of the crystalline lens, the value
of the instrument as a practical test is not very great except in
aphakic eyes.
Section VI. — General Considerations.
The use of mydriatics sometimes entails so much incon.
venience to the patient that it is of importance to know in
what cases they may be dispensed with.
In myopia, the employment of a mydriatic is not as a rule
necessary except in the case of young children, or when astig-
matism is present.
In patients under twenty with hypermetropia or astigmatism,
the accommodation should as a rule be paralyzed.
In those who are slightly older — say, from tw^enty to thirty —
a mydriatic can often be dispensed with, provided that, in the
event of the glasses not relieving the symptoms, an oppor-
tunity of re-testing can be procured.
After the age of thirty, mydriatics are seldom necessary.
Xo hard and fast line can, however, be laid down, and much
will depend on individual circumstances. Thus, if a patient is
using the eyes for near vision for many hours daily, as is the
case with clerks and needlewomen, a very accurate correction
is necessary ; if, on the other hand, the eyes are only used for
near vision for a short time, an approximate estimation, made
without the use of atropine, is sufficient. The fact that a
patient has previously worn glasses without relief to his
symptoms, will also indicate the necessity of a very careful
examination.
When the exact refraction of the eyes has been ascertained,
the question arises as to wdiether full correction should be
ordered, and whether the glasses should be worn always or
only occasionally. In young m3'opes it is said that the con-
stant w^earing of glasses which fully correct the ametropia has
a tendency to increase the myopia, and that it is better to give
such patients a glass which wall enable them to see at their
working distance without using any accommodation. That
406 ERRORS OF REFRACTION.
full correction does tend to increase the myopia is a proposition
which it is difficult to prove, but the belief is almost universal
among German ophthalmic surgeons that such is the case, and
their opportunities of forming an opinion are much greater
than occur in this country, owing to the greater prevalence of
myopia in Germany ; hence it is a safe rule in ordering glasses
for myopes under fifteen years of age, to give less than full cor-
rection, endeavoring to adapt the eye for a distance of about
twenty inches. Directions are to be given that these glasses
should be worn constantly, whilst the additional glass required
for distance may be added in the form of eye-glasses which can
be placed in front of the spectacles when accurate distant
vision is required. If, however, the patient has been under
observation some months, and there has been no increase in
the myopia and no evidence of any thinning of the choroid,
full correction may be given.
In patients from fifteen to thirty -five years of age, full cor-
rection may be ordered for all purposes in Ioav degrees of my-
opia, i. e., of less than — Jg ( — dT>.). After thirty-five, myopes
with a higher correction than — -^^ ( — 3 D.) will not be suited
for near vision, and will require other glasses for such objects,
whilst myopes of yV (^ ^■) ^^'i^^ iiot require glasses for near ob-
jects because they can read at thirteen inches (33 cm). The
difficulty which is felt at first in using the glasses for near
vision is soon overcome by practice. If, however, such patients
have for several years constantly worn glasses which correct
their myopia, they will generally be able to continue using
them for all purposes up to the age of forty-five. After this
they will require for near vision the addition to their glasses
of the presbyopic correction corresponding to their age (see
table on p. 341, and p. 408).
In the higher degrees of myopia even young mj'opes, when
their myopia is corrected, find it irksome or impossible to use
the amount of accommodation necessary for near vision. This
is not on account of the accommodative action being any
greater than it is in emmetropia, but that in myopia there are
structural peculiarities of the ciliary muscle ; and this com-
bined with the fiict that the muscle is seldom, or never, called
into action, renders the efifort both difficult and painful. In
GENERAL CONSIDE E ATIOXS . 407
such cases full correction may be given for distance ;' and for
near vision a glass weaker in proportion to the distance for
which it is desired to adapt the eyes.
For example. — A myope of one-fourth (10 D.) requires to see
at twenty inches (50 cm,). To enable him to do this, a convex
lens having this focal length, i. e., + o^ (+2 D.), must be
added to the glass which corrects the myopia. In this instance
— i ( — 10 D.) adapts the eye for parallel rays, whilst + 2V
(+ 2D.) renders the rays parallel which come from a point
twenty inches (50 cm.) away. Hence — i ( — 8 D.) will effect
the required object.
In ordering glasses for hypermetropia, we have to consider
whether the patient, who has been accustomed to use his accom-
modation constantly, will be able to relax it completely ; this
being necessary for distant vision if full correction should be
given. In young subjects it takes a very long time, and more
patience and perseverance than some possess, to get thor-
oughly accustomed to a full correction ; hence, although a few
surgeons order it, it is generally better to deduct something.
As to the amouuL to be subtracted, there is a good deal of
difference in opinion and practice. Some correct all the mani-
fest hypermetropia ; others subtract a constant fraction —
usually half of the latent; others, again, take off a constant
amount, as -gV or -^ (0.50 or 1.0 D.), from the total hyperme-
tropia. A rule which practically works well, is to deduct half
a dioptre from the total hypermetropia when the glasses are to
be worn constantly, and to give full correction when they are
only to be worn for near vision. After the age of thirtv, full
correction may always be given.
As to whether glasses should be worn constantly or only
occasionally, will depend upon the circumstances of each case.
Theoretically, no doubt, it is best that the ametropia should
be kept constantly corrected, but there are often objections on
the part of patients and friends to the constant wearing of
glasses. Myopes, when supplied with glasses, may generally
be left to follow their own inclinations as to the manner of
using them. In children with hypermetropia, the constant use
of glasses should be insisted on; but in adults with hyperme-
' Assuming that it is considered safe to give full correction (see above, p. 40o).
408 ERRORS OF REFRACTION.
tropia of less than one-thirteenth (3 D.) it is sufficient if the
glasses are worn for near vision. In the higher degrees of
hypermetropia and in astigmatism of one-fortieth (1 D.) or
more, they should be worn constantly.
Patients are often very anxious to have eye-glasses pre-
scribed instead of spectacles. When corrections are only to
be used occasionally, there is no objection to the eye-glass pro-
vided that there is no astigmatism ; but where astigmatism is
present, spectacles are necessary, because with the eye-glass it
is difficult to insure the axis of the cylinder being always in
the correct position. Theoretically, up till about the age of
forty-five, the glass which corrects the eye for distance should
suffice for near vision. This is actually the case, except in
myopia of high degree or in myopia which is not corrected
until after the age of thirty. After forty-five, however, the
natural decay of the function of accommodation (presbj'opia)
removes the near-point to an inconvenient distance, and the
accommodation has therefore to be supplemented by artifi-
cial means. The method of ascertaining the presbyopic cor-
rection for the emmetropic eye proper to each age is given in
page 342. In ametropia, as a rule, the glass required for near
vision, is the presbyopic correction corresponding to the age
of the patient, added to the glass which corrects the ame-
tropia.
Examples. — 1. A patient aged fifty is hypermetropic to the
extent of one-twenty-fourth (1.5 D.) The presbyopic correc-
tion for the age of fifty is one-twentieth (2 D.). The patient
will therefore require for reading -\-4i + ^V = tV (+ 1-^ ^^
4- 2 D. = 3.5 D.)
2. A patient aged fifty-five is myopic to the extent of one-
fortieth (1 D.) The presbyopic correction is one-thirteenth
(3 D.). The patient therefore will require for near vision — ^V
+ iV = 3rV(— l-0r>. + 3D. = 2D.).
In testing a patient for presbyopia, it should always first
be ascertained whether there is any ametropia and its amount,
to which presbyopic correction should be added.
There are a few practical points with reference to spectacles
which should be iittended to. It is essential that they should
not only be of the proper strength, but that they should be so
GENERAL CONSIDERATIONS. 409
fitted that each eye looks through the centre of the glass. So
that in prescribing spectacles when the patient cannot visit the
optician, it is necessary to give the distance from the centre of
one pupil to that of the other, and to state whether they are
to be worn for distance or for reading, etc. Patients often
ask whether they should get " pebbles " or glass. There is
not much practical advantage in the former and. they are much
more expensive ; they are, however, lighter and cooler, and
may therefore be ordered when the glasses would be of in-
convenient weight. In most pebbles, the crystal is cut in the
wrong direction, and although there may be no flaw visible to
the naked eye, such lenses are inferior to those made of glass.
CHAPTER XV.
DISEASES OF THE OCULAR MUSCLES.
ANATOMY AND PHYSIOLOGY — DIPLOPIA APPARENT STRABISMUS — PARALYTIC
STRABISMUS — CONCOMITANT STRABISMUS — NYSTAGMUS — PARALYSIS OF THE
INTRAOCULAR MUSCLES — MYOSIS.
Anatomy and Physiology. — Each eye is acted upon by three
pairs of niuscies; the muscles of each pair rotate the globe in
opposite directions round the same axis ; the three axes cut
each other in a single point, which remains immovable in all
movements, and is therefore called the centre of rotation.
The centre of rotation is situated 13.5 mm. behind the cornea,
and therefore rather behind the geometric centre of the globe.
The visual axis or line is the straight line drawn from the
yellow spot through the optical centre of the eye. In order
that an image may be formed on the yellow spot, the object
must lie on the visual axis.'
The primary position is that in which there is a minimum
innervation of the ocular muscles ; the head is held erect, the
two visual lines are on the same horizontal plane, and are
directed straight in front parallel to each other.
The six muscles referred to above, are the four recti and the
superior and inferior oblique.
All the recti arise from the apex of the orbit. As they pass
forwards, they diverge from one another, forming a hollow cone
which includes the globe, and at last are inserted into the scle-
rotic at distances ranging from 6.5 to 8 mm. from the corneal
' The line of fxaiion joins the object looked at and the centre of rotation.
As. however, it does not coincide with any axis of the eye, or with the course
of any ray, there does not seem to be any practical advantage in retaining the
term.
ACTION OF THE OCULAR MUSCLES. 411
margin. The insertion of the internal rectus is most anterior,
and that of the superior rectus most posterior.
The obliquus superior passes from the apex of the orbit to
the upper and inner part of the orbital margin, and there pass-
ing through a pulley takes a direction backwards and outwards
to be inserted into the upper and outer part of the globe behind
the equator.
The obliquus inferior arises from the inner and anterior part
of the floor of the orbit. It passes backwards and outwards
between the external rectus and the globe, to be inserted into
the sclerotic at its upper and outer part behind the equator.
Action of the ocular muscles. — The action of any muscle will
be best expressed by the direction in which it causes the centre
of the cornea to deviate from the primary position.
The following table shows the direction of the axis of rota-
tion and the action of each individual muscle (see Fig. 118):
Muscles. Axis of rotation. Action.
^ T> 4. f Horizontal. Inner extremity in- 1 ^t j j • j
hup. Kectus ^■ A c t -o '^ c\ U pwards and inwards.
T f^ T> . ■{ clined forwards. Jb orms ansle of )- t-k j j ■ j
int. Kectus ,,,.0 .,, . , ,. ,„. n^, 1 Downwards and inwards.
t bi° with visual line (Fig. 119). J
Ext. Kectus 1 XT f • 1 / Outwards.
Int. Rectus j ..... ^ Inwards.
Sup. Oblique "^ r Downwards and outwards.
Horizontal. Outer extremity in- | Vertical diameter of the
clined outwards. Forms an'trle ^ cornea inclined down-
Inf. Oblique
of 38° with visual line (Fig. 11'.)). 1 wards and outwards.
V Upwards and outwards.
It is evident that if the superior rectus acts in conjunction
with the inferior oblique, the inclination inwards caused by the
former muscle will be counteracted by the outward movement
of the latter, hence a direct movement iqnoards will result. In
the same way, if the inferior rectus and superior oblique act
together, a downward movement is produced. Although in
the above table a definite action is assigned to each muscle,
it must of course be understood that in all the movements of
the eyes, as in those of the limbs, all the muscles are con-
cerned, for they are all in a condition of slight tonic contrac-
tion, so that if any one muscle be divided or paralyzed, its
opponent will cause the eye to deviate, whilst if they are all
divided, the globe is rendered perceptibly more prominent.
412
DISKASES OF THE OCL'I,AU MUSCLES.
Innervation of the muscles. — The nerves supplying the muscles
of the eye are the third, fourth, and sixth pairs. The third
nerve (motor oculi) supplies the superior, inferior, and internal
rectus, the inferior oblique, the levator palpebri\i, the sphincter
Fig. 111'.— Diagram of the attachments of the muscles of the left eye and of their axes
of rotation, the latter being represented by fine lines. The axis of rotation of the
rectus e.\ternus and internus, being perpendicular to the plane of the paper, cannot
be shown. (After Fick.) The thick lines indicate the position of the muscles. The
finer lines represent the axis of rotation.
pupilliis, and the ciliary muscle. The fourth (patheticus) sup-
plies the superior oblique. The sixth (abducens) supplies the
external rectus.
Associated movements. — All movements of the eye have for
their object the direction of the visual lines to the same point
in space; the movements of the two eyes are therefore neces-
sarily associated. Thus in looking upwards or downwards
both eyes are moved, and the same muscles called into play
in each eye. In looking to the right or left, both eyes are
moved ; but the internal rectus of one is associated with the
external rectus of the other. Both the internal recti can be
ASSOCIATED MOVEMENTS. 413
called into action and the eyes rotated inwards, so that the
visual lines converge. It is important to remember that the
act of convergence is quite independent of the other conjugate
movements ; thus, while convergent, and the amount of con-
vergence remaining the same, the eyes may be moved upwards,
downwards, to the right, or to the left. On the other hand,
there may be excessive or deficient convergence without the
action of the internal recti for the other conjugate movements
being in any way interfered with. Convergence is always
associated with contraction of the pupil and the act of accom-
modation, and in the normal eye the amount of accommo-
dation used bears a definite relation to the amount of con-
vergence. Thus, in looking at a distant object, neither accom-
modation nor convergence is used; but in proportion as the
object is brought nearer, the greater are the necessary amounts
of both convergence and accommodation.
When both the visual lines are directed to the same point,
the image of that point falls upon the yellow^ spot in each eye,
and the tw^o retinal images are combined by the mind to form
a single visual impression ; this is called binocular vision.
If, however, while the visual axis of one eye is directed to
a» object, the other deviates from this direction, the condition
is spoken of as strabismus, or squint. It is evident that in the
deviating eye, the image of the object on which the other eye
is fixed, will fall, not on the yellow spot, but on some other
part of the retina. Thus, if the eye deviates inwards, it will
fall to the inner side of the yellow spot ; if outwards, to its
outer side. The mind judges of the position of an object {pro-
jects the image) by the part of the retina on which the image
falls : if on the yellow spot, the object is known to be on the
visual line ; if on the outer side of the yellow spot, the object
is known to lie to the inner side of the visual line; and so
on. llTow, in strabismus, the mind takes no cognizance of the
fact that the eye is deviating, but projects the image as if it
were in its true position. Thus, supposing that one eye devi-
ates inwards, the other eye fixes the object; its image, falling
on the yellow^ spot, is projected as lying on the visual axis,
and is therefore seen by this eye in its true position ; but in
the squinting eye the image falls to the inner side of the
414 DISEASES OF THE OCULAR MUSCLES.
yellow spot, and is therefore projected to a position on the
outer side of that which the visual axis would have if the eye
were not deviated. Two images are seen, a inie and a false,
and the displacement of the false image is in the opposite di-
rection to the deviation of the eye.
Thus, in Fig. 120, let R he the right eye, and l the left,
which deviates inwards. Let c be the centre of rotation,
Fig. 12(i.
Y the yellow spot, and o the object looked at. The yellow spot
in the eye r is directed toward the point o ; that of the eye l
toward x. The image of o, in the left, or deviating eye,
instead of being formed at y, the yellow spot, is formed at o,
and the eye l, which judges of the position of exterior objects
as if it were in its proper position, projects this image in the
TESTS FOR DIPLOPIA. 415
direction from which the luminous rays would come, in order
that, in a normal position of the eye, the image should be
formed at o. To find this last direction, we have to suppose
the eye l returned to its normal direction, so that the visual
line, y x, would occupy the position now occupied by o o.
Then the yellow spot y would be at o in front of o' ; and o
would be displaced at an equal angle, and be found at o'.
Now, the object of which o is the image must be on the line
which is drawn from the image through the optical centre,
i. e., on the line o' o' ; therefore the eye when deviating pro-
jects the image o in the direction o' o', because this is the
direction which the rays would have if the eye were in its
normal position, and the retinal image were at o. Now, this
projection of the object to o' is on the same side as the
deviating eye l, and the diplopia is therefore called homony-
mous.
It will be easily seen that if the eye l had been divergent
instead of convergent, the image would have been projected
to the opposite side. The anterior part of the eye being thus
turned outwards, the posterior part is turned in the opposite
direction, and the image of o w^ould then have fallen on the
outer side of y. And since, in the natural state, it is the
object situated to the inner side which forms its image on the
outer part of the retina, the image is projected in the direction
of the nose, that is, to the right of o. Under such circum-
stances the diplopia is said to be crossed.
Hence in any case of strabismus where diplopia is present
we have the following rule : The displacement of the false image
is always in the direction which is opposite to that of the deviation of
the eye. Thus, when the eye deviates inwards (convergent
strabismus), the diplopia is homonymous; when outwards
(divergent), there is crossed diplopia ; when upwards, the false
image is below ; when downwards, it is above.
Tests for diplopia. — A very simple and ready method of
ascertaining the kind of diplopia is to cover the non-deviating
eye with a deep red glass by means of a spectacle-frame.
Then, in a darkened room, we hold a lighted candle about
three metres in front of the eyes. The patient will then say
that he sees two flames, the one red and the other yellow.
416 DISEASES OF THE OCULAR MUSCLES.
The red flame is the projection of the image formed upon the
eye which has the glass in front of it; the yellow flame belongs
to the uncovered eye.
By now interrogating the patient as to the relative positions
of the two images, we can ascertain the exact nature of the
diplopia. Thus, if the red flame appears on the same side as
the red glass, the diplopia is homonymous and the deviation is
inwards ; if the red flame is on the opposite side, the deviation
is outwards and the diplopia crossed ; if above, the deviation
is downwards; if below, the deviation is upwards; if down-
wards and inwards, the deviation is upwards and outwards ;
and so on for each of the oblique meridians. By this method,
we are able to detect all degrees of deviation. It sometimes
happens in slight forms of strabismus that the patient can suc-
ceed in uniting the double images for some time, and so sees
only one flame. Under such circumstances, we have only to
place a prism, base upwards or downwards, in front of one
eye. This has the eflTect of separating the two images verti-
cally, so as to render their fusion impossible, and the patient
being unable to correct the vertical diplopia by muscular eftbrt,
we can measure the horizontal displacement without difficulty.
Not only the kind but the degree of strabismus can be ascer-
tained by this test. This is directly proportional to the distance
between the two images. It is evident that the distance increases
with the degree of the strabismus.
Again, if we direct the patient to follow the light with his
eyes, the head being kept at rest, whilst we move the candle
in the directions of the various meridians, we find that in
paralytic squint, the diplopia is increased more in looking in
one direction than in another; and that the distance between
the images becomes greater as the eyes are turned in the direc-
tion of the action of the paralyzed muscle.
Again, if we find that during this movement of the eyes in
following the flame, the distance between the images remains
constant, we know that the strabismus is not due to paralysis
of an ocular muscle.
Finally, by measuring the actual distance between the
images, and the distance of the candle from the eye, it is pos-
sible to calculate the angle of the strabismus.
PARALYTIC STRABISMUS. 417
Three chief divisions of strabismus will now be described,
viz., Apparent strabismus , Paralytic strabismus, and Concomitant
strabismus.
Apparent or false strabismus is the term applied to an appa-
rent convergence or divergence of the eyes which is occasion-
ally observed, but which upon careful examination is found to
be due to the angle alpha (p. 339). We are accustomed to
judge of the direction of the eyes by the direction of the optio
axes which pass through the centres of the cornese; but if the
angle alpha is large, and the visual axis is directed toward an
object, the oj^tic axis will then be directed slightly outwards,
and so give rise to apparent divergence. This condition is
sometimes found in hypermetropia. Again, if the angle alpha
is negative, the optic axis will appear to deviate inwards
when the visual axis is directed to the object of fixation.
Such apparent convergence is sometimes observed in myopia.
To distinguish between apparent and real deviation, the patient
is directed to look steadily at an object held about a metre's
distance from the face. If there is no real strabismus, each
visual line will be directed toward the object; and if either eye
is covered, the uncovered eye will still see the object without
shifting its position. If, on the contrary, there is strabismus,
only one visual axis will be fixed on the object, and the other
will deviate. If the fixing eye be now covered, the deviating
eye must be moved in order to see the object, and by the
movement we can judge of the extent and direction of the
previous deviation.
Paralytic strabismus is that in which deviation of the visual
axis is caused by the paralysis or paresis of one or more of the
ocular muscles.
Symptoms common to ocular parcdysis. — 1. The mobility of the
affected eye is diminished in the direction of the action of the
paralyzed muscle, and the field of fixation, if tested by means
of the perimeter, is found to present a definite limitation ac-
cording to the muscle affected.
2. The primary deviation — that is, the deviation of the affected
eye when the healthy eye fixes — is always less than the second-
ary deviation — that is, the deviation of the good eye when the
affected eye fixes.
27
418 DISEASES OF THE OCULAR MUSCLES.
8. Diplopia is generally present. As the eyes are turned in
the direction of action of the affected muscle, the distance
between the images increases. As the eyes are moved in the
direction of action of the opponent of the affected muscle, the
images approach and may coalesce.
4. There is frequently an inclination of the head toward
the side of the paralyzed muscle.
The cause of the muscular paralysis is usually some lesion
of one of the third, fourth, or sixth nerves. This may be cen-
tral^ — that is, in the region of the brain which corresponds to
the deep origin of the nerve affected ; or it may be peripheral, —
that is, somewhere in the course of the nerve either within
the skull or the orbit. These paralyses may be the result of
some tumor or other growth within the orbit, in which case
they are accompanied by other symptoms of the local affection.
In the majority of cases it is impossible to ascertain the exact
position of the lesion. The intimate connection of the nerves
with the meninfjes in the region of the cavernous sinus and
sphenoidal fissure renders them peculiarly liable to be affected
in meningitis, morbid growths, and syphilitic periostitis occur-
ring in these regions. Aneurism of the internal carotid artery
in the cavernous sinus sometimes causes pressure on these nerves.
Fracture of the base of skull sometimes affects these ocular nerves
either by pressure from the bone or by inflammatory exudation.
Symmetrical paralysis of all the ocular muscles (ophthalmoplegia
externa) is indicative of syphilitic disease of the nerve centres;
it is usually permanent, but occasionally it is evanescent.
Paresis of one or more of the ocular muscles is not a very
uncommon precursor of locomotor ataxy.
The muscles most frequently affected separately, are the
external rectus and the superior oblique. The other recti and
the inferior oblique, being supplied by the same nerve, are
frequently paralj'zed together, although separate affections of
these arc not uncommon.
Paralysis of the sixth nerve. — The external rectus is the muscle
affected. Here we find that the outward movement of the
globe is limited. Both primary and secondary deviations are
inwards. There is homonymous diplopia ; the double images
being on the same level, and, as there is no torsion of the globe,
PARALYTIC STRABISMUS. 419
they are parallel to one another : the distance between them
increases when the patient looks toward the side of the eye
aliected.
The line of separation between the portion of the field of
fixation in which there is single vision and that in which there
is diplopia, is situated obliquely ; its lower end being on the
healthy side.
The patient's face is often turned toward the affected side.
Paralysis of the fourth nerve. — The superior oblique is the
muscle affected. The movement of the eye is limited in the
downward and outward direction; and in complete paralysis of
this muscle the downward movement is limited also. The
jnimary deviation is upwards and inwards, whilst the secondary
deviation is downwards and inwards. There is homonymous
diplopia in the lower part of the field of fixation ; the images
being superposed. Owing to torsion of the globe outwards,
the image of the affected eye is oblique, its upper extremity
being inclined inwards. This image is also the lower of the
two, and its obliquity is increased on looking toward the af-
fected side. The vertical distance between the two images is
increased in looking downwards and toward the healthy side.
The fiilse image generally appears nearer to the patient than the
true image. The line of separation between single and double
vision is horizontally oblique ; its lower extremity being on the
affected side. The patient's face is often inclined downwards
and toward the healthy side.
Paralysis of the third nerve. — The paralysis of this nerve may
be coinplete, or only one or more of its branches may be in-
volved.
Complete paralysis of the third nerve presents a very charac-
teristic appearance. There is slight proptosis, and the upper
eyelid falls over the cornea (ptosis). The pupil is moderately
dilated, and does not respond to light. There is paralysis of
the accommodation of the affected eye. The movements of
the eye are limited in the inward, upward, downward, and in-
termediate directioi^s. Both the primary and the secondary
deviations are outwards. There is crossed diplopia. The false
image is oblique, and is inclined toward the affected side : it
also appears nearer to the patient and higher than the true
420 DISEASES OF THE OCULAR MUSCLES.
image. The lateral distance between the images is increased
in looking toward the healthy side. The vertical distance and
the obliquitj- increase on looking upwards, and diminish on
looking downwards and toward the sound side. The patient
often inclines his face toward the sound side and somewhat
upwards.
Partial paralysis of the third nerve may affect one or more of
the muscles supplied by it.
The internal rectus is the muscle most frequently involved.
Its paralysis is accompanied by limited movement of the globe
inwards. Both the primary and the secondary deviations are
outwards. The diplopia is crossed ; the double images being
parallel and on the same level. The distance between the
images is increased when the patient looks toward the sound
side, and when he looks upwards. The line of separation be-
tween the single and double images in the field of fixation is
inclined obliquely; its higher extremity corresponding to the
sound side. The patient turns his face in the direction of the
affected eye.
Paralysis of the superior rectus is characterized by limited
movement of the globe in the direction upwards and slightly
inwards. The primary deviation is downwards, and when the
patient looks upwards this is downwards and outwards. The
secondary deviation is upwards. The diplopia is most marked in
looking upwards. The images are superposed, slightly crossed ;
the false image is the higher, and its upper end is inclined to-
ward the healthy side. The patient turns his face upwards.
The inferior rectus is but rarely paralyzed alone. When
such paralysis exists, there is restricted movement of the globe
in the downward direction. The primary deviation is upwards
and outwards. The secondary deviation is downwards and
outwards. The diplopia is most marked in looking down-
wards. The images are superposed and they are slightly
crossed; the false image being the lower, and its apex inclined
toward the affected side. The vertical separation of the images
is increased by looking downwards and to the affected side.
The patient turns his face downwards and slightly toward the
affected side.
The inferior oblique, when paralyzed, is unable to turn the
PAEA LYTIC STRABISMUS, 421
eye upwards and outwards. The primary deviation is there-
fore downwards and inwards; whilst the secondary deviation
is upwards and inwards. The diplopia is most marked in
looking upwards when the images are superposed and slightly
homonymous. The false image is the higher, and its upper
end is inclined outwards; this obliquity increases on looking
toward the affected side. The patient directs his face upwards
and rather toward the side of the healthy eye.
The treatment of these paralyses must, as fiir as possible, be
regulated by the cause of the affection. When central disease,
of the brain or the medulla, can be traced as the cause of the
local affection, the chief malady must be first dealt with.
When sj'philis is the probable cause, we must have recourse to
the iodide of potassium in large doses, with or without the
use of mercury. Where the local failure is associated with a
rheumatic diathesis, the use of alkalies combined with colchi-
cum, vapor-baths, warm clothing, etc., is advisable. In cases
of great debility after acute illness, as diphtheria, typhoid, or
other causes, the general health must be improved by the
administration of good food, tonics, such as ammonia and
bark, quinine, iron, and cod-liver oil.
In the use of these therapeutic agents, it should be borne in
mind that spontaneous recovery from defective muscular action
and even from paralysis is not uufrequent ; also that these
cases sometimes fluctuate in their severity from day to day.
Electro-therapeutics are sometimes beneficial here, as in other
nerve lesions. Both the jonmary (galvanic, continuous) and
the secondary (induced, faradic) currents are employed. The
plan I usually adopt, is to use both these currents alternately.
The application should be made daily for a period not exceed-
ing five minutes. By means of small moist sponges one pole
of the battery is placed behind or in front of the mastoid pro-
cess, and the other is placed over the closed eyelids of the af-
fected eye. The strength of the current should be as great as
the patient can tolerate without actual pain.
In addition to these medical and electrical remedies, some
precautions may at the same time be taken to prevent, or to
alleviate the discomfort produced b}' the diplopia. Closure of
the affected eye by means of a shade or a disk of ground glass
422 DISEASES OF THE OCULAR MUSCLES.
mounted in a spectacle frame is of the greatest service; thus
preventing the double vision.
In fact, the patient generally closes the affected eye of his
own accord. If the good eye be closed, the diploj)ia certainly
disappears, but there is always the false projection of the image
in the direction of the action of the paralyzed muscle, which
produces vertigo and diflaculty in judging of the position of
surrounding objects, with other disagreeable sensations.
Prisms. — In certain cases which have become stationary,
and in which the images are not too widely separated, the
employment of prisms proves beneficial in both reducing the
diplopia and stimulating the muscle to renewed action. If we
look through a prism, we find that it produces an effect similar
to that of a pathological deviation : it causes diplopia. It
follows, therefore, that b}' the proper employment of a prism
we are often able to neutralize the diplopia. In the use of a
prism, the rule is to place its apex in the same direction as that
in which the eye deviates: thus, if the eye turns outwards, the
apex of the prism must be turned outwards; if the eye turns in,
the apex must be inwards also. In practice, it is well to use a
prism slightly below the full correction, so as to give the affected
muscle an opportunity of exerting itself; thus, should the
diplopia be corrected by a prism of 4°, we would prescribe
a prism of 3° in preference to a four degree prism. Another
practical point is to divide the prism between the two eyes;
thus, supposing a number six is found to reduce the diplopia
when placed before the affected eye with its apex outwards,
we prescribe two number three prisms, apices outwards ; one
for each eye. As the impaired muscle regains its strength,
the strength of the prism must be diminished.
Operative treatment is, never justifiable unless there is evidence
of some recuperative power in the paralyzed muscle, and all
the remedies above mentioned have been duly tried without
success. Even after the deviation has become stationary, it is
well to wait a few months before resorting to operative
measures, inasmuch as spontaneous recoveries sometimes take
place in the most unexpected manner. When, however, a
muscle has been partly paralyzed for upwards of six months,
and has resisted all other treatment, an operation may be of ser-
CONCOMITANT STEABISMUS. 423
vice. This may consist of simple tenotomy of the antagonistic
muscle so as to weaken its action, or it may require advance-
ment of the affected muscle. The mode of procedure in these
operations is exactly similar to that for Concomitant Strabismus.
Concomitant strabismus is the name given to a form of squint
which is caused by excessive or defective convergence of the
visual axes without any impairment of the other conjugate
movements of the eyes.
It differs from paralytic squint in several ways (see p. 417).
1. The mobility of the affected eye is not diminished in any
particular direction, and possesses a normal field of fixation.
2. The primary deviation is equal to the secondary.
3. Diplopia is generally absent, but, when present, does not
disappear in any particular part of the field of fixation. The
two images preserve a constant relation to one another in all
positions of the eyes.
4. There is no particular inclination of the patient's head.
Concomitant squint may be convergent or divergent.
Convergent strabismus (internal strabismus) is generally asso-
ciated with hypermetropia, although it occasionally occurs in
emmetropic and myopic eyes. It generally commences in
early life. A patient who is hypermetropic has always to use
an excessive amount of accommodation in order to see objects
clearly (see Refraction), and we have seen on p. 413 that the
act of accommodation is naturally associated with that of con-
vergence, hence the hypermetrope finds it easier to use the
requisite amount of accommodation if he uses his convergence
at the same time. The consequence of this is that the visual
lines cross between the patient and the object looked at. If
each eye deviated inwards to the same extent, it is evident
that the image of an object placed in the middle line would
fall in each eye to the inner side of the yellow spot; homony-
mous diplopia would be the result, and neither eye would see
the object in its true position. We have seen, however, that
the act of convergence is independent of the other conjugate
movements. So that all the patient has to do, in order to see
the object clearly, is to move both eyes to the right or to the
left, so that (the same amount of convergence being main-
tained) the visual axis of one eye is directed to the object,
424
DISEASES OF THE OCULAR MUSCLES,
while the other deviates inwards. Thus, supposing that the
strabismus was such that if it affected the two eyes equally,
each eye would deviate inwards five degrees from its normal
position ; then, the one eye being directed to the object looked
at, the visual axis of the other would deviate ten degrees
from its normal position. The squinting eye in this case re-
ceives the image [to the inner side of the yellow spot, and
Fig. 121.
therefore projects it outwards, but as it is formed on a peri-
pheral part of the retina, it produces a less intense visual im-
pression than the image on the yellow spot of the other eye;
hence the patient easily learns to disregard it, or, as it is
termed, to " suppress" it.
In the early stages, the patient will often fix with either
CONCOMITANT STRABISMUS.
425
eye indifferently, and the squint is then said to be altemaiing.
After a time, however, he acquires the habit of always fixing
with the same eye, and the squint becomes ^xe<i in the other.
Even when the squint, however, has been fixed for many years,
if the fixing eye be covered, the other can be made to fix on
the object, the eye which is usually the fixing eye will squint;
but, directly the eye is uncovered, it returns to its former
position.
As long as the squint is alternating, each eye is used to the
Fig. 122.
-Strabismometer.
same extent, but directly it has become fixed, the squinting
eye ceases to be used, and its acuity of vision rapidly declines.
This is unaccompanied by any ophthalmoscopic change. "When
the defective vision has existed for any length of time, it can
only be improved by constant use of the eye, and even with
such use the visual acuteness can seldom be entirely restored ;
hence the importance of treating a squint at the time it be-
comes primarily fixed.
It is usually quite easy to detect which is the squinting eye. We
426 DISEASES OF THE OCULAR MUSCLES.
direct the patient to fix upon a small object, such as the tip of
the index finger, held about half a metre's distance in front of
the eyes. One eye is then observed to be directed toward the
object, and the other to be more or less deviating : this is called
primary deviation. If the eye which the patient thus prefers to
use, be then covered by a disk of ground glass, the deviating
eye will be observed to move before it can fix the object, and
the covered eye will now be seen, through the ground glass,
to have deviated in a similar way toward the first eye ; this is
called secondary deviation.
To find the amount of deviation. — 1. This may be approxi-
mately eft'ected by measuring the distance between two vertical
lines, one passing through the middle line of the palpebral
aperture, and the other through the centre of the pupil.
Various instruments (Fig. 122) are made, by which the dis-
tance between these two vertical lines can be measured in
lines or millimetres.
2. The angular measurement of strabismus is more accurate
than the above.
The angle of the strabismus is the angle lohich the visual axis of
the deviating eye makes with the direction which it should have in a
normal condition (Landolt). The measurement of this may be
ettected by using the arc of the perimeter. The graduated
arc ADA (Fig. 121) is placed horizontally. The deviating eye
L is placed at the centre of the arc, and the patient is told to
fix upon a distant object situated at o on the central radius. This
he does with the normal eye r. ISTow the point o is that to
which the deviating eye l would be directed in a normal con-
dition. For all practical purposes it is sufficient to find the
point a:, on the optic axis, and to consider the angle o l a: as the
angle of the strabismus.
To find this, we pass the flame of a candle along the arc of
the perimeter, keeping our own eye close to the candle, until
the image of the latter is seen reflected from the centre of the
cornea. The point x on the arc, at which this image is seen,
is then read off, and we know the angle o l x.
Divergent strabismus usuall}' occurs in association with my-
opia, although it is found in emmetropic and occasionally in
hypermetropic eyes.
CONCOMITANT STRABISMUS. 427
The conDection between myopia and divergence is analogous
to that between hypermetropia and convergence. In mj^opia
the accommodation is little used, and in high degrees not at
all, hence the patient finds it very difficult to use the great
amount of convergence which would be required to obtain
binocular vision at the close range at which he has to hold all
objects. The difficulty of convergence is also increased by the
elongated form of the globe by which it is much less adapted
than the more globular emmetropic eye for rotating in Tenon's
capsule.
At first the divergence is only relative, that is to say, there
is no actual divergence of the visual axes, but they are diver-
gent rf^a//ye to the point looked at; in other words, there is
inability to converge. Later on, the divergence becomes actual.
"When an eye has ceased to be of use for visual purposes,
whether from amblyopia, opacity of the cornea, or other
causes, it frequently undergoes deviation; which as a rule
takes place outwards.
The treatment of concomitant squint. — 1. In all cases, whether
convergent or divergent, the refraction of each eye should be
carefully examined, and correcting glasses prescribed (see Re-
fraction).
Children under five years of age are usually too young to
wear glasses. In such cases all exercises requiring accommo-
dation in the use of the eyes, such as reading fine print, should
be discouraged. The child can be taught by means of large
tj^pes, block letters, etc., until it is of sufficient age to wear
spectacles.
2. The refraction being thus corrected, it is often found
that intermittent strabismus is removed without operation,
and even in cases where the squint has become established and
remains apparently permanent for some wrecks, it is occasion-
ally found that the constant use of appropriate, spectacles will
cure the affection in the course of a few wrecks.
3. When the strabismus is permanent, an operation must be
performed in addition to the optical correction. The opera-
tions for squint are two, viz., tenotomy of the retracting
muscle and advancement of its antao-onist.
428
DISEASES OF THE OCULAR MUSCLES.
Tenotomy of the internal rectus. — This operation is performed
for convergent strabismus. It consists in dividing the tendon
close to its insertion into the sclerotic, and is done subcon-
junctivally. When the deviation is slight (about 15°) the
simple division of the rectus belonging to the deviating eye
is usually sufficient. When the
deviation exceeds this, the in-
ternal recti of both eyes should
be divided. When the deviation
is excessive and the eye so in-
verted that the sclerotic is cov-
ered by the inner canthus, it
is advisable not only to divide
both the internal recti, but also
to liberate the conjunctiva from
the subconjunctival tissue and
the capsule of Tenon by free in-
cision with the scissors before
the tendon is divided.
Operation. — G. Critchett's
method. The instruments re.
quired are : (1) Speculum (Fig.
31) ; (2) Fixation forceps (Fig.
32) ; (3) Squint hook (Fig. 33) ;
(4) Blunt-pointed scissors (Fig.
123).
The patient is recumbent face
upwards. The surgeon stands
facing the patient and on his
right side ; the assistant being on
the opposite side. The eyelids
are to be widely separated by the
speculum. The surgeon pinches
up a fold of the conjunctiva and
subconjunctival tissue at a point
midway between the caruncle
and the cornea ; this is done with the fixation forceps held in
the left hand. With the scissors in the right hand he then
snips through these structures and the capsule of Tenon, and
Fig. 123. — Siiuint Scissors.
TREATMENT OF CONCOMITANT STRABISMUS. 429
exposes the sclerotic, which is known by its smooth, white,
shining appearance. The scissors are now put down and the
squint hook is inserted into the wound, which is still held
open by the forceps ; the hook is first directed rather away
from the cornea toward the caruncle ; its point is then made to
sweep upwards over the convexity of the globe and beneath
the rectus tendon, at the upper border of which it will be seen
projecting beneath the conjunctiva. On now drawing the
hook toward the cornea the tendon will occupy its concavity,
and the globe will be rotated outwards.
It is necessary to be careful to open the fibrous capsule of
Tenon, otherwise the hook will not pass beneath the tendon,
but between it and the conjunctiva. If this has occurred, it
will pass right up to the corneal margin instead of being
arrested by the muscle. The forceps are now relinquished,
and the hook passed to the left hand, by which it is held
parallel to the patient's nose, while some traction is made in a
forward and outward direction so as to tighten the tendon, and
render it accessible to the scissors. The scissors are now to be
passed into the wound between the hook and the eye ; in doing this
the blades should be slightly open, so that one passes in front and
the other behind the tendon. The tendon must then be di-
vided dose to the sclerotic by two or three snips. When this has
been done, the hook can be drawn forwards right up to the mar-
gin of the cornea. It should, however, be introduced a second
time, to ascertain if any strands of tendon have escaped division.
Where a considerable effect is desired, the scissors should be
passed between the conjunctiva and the globe in front of the
rectus before the tendon is divided. During the division of
the conjunctiva, the incision of the surrounding capsule of
Tenon should be more extensive than in a simple tenotomy.
Should this be still insufiicient to correct the deviation, the
eye may be held outwards for a day or two by means of a
stout silk suture. This is passed through the conjunctiva near
the outer margin of ths cornea, embracing about six mm. ; and
the two ends of the thread are fastened to the skin of the
temple by means of strapping.
In order to ascertain the result of the operation, it is necessary to
wait till the patient has regained consciousness: by then direct-
430 DISEASES OF THE OCULAR MUSCLES.
ing him to fix an object held at about half a metre in front of
the eyes we can ascertain whether the desired effect has been
obtained. If there is still convergence, the subconjunctival
tissue of one or both eyes must be more freely divided. If
too much effect has been produced, the divergence thus caused
may be rectified by dividing the tendon of the external rectus
of the deviating eye, or by the advancement of the internal
rectus which has just been divided. Either of these correct-
ing operations may be performed at once or after waiting for
a few weeks.
Tenotomy of the external rectus is performed for the cure of
divergence. The operation is performed in a similar way to
that just described for the internal tendon, except that the
incision, which is now made on the outer side of the globe
opposite the lower edge of the muscle, should be further re-
moved from the cornea. It must be remembered that the
insertion of the tendon is rather further back on the globe
(seven mm.), and that it is in closer apposition with the latter,
and consequently more difficult to hook than the internal rectus.
The main difficulties in the division of either of these
tendons are in opening and introducing the hook into Tenon's
capsule, and in cutting through the tendon without pushing it
off the end of the hook with the scissors.
Muscular advancement or adjustment signifies the detachment
of a tendon from its insertion in the sclerotic, and bringing it
forwards in such a manner that it may become adherent at a
point in front of its original position. By this means its
power in the rotation of the globe is increased. The opera-
tion is most useful in cases of extreme divergence, and more es-
pecially those in which the operation for convergent strabismus
has been followed by deviation in the opposite direction. The
internal rectus is the muscle most commonly advanced,
although the external is sometimes operated upon in this
way.
When there is extreme divergence, it is usual first to divide
the external rectus of the deviating eye, and then to proceed
to the advancement of the internal. Some surgeons, however,
prefer to postpone the tenotomy of the externus for a few
OPERATIONS FOR STRABISMUS. 431
weeks, with the hope of its not being required at all. Various
methods of performing the operation are practised.
The ojyeration which I have found most successful in these
cases, is the same as that performed by my colleague, Mr. An-
derson Critchett. The patient is anfesthetized, and the same
instruments are used as for ordinary tenotomy, with the addi-
tion of three sutures of fine black silk, armed at each end
with a small curved needle. The external rectus of the diverg-
ing eye is first divided in the usual manner. A vertical inci-
sion of about I to I of an inch (1.5 to 2 centimetres) is then
made in the ocular conjunctiva by means of the scissors; the
middle of this incision should be about xV of an inch (2 mm.)
from the inner edge of the cornea. The outer flap of the con-
junctiva and the subconjunctival tissues are then carefully dis-
sected away from the globe, as far as the insertion of the
tendon of the internal rectus. This is then divided close to
the sclerotic, either with the scissors alone or after having
passed the squint hook beneath the tendon. The muscle is
not dissected away from the capsule of Tenon and the con-
junctiva, but these are all held away from the globe en masse,
either with the ordinary fixation forceps or with de Wecker's
double strabismus hook (Fig. 124).
Fig. 124.— De Wecker's Double Strabismus Hook.
The three sutures are now to be introduced. One needle of
each suture is first passed from within outwards through the
flap of conjunctiva attached to the globe; one is introduced
just above the cornea ; one below it; and the third just opposite
its horizontal meridian (Fig. 125) : this being done, the sutures
are made fast by a single knot, and the needles are detached
from these ends of the sutures. The needles at the opposite
ends of the sutures are next passed from within outwards
through the outer flap. The middle suture is passed first
through the middle of the tendon near its extremity, and then
through the conjunctiva at a distance of several mm. from its
432
DISEASES OF THE OCULAR MUSCLES.
cut edge; the upper and lower sutures are similarly introduced
at the upper and lower parts of the tendon respectively, as
shown in the figure. The three sutures, now in their respective
places, are made tense by an assistant, whilst the surgeon
takes away a semilunar fold of conjunctiva and subconjunctival
tissue from the flap they have perforated (see Fig. 124, dotted
line). This may be done with the straight or curved scissors
and the fixation forceps; the amount of conjunctiva thus re-
moved must be proportionate to the effect desired. This done,
Fig. 125 — Operation for Advancement of Internal Rectus.
the edges of the conjunctiva have to be brought into apposition,
and the tendon advanced by tying the three sutures. The
middle suture should be the first to be tied, as it is supposed
to be nearest to the middle of the tendon. "When tied, the
sutures are cut short and are allowed to remain for a week.
The afiei'-treatment. — Simple tenotomy is never attended by
serious reaction. A cold-water compress and bandage can be
worn for twelve hours and then discarded. The subconjunc-
tival extravasation of blood usually disappears in the course
of two weeks, but if severe, as sometimes happens when
vomiting takes place immediately after the operation, its ab-
sorption may require a longer period than this.
AVhere ametropia exists, the correcting glasses should in all
cases be worn from the time of the operation.
Muscular advancement is followed by pain and swelling,
which may be considerable, and usually continue for a few
days. A cold compress should be worn, and the patient kept
in bed during the reaction.
PARALYSIS OF THE INTRAOCULAR MUSCLES. 433
The use of Prisms is recommended by some surgeons (Du
Bois Reymond, Javal) as a means of cure for concomitant
squint. The strength of the prism should be one or two de-
grees less than the angle of the strabismus, so that the patient
can practise fusion of the double image by the use of the two
eyes together. This method can only be of service in those
very rare cases in which there is still binocular vision.
Nystagmus is an oscillating movement of the globes, pro-
duced by the involuntary and jerky contractions of the ocular
muscles. It is commonly associated with some serious defect
of vision which has existed from very early life, such as opaci-,
ties of the cornea after purulent ophthalmia, pyramidal cata-
ract, albinism, choroido-retinitis, and other afiections. It is
sometimes observed in the course of diseases of the brain and
medulla. It is often developed in adult life amongst persons
who work in coal pits (miner's nystagmus).
The oscillatory movement may take place in any direction.
It may be horizontal, vertical, oblique, or rotatory; although
the horizontal movement is the one most frequently met with.
In different cases, and even in the same case, the movements
vary greatly in rapidity and extent. In the miner, for in-
stance, it often only takes place when he is in the stooping
posture.
Treatment fails to cure the affection. The vision should,
when possible, be improved by glasses.
Paralysis of the internal muscles of the globe. — We have already
seen (p. 412) that the third nerve supplies the ciliary muscle
and the circular fibres of the iris, whilst the sympathetic sup-
plies the radiating fibres.
Paralysis of the ciliary muscle (cycloplegia) is found in all
degrees of severity. It is usually associated with a similar
affection of the sphincter pupillte, although it is occasionally
found alone, as after certain cases of diphtheria. It is usually
seen in paralysis of the third nerve. There is loss of the
power of accommodation (p. 340), and the pupil is generally
dilated. Functional troubles, similar to those of presbyopia,
are experienced, and if the eye happens to be hypermetropic
there is deficiency in both near and distant vision. On the
other hand, in myopia the troubles in near vision are much less.
28
434 DISEASES OF THE OCULAR MUSCLES.
Paralysis of tlie accommodation from senile changes (pres-
byopia), and from the use of therapeutic agents such as atro-
pine, hoinatropine, duboisine, daturine, hyoscyamine, etc., will-
be found considered in the chapter on Refraction.
Tlie iris maybe aftected without the ciliary muscle; thus
we may tind paralj'tic myosis, and paralytic mydriasis. Occa-
sionally also both the ciliary muscle and both sets of iris fibres
are affected ; this condition is called ophthalmoplegia interna
(Hutchinson).
Myosis, or contraction of the pupil, may exist alone or in
conjunction with contraction of the ciliary muscle.
1. It may be only a sign of ordinary spasm of the accom-
modation, such as is frequently found in hypermetropia.
2. It may be due to paralysis of the radiating fibres of the
iris, and symptomatic of pressure upon the cervical sympa-
thetic.
3. It may be symptomatic of cerebral or spinal disease.
When myosis exists, and the pupil does not respond to light,
but changes its diameter with accommodation, we have the
condition known as the Argyll Robertson jyupil. It is indica-
tive of locomotor ataxy in a moderately advanced stage.
CHAPTER XVI.
DISEASES OF THE ORBIT.
CELLULITIS — ABSCESS PERIOSTITIS — CARIES — CEDEMA — EMPHYSEMA — DISTEN-
TION OF FRONTAL SINUS — EXOPHTHALMIC GOITRE — TUMORS — LIPOMA
FIBROMA — EXOSTOSES — SARCOMA — SCIRRHUS AND SOFT CANCER — PULSAT-
ING EXOPHTHALMOS — ERECTILE OR CAVERNOUS TUMORS — INJURIES AND
FOREIGN BODIES.
Cellulitis, or inflammation of the loose tissues of the orbit,
may arise spontaneously, or may come on in the course of an
attack of erysipelas.
In the milder cases the inflammation is localized ; there is
redness with oedema of the upper lid, and the conjunctiva is
generally raised either over its whole extent, or over a limited
area, by fluid. If the inflammation extends deeply into the
orbit, the globe will be rendered prominent. In most cases,
the movements of the globe are painful.
In the severer forms the symptoms are all more marked. The
inflammation may be ushered in with a rigor and a rise of
temperature ; there may be pain, swelling, and a dusky
appearance of the upper lid; the globe pushed forwards; the
conjunctiva congested, with considerable chemosis. The move-
ments of the eye are limited, and there is consequent diplopia.
Visual acuteness rnaj- be much interfered with, and the globe
may be involved in the inflammatory process. On digital ex-
amination between the upper part of the globe and the orbital
ridge, the tissues beneath are found to be tense, firm, and
painful on pressure. In some cases semifluctnation can be
felt. There is intense, deep-seated throbbing pain.
The causes of this affection are various, and frequently
43(} DISEASES OF THE ORBIT.
obscure. It often follows erysipelas of the face. Other causes
are injury, septiciemia, inflammation of the lachrymal gland,
periostitis.
Prognosis and treatment. — The milder forms are not danger-
ous ; they usually subside by the use of hot fomentations every
few hours, combined with dry warmth by means of cotton-wool
in the intervals, and general tonic treatment. The severer
forms nearly always lead to suppuration. As soon as this is
suspected to have taken place, exploratory incisions should be
promptly made; for this purpose a sharp scalpel should be
passed either through the upper lid near the edge of the orbit,
or through the conjunctiva above and on each side of the
globe, and then plunged deeply into the orbit ; its point being
directed away from the globe. Hot fomentations and poul-
tices should also be employed.
Acute abscess of the orbit is a most serious affection, not only
because it imperils the eye, but because a fatal termination is
by no means rare. It generally commences with the symp-
toms of acute cellulitis; in a few days these become more pro-
nounced, the pain becomes very severe, the globe more promi-
nent, and fluctuation may be detected. The absence of this
latter symptom, however, must not cause any delay in making
an incision if the other symptoms are sufficiently urgent; for
if suppuration is present, and the pus finds no exit, it burrows
among the ocular muscles, and may lead to their permanent
destruction. The tissue of the optic nerve may also become
involved, or the inflammation may spread through the orbital
plate of the frontal bone to the meninges of the brain, or by
the orbital veins to the cavernous sinus.
Chronic abscess presents less marked symptoms, and is some-
times difficult to diagnosticate from a soft orbital tumor, which,
owing to its elasticity, may appear to be semifluctuant. Pain
may be slight, or altogether absent. There is usually some ten-
derness on pressure. The subconjunctival tissue is congested
and swollen, and there may be considerable proptosis and
lateral displacement. A history of some injury at a distant
period will sometimes help in the diagnosis. An exploratory
incision into the semifluctuant region will often give exit to
purulent matter.
PERIOSTITIS. (EDEMA. EMPHYSEMA. 437
Acute periostitis presents the same symptoms as acute abscess
of the orbit; indeed, pus very rapidly forms beneath the peri-
osteum, dissecting it from the bone, causing the death of the
latter, and not unfrequently leading either to the formation of
an abscess in the anterior lobe of the brain, or to meningitis.
Treatment consists in making an early and free incision
down to the bone. The inflammation is of a low erysipela-
tous type, and antiphlogistic measures are not well borne. A
careful watch must be kept for the onset of cerebral symp-
toms.
Chronic periostitis is usually the result of syphilis, rheumatism,
or scrofula. The pain is of a dull aching character, and is
worse at night. When it affects the margin of the orbit, there
is oedema of the eyelid with tenderness on pressure. When
deeply seated, there is frequently paralysis of one or more of
the ocular muscles, and sometimes prominence of the eyeball.
The treatment consists in giving full doses of iodide of potas-
sium. Counter-irritation is sometimes useful. In scrofulous
cases it is nearly always the margin of the orbit that is affected ;
in such cases the treatment must then of course be directed to
the general disease.
(Edema of the orbital cellular tissue with exophthalmos
occasionally occurs, and usually indicates deep-seated trouble
in the circulation of the ophthalmic vein. This condition may
be brought about by any pressure upon the vein in its passage
through the sphenoidal fissure, such as oftea takes place in the
case of periostitis, tumors of the optic nerve, and such like,
and is then only a sign of embarrassed circulation ; but when,
in addition to these signs, we find the pupil widely dilated, the
globe quite immovable, and that cerebral sjniiptoms are becom-
ing manifest, the case is much more serious, and is indicative
of thrombosis of the cacernous sinus.
Emphysema, or the infiltration of air into the cellular tissues
of the orbit, may be caused by rupture of the ethmoidal cells,
or of the lachrj-mal sac. It may give rise to considerable
proptosis, with swelling of the conjunctiva and eyelids. The
swelling is increased when the patient makes a forcible expira-
tion with the anterior nares closed, as in blowing the nose.
On digital examination it is characterized by a crackling sensa-
438 DISEASES OF THE ORBIT.
tion. It can be reduced by firm pressure exerci§ed over
several days.
Distention of the frontal sinus — tlie result of pent-up secre-
tion or ])us — sometimes presents characters similar to those
of orbital tumor. It is usually the result of an injury, such
as a blow upon the forehead, although a long period usually
elapses before the appearance of the swelling : not unfre-
quently it comes on in children after measles or whooping-
cough. The swelling first appears at the upper part of the
inner angle of the orbit. At first it is hard, but after a time
it may become soft and fluctuating. The skin is freely mov-
able over the tumor. It is usually slow in progress, but is
liable at any time to take on acute suppuration. Before the
bony wall has become absorbed, it may easily be mistaken for
an exostosis, but it rises more gradually from the level of the
adjacent bone, and, by firm pressure, some elastic yielding can
usually be detected. In severe cases, the swelling is so exten-
sive as to push the eyeball downwards and outwards.
Treatment consists in making an opening into the nose to
replace the normal exit afforded by the infundibulum. For
this purpose, a free incision is made into the prominent part
of the tumor, through which a trocar is made to pass into the
nose. A fine drainage-tube is then passed through the hole
and out at the nostril, and there retained for some time. The
cavity may also be syringed out occasionally with tepid, earbo-
lized water. Treated in this way, the swelling generally re-
cedes, and the parts are sometimes restored to their normal
dimensions.
Exophthalmic Goitre (Graves's disease; Basedow's disease) is
the term api)lied to a group of symptoms of which the chief
are : (1) Paroxysmal cardial palpitation, with throbbing of the
vessels of the neck; (2) enlargement of the thyroid body;
and (3) prominence of the eyes. It may, however, exist in
the absence of proptosis on the one hand, or an enlarged thy-
roid on the other. It is usually ushered in by fits of caprice or
irritability of temper ; then come attacks of palpitation which
are often very violent, and are accompanied by a sense of suf-
focation, throbbing of the cervical vessels, and flushing of the
face. By and by the throbbing of the neck becomes more or
EXOPHTHALMIC GOITRE. 439
less permanent, and the thyroid gland is enlarged. This is
from extreme vascularization ; the arteries carrying hlood to
the gland become larger, and the gland appears to be lifted en
masse at each pulsation. The arteries witliin the gland be-
come increased in size and number, and the veins convey
arterial blood, so that the structure resembles a cirsoid aneu-
rism; indeed, the elasticity and pulsation, together with the
existence of blowing murmurs, have caused experienced ob-
servers to mistake this condition for aneurism.
The enlargement usually begins, and is generally larger on
the right side. Hypertrophy of the connective tissue may or
may not follow. Cystic bronchocele is a more rare accom-
paniment, and is probably a mere coincidence.
The eyes begin to look prominent at the same time, or a
little earlier than the thyroid enlargement; they have a shin-
ing appearance which, with the prominence, gives a peculiar
frightened expression to the face. The proptosis is usually
progressive, though stationary periods occur; it is generally
equal on both sides, and there is no strabismus. The retina is
not appreciably altered. Vision is usually normal. Von
Graefe laid some stress upon the fact that the association of
movement between the upper lid and the globe is lost in
Graves's disease ; this is not the effect merely of proptosis, for
it does not occur in cases in which the eye is pushed forwards
by a growth ; it probably results from an interference with the
action of the fibres of Miiller; the symptom, however, is cer-
tainly frequently absent.
It must be carefully borne in mind that the eyes themselves
are not enlarged, but are simply pushed forwards by the vas-
cular distention of the fatty connective tissue at the back of
the orbit. There is a venous stasis of this tissue, causing it to
become turgid like erectile tissue, a simile which Graves him-
self used. The eyeballs usually recede post mortem. True
hypertrophy of the retrobulbar tissue is, however, sometimes
found.
Sleeplessness is a common s\'mptom, especially early in the
case. A more or less permanent febrile condition is some-
times observed (Frissier, Basedow). The appetite may fail, or
may be greater than in health. Vomiting is common, and the
440 DISEASES OF THE ORBIT.
patient grows thin even when the appetite is good. Diarrhoea
is common and iisuall}' alternates with constipation. In women
there is generally amenoirhcca, usually accompanied by profuse
leucorrhcea. Stokes thought the whole disease due to anaemia,
but cases have occurred without any anaemia (Frissier).
Etiology. — The disease is far commoner among women, and
Trousseau states that out of lifty cases collected by Withuisen,
only eight occurred in men. The age is most commonly from
twenty to twenty-live, or a few years earlier, but tl>e disease is
rare in advanced life.
The patients are usually nervous subjects. Several cases
have been traced to fright or grief, but as a rule no cause can
be assigned. Trousseau and many others ascribe the disease
to derangement of the cervical sympathetic nerves and gan-
glia, especially the inferior cervical ganglia; hence paresis of
the vaso-motor system, and consequent dilatation of the vessels.
In various autopsies the above ganglia have been found dis-
eased, showing hypertrophy of the interstitial connective
tissue, and atrophy of the nervous elements. But other
careful observers (Ranvier, Wilks, Dejerine, Cheadle) have
failed to find any abnormal appearances in the sympathetic.
Dr. Cheadle, in an interesting case described in the St.
George^s Hospital Reports, found considerable capillary dila-
tation in the medulla oblongata and upper part of the spinal
cord, but without atrophy or cellular lesions, showing thus
simply increased vascularization. Xo lesions were found else-
where, neither in the viscera nor in the cervical sympatlietic.
The pneumogastric nerve is certainly implicated, as shown by
the disturbances of the digestive tract, and the palpitation of
the heart. The singular nervous sensibility, which is so early
and constant a symptom, and which in some cases has even
gone on to mania after the cure of both the exo|)hthalmos and
the goitre, would seem to point to the brain itself as the initial
seat of the disease.
Treatment. — The avoidance of mental emotion is very im-
portant. Digitalis is lauded by Trousseau, together with the
application of ice to the pnecordium and the thyroid body.
Bromide of potassium is useful, and so are opium and chloral.
Belladonna, which theoretically would be bad, is practically
TUMORS. 441
found to be of great benefit. Yeratum viride carefully given,
is much praised by Aran and See, as making the pulse slower
without increasing the arterial tension as digitalis does.
Iron has been found harmful. The galvanic and faradic
currents have been found to be beneficial in many cases.
During the last year I have handed over several cases to my
colleague, Dr. de Watteville, who assures me that they have
been remarkablj- benefited by this treatment. lie applies the
galvanic current about ten or fifteen minutes daily for several
weeks in succession, placing one pole over the nape, and the
other all over the anterior portions of the neck.
Tumors of all kinds are found in the orbit; they may orig-
inate within the tissues of the cavity; they may commence
within the eye and thence extend to the orbit ; or they may
invade that cavity from surrounding parts, as the nose, the
palate, the antrum, the skull, or the temporal fossa. Orbital
tumors may be non-malignant and of slow growth, as the
cystic, the fibrous, and the fatty kinds ; they may be malig-
nant and more or less rapid in progress, as the sarcomata and
carcinomata ; or they may be pulsating, as the vascular tumors.
Symptoms. — The presence of a tumor of any notable magni-
tude always gives rise to protrusion of the globe (proptosis).
When the tumor is deeply seated, and at the apex of the orbit,
this is usually one of the first signs of its existence ; when situ-
ated at one side of the orbit it usually causes lateral as well as
forward displacement. In proportion to the increase of the
tumor, so does the globe become displaced, until in severe
cases it is protruded beyond the palpebral aperture. Func-
tional troubles are, also, always present, and will vary accord-
ing to the position and size of the swelling; when the cranial
nerves are pressed upon, pain will be severe, and the move-
ments of the globe impeded; should the optic nerve be in-
volved, its function will be interfered with, and the vision
partly or entirely destroj-ed ; with lateral deviation where
vision remains, diplopia is always produced. Pressure upon
the ophthalmic vein is likel}'^ to set up oedema of the orbital
tissues. Proptosis is not always easy to make out ; it may be
mistaken for enlargement of the globe such as is sometimes
found in progressive myopia and secondary, glaucoma. In
442 DISEASES OF THE ORBIT.
such cases, if the upper lid is elevated by the surgeon's finger,
and the patient told to look downwards, the antero-posterior
elon<ration of the fflobe will be at once detected.
After a time, the tumor becomes apparent at some part of
the margin of the orbit, and can then be examined by palpa-
tion, by ascultation, and, if necessary, by exploratory punc-
tures. Whenever an orbital tumor is found to exist, the con-
dition of all surrounding regions, as the mouth, pharynx, and
nasal cavities, should be carefully examined.
Lipoma and Fibroma are extremely rare in the orbit; a few
cases, however, are recorded.
Cysts occurring in the orbit are not uncommon ; they are
usually either dermoid (see p. 24) or hydatid.
Exostoses of the orbit are similar to those occurring in other
parts of the body. They are usually of the ivory variety, and
attached by a broad base; in such cases it is impossible to
remove them. Occasionally, however, they are pedunculated,
and may then be sawn and wrenched oft. Such operations
are, however, not altogether free from risk when, as is usually
the case, the growth is attached to the roof of the orbit; for
a portion of the latter may easily be torn away, and a fatal
meningitis set up.
More rarely exostoses are met with which contain large
cystic cavities communicating w^ith each other; this variety
sometimes attains enormous dimensions.
Exostoses of the orbit are slow in development, and pain-
less in progress, producing in succession all the symptoms
that have been above enumerated as characteristic of intra-
orbital tumor.
Sarcoma is the most frequent of the new growths aftecting
the orbit. It may occur by extension from the choroid (p.
169), or it may first appear in the cellular tissue of the orbit.
Its rate of progress is very variable ; when it develops rapidly
the tumor presents but little pigmentation, whilst the slow-
growing sarconuita are usually dark in color, and are some-
times quite black.
The treatment consists in the early and complete removal of
the diseased tissues. AViien the tumor is small, circumscribed,
and near the surface, it can occasionally be removed without
SARCOMA. 443
molesting the globe of the eye. To facilitate this, the palpe-
bral opening may be enlarged by dividing the lids at the outer
canthus, and then dissecting in the direction of the tumor,
which, when exposed, may be seized with vulsellum forceps
and cleared from its surroundings by means of a steel director,
or by a strong, curved, blunt-ended scissors, and then cut or
torn away.
Sometimes a small orbital tumor can be removed by an
incision through the skin at the margin of the orbit without
interfering with the conjunctival sac.
When the tumor or new growth is extensive, and involves
the tissues of the orbit, or has recurred after removal, it is
necessary to take away the globe and the whole of the orbital
contents. To effect this, the external commissure must be
divided to the edge of the orbit, the conjunctiva separated
by incision through the whole extent of the upper and lower
culs-de-sac. The eyelids are then seized with forceps or re-
tractors, and drawn upwards and downwards by an assistant.
The globe can now be enucleated before taking out the tumor;
or the whole mass, including the eye, can be seized with vul-
sellum forceps and pulled forwards, while it is detached from
the walls of the orbit with strong blunt-ended curved scissors.
Having thus removed the greater part of the tumor, careful
digital examination must be made, and any further portions
of tissue which appear to be diseased removed. Hemorrhage
is usually copious, but generally ceases after pressure with
sponges or pledgets of cotton-wool. If it cannot be controlled
by these means, a button-shaped thermal cautery at a dull-red
heat may be used, or the strong perchloride of iron solution
may be applied.
When the tumor is suspected to be sarcoma or carcinoma,
it is well to supplement the extirpation by chloride of zinc
paste (F. 38) : small strips of lint about half an inch wide and
two inches long are covered with this and placed inside the
orbit over the exposed surface. These are then covered with
layers of cotton-wool. The eyelids must be protected with
vaseline; otherwise, sloughing is sure to take place. To pre-
vent further hemorrhage, the lids are then closed over the wool,
and covered with a tight compress. A hypodermic injection
444 DISEASES OF THE OKBIT.
of morphia should be given before the patient recovers from
the annesthetic ; otherwise, the pain from the chloride of zinc
is excruciatiiiET.
Scirrhus and soft cancer occur in the orbit either primarily
or by extension from surrounding parts.
The treatment consists in complete removal of the diseased
tissues, and in the application of the caustic paste (F. 38) to
the exposed surface.
Pulsating exophthalmos. — Cases are occasionally met Avith in
which the globe becomes protruded at the same time that a
soft pulsating swelling, with aneurismal bruit and thrill, ap-
pears at the upper and inner angle of the orbit.
The history usuallj- given is either that the patient has sud-
denly heard a loud snap, and that this has been succeeded by
an intermittent buzzing or blowing noise, and soon afterwards
by the pulsating swelling ; or that the symptoms have come
on very shortly after a severe injury to the head. In the
majority of these, symptoms of fracture of the base have been
present.
In a third class of cases, a perforating wound either in the
orbit or the roof of the mouth has been the immediate cause.
In the earlier cases the symptoms were supposed to be due
to intraorbital aneurism — an opinion which was strengthened
by the discovery of such aneurisms in two cases by Guthrie
and Carron du Villards. Later autopsies have proved that, at
any rate, in the majority of cases, the pulsating swelling in the
orbit is formed, not by the ophthalmic artery, but by the vari-
cose and distended ophthalmic vein, that this distention can
be traced back to the cavernous sinus, between which and the
internal carotid artery a communication often exists. This
arterio-venous communication may be brought about by the
giving way of an atheromatous patch ;^ by the rupture of an
aneurism in the sinus,^ by a fracture of the base passing across
the sinus,^ or by a wound. Thus in one of Xelaton's cases,*
> Hirschfeld, Gaz. des Hopit., 1859, p. 57.
' Baron, Med.-Chir. Tran?., xlviii. ; Kunneley, Med.-Chir. Trans., xlii.
' N^laton, Delens de la Communication dc la Car. Int. et du Sinus Cav., Paris,
187 .
*Nelat<>n, Delens, loc. cit.
PULSATING TUMORS. 445
the rib of an umbrella thrust into the right orbit passed
through the body of the sphenoid and wounded the left carotid
artery as it lay in the sinus; the injury was shortly followed
by pulsating exophthalmos on the left side.
In Schaefke's case, the artery was wounded by a pistol shot
tired into the mouth.
In a few cases, both orbits have been affected ; this occurred
in a case published by Mr. W. Adams Frost' The patient at
the time of observation was thirty-eight years old. AVhen ten
years of age he had been run over by a timber wagon. He
had symptoms of fracture of the base, and the characteristic
symptoms of pulsating exophthalmos appeared in the left orbit
and had persisted ever since ; shortly before he came under
observation a small pulsating swelling appeared in the right
orbit.
In a few cases, the symptoms have been due to a malignant
tumor in the orbit.
Treatment and prognosis. — Ligature of the common carotid
artery has been extensively employed, and with a fair amount
ot success; other measures, such as rest, low diet, application
of ice, galvano-puncture, and the injection of styptics, have
also been successful in some cases. The affection, however,
tends, after having reached a certain stage, to become station-
ary, and not infrequently undergoes spontaneous cure, so that
unless the noise in the head should be distressing, or the in-
crease in the size of the swelling rendered its rupture prob-
able, a prudent surgeon would not adopt such of the above
modes of treatment as are fraught with danger to life.
Erectile or cavernous tumors. — These growths, whose struc-
ture resembles very much that of the corpora cavernosa, seem
to be more frequent in the orbit than elsewhere. They are
slow-growing, but tend to mould themselves to the parts with
which they come in contact, so that their removal en masse
without injury to the optic nerve and muscles is generally
impossible, while their great vascularity renders a partial
operation troublesome and dangerous.
1 Trans. Ophthal. Soc, vol. iii.
446 DISEASES OF THE OKBIT.
Injuries and foreign bodies. — Tlie orbit is not a very uncom-
mon situation for a foreign bodj' to become embedded, while,
owins^ to the amount of fat which the orbit contains, its
presence may be unsuspected for many days — hence the im-
portance of making a very careful examination of a wound in
the eyelid or conjunctiva. As an instance of the ease with
whicli a large foreign body may be concealed in the orbit, the
case published by Mr. Carter is probably unique. An old
man, while drunk, fell down a flight of steps, at the bottom of
which was a row of hat-pegs. He received a contusion, and a
cut on the eyelid, which, after a few days, induced him to seek
advice. A surgeon treated him for several days, and then no-
ticed a black substance lying in the wound; on seizing this
with forceps he succeeded in withdrawing the shaft of a hat-
peg measuring three and a quarter inches in length.^
^ The peg is in St. George's Hospital Museum.
APPENDIX.
FORMULA.
1. Mitigated nitrate of silver crayon is made by fusing together
equal parts of nitrate of silver and nitrate of potash, and
running into moulds.
2. The same, consisting of 1 part nitrate of silver, 2 parts nitrate of
potash.
3. The same, consisting of 1 part nitrate of silver, 3 parts nitrate of
potash.
4. The same, consisting of 1 part nitrate of silver, 3 J parts nitrate
of potash.
5. Argent, uitrat. gr. i ; aquse destill. fgj. M.
6. Argent, nitrat. gr. x ; aqute destill. fgj. M.
7. Argent, nitrat. gr. XX ; aquse destill. fgj. M.
8. Zinci sulphat. gr. ij ; aquse destill. fgj. M.
9. Aluminis gr. ij ; aquse destill. fsj. M.
10. Zinci chlorid. gr. ij ; aquse destill. f§j. M.
11. Sodse carbonat. gr. x ; aquse destill. fgj. M.
12. Sodse carbonat. gjss ;. liq. carbonis detergens fjij ; aquse Oj. M.
13. Sod. biborat. gr. x ; aquse fsj. M.
14. Acidi boracici gr. iv ; aquse fsj. M.
15. Quinise sulphatis gr. iij ; acid sulph. dil. q. s., aquse. fsj. M.
16. Acidi carbolici gr. ij ; aquse tgj. M.
17. Homatrop. hydrobromat. gr. ij ; aquse dest. fsj. M.
18. Atropia^ sulphatis gr. i . aquse dest. fsj. M.
19. Atropise sulphatis gr. ij ; aquse dest. fsj. M.
20. Atropise sulphatis gr. iv ; aquse dest. fsj. M.
21. Duboisise sulphatis gr. j ; aquse dest. fsj. M.
22. Daturise sulphatis gr. iv ; aquse dest. fsj. M.
448 APPENDIX.
NO.
23. Ext. belladon. .^ij ; aqufe Oj. M.
24. Hydrarg. oxid. fiav. gr. ij ad gr. iv ; ung. petrolei §j. M.
25. Ung. hyd. nitrat. gr. xx ; ung. cetacei ^ij. M.
26. Ung. hyd. oxid. rub. gr. xx ; ung. cetacei jij. M.
27. Liq. plunibi subacetatis 5J ; aquie destill. Oj. M.
28. Cliloral. hydrat. gr. xx ad gr. xxx ; syrup, aurant. cort. f3ij ; aquie
l^jss. M.
29. Morphire hydrochloratis gr. i ; aqute dest. n^^v. M.
30. Pilocarpin. hydrochlorat. gr. iv ; aquie f5J. M.
31. Eserinic sulphatis gr. iv ; aqute fsj. M.
32. Pilocarpin. hydrochlorat. gr. v; aquse fgj. M. Three minims to
be injected hypodermically daily ; the strength of the dose to
be increased gradually. The object is to produce profuse
perspiration and slight salivation. Used in cases of detached
retina, choroiditis, and retinitis.
33. Sulphate of copper, alum, nitrate of potash, equal parts fused to-
gether, and camphor -^ part of the whole added. Run into
moulds and keep in stoppered bottles. This mixture is called
Lapis Divinus.
34. Atropiie sulphatis gr. ij ad gr. xx ; ung. petrolei sj. M.
35. Pil. hydrarg. gr. ijss ; ext. hyoscy. gr. ijss. M.
36. Pil. hydrarg. gr. ijss ; pulv. opii gr. }. M.
37. Liq. hydrarg. perchlor. f^j ; tinct. cinchonse fjss ; aquse fsj. M.
38. Zinci chlorid. 5ss; farinte 3j ; liq- opii sed. fgss. M.
SELECTIOiNS FROM THE TEST-TYPES
PROF. EDWARD JAEGER, OF VIENNA,
DR. H. SNELLEN, OF UTRECHL
29
DIRECTIONS FOR THE USE OF THE TEST-TYPES.
[In using the reading tests, the patient should be made to endeavor with
each eye separately to read the smallest type that he is able, at the nearest
and the farthest points possible. The size of the type, with both the points
obtained, are then to be registered for future comparison.
The types for distance should be placed twenty feet fix)m the patient, and
on a level with his eye. Each eye should be examined separately in ascer-
taining the line of smallest letters seen. The method of registering this
value has been explained in the text.
For full description of both the types of Jaeger and Snellen, see pages
344-346.-0.1
TEST-TYPES,
CORRESPONDING TO THE SCHRIFT-SCALEN OF
EDWARD JAEGER, OF VIENNA.
JSi^o. 1. — Diamond.
A Foi being caught in a trap, was glad to compound for his neck by leaving hia tail behind him; but upon coming abroad into
the world, he be^an to be so aenaible of the disgrace such a defect would bring upon him, that he almost wished he bad died
rather than come awaj without it. However, resolving to make the best of a bad matter, he called a meeting of the rest of the
Foies, aud proposed that all should follow his example. "You have no notion," said he, "of the ease and comfort with which
I now moTe about: I could never have believed it if I had not tried it myself; but really when one comes to reason upon it, a
tail is such an ugly, inconvenient, unnecessary appendage, that the only wonder is that, as Foies.we could have put up with it so
long. I propose, therefore, my worthy brethren, that you all profit by the experience that I am most willing to afford you, and
that all Foxes from this day forward cut off their tails." Upon this one of the oldest stepped forward, and said, *" I rather think.
No. 2.— Pearl.
my friend, that you would not have advised us to part with our tails, if there were any chance of
recovering your own." A Man who had been bitten by a Dog was going about asking who could cure
him. One that met him said, '■ Sir, if you would be cured, take a bit of bread and dip it iu the blood of
the wound, and give it to the dog that bit you." The man smiled, and said, "If I were to follow your
advice. I should be bitten by all the dogs in the city." He who proclaims himself ready to buy up his
enemies will never want a supply of them. A certain man had the good fortune to possess a Goose that
laid him a Golden Egg every day. But dissatisfied with so slow an income, and thinking to seize the
whole treasure at once, he killed the Goose, and cutting her open, found her— just what any other goose
No. 4. — Minion.
would be ! Much wants more and loses all. A Dog made his bed in a Manger, and
lay snarling and growling to keep the horses from their provender. " See," said one
of them, "what a miserable cur! who neither can eat corn himself, nor will allow
those to eat it who can." A Viper entering into a smith's shop began looking about
for something to eat. At length, seeing a file, he went up to it, and commenced
biting at it ; but the File bade him leave him alone, saying, " You are likely to get
little from me whose business it is to bite others." A Cat, grown feeble with age
No. 6. — Bourgeois.
and no longer able to hunt the Mice as she was wont to do, bethought
herself how she might entice them within reach of her paw. Thinking
that she might pass herself off for*a bag, or for a dead cat at least, she
suspended herself by the hind legs from a peg, in the hope that the
Mice would no longer be afraid to come near her. An old Mouse, who
was wise enough to keep his distance, whispered to a friend, "Many a
No. 8, — Small Pica.
bag have I seen in ray day, but never one with a cat's
head." " Hang there, good Madam," said the other, " as
long as you please, but I would not trust myself within
reach of you though you were stuffed with straw." Old
birds are not to be caught with chaff. As a Cock was
jaeger's test-types. 453
No. 10.— Pica.
scratching up the straw in a farm-yard, in search of
food for the hens, he hit uj^on a Jewel that by some
chance had found its way there. Ho ! said he,
you are a very fine thing, no doubt, to those who
No. 12.— English.
prize you; but give me a barley-corn before
all the pearls in the world. The Cock was
a sensible Cock ; but there are many silly
people who despise what is precious only
No. 14. — Great Primer.
because they cannot understand it.
A Man who kept a Horse and
an Ass was wont in his journeys
No. 15. — 2-li)ie English.
to ^pare the Hor^e,
and put all the hur-
den upon the A^^^^
SELECTIONS FROM SNELLEN'S TEST-TYPES. 455
li-
The Gallic tribes fell off, and sued for peace. Even
the Batavians became weary of the hopeless contest,
while fortune, after much capricious hovering settled
at last upon the Roman side. Had Civilis been suc-
cessful, he would have been deified; but his misfortunes,
at last, made him odious in spite of his heroism. But
the Batavian was not a man to be crushed, nor had
he lived so long in the Roman service to be out-
matched in politics by the barbarous Germans.
He was not to be sacrificed as a peace-offering to
revengeful Rome. Watching from beyond the Rhine
the progress of defection and the decay of national
2.
enthusiasm, he determined to be beforehand with those who were now his enemies. He
accepted the offer of negotiation from Cerialis. The Roman general was eager to grant a
full pardon, and to re-enlist so brave a soldier in the service of the empire. A colloquy was
agreed upon. The bridge across the Nabalia was broken asunder in the middle, and Cerialis
and Civilis met upon the severed sides. The placid stream by which Roman enterprise had
connected the waters of the Rhine with the lake of Flevo, flowed between the imperial
commander and the rebel chieftain. — Here the story abruptly terminates.
The remainder of the Roman's narrative is lost, and upon that broken bridge
the form of the Batavian hero disappears for ever. His name fades from
history; not a syllable is known of his subsequent career; everything is
buried in the profound oblivion which now steals over the scene where he
was the most imposing actor. The contest of Civilis with Rome contains a
remarkable foreshadowing of the future conflict with Spain, through
which the Batavian republic, fifteen centuries later, was to be
founded. The characters, the events, the amphibious battles, despe-
rate sieges, slippery alliances, the traits of generosity, audacity,
and cruelty, the generous confidence, the broken faith, seem so
closely to repeat themselves, that History appears to present the
3*.
selfsame drama played over and over again, with but
a change of actors and of costume. There is more than
a fanciful resemblance between Civilis and William the
Silent, two heroes of ancient German stock, who had
learned the arts of war and peace in the service of a
foreign and haughty world-empire. Determination,
SELECTIONS FROM SNELLEN'S TEST-TYPES. 457
concentration of purpose, constancy in cala-
mity, elasticity almost preternatural, self-
denial, consummate craft in political combi-
nations, personal fortitude, and passionate
patriotism, were the heroic elements in both.
The ambition of each was subordinate to the
51
cause which he served. Both refused
the crown, although each, perhaps,
contemplated, in the sequel, a Bata-
vian realm of which he would have
been the inevitable chief. Both offe-
red the throne to a Gallic prince,
for Classicus vras but the
prototype of Anjou, as
Brinno of Brederode^ and
neither vras destined^ in
this "world, to see his sacri-
fices crovrned "with success.
PLW
^iSTj.
Z B
R T
'Jj^'S^,
PI 11
SiC,
INDEX.
ABERKATION, 836
chromatic, 337
spherical, 336
Abscess, 96
of cornea, 96
of orbit, 436
Accommodation, 340
amplitude of, 341
spasm of, 354, 369
Achromatopsia, 252
Acute glaucoma, 315
Acuteness of vision, 344
Advancement of internal rectus, 430
Albuminuric retinitis, 204
pathology of, 206
plates of, 206
prognosis of, 206
signs of, 204
Alpha angle, the, 242, 339
Amaurosis, 219
degrees of, 219
in infancy, 221
tobacco, 219
simulated, 226
Amblyopia, tobacco, 219
from strabismus, 222
Ametrometer, Thomson's, 391
Ametropia, 346
Amplitude of accommodation, 341
Angle, alpha, 242, 339
in myopia, 350
visual, 343, 410
Ankyloblepharon, 42
Anterior chamber, 146
paracentesis of, 146
Anterior principal focus, 331
synechia, 99
Apparent strabismus, 417
Aqueous humor, 139
Argyll Robertson's operation for ec-
tropion, 37
Argyll Robertson's pupil, 434
Arlt's operation for entropion, 34
Arterial pulsation in glaucoma, 312
Artificial eyes, 115
celluloid, 115
Frost's, 339, 348, 353, 404
glass, 115
pupil, 176
Associated movements, 412
Asthenopia, 353
Astigmatic cloclt. Carter's, 385
disk, Oliver's revolving, 388
surface, refraction at, 355
Astigmatism, 355
compound, 19
of cornea, 343, 404
correction of, 385
definition of, 356
erect image in, 893
laws for refraction in, 856, 357
shadow-test in, 401
simple, 357, 387
varieties of, 356
vision in, 385
Atrophy of optic disk, 197
primary, 198
secondary, 199
symptoms of, 197
treatment of, 199
Atropia, action of sulphate of, 373
Atropine, 144
duration of, 370
efiects of, 144
in ghuicoma, 315
in hypermetropia, 370
in iritis, 144
irritation, 144
when necessary, 405
Axes of convex lens, 334
BASEDOW'S disease, 438
Biconvex lens, 333
Blepharitis, 20
Blepharospasm, 19
460
INDEX.
Blindness, color-, 252
varieties of, 252
Blind spot, 188, 233
Burns, 120
of cornea, 120
of eyelids, 42
nANAL, 264
\j of Petit, 264
of Schlemm, 125
Canaliculus, division of, 51
knife. Bowman's, 51
AVeber's, 51
obstruction of, 47
Carter's astigmatic clock, 385
Cataract, 264
artificial pupil for, 272
causes of, 269
classification of, 264
symptoms of, 270
treatment of, 272
Cataract extraction, 280
accidents and complications, 289
in capsule, 292
opaque capsule after, 297
sequehe of, 293
Cataract, operations for, 271
couching, 271
Critchett's, Anderson, 287
Daviel's, 282
extraction (see above).
flap operation, 281
Liebreich's, 287
linear method (Gibson's), 277
linear method (von Graefe's), 283
Macnamara's, 293
needling, 274
Pagenstecher's, 202
preliminary iridectomy, 281
solution, 273
Streatfeild's, 287
suction, 278
Taylor's, 287
Warlomont's, 287
De Wecker's, 287
Cataract, varieties of, 264
central, 264
congenital, 268
cortical, 265, 266
diabetic, 269
general, 268
hard, 268
lamellar, 265, 266
mixed, 268
Morgagnian, 269
nuclear, 264, 266
poster io polar, 266, 267
pynimida .266, 267
senile, 2
Cataract —
soft, 268
traumatic, 269
zonular, 265, 266
Cavernous tumors of orbit, 445
Cellulitis of orbit, 435
Cerebral hemianjesthesia, 224
Chalazion, 22
Chancre of eyelid, 28
Choroid, 138
anatomy, 138
coloboma of, 170
ophthalmoscopic appearances of, 150
rupture of, 159
sarcoma of, 167
tubercle of, 158
Choroiditis, 151
in myopia, 350
Choroido-retinitis, syphilitic, 154
Chromatic aberration, 33
Chronic glaucoma, 315
Ciliary arteries. 137
body, anatomy, 136
muscle, 135
paralysis of, 433
nerves, 139
region, wounds of, 130
Coloboma of choroid, 170
of iris, 170
Colors, complementary, 245
primar\', 244
of the solar spectrum, 243
Color-blindness, congenital, 251
frequency of, 258
methods of testing, 255
total, 252
varieties of, 252
Color-sense, the, 247
Hering's theory of, 249
Young's theory of, 248
Young-Helmholtz's theory of, 249
Color-vision, congenital defects of,
251
normal, 243
methods of testing, 255
Colors used in testing (plate), 2-56
Concave lenses in myopia, 348
images formed by, 336
Concomitant squint, 423
diagnosis of, 425
pathology of, 423
treatment of, 427
Congenital defects of color-vision, 251
opaque nerve fibres, 200
Conical cornea, 115
operations for, 117
Conjugate foci, 331
Conjunctiva, 62
amyloid degeneration of, 82
xerosis of, 83
INDEX,
461
Conjunctivitis, catarrhal, 70
diphtheritic, 78
gonorrhoeal, 65
granuhir, 72
membranous, 78
infantile, 65
phlyctenular, 77
purulent, 62
Contagious ophthalmia, 62
Convergence in myopia, 350
Convergent strabismus, 354
Convex lenses, images formed by, 335,
336
Cornea, abscess of, 96
anatomy of, 84
astigmatism of, 348, 404
burns of, 120
epithelioma of, 123
opacities of, 106
tattooing, 107
ulcers of, 98
wounds of, 121
Couper's ophthalmoscope, 361
Cowell's operation for glaucoma, 824
Crescent, myopic, 157, 350 j
Critchett's, Anderson, operation for i
cataract, 287
Crossed diplopia, 415
Cuppino-, glaucomatous, 188, 211
physiological, 183, 192
Cyclitis, 149
Cylindrical lenses, 358
Cysticercus in vitreous, 307
Cysts of orbit, 442
DATUEIA, action of sulphate of, 376
Daturin, 370
Day-blindness, note 225
Dermoid cyst, 24
Desmarre's retractor, 69
Detachment of the retina, 210
Diabetic cataract, 269
retinitis, 210
Dilatation of pupil in glaucoma.
Dioptric system of eye, 338
Diphtheritic conjunctivitis, 78
Diplopia, 415
crossed, 415
homonymous, 415
tests for, 415
Direct method, 364
as test for refraction, 392
Disk, optic, 197
atrophy of, 197, 198, 199
cupping of, 183, 192, 311
hyper;emia of, 192
Dislocation of lens, 298
Distention of frontal sinus, 438
Distichiasis, 32
Divergent strabismus, 427
Dondeis's schematic eye, 838
Duboisin, 370
Ij^CTROPION, 36
J Argyll Robertson's operation for, 37
Diett'enbach's operation for, 39
skin-grafting for, 41
Wharton Jones's operation for, 38
"Wolfe's operation for, 89
Egyptian ophthalmia, 62
Electro-magnet, tSnell's, 306
Embolism of the central artery of the
retina, 201
Emmetropia, 346
Emphysema of orbit, 437
Entropion, 82
Arlt's operation for, 34
Enucleation of eye, 113
Epicanthus, 41
Episcleritis, 71, 117
of cornea, 123
Epithelioma of eyelids, 26
Erectile tumors of orbit, 57
Errors of refraction, 346
Eserine, 102
in glaucoma, 321
in ulcers of cornea, 105
Exclusion of pupil, 142
Exophthalmic goitre, 438
Exoplithahnos, pulsating, 444
Exostoses of orbit, 442
External rectus, 411
action of, 411
paralysis of, 418
tenotomy of, 430
Extraction of cataract, 280
Eye, 338
dioptric system of, 338
optical constants of, 838
optical defects of, 342
optical properties of, 337
tension of, 310
Eyelids, 17
anatomy of, 17
burns of, 42
movements of, 19
physiology of, 17
FALSE image in diplopia, 415
Far-point, 852
in hypermetropia, 352
in myopia, 347, 384
virtual, 352
Fibroma of orbit, 442
Field of fixation, 239
limits of, 240
modes of testing, 241
462
INDEX.
Field of vision, 229
normal, plate of, 232
forcnlors, 229, 233
Fistula of lachrymal sac, 60
Flap operation for cataract, 281
Foreign bodies in cornea, 122
in eye, 306
in orbit, 446
in vitreous, 305
Formula for anterior principal focus,
331
conjugate foci, 331, 332
principal focus, 330, 334
Frontal sinus, distention of, 438
Frost's artificnil eye, 339, 348, 353,
404
Fulminating glaucoma, 315
Fuiidus-image test, 394
GLAUCOMA, 309
acute, 315
arterial pulsation in, 312
chronic, 315
contraction of field in, 313
cupping in, 311
dilatation of pupil in, 313
fulminans, 315
hemorrhagic, 316
primary, lirailey's theory of, 317
eserine in, 321
iridectomy in, 321
pathology of, 316
Priestlej' Smith's theory of,
317
sclerotomy in, 323
symptoms of, 309
treatment of, 320
Weber's theory of, 318
secondary, 325
causes of, 325
symptoms of, 325
treatment of, 325
subacute, 315
visual field in (plate), 238
Glioma of the retina, 215
diagnosis of, 217
pathology of, 216
plate of, "^21 6
symptoms of, 215
Groitre, exophthalmic, 438
Gonorrhoea! ophthalmia, 65
Graefe's, von, linear operation for cata-
ract, 283
Granular conjunctivitis, 72
Graves's disease, 438
Green-blindness, 252
Gumma of ciliary body, 167
of iris, 166
of eyelids, 28
HEMORRHAGES of the optic nerve,
200
of the retina, 203
into vitreous, 308
Hemorrhagic gluuc<inia, 316
Helmholtz's ophthalmoscope, 360
Hemeralopia, note 225
HemianiBsthesia, cerebral, 224
hysteiical, 224
Hemianopsia, 222
Hemiopia, 222
varieties of, 222
Charcot's theory of, 223
plate of, 222
symptoms of, 222
Bering's theory of the color-sense, 249
Heurteloup's artificial leech, 145
Holmgren's wools, 256
Dr. Thomson's arrangement of, 258
Homatropine, 370
action of hj'drobromate of, 373
Homonymous diplopia, 415
Hordeolum, 22
Hyaloid membrane, 302
Hyoscyamia, action of sulphate of, 376
Hyper.'emia of disk, plate of, 192
H3-permetropia, 346, 351
axial, 351
acct)mmodation in, 354
convergent strabismus in, 354
correction of, 407
latent, 369
manifest, 368
mydriatics in, 370
pathology of, 353
s^'mptoms of, 353
virtual image in, 395
Hypopyon, 97 ''
Hysterical hemianiesthesia, 224
TMAGE, 415
J^ false, ill diplopia, 415
real, 334
virtual, 334
Index of refraction, 334
Indirect method as test for refraction,
394
Inferior rectus, 420
paralysis of, 420
Inoculation for pannus, 93
Internal rectus, 428
anatomy of, 428
advancement of, 430
paralysis of 420
tenotomy of, 428
Inverted image, 394
in emmetropia, 365
in hypermetropia, 394
Iodoform in purulent ophthalmia, 68
INDEX.
463
Iridectomy, 176
for artificial pupil, 176
in glaucoma, 321
preliminary, for cataract, 281
for posterior synechise, 148
Irideremia, 170
Iridodesis, 178
Iridotomv, 178
Iris, 170'
absence of, 170
coloboma of, 170
gumma of, 166
tubercle of, 167
Iritis, 140
plastica, 172
rbeumatica, 143, 146
serosa, 141
suppurativa, 143
syphilitica, 143
traumatic, 147
treatment of, 144
Ischffimia of the retina, 201
J AVAL'S ophthahnometer, 404
Jequirity in pannus, 93
Juler's ophthalmoscope, 363
KERATITIS, interstitial, 87
phlyctenular, 95
punctata, 91, 141
suppurative, 96
Xeratoscopy, 404
LACHRYMAL apparatus, 45
anatomy of, 45
canaliculi, 46
ducts, 45
glands, 45
cysts of, 49
extirpation of, 49
fistula of, 50
hypertrophy of, 48
inflammation of, 47
probes, 55
sac, 46
abscess of, 53
fistula of, 60
syringe, 58
Lang's ophthalmoscope, 321
Laws of refraction, 328
Leech, artificial, 145
Lens, crystalline, 262
'dislocation of, 266, 298
histology of, 262
Lenses, 358
cylindrical, 358
numbering of, 358
Lenses, trial, 357
Leucocytha-mic retinitis, 208
Liebreich's operation for cataract, 287
Ligament, suspensory, 264
Ligamentum pectinatum, 126
Line of fixation, 410
visual, 410
Linear operation for cataract, 277
Lipoma of orbit, 442
Long-sightedness, 353
Lymphatics of eye, 139
MACNAMARA'S operation for cata-
ract, 293
Macula-lutea, 186
Malingering, 226
modes of detecting, 226
McHardy's perimeter, 234
Megalopsia, 226
Meibomian glands, 18
cyst, 22
Metamorphopsia, 226
Metrical system of numbering lenses,
358
Micropsia, 226
Miliary tubercle of iris and choroid,
167
Military ophthalmia, 62
Moll, glands of, 17
Molluscum contagiosum, 28
Movements, associated, 412
Mucocele, 53
Miiller, fibres of, 186
MusciB volitantes, 303
Muscles, 411
action of, 411
innervation of, 412
ocular, 411
orbicularis, 17, 18
Mydriatics, 370
in hypermetropia, 370
when necessary, 405
comparative action of, 370-382
Myopia, 346
axial, 346
causes of, 349
choroiditis in, 350
concave lenses in, 385
convergence in, 350
correction of, 348, 406
divergence in, 395
emergent rays in, 347
"far-point" in, 384
fundus changes in, 346
inverted image in, 395
pathology of, 349
prevention of, 351
progressive, 349
refractive, 346
464
INDEX.
Myopic crescent, 157, 350
Myosis, 434
N^VI, 25
Nasal duct, 47
stricture of, 52
Needle operation for cataract, 274
Neuritis, optic, 193
Night-blindness, 225
Nodal points, 333, 338
Nyctalopia, note 225
Nystagmus, 433
OCCLUSION of pupil, 142
Ocular muscles, 417
paralysis of, 417
(Edema of oibit, 437
Oliver's revolving astigmatic disk, 388
Onyx, 97
Opacities of vitreous, 303, 304
Opaque nerve-fibres, 200, 201
Operations :
for ptosis, 31
for trichiasis, 34
for entropion, 35
for ectropion, 36, 38, 39
skin-grafting, 42
for symblepharon, 43
extirpation of lachrymal glands,
49
division of canaliculus, 51
for pterygium, 81
peritomy, 92
paracentesis of anterior chamber,
103
Saemisch's, for corneal ulcer, 104
tattooing cornea, 107
transplantation of cornea, 108
enucleation, 113
for conical cornea, 117, 118, 119
iridectomy, 148, 171
for glaucoma, 173
for posterior synechia, 147
optical, 177, 272
preliminary, 281
iridodesis, 178
iridotomy, 178
for cataract (see Cataract), 274
sclerotomy, 323
paracentesis of vitreous, 324
for strabismus, 431
Ophthalmia, catarrhal, 70
contagious, 62
Egyptian, 62
gonorrhceal, 65
granular, 72
military, 62
neonatorum, 65
Ophthalmia —
purulent, 62
sympathetic, 162
Ophthalmometer, Javal's, 404
Ophthalmoscope, 359
as test of refraction, 391, 393, 394
Juler's, 363
use of, 364
varieties of, 360-363
Optic atrophy, visual field in, plate of,
222, 232
Optic commissure decussation in, 223
disk, 181
nerve, anatomy of, 180
atrophy of, 197
hemorrhages of, 200
sheath, 140, 181
source of fibres in, 223
Optic neuritis, 193
causes of, 196
pathology of, 195
sj'mptoms of, 193
theories of, 196
Optic tract, source of fibres in, 223
Optical centre of convex lens, 333
constants of eye, 338
defects of eye, 342
parallax, 312
principles, 327
properties of eye, 337
Optometer, Tweedy 's, 390
Ora serrata, 186
Orbicularis palpebrarum, 18
Orbit, abscess of, 436
cellulitis of, 435
cysts of, 442
diseases of, 435
emphysema of, 437
exostoses of, 442
fibroma of, 442
foreign bodies in, 446
injuries of, 446
lipoma of, 442
cedema of, 437
periostitis of, 437
sarcoma of, 442
scirrhus of, 444
tumors of, 441
PAGENSTECHER'S operation for
cataract, 292
Pannus, 73, 92
inoculation for, 93
jequirity, 93
Pannus, peritomy for, 92
Papillitis, 193
Papillomata of eyelids, 27
Paracentesis of anterior chamber, 103
of vitreous chamber, 324
INDEX.
465
Parallactic movements of vessels, 312
Parallel displacement, 328
Paralysis of ciliary muscle, 433
of ocular muscles, 417
causes of, 418
treatment of, 421
of ocular nerves, 418-420
Paralvtic strabismus, 417
Perimeter, 231
mode of usinc;, 231
McHardy's, 234
Priestley Smith's, 235
Perimetric observations, importance of,
237
Periostitis of orbit, 437
Peritomy, 92
Phlyctenular conjunctivitis, 77
keratitis, 95
Physiological cup, plate of, 192
Pigmentary retinitis, 209, 210
plate of visual field in, 238
symptoms of, 209
Pinguecula, 82
Plastic iritis, 172
Posterior staphyloma, 158, 350
synechia, 147
operations for, 147
Preliminary iridectomy for cataract,
281
Presbyopia, 340
correction of, 342, 408
Primary colors, 244
deviation in strabismus, 417
Principal axis of lens, 333
of spherical surface, 330
Principal focal plane, 330
focus, 330
meridians in astigmatism, 355, 386
Prisms in diplopia, 422
refraction by, 329
in strabismus, 433
Probes, lachrymal, 55
Progressive myopia, 349
Projection, false, 414
of image, 413
Pseudo-glioma, 152, 218, 308
plate of, 216
Pterygium, 80
treatment of, 81
Ptosis, 30, 419
Pagenstecher's operation for, 31
Pulsating exophthalmos, 444
Punctum, displacement of, 50
remotum, 347
Pupil, Argyll Eobertson's, 434
exclusion of, 142
movements of, 133
occlusion of, 142
Purulent ophthalmia, 62
Pyramidal cataract, 99
REAL image, 334
Eed-bliiidness, 252
Eefraction, 346
errors of, 346
index of, 334
laws of, 328
at plane surface, 328
at spherical surface, 329-332
methods of estimating, 367
through prism, 329
Kenal retinitis, 104
Ketina, 183
anatomy of, 184
detachment of, 212
glioma of, 215
inflammation of, 104
ophthalmoscopic appearance of,
189
phvsiologv of, 187
plates of, 212
Retinal artery, 201
embolism of, 201
Retinal hemorrhages, 203
ischiemia, 201
pulsation in, 191
veins, pulsation in, 191
Retinitis, 204
albuminuric, 204
diabetic. 208
leucocythaemic, 208
pigmentosa, 209
syphilitic, 208
Eetmo-choroiditis, syphilitic, 154
Retinoscopy, 396
Rheumatic iritis, 143, 146
Ring scotoma, 239
Rodent cancer, 26
Rotation, centre of, 410
Rupture of choroid, 1-59, 202
OAEMISCH'S operation, 104
Sarcoma, 28
of conjunctiva, 28
of choroid, 167
of orbit, 442
Scheiner's test, 391
Schematic eye, 338
Schlemm, canal of, 125
Scleritis, 126
sclerotic, 125
anatomy of, 125
ring, 183
rupture of, 127
wounds of, 129
Sclerotomy in primary glaucoma, 323
Scotoma, 233
mode of detecting, 233
for colors, 234
ring, 239 •
30
466
INDEX.
Secondary axes, 334
deviation in strabismus, 417
glaucoma, 32o
Serous iritis, 141
Shadow-test, 396
examples, 400
in aslii;matism, 401
in hyperinetropia, 398
in myopia, 398
Simulated amblyopia, 226
Skin-ffrafting for ectropion, 41
Smith's, Priestley, perimeter, 235
Snellen's types, 34-3, 449
Snow-blindness, 226
Sparklins; synchisis, 305
Spasm of accommodation, 354, 3G9
Spectacles, wearing of, 405
Spectrum, solar, 243
Spherical aberration, 336
Squint (see Strabismus).
Staphyloma, anterior. 111
posterior, 158, 350
Strabismus, 413
apparent, 417
concomitans, 423
measurement of, 426
paralytic, 417
Streatfeiki's operation for cataract, 287
Streatfeild-Snellen operation for entro-
pion, 35
Stye, 22
Subacute, glaucoma, 315
Suction operation for cataract, 278
Superior oblique, paralysis of, 419
rectus, paralysis of, 420
Suppurative iritis, 143
Sus[iensory ligament, 264
Sycosis tarsi, 20
Symblepharon, 43
Teale's operation for, 44
Wolfe's operation for, 44
Sympathetic inflammation, 162
causes of, 159
pathology of, 161, 163
treatment of, 164
Sympathetic invitation, 159, 162
ophthalmitis, 162
Synchisis scintillans, 305
Synechia, anterior, 99
posterior, 142
Svphilitic choroido-retinitis, 154
iritis, 143
retinitis, 208
ulceration of eyelid, 28
TARSAL cartilages, 18
tumor, 22
Tattooing, 107
Taylor's operation for cataract, 287
Teale's operation for symblepharon, 44
Tenon, capsule of, 126
Tension, intraocular, 310
Test-types, directions for use of, 450
Tinea' tarsi, 20
Tobacco amaurosis, 219
Transplantation of cornea, 109
Trephining cornea, 118
Trial case, 358
frame, 358
lenses, 257
testing refraction by, 367
Tubercle of choroid, 158
of iris, 167
Tumor of orbit, 441
Tumors, cavernous, 445
erectile, 445
Tweedy 's optometer, 390
Tyrrcl's hook, 177
ULCERS of eyelids, tertiary svphi-
litic, 28
cornea, 98
eserine in, 105
deep, 98
paracentesis in, 103
Saemisch's operation in, 104
scraping in, 104
serpiginous, 99
superficial, 88
treatment of, 101
Ulcer, rodent, 26
Uveal tract, anatomy of {see Choroid),
130
VENOUS pulsation, 312
Violet-blindness, 252
Virtual image, 334
Vision, color-, normal, 243
Visual acuteness, 344
angle, 343
axis, 410
purple, 250
field. 229
for colors, 232
in detachment of retina, 238
in glaucoma, 238
in hemiopia, 239
in optic atrophy, 237
in pigmentary retinitis, 238
limits of, 229
in toxic amaurosis, 239
modes of testing, 22w
Vitiligo; 25
Vitreous cells, 303
chamber, paracentesis, 324
cvsticercus in, 307
fluidity of, 305
INDEX.
467
Vitreous —
foreign bodies in, 305
hemorrhages into, 308
humor, 802
opacities, 303
WARLOMONT operation for cata-
ract, 287
Warts of eyelid, 27
Weber's canaliculus knife, 51
theory of glaucoma, 318
Wecker's, de, campimetre operation
for cataract, 287
Wolfe's operation for symblepharon,44
for ectropion, 39
Wools, Holmgren's 256
Wounds of ciliary region, 129
Wounds of —
cornea, 121
sclerotic, 129
X
ANTHELASMA palpebrarum, 25
YELLOW spot, 186, 190
X Yellow spot region, hemorrhages
into, 203
Young's theory of the color-sense, 248
Young-Helmholtz theory of the color-
sense, 248
yONULE of Zinn, 264
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About the first book purchased by the medical tJP''"', f^''' "if^^J' *°<;?^^ »°d with a brevity as ad-
student is the Medical Dictionary. The lexicon ^^rMe &s itis pTRCtic&l.-Southern Medical Record,
explanatory of technical terms is .simply a nine qua ^' •
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te the practising physician. To meet the wants of tious of the subjects treated under each head. It
students and most physicians the dictionary must ""ell deserves the authority and popularity it has
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while persjiicacious. It was because Dunglison's Few works of this class exhibit a grander monu-
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dictionary of general use wherever medicine was London Lancet, May 13, 1875.
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Surgeon to St. Bartholomew's and the Foundling Hospitals, London.
Landmarks, Medical and. Surgical. Second American from the latest revised
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in
the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila-
delphia School of Anatomy. In one hand.some 12mo. volume of 148 pages. Cloth, $1.00.
This little book is all that can be desired within almost to learn it by heart. It teaches diagnosis by
its scope, and its contents will be found simply in- external examination, ocftlar and palpable, of the
valuable to the young surgeon or physician, since bodv, with such anatomical and physiological facts
they bring before him such data as he requires at as directly bear on the subject. It is eminently
every examination of a patient. It is written in the student's and young practitioner's book. — Phy-
ianguage so clear and concise that one ought sician and Surgeon, Nov. 1881.
JYILSOW, BRASMVS,I.R.S.
A System of Human Anatomy, General and Special. Edited by W. H.
GoBRECHT, ^I. D., Professor of General and Surgical Anatomy in the Medical College of
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations.
Cloth. $4.00; leather, $5.00.
S3IITH, JX. S., 31. n., and SORJVBR, W3I. B.,M,I>.,
Emeritus JP>-of. of Surgery in the Univ. of Penna., etc. Late Prof, of Anat. in the Univ. of Penna.
An Anatomical Atlas, Illustrative of the Structure of the Human Body. In one
large imperial octavo volume of 200 pages, with 634 beautiful figures. Cloth, $4.50.
CLBLAJS^D, JOII]S\3Ln., F. R. S.,
Professor of Anatomy and Phiisiology in Queen's College, Galway.
A Directory for the Dissection of the Human Body. In one 12mo,
volume of 178 pages. Cloth, $1.25.
6 Lea Brothers & Co.s Publications — Anatomy.
ALLEN, HAJRRISON, M. D.,
Professor of Physiology in the University of Pennnylvania.
A System of Human Anatomy, Including Its Medical and Surgical
Relations. For the use of Practitionei-s and Students of Medicine. With an Intro-
ductory Section on Ilistuhigj. By E. O. Shakespeare, M. D., Ophthalmologist to
the riiihidelphia Hospital. Comprising S13 double-columned quarto pages, with 3S0
illustrations on 109 fall page lithographic plates, many of which are in colors, and 241
engravings in the text. In six Sections, each in a portfolio. Section I. Histology.
Section II. Bones and Joints. Section III. Muscles and Fascle. Section IV.
Arteries, Veins and LvMrHATics. Section V. Nervous System. Section VI.
Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology,
Developmf^-t, Teratology, Superficial Anatomy, Post-Mortem Examinations,
and General and Clinical Indexes. Price per Section, each in a handsome portfolio,
$3.50 ; also bound in one volume, cloth $23.00 ; very handisome half Kussia, raised bands
and open back, $25.00. For sale by subscription only. Apply to the Publishers.
Extract from Introduction.
It is the design of this book to present the facts of human anatomy in the manner best
suited to the requirements of the student and the practitioner of medicine. The author
believes that such a book is needed, inasmuch as no treatise, as far as he knows, contains, in
addition to the text descriptive of the subject, a systematic presentation of such anatomical
facts as can be applied to practice.
.•V book which will be at once accurate in statement and concise in terms ; which will be
an acceptable expression of the present state of the science of anatomy ; which will exclude
nothing that can be made applicable to the medical art, and which will thus embrace all
of surgical importance, while omitting nothing of value to clinical medicine, — would appear
to have an excuse for existence in a coinitry where most surgeons are general practitioners,
and where there are few general practitioners who have no interest in surgery.
It is to be considered a study of applied anatomy ' care, and are pimply superb. There is as much
In its widest sense — a systematic presentation of of practical application of anatomical points to
such anatomical facts as can be applied to the ■ the every-day wants of the medical clinician as
practice of medicine as well as of surgerj'. Our ' to those of the operating surgeon. In fact, few
author is concise, accurate and practical in his ! general practitioners will read the work without a
statements, and succeeds admirably in infusing : feeling of surprised gratification that so many
an interest into the study of what is generally con- ! Doints, concerning which they may never have
sidered a dry subject. The department of Histol- I thought before are so well presented for their eon-
ogy is treated in a masterly manner, and the sideration. It is a work which is destuied to be
ground is travelled over by one thoroughly famil- ] the best of its kind in any language.— .Ve<iicai
far with it. The illustrations are made with great | Record, Nov. 25,1882.
CLABKE, W, B,, F.B. C.S. & LOCKWOOD, C. B., F,B. C.S,
Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London.
The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with
49 illustrations. Limp cloth, red edges, $1.50. Just ready. See Students' Series of
Manuals, page 3.
This is a very excellent manual for the use of the part, are good and instructive. The book is neat
student who desires to learn anatomy. The meth- and convenient. We are glad to recommend it. —
ods of demonstration seem to us very satisfactory. Boston Medical and Surgical Journal, Jan. 17, 1884.
There are many woodcuts which, 'for the most
TBBVBS, FBBBBMICK, F, B, C. S.,
Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital.
Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages,
with 61 illustrations. Limp cloth, red edges, $2.00. Just ready. See Students' Series of
Manuals, page 3.
He has produced a work which will command a 1 q^uickened by daily u.«e as a teacher and practi-
larger circle of readers than the class for which it j tioner, has enabled our author to prepare a work
was written. This union of a thorough, practical 1 which it would be a most difficult task to excel.—
acquaintance with these fundamental branches, j The American Practitioner Feb. 1884.
CUBJSOW, JOHN, M, IS^F. B, C. B.,
professor of Anatomy at King's College, Physician at King's College Hospital.
Medical Applied Anatomy. In one pocket-size 12mo. volume. Preparing.
See Studeitt.i Scries of ^fanuals, page 3.
BELLAMY, EBWABB, F. B. C. S.,
Senior Assistaut-Surgecn to the Chariw/- Cross Hospital, London.
The Student's Guide to Surgical Anatomy : Being a Description of the
most Important Surgical Regions of the Human Body, and intended as an Introduction to
operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25.
HARTSHORNE'S HANDBOOK OF ANATOMY I HORNER'S SPECIAL ANATOMY AND HISTOL-
AND physiology. Second edition, revised. | OGY. Eighth edition, extensively revised and
In one royal 12mo. volume of 310 pages, with 220 i modified. In two octavo volumes of 1007 pages,
woodcuts. Cloth, $1.75. with 320 woodcuts. Cloth, $6.00.
Lea Brothers & Co.'s Publications — Physics, Physiol., Anat. 7
DBAPEH, JOHN C, 31. 2>., iX. D.,
Professor of Chemistry in the University of the City of New York.
Medical Physics. A Text-book for Students and Practitioners of Medicine. In
one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. Just ready .
From the Preface.
The fact that a knowledge of Physics is indispensable to a thorough understanding of
Medicine has not been as fully realized in this country as in Europe, where the admirable
works of Desplats and Gariel, of Kobertson and of numerous German writers constitute a
branch of educational literature to which we can show no parallel. A full appreciation
of this the author trusts will be sufficient justification for placing in book form the sub-
stance of his lectures on this department of science, delivered during many years at the
University of the City of New York.
Broadly speaking, this work aims to impart a knowledge of the relations existing
between Physics and Medicine in their latest state of development, and to embody in the
pursuit of this object whatever experience the author has gained during a long period of
teaching this special branch of applied science.
Certainly we have no textbook as full as the ex- | and it is one of the most valuable scientific
cellent one he has prepared. It begins with a , trestises given to the medical profession for a
statement of the properties of matter and energy, i number of years. It is profusely and handsomely
After these the special departments of physics are illustrated. The work should have a place upon
explained, acoustics, optics, heat, electricity and every physician's library shelf. — Maryland Medical
magnetism, closing with a section on electro- ; Jb!(rna/,. Julv 18, 1885. q.
biologj'. The applications of all these to physiologj- j This is the only vrork with which we are ac-
»nd medicine are kept constantly in view. The j quainted in which physics is treated with reference
text is amply illustrated and the many difficult to medicine. Preceptors who are axious that their
points of the subject are brought forward with re- pupils should have a scientific knowledge of med-
markable clearness and ability. — Medical and Surg- icine, should make this work a textbook, and re-
ical Reporter, July 18, 1885. q. quire a thorough study of it. — (Xncinnati Medical
The volume from beginning to end teems with News, July 18, 1885. q.
useful information. Take the book as a whole |
ROBEBTSOJS, J. McGBEGOB, M. A,, M. B.,
Muirhead Demonstrator of Physiology, University of Olasgow.
Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra-
tions. Limp cloth, $2.00. Just ready. See Students' Series of Manuals, page 3.
The title of this work sufficiently explains the i ments. It will be found of great value to the
nature of its contents. It Is desigiied as a man- ; practitioner. It is a carefully prepared book of
ual for the student of medicine, an auxiliary to \ reference, concise and accurate, and as such we
histext-bookinphysiology, and it wouldbeparticu- | heartily recommend it. — Journal of the American
larly useful as a guide to his laboratory experi- | Medical Association, Dec. 6, 1884.
DALTON, JOHIiT C, M. I).,
Prof essor Emeritus of Physiology in the College of Physicians and Surgeons, New York.
Doctrines of the Circulation of the Blood. A History of Physiological
Opinion and Discover}^ in regard to the Circulation of the Blood. In one handsome
12mo. volume of 293 pages. Cloth, §2. Just ready.
Dr. Dalton's work is the fruit of the deep research revolutionized the theories of teachers, than the
of a cultured mind, and to the busy practitioner it discovery of the circulation of the blood. This
cannot fail to be a source of instruction. It will explains the extraordinary interest it has to all
inspire him with a feeling of gratitute and admir- medical historians. The volume before us is one
»tion for those plodding workers of olden times, ' of three or four which have been written within a
who laid the foundation of the magnificent temple few years by American physicians. It is in several
of medical science as it now stands. — Neiv Orleans respects the most complete. The volume, though
iledical and Surgical Journal, Aug. 1885. small in size, is one of the most creditable con-
In the progress of physiological study no fact tributionsfroman American pen to medical history
was of greater moment, none more completely that has appeared. — Med. <fc Surg. Rep., Dec. C, 1884.
BY THE SAME AUTHOR.
The Topographical Anatomy of the Brain. In three very handsome quarto
volumes comprising 178 pages of descriptive text. Illustrated with 48 full page photo-
graphic plates of Brain Sections, with a like number of explanatory plates, as well as many
woodcuts through the text.
BELL, F, JEFFREY, 3L A.,
Professor of Comparative Anatomy at King's College, London.
Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages,
with 229 illustrations. Limp cloth, $2.00. Just ready. ^e& Students' Series of Manuals, ^digeZ.
ELLIS, GEOBGE fiNEIt,
Emeritus Professor of Anatomy in University College, London.
Demonstrations of Anatomy. Being a Guide to the Knowledge of the
Human Body by Dissection. From the eighth and revised London edition. In one very
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, 5>4.25 ; leather, §5.25.
MOBEBTS, JOHJS^., A, 3L, M. J).,
Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic and Coll. for Graduates in Medicine.
The Compend of Anatomy. For use in the dissecting-room and in preparing
for examinations. In one 16mo. volume of 19G pages. Limp cloth, 75 cents.
8 Lea Brothers & Co.'s Publications — Physiology, Chemistry.
n ALTON, JOHN C, 31. J).,
Piofcisor of Pluisiologij in the College of Physicians and Surgeons, Nevi i'ork, etc.
A Treatise on Human Physiology. Designed for the use of Students and
Practitioners of Medicine. Scvcntli edition, thoroughly revised and rewritten. In one
very handsome octavo vohinie of 722 pages, with 252 beautiful engravings on wood. Cloth,
$5.00; leather, $0.00; very liandsonie half Russia, raised bands, $6.50.
The merits of Fiofessor Da'lton's t<-xt-book, his more compact formj yet its delightful charm is re-
smooth and i>lea.«ing style, the remarkable clear- I fained, and no .<!uh_)ect is thrown into obscurity,
ness of his descriptions, which leave not a chapter j Altogether this edition is far in advance of any
obscure, his cautious judgment and the general | previous one, and will tend to keep the profession
correctness of his facts, arc perfectly known. They j posted as to tlie most recent additions to our
have made his text-book the one most familiar physiological knowledge. — Michigan Me<liral News,
to American students.— Jl/rd. liford, March 4, 1S82. April, 1S82.
Certainly no phy.«iological work hft.s ever issued ; One can scarcely open a college catalogue that
from the press that presented its subject-matter in j does not have mention of Dalton's J'hf/swlogy as
a clearer and more attractive light. Almost every the recommended te.xt or consultntion-book. For
page bears evidence of the exhaustive revision American students we would unreservedly recom-
that has taken place. The materifkl is placed in a i mend Dr. Dalton's work.- To. il/ed.il/on//i'i/,"July,'82.
FOSTEB, MICSAJELf^r. IK, F. B, S,,
Prt-hrtor in Phi/siologi/ aii'l Fellow of Trinitii College, Cambridge, England.
Text-Book of Physiology. Third American from the fourth Engli.sh edition,
with notes and additions by E. T. Keichert, M. D. In one handsome royal 12mo. volume
of 908 pages, with 271 illnslration-s. Cloth, $3.25; leather, $3.75. Just ready.
Dr. Foster's work tipon physiology is so well- ' to know and what maybe passed over by them as
known as a text-book in this cnuntryjtliatitneeds not importaijt. From tJie beginning to the end,
but little to be said in regard to it. There is j physiology is taught in a systematic manner. To
scarcely a medical college in the United States ' this third American edition numerous additions,
where it is not in the hands of the students. The corrections and alterations have been made, so
author, more than any other writer with wlicm that in its present form the usefuinet-s of the book
we are acc|Uainted, seems to understand what will be found to be much increased. — Cincinnati
portions o( the science are essential for students Medical A'cws, Jn\y \SS5.
POWEB, HENBY, M. B,, fTb. C, S.,
Examiner in Physiology, Royal College of Surgeons of England.
Human Physiology. In one handsome pocket-size li'mo. volume of 396 pages,
with 47 illustrations. Cloth, $1.50. See Shidents' Series of Manuals, page 3.
The prominent character of this work is tliat of
judicious condensation, in which an able and suc-
cessful ert'ort appears to have been made by its
dccomplished aiithi r to teacli the greatest number
of facts in the fewest possible words. The result
is a specimen of concentrated intellectual pabu
lum seldom surpassed, which ought to be care
to every one of our reader.s. — The American Jour-
nal of the Medical Sciences, October, 1884.
This little work is deserving of the highest
praise, and we can hardly conceive how the main
facts of this science could have been more clearly
or concisely stated. The price of the work is such
as to place it within the reach of all, while the ex-
fuUy ingested and digested by every practitioner cellence of its text will certainly secure for it most
who desires to keep himself well informed upon ; favorable commendation — Cincinnati Lancet and
this most progressive of the medical sciences.: C/inir, Feb. 10, 1884.
The volume is one which we cordially recommend
CABJPENTEB, WM. B,, M, !>., F B. S,, F. G, S., F. Z. S.,
Registrar to the University of London, etc.
Principles of Human Physiology. Edited by Henry Power, M. B., Lond.,
F. R. C. S., Examiner in Natural Sciences, University of Oxford. A new American from the
eighth revised and enlarged edition, with notes and additions by Francis G. S>riTH, M. D.,
late Professor of the Institutes of Medicine in the University of Pennsylvania. In one
very large and handsome octavo volume of 1083 pages, with two plates and 373 illus-
trations. Cloth, $5.50; leather, $fi..50; half Russia, $7^
FOWNES, GEOBGE, Bh. K
A Manual of Elementary Chemistry; Theoretical and Practical. Em-
bodying Watt.-' Inorcjonic Chemistry. New American edition. In one large royal 1 2mo.
volume of over 1000 pages, with 200 illustrations on wood and a colored plate. Cloth,
$2.75 ; leather, $3.25. In afeiv days.
A notice of the previous edition is appended.
The book opens with a treatise on Chemical
Physics, including Heat, Light, Magnetism and
Electricity. These subjects are treated clearly
and briefly, but enough is given to enable the stu-
dent to comprehend the faet.s and laws of Chemis-
try proper. It is tlie fashion of late years to omit
these topics from works on chemistrv but their
omission is not to be commended. As was required
by the great advance in the science of Chemistry
of late years, the chapter on the General Principles
of Chemical Philosophy has been entirely rewrit-
ten. The latest views on Equivalents, Quantiva-
lence, etc., are clearly and fully set forth. This
last edition is a great improvement upon its prede-
cessors, which is saying not a little of a book that
has reached its twelfth edition. — Ohio Medical Re-
corder, Oct., 1878.
Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated
by Ira Remsex, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3.
GALLOWAY'S QUALITATIVE ANALYSIS. New '
edition. I
LEHMANN'S MANUAL OF CHEMICAL PHYS- I
lOLOGY. In one octavo volume of 3-27 pages
with 41 illustrations. Cloth, 82.2.5.
CARPENTER'S PRIZE ES.SAY ON THE USE AND
Ancsr. OF AtconoLir Liqcoks is Hkai.tii .vxd Dis-
EASE. With explanationsof scientific words. Small
12mo. 178 pages. Cloth, 00 cents.
Lea Brothers & Co.'s Publications — Chemistry.
FBANKLANjD, IE., D, C. i., F. R,S., &JAPP, F. M,, F. I. C,
Professor of Chemistry in the Normal School
of Science, London.
Assist. Prof, of Chemistry in the Normal
School of Science, London.
Inorganic Chemistry. In one handsome octavo volume of 600 pages, with 51
woodcuts and 2 lithographic plates. Cloth, $3.75; leather, $4.75. In a few days.
This work on elementary chemistry is based upon principles of classification, nomen-
clature and notation which have been proved by nearly twenty years experience in teaching
to impart most readily a sound and accurate knowledge of the science.
ATTFIELD, JOHN, Fh. JD.,
Professor of Practical Chemistry to the Pharmaceutical Society of &reat Britain, etc.
Chemistry, General, Medical and Pharmaceutical ; Including the Chem-
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science,
and their Application to Medicine and Pharmacy. A new American, from the tenth
Engli.sli edition, specially revised by the Author. In one handsome royal 12mo. volume
of 728 pages, with 87 illustrations. Cloth, $2.50 ; leather, $3.00.
A te.'tt-book which passes through ten editions
in sixteen years must have good qualities. This
remark is certainlj' applicable to Attfleld's Chem-
istry, a book which is so well known that it is
hardly necessary to do more than note the appear-
ance of this new and improved edition. It seems,
however, desirable to point out that feature of the
book which, in all probability, lias made it so
popular. There can be little doubt that it is its
thoroughly practical character, the expression
being used in its best sense. The author under-
stands what the student ought to learn, and is able
to put himself in the student's place and to appre-
ciate his state of mind. — American Chemical Joxi/r-
nal, .ipril, 1884.
It is a book on which too much praise cannot be
bestowed. .\s a text-book for medical schools it
is unsurpassable in the present state of chemical
science, and having been prepared with a special
view towards medicine and pharmacy, it is alike
indispensable to all persons engaged in those de-
partments of science. It includes the whole
chemistry of the last Pharmacoposia. — Pacific Medi-
cal and Sugrical Journal, Jan. 1884.
BLOXAM, CHARLES L.,
Professor of Chemistry in A'inp's College, London.
Chemistry, Inorganic and Organic. New American from the fifth Lon-
don edition, thoroughly revised and much improved. In "one very handsome octavo
volume of 727 pages, with 292 illustrations. Cloth, $3.75 ; leather, $4.75.
Comment from us on this standard work is al-
most superfluous. It differs widely in scope and
aim from that of .\ttfield, and in its way is equally
beyond criticism. It adopts the most direct meth-
ods in stating the principles, hypotheses and facts
of the science. Its language is so terse and lucid,
and its arrangement of matter so logical in se-
quence that the student never has occasion to
complain tllat chemistry is a hard study. Much
attention is paid to experimental illustrations of
chemical principles and phenomena, and the
mode of conducting these experiments. The book
maintains the position it has always held as one of
the best manuals of general chemistry tn the Eng-
lish language. — Detroit Lancet, Feb. 1S84.
The general plan of this work remains the
same as in previous editions, the evident object
being to give clear and concise descriptions of all
known elements and of their most important
compounds, with explanations of the chemical
laws and principles involved. We gladly repeat
now the opinion we expressed about a former
edition, that we regard Bloxam's Chemistry as
one ot the best treatises on general and applied
chemistry. — American Jour, of Pharmacy, Dec. 1883.
SIMON, W., Fh. J)., M. J>.,
Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and
Professor of Chemistry m the Maryland College of Pharmacy.
Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine.
In one 8vo. vol. of 410 pp., with 16 woodcuts and 7 plates, mostly of actual deposits,
with colors illustrating 56 of the most important chemical reactions. Cloth, $3.00 ; also
without plates, cloth, $2.50. Jmt ready.
This book supplies a want long felt by students 1 plates, beautifully executed. Illustrating precipi-
of medicine and pharmacy, and is a concise but ! tates of various reactions, form a novel and valu-
thorough treatise on the subject. The long expe- | able feature of the book, and cannot fail to be ap-
rience of the author as a teacher in schools of preciated by both student and teacher as a help
medicine and pharmacy is conspicuous in the over the hard places of the science. — Maryland
perfect adaptation of the work to the special needs Medical Journal, Nov. 22, 1884.
of the student of these branches. The colored
ME3ISEN, IRA, M. J>., Fh, H.,
Professor of Chemistry in the Johns Uopkins University, Baltimore.
Principles of Theoretical Chemistry, with special reference to the Constitu-
tion of Chemical Compounds. Second and revised edition. In one handsome royal 12mo.
volume of 240 pages. Cloth, $1.75. Just ready.
of chemistry. The high reputation of the author
assures its accuracy in all matters of fact, and its
judicious conservatism in matters of theory, com-
bined with the fulness with which, in a small
compass, tbe present attitude of chemical science
towards the constitution of compounds is con-
sidered, gives it a value much beyond that accorded
to the average text-books of the day. — Am&rican
Journal of Science, March, 1884.
The book is a valuable contribution to the chemi-
cal literature of instruction. That in so few years
a second edition has been called for indicates that
many chemical teachers have been found ready
to endorse its plan and to adopt its methods. In
this edition a considerable proportion of the book
has been rewritten, much new matter has been
added and the whole has been brought up to date.
We earnestly commend this book to every student
10 Lea Brothers & Co.'s Publications — Chemistry.
CHARLES, T. CRANSTOVN, M. !>., F, C. S., M. S.,
FormerUi Asst. Prof, awl Dt^moiist. of Ccniivfri/ nnd Chemienl Physirx, Queen's College, Belfast.
The Eiements of Physiological and Pathological Chemistry. A
Handbook for Medical Students and rractitionere. Containing a general account of
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and
Excretions of the Body in Health and in Disesise. Together witli the methods for pre-
paring or separating tlieir chief constituents, as also for their examination in detail, and
an outline svllabus of a practical course of instruction for students. In one handsome octavo
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50.
The work is thoroughly trustworthy, and in- | Dr. Charlos' mnniinl admirably fulfils its inten-
fornied throuKhout by a Rcnnino scientific spirit. ^ tion of giving his readers ou the one hand a snm-
The author deals with the chemistry of the diges- mary, comprehen.sive but remarkably compact, of
tiTe secretions in a sy.stemntic manner, which I the mass of facts in the sciences which have be-
leavcs nothing to be desired, and in reality sup- i come indispensable to the physician ; and, on the
plies a want in English literature. The book ap- \ other hand, of a system of practical directions so
pears to us to be at once full and systematic, and ■ minute that analj'ses often considered formidable
to show a just appreciation of the relative import- I may be pursued by any intelligent person. —
ance of the various subjects dealt with. — British Archives of Medicine, Dee. 188-1.
Medical Journal, November 29, 1884. I
HOFFMAJm^, F., A.M., Fh.J)., & FOWFB, F.B., Fh.D.,
Public Analyst to the State of Xew York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy.
A Manual of Chemical Analysis, as applied to the Examination of Medicinal
Chemicals and their Preparations. Being a Guide for the Determination of their Identity
and Quality, and for the Detection of Impurities and Adulterations. For the use of
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and
Medical Students. Third edition, entirely rewritten and much enlarged. In one very
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25.
We congratulate the author on the appearance ' tion of them singularly explicit. Moreover, it is
of the third edition of this work, published for the ; exceptionally free from typographical errors. We
first time in this ccuntry also. It is admirable and i have no hesitation in recommending it to those
the information it undertakes to supply is both who are engaged either in the manufacture or the
extensive and trustworthy. The selection of pro- I testing of medicinal chemicals. — London Pharma-
cesses for determining the purfty of the substan- ! ceutical Journal and Transactions, 1883.
ces of which it treats is excellent and the descrip- |
CLOWES, FRANK, D. Sc, Londmi,
Senior Science-Master at the Sigh School, yeiccastle-undei--Lyme, etc
An Elementary Trea,tise on Practical Chemistry and Qualitative
Inorganic Analysis. Specially adapted for use in the Lalx)ratories of Schools and
Colleges and by Beginners. Third American from the fourth and revised English edition.
In one verv handsome roval 12mo. volume of about 400 pages, with about 50 illustrations.
Cloth, $2.50. In a few days. •
The style is clear, the language terse and vigor- ' and text book. — Medical Record, July 18, 1885.
cue. Beginning with a list of apparatus necessary We may simply repeat the favorable opinion
for chemical work, he (gradually unfolds the sub- which we expressed after the examination of the
ject from its simpler toits morecomplex divisions. ■ ^'-''- "i- = - '- »•■ ■ = --' :- "■-
It is the most readable book of the kind we have
yet seen, and is without doubt a systematic,
intelligible and fully equipped laboratory guide
ject from its simpler to its more complex divisions. , previous edition of this work. It is practical in its
It is the most readable book of the kind we have ' aims, and accurate and concise in its statement
yet seen, and is without doubt a systematic, — American Journal of Pharmacy, Xngafi,Xiio.
RALFE, CHARLES H., M. !>., F, R. C. F.,
Assistant Phi/.ncian at the London Hospital.
Clinical Chemistry. In one pocket-size I2mo. volume of 314 pages, with 16
illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 3.
cine. Dr. Balfe is thoroughly acquainted with the
latest contributions to his science, and it is quite
refreshing to find the subject dealt with so clearly
and simplj', yet in such evident harmony with the
modern scientific methods and spirit. — Metiicnl
Record, February 2, 1884.
This is one of the most instructive little works
that we have met with in a long time. The author
is a phvsician and physiologist, as well as a chem-
" thi " ■ ■ "■" ■
ist, con.-equeiitly the book is unqiialifiedly prac-
tical, telling the physician just what he oiiciit to
know, of the applications of chemistry in medi-
CLASSEN, ALEXANDER,
Professor in the Royal Polytechnic School, Aix-la-Chapelle.
Elementary Quantitative Analysis. Translated, with notes and additions, by
Edgar F. Smith. Ph. D., Assistant Professor of Chemistry in the Towne Scientific School,
University of Penna. In one 12mo. volume of 324 pages, with 36 illust. Cloth, $2.00.
It is probably the best mantial of an elementary j and then advancing to the analysis of minerals and
nature extant insomuch as its methods are the ' such products as are met with "in applied chemis-
best.'<It teaches by examrles, commencing with I try. It is an indispensable book for students in
single determinations, followed by separations, ! chemistry.— Boston Joiirnni o/ CTiemw^rj/, Oct. 1878.
GREENE, WILLIAM H., M. D.,
Dn)ion.-<trator of Chemistr;/ in the Medical Department of the University of Pennsylvania.
A Manual of Medical Chemistry. For the use of Students. Based upon Bow-
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75.
It Is a concise manual of three hundred pages, j the recognition of compounds due to pathological
giving an excellent summary of the best methods I conditions. The detection of poisons is treated
of analyzing the liquids and solids of the body, both I with sufficient fulness for the purpose of thestu-
forthe estimation of their normal constituents and ' dent or practitioner.— 5o.<(o7i Jl. o/ CAetn., June,' '80.
Lea Brothers & Co.'s Publications — Pharm., Mat. Med., Thei-ap. 11
BBUJSTTOJSr, T. LAVDEIt, 31. D., D.Sc, F.B.S,, F.B.CP.,
Lecturer on Materia Mcdica and Therapeutics at St. Bartholomew'' s Hospital, London, etc.
A Text-book of Pharmacology, Therapeutics and Materia Medica;
Including the Pharmacy, the Physiological Action and the Tlierapeutical Uses of Drugs,
In one handsome octavo Tohime of about 1000 pages, with 188 illustrations. Cloth, $5.50 ;
leather, $6.50. In press.
It is with peculiar pleasure that the early appearance of this long expected work is
announced by the publishers. Written by the foremost authority on its subject in Eng-
land, it forms a compendious treatise on materia medica, pharmacology, pharmacy, and
the practical use of medicines in the treatment of disease. Space has been devoted to the
fundamental sciences of chemistry, physiology and pathology, wherever it seemed necessary
to elucidate the proper subject-matter of the book. A general index, an index of diseases
and remedies, and an index of bibliography close a volume which will undoubtedly be of
the highest value to the student, practitioner and pharmacist.
It is a scientific treatise worthy to be ranlced with
the highest productions in physiology, either in
our own or any other language. Everything, is
practical, the dry, hard facts of phj'siology being
pressed into service and applied to the treatment
of the commonest complaints. The information
is 90 systematically arranged that it is available
for immediate use. The index is so carefully
compiled that a reference to any special point is
at once obtainable. Dr. Brunton is never satisfied
with vague generalities, but gives clear and pre-
cise directions for prescribing the various drugs
and preparations. We congratulate students on
being at last placed in possession of a scientific
treatise of enormous practical importance. — The
Lancet, .June 27, 1885.
PABBISS, EDWABD,
Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy.
A Treatise on Pharmacy : designed as a Text-book for the Student, and as a
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions.
Fifth edition, thoroughly revised, by Thoma-s S. Wiegand, Ph. G. In one handsome
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, $6.
No thoroughgoing pharmacist will fail to possess I Each page bears evidence of the care bestowed
himself of so useful a guide to practice, and no
physician who properly estimates the value of an
accurate knowledge of the remedial agents em-
ployed by him in daily practice, so far as their
miscibility, compatibility and most effective meth-
ods of combination are concerned, can afford to
upon "it,~and conveys valuable information from
the rich store of the editor's experience. In fact,
all that relates to practical pharmacy — apparatus,
processes and dispensing — has been arranged and
described with clearness in its various aspects, so
as to afford aid and advice alike to the student and
leave this work out of the list of their works of I to the practical pharmacist. The work is judi'
reference. The country practitioner, who must
always be in a measure liis own pharmacist, will
find it indispensable. — Louisville Medical News,
March 29, 1884.
This well-known work presents itself now based
upon the recently revised new Pharmacopoeia.
ciously illustrated with good woodcuts — American
Journal of Pharmacy, .January, 1884.
There "is nothing to equal Parrish's Pharmacy
in this or any other language. — London Pharma-
ceutical Journal.
JBLEBMANW, Dr. L.,
Professor of Physiology in the University of ZuricK
Experimental Pharmacology. A Handbook of Methods for Determining the
Physiological Actions of Drugs. Translated, with the Author's permission, and with
extensive additions, by Egbert Meade Smith, M. D., Demonstrator of Physiology in the
University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32
illustrations. Cloth, §1.50.
MAISCS, JOSNM., Phar. J).,
Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy.
A Manual of Organic Materia Medica; Being a Guide to Materia Medica of
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists
and Physicians. New (second) edition. In one handsome royal 12mo. volume of 550
pages, with 242 illustrations. Cloth, $3.00. Just ready.
This worlv contains the substance, — the practical
"kernel of the nut" picked out, so that the stu-
dent has no superfluous labor. He can confidently
accept what this work places before him, without
any fear that the gist of the matter is not in it.
Another merit is that the drugs are placed before
him in such a manner as to simplify very mucii
the study of them, enabling the mind to grasp
them more readily. The illustrations are most
excellent, being very true to nature, and are alone
worth the price of the book to the student. To the
practical physician and pharmacist it is a valuable
work for handy reference and for keeping fresh
in the memory the knowledge of materia medica
and botany already acquired. We can and do
heartily recommend it. — Medical and Surgical Re-
porter,'Feh. 14, 1885.
BBUCJ3, J, MITCHELL, M. D., F. B. C. P.,
Pliysicinn and Lecturer on Materia Medica and Therapeutics at Charing Gross Hospital, London.
Materia Medica and Therapeutics. An Introduction to Rational Treat-
ment. In one pocket-size 12mo. volume of 555 pages. Limp cloth, $1.50. Jv^t ready.
See Students' Series of Manuals, page 3.
GBIFFITM, BOBEBT EGLESFIELD, M. D.
A Universal Formulary, containing the Methods of Preparing and Adminis-
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut-
ists. Third edition, thoroughly revised, with numerous additions, by John M. Maisch,
Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy.
In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leather, $5.50.
12 Lea Brothers & Co.'s Publications — Mat. Med., Therap.
8TILLB, A., M, J),, ZL. X>., <e MAISCJEC, J. 31., Thar, J>.,
Professor Emeritus of the Theory and Prae- Prof, of Mat. Med. and Botany in Phila.
iiee of Medicine and of Clinical Medicine CoUene of Pharmacy, Sec^y to the Ameri-
in the University of Penn.<!jdvania. can Pharmaceutical Afsociation.
The National Dispensatory : Containing the Natural History, Chemistry, Phar-
macy, Actions and Uses of Medicines, inchiding those recognized in the Phannacopcnias of
the United States, Great Britain and Germany, with numerous references to tlte French
Codex. Third edition, thoroughly revisetl and greatly enlarge<l. In one magnificent
imperial octavo volume of 1767 pages, with 311 fine engravings. Cloth, $7.25;
leather, $8.00; half Russia, open back, $19.00. With Denison's " Ready Reference Index "
$1.00 in addition to price in any of above styles of binding. Just ready.
In the present revision the authors liave labored incessantly with the view of making
the third edition of The National Dispensatory an even more complete represen-
tative of the pharmaceutical and therapeutic .science of 1884 than its first edition was of
thatoflS79. For this, ample material has been aflbrded not only by the new United
States Pharmacopoeia, but by those of Germany and France, which have recently appeared
and have been incorporateil in the Dispensatory, together with a large number of ncA^non-
officinal remedies. It is thus rendered the representative of the most advanced state of
American, English, French and German pharmacology and therapeutics. The vast amount
of new and important material thus introduced may be gathered from the fact that the
additions to this edition amount in themselves to the matter of an ordinary full-sized octavo
volume, rendering tlie work larger by twenty-five per cent, than the last edition. The
Therapeutic Index (a feature peculiar to this work), so suggestive and convenient to the
practitioner, contains 1600 more references than tlie last edition — the General Index
3700 more, making the total number of references 22,300, while the list of illustrations
has been increased by 80. Every efibrt has been made to prevent undue enlargement of
the volume by having in it nothing that could be regarded as superfluous, yet care has
been taken that nothing should be omitted which a pharmacist or physician could expect
to find in it.
The appearance of the work has been delayed by nearly a year in consequence of the
determination of the authors that it should attain as near an approach to absolute ac-
curacy as is humanly possible. With this view an elaborate and laborious series of
examinations and tests have been made to verify or correct the statements of the Pharma-
copoeia, and very nmnerous corrections have been found necessary. It has thus been ren-
dered indispensable to all who consult the Pharmacopoeia.
The work is therefore presented in the full expectation that it will maintain the
position universally accorded to it as the standard authority in all matters pertaining to
Its subject, as registering the furthest advance of the science of the day, and as embody-
ing in a shape for convenient reference the recorded results of human experience in the
laboratory, in the dispensing room, and at the bed-side.
Comprehensive in scope, vast in design and | np to date. The work has been very well done, •
splendid in execution, The National Dispensatorv large number of extra-pharmacopoeia! remedies
may be justly regarded as the most important work : liaving been added to those mentioned in previous
of its kind extant. — Louisx^ille Medical iV'eies, Dec. ' editioas. — London Lancet, Nov. 22, 1884.
*i 1884. I Its completeness as to subjects, the comprehen-
We have much pleasure in recording the appear- siveuess of its descriptive language, thethorough-
ance of a third edition of this excellent work of j ness of the treatment of the topics, its brevity not
reference. It is an admirable abstract of all that ' sacrificing the desirable features of information
relates to chemistry, pharmacy, materia medica, j for whieii such a work is needed, make this vol-
pharmacology and therapeutics. It may be re- j time a marvel of excellence. — Pharmaceutical Re-
garded as embodying the Pharmacopoeias of the cord, Aug. 15, 1884.
civilized nations of the world, all being brought i
FARQVSABSON, MOBJSJRT, M. D.,
Lecturer on Materia Medica at St. Man/'s Hofpital Medical School.
A Guide* to Therapeutics and Materia Medica. Third Americiui edition,
specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by
Irank Woodbury, M. D. In one handsome 12mo. volume of 524 pages. Cloth, $2.25.
Dr. Farquharson's Therapeutics is constructed umned pages — one side containing the recognized
npon a plan which brinars Vjefore the reader all the physiological action of the medicine, and the other
essential points with reference to the properties of the disease in which observers fwho are nearlv al-
drugs. It impresses these upon him in such a way wavs mentioned) have obtained from it good re-
as to enaUe him to take a clear view of the actions suits — make a very good arrangement. The early
of medicines and the disordered conditions in chapter containing rules for prescribing is excel-
which they must prove useful. The double-col- \ent.— Canada Med. and Surg. Journal, Dec. 18S2.
STILLE, ALFRED, M. D., Xi. J).,
Professor of Theory and Practice of Mai. and of Clinical Med. in the Univ. of Penna.
Therapeutics and Materia Medica. A Systematic Treatise on the Action and
Uses of Medicinal Agents, including their Description and History. Fourth edition,
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages.
Cloth, $10.00; leather, $12.00; very handsome halt Russia, raised bands, $13.00.
We can hardly admit that it has a rival in the ' in pharmacodynamics, but as by far the most corn-
multitude of its citations and the fulness of its plete treatise upon the clinical and practical side
research into clinical histories, and we must assign of the question.— JBo«^on Medical and Surgical Jour-
It a place in the physician's librarj'; not, indeed, nal, Nov. 5, 1874.
as fully represenving the present state of knowledge
Lea Brothers & Co.'s Publications — Pathol., Histol. 13
COATS, JOSBm, 31, 2)., F, F. J>. S.,
Pathologist to the Olasgotv Western Infirmary.
A Treatise on Pathology. In one very handsome octavo volume of 829 pages,
with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50.
The work before us treats the subject of Path- I condition effected in structures by disease, and
ology more extensively than it is usually treated ; points out the characteristics of various morbid
in similar works. Medical students as well as agencies, so that they can be easily recognized. But,
physicians, who desire a work for study or refer- I not limited to morbid anatomy,it explains fully how
ence, that treats the subjects in the various de- the functions of organs are disturbed by abnormal
partments in a very thorough manner, but without conditions. There is nothing belonging to its de-
prolixity, will certainly give this one the prefer- partment of medicine that is not as fully elucidated
ence to any with which we are acquainted. It sets as our present knowledge will admit.— Cinctrmatt
forth the most recent discoveries, exhibits, in an j Medical News, Oct. 1883.
interesting manner, the changes from a normal
GBEBJSr, T. HJEJVBT, 31. D.,
Lecturer on Pathologt/ and Morbid Anatomy at Charing-Cross Hospital Medical School, London.
Pathology and Morbid Anatomy. Fifth American from the sixth revised
and enlarged English edition. In one very handsome octavo volume of 482 pages, with
150; line engravings. Clotli, $2.50.
The fact tliat this well-known treatise has so No work in (he English language is so admirably
rapidly reached its sixth edition is a strong evi- ^ adapted to the wants of the student and practi-
dence of its popularity. The author is to be eon- tioner as this, and we would recommend it most
gratulated upon the thoroughness with which he : earnestly to every one.— yashville Journal of Medi-
has prepared this work. It is thoroughly abreast cine ar.d Surgery, Nov. 1884.
with all the most recent advances in pathology. .
WOODHEAD, G. SI31S, 31. D., F. M. C. P. E.,
Demonstrator of Pathology in the University of Edinburgh.
Practical Pathology. A Manual for Students and Practitioners. In one beau-
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00.
It forms a real guide for the student and pracH- ; The author merits all praise for having produced
tioner who is thoroughly in earnest in his en- • a valuable work. — Medical Record, May 31, 1884.
deavor to see for himself and do for himself. To [ It is manifestly the product of one who has him-
the laboratory student it will be a helpful com- selftravelledoverthe whole fieldand who isskilled
panion, and all those who may wish to familiarize ' not merely in the art of histology, but in the obser-
themselves with modern methods of examining ' vation and interpretation of morbid changes. The
morbid tissues are strongly urged to provide ' work is sure to command a wide circulation. It
themselves with this manual. The numerous i should do much to encourage tiie pursuit of path-
drawings are not fancied pictures, or- merely i ology, since such advantages in histological study
schematic diagrams, but they represent faithfully have never before been offered. — The Lancet, Jan.
the actual images seen under the microscope. 1 5, 1884.
SCHAFEM, EnWARJD A., F. jB. S.,
Assistant Professor of Physiology in University College, London.
The Essentials of Histology. In one octavo volume of 246 pages, with
281 illustrations. Cloth, $2.25. Shortly.
CORJSJL, v., and MAJmEB, Z.,
Prof, in the Faculty of Med. of Paris. Prof, in the College of France.
A Manual of Pathological Histology. Translated, with notes and additions,
by E. O. Shakespeare, M. D., Pathologist and Ophthalmic Surgeon to Philadelphia
Hospital, and by J. Henry C. Simes, ^I. D., Demonstrator of Pathological Histology in
the University of Pennsylvania. In one very handsome octavo volume of 800 pages, with
360 illustrations. Cloth, $5.50 ; leather, $6.50 ; half Kussia, raised bands, $7.
KLEIN, E., 31. D., F. B. S.,
Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hosp., London.
Elements of Histology. Inonepocket-sizel2mo. volume of 360 pages, with 181
illus. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 3.
Although an elementary work, it is by no means
superficial or incomplete, for the author presents
in concise language nearlyall the fundamental facts
regarding the microscopic structure of tissues.
The illustrations are numerous and excellent. We
commend Dr. Klein's Elements most heartily to
the student.— Jfedicai Record, Dec. 1, 1883.
FEP-PEB, A. J., 31. B., M. S., F. B. C. S.,
Surgeon and Lecturer at St. Mary's Hospital, London.
Surgical Pathology. In one iwcket-size 12mo. volume of 511 pages, with 81
illustrations. Limp clotli, red edges, $2.00. See Students' Series of Manuals, page 3.
It is not pretentious, but it will serve exceed- I illustrated. The student will find in it nothing
ingly well as a book of reference. It embodies a | that is unnecessary. The li.'^t of subjects covers
great deal of matter, extending over the whole ! the whole range of surgery. The book supplies a
field of surgical pathology. Its form is practical, very manifest want and should meet with suo-
its language is clear, and the information set cess. — New York Medical Journal, May 31, 1884.
forth is well-arranged, well-indexed and well- 1
SCHAFER'S PRACTICAL HISTOLOGY. In one I OGY. Translated by Joseph Leidt, M. D. In one
handsome royal 12mo. volume of 308 pages, with I volume, very large imperial quarto, with 320
40 illustrations. I copper-plate figures, plain and colored and des-
GLUGE'S atlas of PATHOLOGICAL HISTOL- | criptive letter-press. Cloth, U.OQ
14
Lea Brothers & Co.'s Publications — Practice of Med.
FLINT, AUSTIN, M, !>.,
Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y.
A Treatise on the Principles and Practice of Medicine. Designed for
the use of Students :ind Practitioners of Medicine. With an Appendix on the Researches
of Koch, and their bejiring on tlie Etiology, Pathology, Diagnosis and Treatment of
Phthisis. Fifth edition, revised and largely rewritten In one large and closely-printed
octavo volume of 1160 pages. Cloth, $5.50; leather, $6.50; half Russia, $7.
Koch's discovery of the bacillus of tubercle gives promise of being the greatest
boon ever conferred by science on humanity, surpassing even vaccination in its benefits to
mankind. In the appendix to his work^ Professor Flint deals with the subject from a
practical standpoint, discussing its bearings on the etiology, pathology, diagnosis, prog-
nosis and treatment of pulmonary phthisis. Thus enlarged and completed, this standard
work will be more than ever a necessity to the physician who duly appreciates the re-
sponsibility of his calling.
A well-known writer and lecturer on medicine I This work is so widely known and swcepted as
recently expressed an opinion, in the highest de- ] the best American text-book of the practice of
gree complimentary of the admirable treatise of i medicine that it would seem hardly worth while to
Dr. Flint, and in eulogizing it, he described it ac- i give this, the fifth edition, anything more than a
curately as "readable and reliable." No text-book | passing notice. But even the most cursory exami-
Ifl more calculated to enchain the interest of the nation shows that it is, practically, much more
gtudent. and none better classifies the multitudi- than a revi.sed edition; it is, in fact, rather a new
nous subjects included in it. It has already so far [ work throughout. This treatise will undoubtedly
won its way in England, that no inconsiderable | continue to hold the first place in the estimation
number of men use it alone in the study of pure ; of American physicians and students. No one of
medicine; and we can say of it that it is in every | our medical writers approaches Professor Flint in
way adapted to serve, not only as a complete guide. ' clearness of diction, breadth of view, and, what we
but also as an ample Instructor in the science ana I regard of transcendent importance, rational esti-
practice of medicine. The style of Dr. Flint is mate of the value of remeaial agents. It is thor-
always polished and engaging. The work abounds ' oughly practical, therefore pre-eminently the book
In perspicuous explanation, and is a most valuable i for American readers. — St. Louis Clin. Rec, Mar. '81.
text-book cf medicine. — London Medical News.
HABTSSOBNE, SJENMT, M. D., LL, D.,
Lately Professor of Hygiene in the University of Pennsylvania.
Essentials of the Principles and Practice of Medicine. A Handbook
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one
royal r2mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00.
Within the compass of 600 pages it treats of the 1 this one; and probably not one writer in our day
history of medicine, general pathology, general ; had a better opportunity than Dr. Hartshorne for
symptomatology, and physical diagnosis (including i condensing all the views of eminent practitioners
laryngoscope, ophthalmoscope, etc.), general ther- j Into a 12mo. The numerous illu.strations will be
apeutics, nosology, and special pathology and prac- very useful to studentjs especially. These essen-
tice. There is a wonderful amount of information ] tials, as the name suggests, are not intended to
contained in this work, and it is one of the best i supersede the text-books of Flint and Bartholow,
of its kind that we have seen. — Giasgoic Medical j but they are the most valuable in affording the
Journal, Nov. 1882. I means to see at a glance the whole literature of any
An indispensable book. No work ever exhibited ; disease, and the most valuable treatment. — Chicago
a better average of actual practical treatment than i Medical Journal and Examiner, April, 1882.
BBISTOWB, JOBN SYBB, M. X)., F, M, C, F,,
Phy.iician and Joint Lecturer on Medicine at St. Thomas' HospitaL
A Treatise on the Practice of Medicine. Second American edition, revised
by the Author. Edited, with additions, by JAsres H. Hutchinsox, M.D., physician to the
Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations.
Cloth, $5.00; leather, $6.00; very handsome half Russia, raised bands, $6.50.
The reader will find every conceivable subject
connected with the practice of medicine ably pre-
sented, in a style at once clear, interesting and
concise. The additions made by Dr. Hutchinson
are appropriate and practical, and greatly add to
its usefulness to American readers. — Buffalo Med-
ical and Surgical Journal, March, 1880.
WATSON, SIB THOMAS, M, D.,
Late Physician in Ordinary to the Queen.
Lectures on the Principles and Practice of Physic. A new Ajnerican
from the fifth English edition. Edited, with addition.s, and 190 illustrations, by Hexkt
Hartshorke, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania.
In two large octavo volumes of 1840 pages. Clo'th, $9.00 ; leather, $11.00.
LECTURES ON THE STUDY OF FEVER. By
A. Hrneos, M. D., M. R. I. A. In one octavo
volume of 308 pages. Cloth, $2.50.
STOKES" LECTURES ON FEVER. Edited by
John William Moore, M. D., F. K. Q. C. P. In
one octavo volume of 280 pages. Cloth, 82.00.
A TREATISE ON FEVER. By Robert D. Lyohs,
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25.
LA ROCHE ON YELLOW FEVER, considered in
its Historical, Pathological, Etiological and
Therapeutical Relations. In two large and hand-
some octavo volumes of 1468 pp. Cloth, 87.00.
A CENTTRY OF AiMERICA>" MEDICINE, 1776—1876. By Drs. E. H. Clabke, H. J.
BioELOw, S. D. Gross, T. G. Thomas, and J. S. Billings. In one 12mo. volume of 370 pages. Cloth, 82.25.
Lea Brothers & Co.'s PublicatiOxVs — Systems of Med. 15
For Sale by Subscription Only,
A System of Practical Medicine.
B Y AMERICAN A UTHORS,
Edited by WILLIAM PEPPER, M. D., LL. D.,
PBOVOST AND PROFESSOR OF THE THEORY AND PRACTICE OP MEDICINE AND OF
CLINICAL MEDICINE IN THE UNIVERSITY OP PENNSYLVANIA,
Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the
Hospital of the University of Pennsylvania.
In jive imperial octavo volumes, containing about 1100 pages each, with Ulustrationa. Price per
volume, doth, $5; leather, $6 ; half Russia, raided bands arid open back, $7. Volume I.
(General Pathology, Sanitary Science and General Diseases) contains 1094 pages,
with 24 illustrations and is just ready. Volume II. (General Diseases [con-
tinued] and Diseases of the Digestive System) contains 1312 pages,
with 27 illustrations, and is just ready. Volume III. (Diseases of
the Respiratory, Circulatory and Haematopoietic Systems)
containing about 1050 pages, vrill be ready October Ist,
and the subsequent volumes at intervals of four
months thereafter.
The publishers feel pardonable pride in announcing this magnificent work. For
three years it has been in active preparation, and it is now in a sufficient state of forward-
ness to justify them in calling the attention of the profession to it as the work in which
for the first time American medicine is thoroughly represented by its worthiest
teachers, and presented in the full development of the practical utility which is its
preeminent characteristic. The most able men — from the East and the West, from the
North and the South, from all the prominent centres of education, and from aU the
hospitals which afford special opportunities of study and practice — have united in
generous rivalry to bring together tnis vast aggregate of specialized experience.
The distinguished editor has so apportioned the work that each author has had
assigned to him the subject which he is peculiarly fitted to discuss, and in which his views
will be accepted as the latest expression of scientific and practical knowledge. The
practitioner will therefore find these volumes a complete, authoritative and unfailing work
of reference, to which he may at all times turn with full certainty of finding what he needa
in its most recent aspect, whether he seeks information on the general principles of medi-
cine, or minute guidance in the treatment of special disease. So wide is the scope of the
work that, with the exception of midwifery and matters strictly surgical, it embraces the
whole domain of medicine, including the departments for which the physician is accustomed
to rely on special treatises, such as diseases of women and childi-en, of the genito-urmary
organs, of tlie skin, of the nerves, hygiene and sanitary science, and medical ophthalmology
and otology. Moreover, authors have inserted the formulas which they have found most
efficient in the treatment of the various affections. It may thus be truly regarded as a
Complete Library of Practical Medicine, and the general practitioner possessing it
may feel secure that he wHl require little else in the daily round of professional duties.
In spite of every effort to condense the vast amount of practical information fur-
nished, it has been impossible to present it in less than 5 large octavo volumes, containing
about 5500 beautifully printed pages, and embodying the matter of about 15 ordinary
octavos. Illustrations are introduced wherever they serve to elucidate the text.
_ As material for the work is substantially complete in the hands of the editor, the pro-
fession may confidently await the appearance of the remaining volumes upon the dates
above specified. A detailed prospectus of the work wUl be sent to any address on appli-
cation to the publishers.
It is a large undertaking, but quite Justifiable in
the ease of a progressive nation like the United
States. At any rate, if we may judge of future
volunaes from the first, it will be justified by the
result. We have nothing but praise to bestow
upon the work. The articles are the work of
writers, many of whom are already recognized in
this country as authorities on the particular topics
on which they deal, whilst the others show by the
way they have handled their subjects that they
are fully equal to the task they had undertaken-
* * * A work which wa cannot doubt will mak«
a lasting reputation for itself.— iondon Medical
Times and Gazette, May 9, 1886.
UBYNOLnS, J. nUSSBLJL, M. D,,
Professor of the Principles and Practice of Medicine in University College, London.
A System of Medicine. With notes and additions by Henry Habtshorne,
A. M., M. D., late Professor of Hygiene in the University of Pennsylvanin. In three large
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra-
tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Russia, raised bands,
$6.50. Per set, cloth, $15; leather, $18; half Russia, $19.50. Sold only by subscription.
16 Lea Brothers & Co.'s Publications — Clinical Med., etc.
8TILLE, ALFRED, M, D., LL. I).,
Prafessor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of PentM.
Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat-
ment. In one handsome 12mo. volume of 1G3 pages, with a chart. Cloth, §1.25. Just ready.
The threatened importation of cliolera into the country renders peculiarly timely
this work of an authority upon the subject so eminent as Professor Still6. The history
of previous epidemics, their modes of propagation, the vast recent additions to our
knowledgeof the causation, prevention and treatment of the disease, all have been handled
80 skilfiilly as to present with brevity the information which every practitioner should
possess in advance of a visitation.
This timely little work is full of the learning i for a rational system. Altogether, the monograph
and good judgment which marks all that comes ' is one that will have an excellent influence on the
from the pen of its distinguished author. What , professional mind. — Medical and Surgical Reporter,
he has to say on treatment is cliaracterized by | August 1, 1885. q.
his.usual caution and his well-known preference |
FLIXT, AUSTIN, 31, 3,
Clinical Medicine. A Systematic Treatise on the Diagnosis and Treatment of
Diseases. De.signed for Students and Practitioners of Medicine. In one large and hand-
some octavo volume of 799 pages. Cloth, $4.50 ; leather, $5.50 ; half Russia, $6.00.
It is here that the skill and learning of the great ' sistently with brevity and clearness, the different
clinician are displayed. He has given us a store- i subjects and their several parts receiving the
house of medical knowledge, excellent for the stu- attention which, relatively to their importance,
dent, convenient for the practitioner, the result of medical opinion claims for them, is still more diffi-
A long life of the mcst faithful clinical work, col- ' cult. This task, we feel bound to say, has been
lectea by an energy as vigilant and systematic as executed with more than partial success by Dr.
untiring, and weighed by a judgment no less clear Flint, whose name is already familiar to students
than his observation is close.— .4?-c/iires o/"il/ftiici»e, of advanced medicine in this country as that of
Dec. 1879. the author of two works of great merit on special
To give an adequate and useful conspectus of the i subjects, and of numerous papers exhibiting much
extensive field ofmodern clinical medicine is a task | ongmality and__extensive research.— 7 /je Dublin
ofno ordinary difficulty; but toaccnmplish this con- i Journal, Dec. 1879.
By the Same Author.
Essays on Conservative Medicine and Kindi*ed Topics. In one very hand-
some royal 12mo. volume of 210 pages. Cloth, $1.38.
BBOAJDBENT, W. S., M, D., F, B, C. P.,
Physician to and Lecturer on Medicine at St. Mary's Hospital.
The Pulse. In one 12mo. volume. See Series of Clinical Manuals, page 3.
SCHBEIBER, JDB.JOSEFH.
A Manual of Treatment by Massage and Methodical Muscle Ex-
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome
octavo volume of about 300 pages, with about 125 fine engravings. Preparing.
IINLAYSON, JAMES,^. J>., Editor,
Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc.
Clinical Diagnosis. A Handbook for Students and Practitioners of Medicine.
With Chapters by Prof. Gairdner on the Physiognomy of Disease ; Prof. Stephens on
Diseases of the Female Organs ; Dr. Robertson on Insanity ; Dr. Gemmell on Physical
Diagnosis ; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor
on Case-taking, Family History and Symptoms of Disorder in the Various Systems. In
one handsome 12mo. volume of 546 pages, with 85 illustrations. Cloth, $2.63.
FENWICK, SAMUEL, M. D.,
Assistant Physician to the London Hoipttal.
The Student's Guide to Medical Diagnosis. From the third revised and
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with
87 illustrations on wood. Cloth, $2.25.
TAJSNEB, TJl03IASlSAWKES, M. I>.
A Manual of Clinical Medicine and Physical Diagnosis. Third American
from the secnad London edition. Revised and enlarged by Tilbury Fox, M. D.
In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50.
FOTHEBGILL, J. M., M, JD., Edin., M. B. C. F., Lond.,
Physician to the City of London Hospital for Diseases of the Chest.
The Practitioner's Handbook of Treatment ; Or, The Principles of Thera-
peutics. New edition. In one octavo volume. Preparing.
STURGES" "INTRODUCTION TO THE STUDY
OF CLINICAL MEDICINE. Being a Guide to
the Inve.«tigation of Disease. In one handsome
l2mo. volume of 127 pages. Cloth, $1.25.
DAVIS' CLINICAL LECTURES ON VARIOUS
IMPORTANT DISEASES. By N. S. Davis,
M. D. Edited by Frank H. Davis, M. D. Second
edition. 12mo. 287 pages. Cloth, 81.75.
Lea Brothers & Co.'s Publications — Hyj^ene, Electr., Pract. 17
BICHAJUDSOW, B. TF., 31. A., M.I)., LL. D., F.JK.S., F.S.A.
Fellow of the Roijal College of Physicians, London.
Preventive Medicine. In one octavo volume of 729 pages.
$5 ; very handsome half Russia, raised bands, $5.50.
Cloth, $4; leather,
Dr. Richardson has succeeded in producing a
work which is elevated in conception, comprehen-
sive in scope, scientific in character, systematic in
arrangement, and wliich is written in a clear, con-
cise and pleasant manner. He evinces the happy
faculty or extracting the pith of what is known on
the subject, and of presenting it iiva most simple,
intelligent and practical form. There is perhaps
the question of disease is comprehensive, masterly
and fully abreast with the latest and best knowl-
edge on the subject, and the preventive measures
advised are accurate, explicit and reliable. — The
American Journal of Ihe Medical Sciences, April, 1884.
This is a book that will surely find a place on the
table of every progressive physician. To the
medical profession, whose duty is quite as much to
no similar work written for the general public : prevent as to cure disease, thebook will be a boon,
thatcontains such acomplete, reliable and instruc- — Boston Medical ami Surgical Journal, Mar. 6, 1884.
tive collection of data upon the diseases common | The treatise contains a vastamount of solid, valu-
to the race, their origins, causes, and the measures i able hygienic information. — Medical and Surgical
for their prevention. The descriptions of diseases Reporter, Feb. 23, 1884.
are clear, chaste and scholarly; the discussion of 1
BARTHOLOW, BOBERTS, A. M., M. D., LL. J>.,
Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc.
Medical Electricity. A Practical Treatise on the Applications of Electricity
to Medicine and Surgery. Second edition. In one very handsome octavo volimae of 292
pages, with 109 illustrations. Cloth, $2.50.
The second edition of this work following so ' A most excellent work, addressed by a practi-
soon upon the first would in itself appear to be a | tioner to his fellow-practitioners, and therefore
sufficient announcement; nevertheless, the text | thoroughly practical. The work now before us
has been so considerably revised and condensed, has the exceptional merit of clearly pointing out
and so much enlarged by the addition of new mat- where the benefits to be derived from electricity
ter, that we cannot fail to recognize a vast improve- ' must come. It contains all and everything that
ment upon the former work. The author has pre- 1 the practitioner needs in order to understand in-
pared his work for students and practitioners — for ' telligently the nature and laws of the agent he is
those who have never acquainted themselves with : making use of, and for its proper application in
the subject, or, having done so, find that after a | practice. In a condensed, practical form, it pre-
time their knowledge needs refreshing. We think sents to the physician all that he would wish to
he has accomplished this object. The book is not
too voluminous, but is thoroughly practical, sim-
ple, complete and comprehensible. It is, more-
over, replete with numerous illustrations of instru-
ments, appliances, etc. — Medical Record, November
15, 1882.
remember after perusing a whole library on medical
electricity, including the results of the latest in-
vestigations. It is the book for the practitioner,
and the necessity for a second edition proves that
it has been appreciated by the profession. — Physi-
cian and Surgeon, Dec. 1882.
TJBCE YEAJR-BOOK OF TREATMENT.
A Comprehensive and Critical Review for Practitioners of Medi-
cine. In one 12mo. volume of 320 pages, bound in limp cloth, with red edges, $1.25.
This work presents to the practitioner not only a complete classified account of all
the more important advances made in the treatment of Disease during the year ending
Sept. 30, 1884, but also a critical estimate of the same by a competent authority. Each
department of practice has been fully and concisely treated, and into the consideration of
each subject enter such allusions to recent pathological and clinical work as bear directly
upon treatment. As the medical literature of all countries has been placed under contri-
bution, the references given throughout the work, together with the separate indexes of
subjects and authors, will serve as a guide for those who desire to investigate any thera-
peutical topic at greater length.
In a few moments the busy practitioner can re-
fresh his mind as to the principal advances in
treatment for a year past. This kind of work is
peculiarly useful at the present time, when current
literature is teeming with innumerable so-called
advances, of which the practitioner has not time
to determine the value. Here he has, collected
from many sources, a resume of the theories and
facts which are new, either entirely or in part, the
decision as to their novelty being made by those
who by wide reading and long experience are
fully competent to render such a verdict. — Ameri-
can Journal of the Medical Sciences, April, 1885.
It is a coniplete account of the more important
advances made in the treatment of disease. Ex-
treme pains have been taken to explain clearly in
the fewest possible words the views of each
writer, and the details of each subject. One of
the principle points about the book is its practical,
yet concise language. Each editor has well per-
formed his duty, and we can say with truth that
it is a volume well worth buying for frequent use.
— Virginia Medical Monthly, March, 1885.
HABERSHOJSr, S. O., 31. JD.,
Senior Physician to and late Led. on Principles aiid Practice of Med. at Ony's Hospital, London.
On the Diseases of the Abdomen ; Comprising those of the Stomach, and
other parts of the Alimentary Caiial, Oesophagus, Caecum, Intestines and Peritoneum. Second
American from third enlarged and revised English edition. In one handsome octavo
volume of 554 pages, with illustrations. Cloth, $3.50.
PAVY'S TREATISE ON THE FUNCTION OF DI-
GESTION; its Disorders and their Treatment.
From the second London edition. In one octavo
volume of 238 pages. Cloth, 82.00.
CHAMBERS' MANUAL OF DIET AND REGIMEN
IN HEALTH AND SICKNESS. In one hand-
some octavo volume of 302 pp. Cloth, 82.75.
BARLOW'S MANUAL OF THE PRACTICE OF
MEDICINE. With additions by D. F. Condie,
M. D. 1 vol. 8vo., pp. 603. Cloth, 82.50.
TODD'S CLINICAL LECTURES ON CERTAIN
ACUTE DISEASES. In one octavo volume of
320 pages. Cloth, $2.50.
HOLLAND'S MEDICAL NOTES AND REFLEC-
I TIONS. 1 vol. 8vo., pp. 493. Cloth, 83.50.
18 Lea Brothers & Co.'s Publications — Throat, Lungs, Heart.
COHEN, J. SOLIS, M, J>.,
Lecturer on Larptxjosrnpij aiui DUeoscs of the Throat ami Chest in the Jeferson Medical College.
Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third
edition, tlioroughly revised and rewritten, with a large number of new illustrations. In
one very handsome octavo volume. Preparing.
SEILEB, CARL, M. !>.,
Lecturer on Lnrj/ngoseop;i in the University of Pennaylvania.
A Handbook of Diagnosis and Treatment of Diseases of the Throat,
Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume
of 294 Images, with 77 illustrations. Cloth, $1.75.
It is one of the best of the practical text-books | the es<sentials of diagnosis and treatment in dis-
on thi.s subject with which we are acquainted. The ' eases of the throat and nose. The art of laryngos-
present edition li»« been increased in size, but its copy, the anatomy of the throat and nose and the
eminently practical character has been main- [ pathology of the mucous membrane are discussed
tained. Many new illustrations have also been i with conciseness and ability. The work is pro-
Introduced, a case-record sheet has been added. I fusely illustrated, excels in many essential teat-
and there are a Taluable bibliography and a goo<l I ures. and deserves a place in the office of th©
index of the whole. For any one who wishes to I practitioner who would inform himself as to the
make himself familiar with the practical manage- nature, diagnosis and treatment of a class of dis-
ment of oases of throat and nose disease, the book I eases almost inseparable from general medical
will be found of great Talue. — yew York Medical practice. With advanced students the book must
journal, .June 9, 1883. be very popular on account of its condensed style.
The work before us is a concise handbook upon | —Louisville Medical JS'ews, June 26, 188.3.
BROWJSE, LENNOX, F. It. C. S., Edin.,
Senior Surgeon to the Central London Throat and Ear Hospital, etc
The Throat and its Diseases. Second American from the second English edi-
tion, thoroughly revised. With 100 typical illustrations in colors and 50 wood engravings,
designed and executed by the Author. In one very handsome imperial octavo volume of
about 350 pages. Preparing.
FLINT, AUSTIN, M. D.,
Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, y. Y.
A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of
Diseases of the Lungs and Heart, and of Thoracic Aneurism. Third edition. In one hand-
some royal 12mo. volume of 240 pages. Cloth, $1.63.
It is safe to say that there is "not in the English ' the results of his careful study and ample ex-
language, or any other, the equal amount of clear, j perienee in such wise that the young will find it the
hensible information touching i nest
xpioratiou of the chest, in an equal
nutriber of words. Professor Flint's language is their knowledge. — American Practitioner, June^
exact and comprehensible information touching i nest source of instruction, and the old the most
al
the physical exploration of the chest, in an equal pleasant means of reviving and complementing
number of words. Professor Flint's language is their
precise and simple, conveying without dubiety ! 1883.
BY THE SAME AUTHOR.
Physical Exploration of the Lungs by Means of Auscultation and
Percussion. Three lectures delivered before the Pliiladelphia County Medical Society,
1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00.
A Practical Treatise on the Physical Exploration of the Chest and
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50.
Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and
Complications, Fatality and Prognosis, Treatment and Physical Diag-
nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages.
Cloth, $.3.50.
A Practical Treatise on the Diagnosis, Pathology and Treatment of
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume
of 550 pages, with a plate. Cloth, $4.
GROSS, S. 2>., M.n., LL.n., n.C.L. Oxon., LL.n. Cantab.
A Practical Treatise on Foreign Bodies in the Air-passages. In one
octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75.
^^^Vi'l^oS!^' DISEASES OF THE LUNGS AND I SMITH ON CONSUMPTION; its Early andReme-
AIR-PASSA<;ES. Their Patholog>-, Physical Di- diable Stages. 1 vol. 8vo., pp. 253. Cloth, 82.25.
Xfnd"' a^ur^rv^^pH'^FnlTith '"^°,*- , *^* LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490
second and revi.sed English edition. In one I naees Cloth fts (O
octavo volume of 475 pages. Cloth. $3.50 I P^^es. (.lotn, 5:^.110.
Qi x-nv n-K nrPHTWTTDri •. « / ^ ^ .1 WILLIAMS ON PULMONARY CONSUMPTION;
r^F^ 2wK ^^?^^iv.'*"J?'""''® •^'^ ^'■^**- »t« Nature, Varieties and Treatment. With an
^.!rhn\ ,,• 1^°' "/ •*'*® H'st<>7 of Its Pre- , analysis of one thousand cases to exemplify its
Ih H«n iJ^^^ i^^""""",'*'- Second and revised duration. In one 8vo. vol. of 303 pp. Cloth, ^50.
edition. In one 12mo. vol.. dd 158 Cloth 81 m 1 rt- • »
w.T oxTP ,-xv- -T-rr,. r^rcl JONES' CLINICAL OBSERVATIONS ON FUNC-
^^^^Dc^^TWaPill^^P ^"^ '^^^ HEART TIONAL NERVOUS DISORDER.S. Second Am-
A:>LH.TKi,.M vi^sbtLfc. Third American edi- erican edition. In one handsome octavo volume
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. j of 340 pages. Cloth, $3.26.
Lea Brothers & Co.'s Publications — Nerv. and Ment. Dis., etc. 19
MITCHELL, S. WBIR, 31. 2>.,
Physician to Orthopocdic Hospital and the Infirmary for Diseases of the Nervous System, PhUa., etc.
Lectures on Diseases of the Nervous System; Especially in Women.
Second edition. In one r2mo. volume of 288 pages. Cloth, $1.75. Just ready.
We feel .sure that tlie new edition of Dr. Mitcli-
ell's admirable lectures will be received on this
side of the Atlantic with more than ordinary at-
tention. His subject, the nervous disorders of
women, is one that interests every practitioner,
and his views on treatment are gradually receiving
general acceptance. — London Medical Times and
tiazette, July 4, 1885.
MOSS, JA3IES, M.n., F.R. C. JP., LL. D,,
Seni&r Assistar.t Physician to the Manchester Royal Infirmary.
A Text-Book on Diseases of the Nervous System. In one handsome
octavo volume of 600 pages, fully illustrated. Shortly.
HAIIILTOW, ALLAN McLAJSTE, M. D.,
Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelPs Island, N. Y.
Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly
revised and rewritten. In one octavo volume of 598 pages, vrith 72 illustrations. Cloth, $4
When the firstedition of this good book appeared j characterized this hookas the best of its kind in
we gave it our emphatic endorsement, and the 1 any language, which is a handsome endorsement
present edition enhances our appreciation of the j from an exalted source. The improvements in the
Dook and its author as a safe guide to students of new edition, and the additions to it, will justifV its
clinical neurology. One of the best and most purchase even by those who possess the old. —
critical of English neurological journals, Brain, has , Alienist and Neurologist, April, 1882.
TTJKE, DANIEL HACK, 31, D,,
Joint Author of The Annual of Psychological Medicine, etc.
Illustrations of the Influence of the Mind upon the Body in Health
and Disease. Designed to elucidate the Action of the Imagination. New edition.
Thoroughly revised and rewritten. In one handsome octavo volume of 467 pages, with
two colored plates. Cloth, $3.00.
It is impossible to peruse these interesting chap-
ters without being convinced of the author's per-
fect sincerity, impartiality, and thorough mental
grasp. Dr. Tuke has exhibited the requisite
amount of scientific address on all occasions, and
the more intricate the phenomena the more firmly
has he adhered to a physiological and rational
method of interpretation. Guided by an enlight-
ened deduction, the author has reclaimed for
science a most interesting domain in psychology,
previously abandoned to charlatans and empirics.
This book, well conceived and well written, must
commend itself to every thoughtful understand-
ing. — New York Medical Journal, September C, 1884.
CLOTJSTON, TH03IAS S., 31. n., F. B. C. P., L. jB. C. S.,
Lecturer on Mental Ihseases in the University of Edinburgh.
Clinical Lectures on Mental Diseases. With an Appendix, containing an
Abstract of the Statutes of the United States and of the Several States and Territories re-
lating to tlie Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor
of Mental Diseases, Medical Department of Harvard University. In one handsome
octavo volume of 541 pages, illustrated with eight lithographic plates, four of which
are beautifully colored. Cloth, $4.
The practitioner as well as the student will ae- | the general practitioner in guiding him to a diag-
cept the plain, practical teaching of the author as a ! nosis and indicating the treatment, especially in
forward step in the literature of insanity. It is I many obscure and doubtful cases of mental dis-
refresliing to find a physician of Dr. Clouston's I ease. To the American reader Dr. Folsom's Ap-
experience and high reputation giving the bed- pe>idur adds greatly to the value of the work, and
side notes upon which liis experience ha? been will make it a desirable addition to every library,
founded and his mature judgment established. — American Psychological Journal, J\i\y,l8Si.
Such clinical observations cannot but be useful to
Folsom's Abstract may also be obtained separately in one octavo volume of
108 pages. Cloth, $1.50.
SAVAGE, GEORGE H., 31. D.,
Lecturer on Mental Diseases at &uy's Hospital, London.
Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol-
ume of 551 pages, with 18 tj-pical illustrations. Cloth, $2.00. Just ready. See Series of
Clinical Manuals, page 3.
As a handbook, a guide to practitioners and 3tu- I common sense is everywhere apparent. We re-
dents, the book fulfiU an admirable purpose. The peat that Dr. Savage has written an excellent
many forms of insanity are described with char- m.anual for the practitioner and student. — Am-
acteristic clearness, the illustrative cases are care- erican Journal of Insanity, April, 1885.
fully selected, and as regards treatment, sound |
PLATFAIB, W. S., 31. D., F. It. C. F.,
The Systematic Treatment of Nerve Prostration and Hysteria. In
one handsome small 12mo. volume of 97 pages. Cloth, $1.00.
Blandford on Insanity and its Treatment: Lectures on the Treatment,
Medical and Legal, of Insane Patients. In one very handsome octavo volume.
20 Lea Brothers & Co.'s Publications — Surgery.
GBOSS, S. J)., M, D., XX. D., JD. C. X. Oxon., LL, D.
Cantab, f
Emerititi Professor of Surgery in the J^erson Medical College of Philadelphia.
A System of Surgery : Pathological, Diagnostic, Therapeutic and Operative.
SLxth edition, tlioroughly revised and greatly improved. In two large and beautifully-
printe<l imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings.
Strongly bound in leather, raised bands, $15; half Kussia, raised bands, $16.
Dr. Gross' Si/stem of Suraery has long been the material has been Introduced, and altogether the
standard work on that subject for students and distinguished author has reason to be satisfied
practitioners.— Z,on(/t>ii Lancet, May 10, 1884. that he has placed the work fully abreast of the
The work a* a whole needs no commendation, state of our knowledge.— J/ed. ij«ryrrf, Nov. 18, 1882.
Many years ago it earned for itself the enviable rep- His System of Surgery, which, since its first edi-
utation of the loading American work on surgery, tion in 1859, has been a standard work in this
and it is still capnMe i.f maintaining that standard. I country as well as in America, in "the whole
The reason for this need only be mentioned to be domain of surgery," tells how earnest and labori-
appreciated. The author has always been calm ous and wise a surgeon he wa.s. how thoroughly
and iudicious in his statements, has Wed his con- he appreciated the work done by men in other
elusions on much study and personal experience, countries, and how much he contributed to pro-
ha-s been able to grasp his subject in its entirety, : mote the science and practice of surgery in his
and, at>ove all, lias conscientiously adhered to own. There has been no man to whom America
truth and fact, weighing the evidence, pro and Is so much indebted in this respect as the Nestor
eon, accordingly. A considerable amount of new I of surgery. — Britiih Medical Journal, May 10, 1884.
ASJECJanjUST, JOHJST, jr., M. x>..
Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hoepital, Philadelphia.
The Principles and Practice of Surgery. Fourth edition, enlarged and
revised. In one large and handsome octavo volume of about 1100 pages, with about 575
illustrations. Shortly.
GOULD, A. FJEABCE, 31. S., M. B,, F. B. C. S„
A^-sistnnt Surgeon to Midiilesex Hospitril.
Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589
pages. Cloth, $2.00. Just ready. See Sturlenl'i' Series of 3fami-als, page 3.
The student and practitioner will find the i and if practitioners would devote a portion of their
principles of surgical aiagnosis very satisfactorily I leisure to the study of it, they would receive
set forth with all unnecessary verbiage elimi- immense benefit in the way of refreshing their
nated. Every medical student attending lectures ', knowledge and bringing it up to the present state
should have a copy to study during the intervals, i of progress. — Cincinnati Medical ]!fews, Jan., 1888.
GIBJSEY, V. JP., M7n7,
Surgeon to the Orthopccdie Hospital, Neic York, etc.
Orthopaedic Surgery. For the use of Practitioners and Students. In one hand-
some octavo volume, profusely illustrated. Preparing.
BOBEBTS, JOHJSr B., A. M., 31. D.,
Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy.
The Principles and Practice of Surgery. For the use of Students and
Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 500
pages, with many illustrations. Preparing.
BELLA3IY, EJDWABI), F. B. C. S.,
S>trgeon and Lectur»r on Surgery at Charing Cross Hospital, London.
Operative Surgery. Shortly. See St%idents' Series of Manuals, page 3.
STI3ISOX, LEWIS A., B. A., 3f. JD.,
Pof. of Pathol. Anat. at the Univ. of the City of Kew York, Surgeon and Curator to Bellevue Hotp.
A Manual of Operatire Surgery. New (second) edition. In one very hand-
some royal 12mo. volume of about 500 pages, with about 350 illustrations. Cloth, $2.50.
Shortly.
A notice of the previous edition i% appended.
This volume is devoted entirely to operative sur- I every student should possess one. This work
gery, and is Intended to familiarize the student does" away with the necessity of pondering over
with the details of operation.* and the different I larger works on surgery for descriptions of opera-
modes of performing them. The work is hand- tions, as it presents in a nutshell what is wanted
Bomely illustrated, and the descriptions are clear by the surgeoQ without an elaborate search to
and well-drawn. It is a clever and useful volume; | find it.— Maryland Medical Journal, August, 1878.
SARGENT ON BANDAr.ING.^Np OTHER OPERA- PIRRIE'S PRINCIPLES AND PRACTICE OF
TIONS OF MINOR .SURGERY. New edition, i SUR<iERY. Edited bv Joh.v Neill, M. D. In
with a Chapter on military surgery. One 12mo. one 8vo. vol. of 784 pp. w"ith 31G illus. Cloth, (^.75.
mIiiTr-" PRlNcTr'SoFlr«r^ COOPER'S LECTURES ON THE PRINCIPLES
*'im;ri^an';r^[n'lhr,'i.?^^fdl1i\,?r^g^^]i-tio'n"."'- 'tl i t^'S^S''W>S^n^>^''^^'- '''°°' ''"'°'
one svo. vol. of G38 pages, with 340 illustrations. ^ ' ' ^"^ *' ' ^
Cloth, $3.75. j SKEY'S OPERATIVE SURGERYMn OMe vol.Svo.
MILLER'S PRACTICE OF SURGERY. Fourth of 6G1 pages, with 81 woodcuts. Cloth, 83.25.
and revised American from the last Edinburgh GIBSON'S INSTITUTES AND PRACTICE OF
©ditioa. In one large 8 vo. ToL of 682 pages, with SURGERY. Eighth edition. In two octavo vols.
SM illustrations. Cloth, J8.T5. < of 965 pages, with S4 plates. Leather 86.69.
Lea Brothers & Co.'s Publications — Surgery.
21
ERICHSBN, JOHN JE., F. B. S., F, JR. C. S.,
ProfesAor of Surgery in University College, London, etc.
The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis-
eai3es and Operations. From the eighth and enlarged English edition. In two large and
beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood.
Cloth, $9; leather, raised bands, $11 ; half Kussia, raised bands, |12. Just ready.
After the profession has placed its approval upon I mneh to be said in the way of comment or criti-
a work to the extent of purchasing seven editions, cism. That it still holds its own goes witliout say-
it does not need to be introduced. Simultaneous ing. The author infuses into it his large experi-
with the appearance of this edition a translation I ence and ripe judgment. Wedded to no sciiool,
is being made into Italian and Spanish. Thus j committed to no theory, biassed by no hobby, he
this favorite text^booli on surgery holds its own in ] imparts an honest personality in his observations,
spite of numerous rivals at the end of thirty years.
It is a grand book, worthy of the art in the interest
of wliich it is written. — Detroit Lancet, Jan. 10, 1885.
After being before the profession for thirty
years and maintaining during that period a re-
putation as a leading work on surgery, there is not
and his teachings are the rulings of an impartial
judge. Such men are always safe guides, and their
worlcs stand the tests of time and experience.
Such an author is Erichsen, and such a work is his
Surgery.— Medical Record, Feb. 21, 1885.
BUYANT, TH03IAS, F. M, C. S,,
Surgeon and Lecturer on Surgery at Guy^s Hospital, London.
The Pl'actiee of Surgery. Fourth American from the fourth and revised Eng-
lish edition. In one large and very liandsome imperial octavo volume of 1040 pages, with
727 illustrations. Cloth, $6.50; leather, $7.50; half Kussia, $8.00. Just ready.
The treatise takes in the whole field of surgery,
that of the eye, the ear, the female organs, ortho-
psedios, venereal diseases, and military surgery,
as well as more common and general topics. All
of these are treated with clearness and vrith
sufficient fulness to suit all practical purposes.
The illustrations are numerous and well printed.
We do not doubt that this new edition will con-
tinue to maintain the popularity of this standard
work. — Medical and Surgical Reporter, Feb. 14, '85.
This most magnificent worli upon surgery has
reached a fourth edition in this country, showing
the high appreciation in which it is held by the
American profession. It comes fresli from the
pen of the author. That it is the very best work
on surgery for medical students we think
there can be no doubt. The author seems to have
understood just what a student needs, and has
prepared the work accordinglj'. — Cincinnati Medical
JS^ews, January, 1885.
By the same Author.
Diseases of the Breast. In one 12mo. volume. Preparing. See Series of Clinical
Manuals, page 3.
BUTLIIi^, BCFJVBY T., F. B. C. S.,
Assistant Surgeon to St. Bartholomew'' s Hospital, London.
Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored
plates and 3 woodcuts. Cloth, $3.50. Just ready. See Series of Clinical Mamials, page 3.
FSMABCS, Dr. FBIFDBICBC,
Professor of Surgery at the University of Kiel, etc.
Early Aid in Injuries and Accidents. Five Ambulance Lectures. Trans-
lated by H. R. H. Princess Christian. In, one handsome small 12mo. volume of 109
pages, with 24 illustrations. Cloth, 75 cents.
The course of instruction is divided into five
sections or lectures. The first, or introductory
lecture, gives a brief account of the structure and
organization of the human body, illustrated by
the methods of affording first treatment in cases
of frost-bite, of drowning, of suffocation, of loss of
consciousness and of poisoning are described;
and the fifth lecture teaches how injured persoas
olear, suitable diagrams. The second teaches how | may be most safely and easily transported to their
to give judicious help in ordinary injuries — contu- i homes, to a medical man, or to a hospital. Th«
sions, wounds, ha?morrhage and poisoned wounds. [ illustrations in the book are clear and good. — Medi-
The third treats of first aid in cases of fracture cal Times arui Oazstte, Nov. 4, 1882.
and of dislocations, in sprains and in burns. Next, |
IBFIHES, FBEBEBICK, F. B. C. S.,
Atsistnnt Surgeon to and Lecturer on Surgery at the London Hospital.
Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 6*
illustrations. Limp clotli, blue edges, $2.00,
page 3.
A standard work on a subject that ha-s not been
so comprehensively treated by any contemporarj'
English writer. Us completeness renders a full
review difficult, since every chapter deserves mi-
Just ready. See Series of Clinical Manuals^
Justice to the author in a few paragraphs. Intei-
tival Obstruction is a work that will prove of
equal value to the practitioner, the student, the
pathologist, the physician and the operating sur-
nute attention, and it is impossible to do thorough \ geon. — Britiih Medical Journal, Jan. 31, 1885-
BALL, CHABLES B., M. C7i., Bub., F. B. C. S. E.,
Surgeon and Teacher at Sir P. Dun's Hospital, Dublin.
Diseases of the Rectum and Anus. In one 12mo. volume of 550 pages.
Preparing. See Series of Clinical Manual.^, page 3.
BBJJITT, BOBEBT, M. B. C. S., etc.
The Principles and Practice of Modern Surgery. From the eightk
Tjonden edition. In one Svo. volume of flS7 pJiges, with 432 illus. Cloth, $4 ; leather, $5.
22 Lea Brothers & Co.'s Publications — Surgery.
HOLMES, TI3IOTJSY, M. A.,
Surgeon and Lecturer on Surgery at St. George's Hospital, London.
A System of Surgery ; Theoretical and Practical. IN TREATISES BY
VARIOUS AUTHORS. Ameuican edition, thorouohly RE\^SED and re-edited
by John II. Packard, M. D., Surgeon to the Eniscojxil and St. Joseph's Hospitals,
Philadelpliia, assisted by a corps of tJiirty-tliree of tlie most eminent American surgeons.
In three large and very handsome imperial octavo volumes containing 3137 double-
columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully
colored. Price per volume, cloth, $6.00 ; leather, $7.00 ; half Russia, $7.50. Per set, cloth,
$18.00; leather, $21.00; half Russia, $22.50. Sold only by subscription.
VoLUJiE I. contains General Pathology, Morbid Processes, Injuries rN Gen-
eral, Complications of Injuries and Injuries of Regions.
Volume II. contains Diseases of Organs of Special Sense, Circulatory Sys-
tem, Dige-stive Tract and Genito-Urinary Organs.
Volume III. contains Diseases of the Respiratory Organs, Bones, Joints and
Muscles, Diseases of the Nervous System, Gutjshot Wounds, Operative and
Minor Surgery, and Miscellaneous Subjects (including an essay on Hospitals).
This great work, issued some years since in England, has won such universal confi-
dence wlierever the language is spoken that its republication here, in a form more
thoroughly adapted to the wants of the American practitioner, has seemed to be a duty
owing to the profession. To accomplish this, each article has been placed in the hands of
a gentleman specially competent to treat its subject, and no labor has been spared to bring
each one up to the foremost level of the times, and to adapt it thoroughly to the practice
of the country. In certain cases this has rendered necessary the substitution of an entirely
new essay for the original, as in the case of the articles on Skin Diseases, on Diseases of
the Absorbent System, and on Anaesthetics, in the use of which American practice differs
from that of England. The same careful and conscientious revision has been pursued
throughout, lea^ling to an increase of nearly one-fourth in matter, while the series of
illustrations ha.s been nearly trebled, and the whole is presented as a complete exponent
of Britiirh and American Surgery, adapted to the daily needs of the working practitioner.
In order to bring it within the reach of every member of the profession, the five vol-
umes of the original have been compressed into three by employing a double-columned
royal octavo page, and in this improved form it is offered at less than one-half the price of the
original. It is printed and bound to match in every detail with Reynolds' System of Medi-
cine. The work will be sold by subscription only, and in due time every member of the
profession will be called upon and offered an opportunity to subscribe.
The authors of the original English edition are ' the library'of any medical man. It is more wieldly
men of the front rank in England, and Dr. Packard and more useful than the English edition, and with
has been fortunate in securing as his American its companion work — "Reynolds' System of Medi-
coadjutors such men as Barth'olow, Hyde, Hunlj cine" — will well represent the present state of our
Conner, Stinison, Morton, Hodeen, Jewell ana science. One who is familiar with those two works
their colleagues. As a whole, the work will be will be fairly well furnished head-wise and hand-
solid and substantial, and a valuable addition to I wise. — The Medical JS'ews, Jan. 7, 1882.
STI3ISOIf^, LEWIS A., B. A.% M. D.,
Professor of Pathological Anatomy at the University of the City of New Ycn-k, Surgeon and Curator
to Bellevue Hospital, Surgeon to the Presbyterian 6ospital, New York, etc.
A Practical Treatise on Fractures. In one very handsome octavo volume of
598 pages, with 360 beautiful illustrations. Cloth, $4.75 ; leather, $5.75.
The author has given to the medical profession the surgeon in full practice. — N. O. Medical and
in this treatise on fractures what is likely to be- Surgical Journal, March, 1883.
lTl^^Tl'^!\'uJ'^!.^ZVrV-^^r^^^^^ The author gives in clear language all that the
nr fnr'^wil^t^r^nr.hV 1 ^^"k^ practical surgeon need know of tfie science of
fhnr^oi.i nl u.^lArV^ ^ language. The au- fractures, thlir etir.iogv, symptoms, processe.« of
monnlr J MififunLr V ' ,r'^''TP'»^^^^^^^^ union, and treatment, according to the latest de-
,^no .![;f«nLn V r r ,,,^^fi'^^^^ ^^'l^l^"^' " ^^^'^ velopAieuts. Ou the ba.sis of mechanical analysis
n^hPrteul Lnf^^nTtro !*i^ V the author accurately and clearlv explains the
nn/h Th«^rjrit«^nr^n i ^V^ c'inica' features of fractures, and by the same
trllL Jnr «hrfv^ hf^ nn7^, V / <^'»ct"re.. and their ^^^i,^^ ^.^j^es at the proper diagnosis snd rational
d^n htu liWpwi««^rJ.; na ?, / P'"°^°"",1 ^ »■ treatment. A thorough explanation of the patho-
«f«t.' His mo7« nf r.^aTmLn ^f f^fTff "^ ^'f f'"'*^' 'ogi^a' anatomv and I cariful description of the
«r«i,«minVn*wInmwi 2^> i^v .1 different fract- ^„»ious methods of procedure make the book full
;'hTi?r^rj'^'t^trblro'nP??^rur'esran^d"'lt^'w'fn ?J,,-^- for every |ractitioner.-C^.r.,6,.« /.r
be welcomed not onlv as a t«it-book, but also by ^""^"'^3"' May 19, 1883.
MABSH, SOWAItD, F. B. C, S.,
Snuor Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London.
Diseases of the Joints. In one 12mo. volume. Preparing. See Series of Clinical
Manuals, page 3.
BICK, T. BICKEBING, F. B. C. S.,
Surgeon to and Lecturer on Surgery at St. George's Hospital, London.
Fractures and Dislocations. In one 12mo. volume. Preparing. See Series
of Clinical Manuals, page 3.
Lea Brothers & Co.'s Publications — Frac, Disloc, Ophtlial. 23
HAMILTOW, FMAJV^JBC., M, JD., LL. D.,
Surgeon to Bellevne Hospital, New York.
A Practical Ti'eatise on Fractures and Dislocations. Seventh edition,
thoroughly revised and much improved. In one very Ixandsome octavo vohmie of 998
pages, with 379 ilhistrations. Cloth, $5.50: leather, $6.50; very handsome half Russia,
open back, $7.00. Just ready.
Hamilton's ^reat experience and wide acquaint- 1 cent work, and especially of the recorded re-
ance with the literature of the subject have enabled j searches and improvements made by the author
him to complete the labors of Malgaigne and to himself aud his countrymen. — British Medical
place the reader in possession of the advances
made during thirty years. The editions have fol-
lowed each other rapidly, and they introduce us
to the methods of practice, often so wise, of his
American colleagues. More practical than Mal-
gaigne's work, it will sc-rve as a valuable guide to
the practitioner in the numerous and enibarrass-
ing ca.ses which come under his observation. —
Archix^es Generates de Medecine, Paris, Nov. 1884.
This work, which, since its first appearance
twenty-five years ago, has gone through many
Journnl, May 9, 18S5.
With its first appearance in 1859, this work took
rank among the classics in medical literature,
and has ever since been quoted by surgeon.s the
world over as an authority upon the topics of
which it treats. The surgeon, if one can be found
who does not already know the work, will find it
scientific, forcible and scholarly in text, exhaustive
in detail, and ever marked by a spirit of wise con-
servatism. — Louisville Medical News, J.an. 10, 1885.
For a quarter of a century the author has been
editions, and been much enlarged, may now be elaborating and perfecting his work, so that it
fairly regarded as the authoritative book of refer- \ now stands as the best of its kind in any lan-
enee on the subjects of fractures and dislocations. ; guage. As a text-book and as a book of reference
Each successive edition has been rendered of I and guidance for practicioners it is simply invalu-
greater value through the addition of more re- | able. — New Orleans Med. andSurg.JournU, i\ov.l8Si.
JTJLEJR, HBJSritY B., F, B. C. S.,
Senior Ass't Surgeon, Royal Westminster Ophthalmic Hasp. ; late Clinical Ass't, Moorfields, London.
A Handbook of Ophthalmic Science and Practice. In one handsome
octavo volume of 460 pages, with 125 woodcuts, 27 colored plates, and selections from the
Test-types of Jaei^cr and Snellen. Cloth, $4.50 ; leather, $5.50. Just ready.
This work is distinguished by the ^reat num-
ber of colored plates which appear in it for illus-
trating various pathological conditions. They are
very beautiful in appearance, and have been
executed with great care as to accuracy. An ex-
amination of the work shows it to be one of high
standing, one that will be regarded as an authority
among oplithalmologists. The treatment recorn-
mended is sucli as tlie author has learned from
actual experience to be the best. — Cincinnati Medi-
cal News, I)ec. 1884.
It presents to the student concise descriptions
and typical illustrations of all important eye
affections, placed in juxtaposition, so as to be
f rasped at a glance. Beyond a doubt it is the
est illustrated handbook of ophthalmic science
which has ever appeared. Then, what is still
better, these illustrations are nearly all original.
We have examined this entire work with great
care, and it represents the commonly accepted
views of advanced ophthalmologists. We can most
heartily commend this book to all medical stu-
dents, practitioners and specialists. — Detroit
Lancet, Jan. 1885.
WELLS, J. SOELBEJRG, F. M. C. S.,
Professor of Ophthalmology in King^s College Hospital, London, etc
A Treatise on Diseases of the Eye. Fourth American from the third London
edition. Thoroughly revised, with copious additions, by Chakles S. Bull, M. D., Surgeon
and Pathologist to the New York Eye and Ear Infirmary. In one large octavo volume of
822 pages, with 257 illustrations on wood, six colored plates, and selections from the Test-
types of Jaeger and Snellen. Cloth, $5.00 ; leather, $6.00 ; half Russia, $6.50.
The present edition appears in less than three
years since the publication of the last American
edition, and j'et, from the numerous recent inves-
tigations that have been made in this branch of
medicine, many changes and additions have been
required to meet the present scope of knowledge
upon this subject. A critical examination at once
show.s the fidelity and thoroughness with which
the editor has accomplished his part of the work.
The illustrations throughout are good. This edi-
tion can be recommended to all as a complete
treatise on diseases of the eye, than which proba-
bly none better exists. — Medical Hecord, Aug. 18, '83.
NETTLESHLF, EL>WAItI), F. B. C. S,,
Ophthalmic Surg, and Lect. on Ophth. Surg, at St. Thomas'' Hospital, London.
The Student's Guide to Diseases of the Eye. Second edition. With a chap-
ter on the Detection of Coloi--Blindness, by William Thomson, M. D., Ophthalmologist
to the Jefferson Medical College. In one royal 12mo. volume of 416 pages, with 138
illustrations. Cloth, $2.00.
This admirable guide bids fair to become the
favorite text-book on ophthalmic surgery with stu-
dents and general practitioners. It bears through-
out the imprint of sound judgment combined w^th
vast experience. The illustrations are numerous
and well chosen. This book, within the short com-
pass of about 400 pages, contains a lucid exposition
of the modern aspect of ophthalmic science. —
Medical Record, June 23, 1883.
BBOWNE, EL>GAB A.,
Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skin Diseases.
How to Use the Ophthalmoscope. Being Elementary Instructions in Oph-
thalmoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116
pages, with' 35 illustrations. Qoth, $1.00.
LAWSON ON INJURIES TO THE EYE, ORBIT
AND EYELIDS: Their Immediate and Remote
Eefects. 8 vo., 40-t pp., 92 illus. Cloth, 83.50.
LAURENCE AND MOON'S HANDY BOOK OF
OPHTHALMIC SURGERY, for the use of Prac-
titioners. Second edition. In one octavo vol-
ume of 227 pages, with 65 illust. Cloth, 82.75.
CARTER'S PRACTICAL TREATISE ON DISEAS-
ES OF THE EYE. Edited by John Green, M. D.
In one handsome octavo volume.
24 Lea Brothers & Co.'s Publications — Otol., Urin. Dis., Dent.
BVRJS^ETT, CHABLES JET., A, M., ilf. !>.,
Professor of Otohgii in the Philadelphia Polyclinie ; Prcsidait of the American Otological Soeiety.
The Ear, It8 Anatomy, Physiology and Diseases. A Practical Treatise
for the use of Medical Students and Practitioners. New (second) edition. In one handsome
octavo volume of 5S0 pages, witli 107 ilhistralions. Cloth, $4.00 ; leather, $5.00. Just ready,
Wenote with pleasure the ftppeftrance of a second carried out, and much new matter added. Dr.
edition of thi? valuable work. When it first came Burnett's work must be regarded as a very valua-
out it was accepted K>j' the profession as one of ble contribution to aural surgery, not only on
the standard works on modern aural surgery in account of its comprehensiveness, but because it
tiie English language; and in his second edition contains the results of the careful personal observa-
Dr. Burnett has fully maintained his reputation, tion and experience of this eminent aural surgeon,
for the book is replete with valuable information ' — London Lancet, Feb. 21, 1885.
and suggestions. The revision has been carefully
POLITZEB, A BAM,
Imperial- Roi/al Prof, of Aural Therap. in the Univ. of Vienna.
A Text-Book of the Ear and its Diseases. Translated, at the Author's re-
quest, by Jamis Patterson Cassells, M. D., M. R. C. S. In one handsome octavo vol-
ume of 800 pages, with 257 original illustrations. Cloth, $5.50.
The work itself we do not hesitate to pronounce section, and this again by the pathological physi-
tlie best upon the subiect of aural diseases which olopy, an arrangement which serves to keep up the
has ever appeared, systematic without being too interest of the student by showing the direct ap-
diffuse on onsolete subjects, and eminently prae- plication of what has preceded to the study of dis-
tical in every sense. T)ie anatomical descriptions ease. The whole work can be recommended as a
of each separate division of the ear are admirable, reliable guide to the student, and an efficient aid
and profuselv illustrated by woodcut-s. Thev are to the practitioner in his treatment. — Boston Medr
followed immediately by the physiology of the , ical and Surgical Journal, .June 7, 1883.
ROBERTS, WILLIA3I, 31. I),,
Lecturer on Medicine in the Manchester School of Medicine, etc.
A Practical Treatise on Urinary and Renal Diseases, including Uri-
nary Deposits. Fourth American from the fourth Ixtndon edition. In one hand-
some octavo volume of 609 pages, witli 81 illustrations. Cloth, $3.50. Just ready.
The peculiar value and finish of the book are directly or indirectly to the diagnosis, prognosis
derived from its resolute maintenance of a clinical i and treatment of urinary diseases, and possesses
and practical character. This volume is an un- t a completeness not found elsewhere iu our Ian-
rivalled exposition of everything which relates [ guage. — The Medical Chronicle, July, 1885. q.
GROSS, S. 7>., 31. D., LL. J)., Z>. C. X., etc.
A Practical Treatise on the Diseases, Injuries and Malformations
of the Urinary Bladder, the Prostate Gland and the Urethra. Third
edition, thoroughly revised by SAMrEL W. Gro.s.-^, M. D., Professor of the Principles of
Surgery and of Clinical Siu-gery in the Jefferson Medical College, Philadelphia. In one
octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50.
MORRIS, HEJS'^RY, M. B., F. R. C. S.,
Surgeon to and Lecturer on Surgery at Middlesex Hospital, London.
Surgical Diseases of the Kidney. In one 12mo. volume. Preparing. See
Series of CUniccU 3Ianuah, page 3.
LUCAS, CLEMEJS^T, M. B., B. S., F. R. C. S.,
Senior Assistant Surgeon to Guy's Hospital, London.
Diseases of the Urethra. In one 12mo. volume. Preparing. See Series
of Clinical Manuals, page 3.
TH03IFS0JSr, SIR HENRY,
Surgeon and Professor of Clinical Surgery to University College Hospital, London.
Lectures on Diseases of the Urinary Organs. Second American from the
thirvl English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25.
By the Same Author.
On the Pathology and Treatment of Stricture of the Urethra and
Urinary Fistulae. From the third English edition. In one octavo volume of 359
pages, with 47 cuts and 3 plates. Cloth, $3.50.
COLEMAJS^, A., L. R. C. P., F. R. C. S., Exam. L. D. S.,
Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., Loruion.
A Manual of Dental Surgery and Pathology. Thoroughly revised and
adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D.,
D. D. S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo
Tolume of 412 pages, with 331 illustrations. Cloth, $3.25.
BASHAM ON REXAL DISEASES : A Clinical I one 12mo. vol. of 301 pages, with 21 Illustrations.
Guide to their Diagnosis and Treatment. In | Cloth, ^.00.
Lea Brothers & Co.'s Publications — Veuereal, Impotence.
25
BTJMSTEAD, F. J.,
31. I)., LL, D.,
Late Professor of Venereal Diseases
at the CoHege of Physicians and
Surgeons, Keic York, etc.
and TAYZOB, B. W.,
A. 31., 31. jy.,
Surgeon to Charity Hospital, New York, Prof, of
Venereal and Skin Diseases in the University of
Vermont, Prcs. of the Am. Dermatological Ass'n.
The Pathology and Treatment of Venereal Diseases. Including the
results of recent investigations upon the subject. Fifth edition, revised and largely re-
written, by Dr. Taylor. In one large and handsome octavo volume of 898 pages with
139 illustrations, and thirteen chromo-lithographic figures. Cloth, $4.75; leather, $5.75;
very handsome half Russia, $6.25.
It is a splendid record of honest labor, wide The character of this standard work is so well
research, just comparison, careful scrutiny and kn'^nvn that it would be superfluous here to pass in
original expeiience, which will always he held as review its general or special points of excellence,
a high credit to American medical literature. This The verdict of the profession )ias been passed; it
is not only the best work in the English language has been accepted as the most thorougii and com-
upon the subjects of which it treats, but also one ; plate exposition of the pathology and treatment of
wnich has no equa. in other tongues for its clear, venereal diseases in the language. Admirable as a
comprehensive and practical handling of its , model of clear description, an exponent of sound
themes. — American Journal of the Medical Sciences, ! pathological doctrine, and a guide for rational and
Jan, 1884. successful treatment, itisan ornament tothe rnedi-
It i.s certainly the best single treatise on vene- cal literature of this countrj'. The additions made
real in our own, and probably the best in any Ian- to the present edition are eminently judicious,
guage. — Boston Medical and Surgical Journal, April from the standpoint of practical utility. — Journal oj
3, 1884. , Cutaneous and Venereal Diseases, Jan. 1884.
COBJSIL, v.,
Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital.
Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially
revised by the Author, and translated with notes and additions by .J. Henry C. Simes,
M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and
J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery
in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with
84 very beautiful illustrations. Cloth, $2
The anatomical and histological characters of the
hard and soft sore are admirably described. The
multiform cutaneous manifestations of the disease
are dealt with histologically in a masterly way, as
we should indeed expect them to be, and the
accompanying illustrations are executed carefully
and well. The various nervous lesions which are
the recognized outcome of the sypljilitic dyscrasia
are treated with care and consideration. Syphilitic
epilepsy, paralysis, cerebral syphilis and locomotor
ataxia are subjects full of interest ; and nowhere in
the whole volume is the clinical experience of the
author or the wide acquaintance of the translators
with medical literature more evident. The anat>
omy, tlie histology, the pathology and the clinical
features of syphilis are represented in this work In
their best, most practical and most instructive
form, and no one will rise from its perusal without
the feeling that his grasp of the wide and impor-
tant subject on whicji it treats is a stronger and
surer one. — The London Practitioner, Jan. 1882.
MVTCHIXSOW, JOjS^ATHAW, F. B. S., F. B. C. S.,
Consulting Surgeon to the London Hospital.
Syphilis. In one 12mo. volume. Preparing. See /Series of Clinical Manuals, page 3.
GBOSS, SAMUEL W., A. 31., 31. D.,
Professor of the Drinciples of Surgery and of Clinical Surgery in the Jefferson Medical College.
A Practical Treatise on Impotence, Sterility, and Allied Disorders
of the Male Sexual Organs. Second edition, thoroughly revised. In one very hand-
some octavo volume of 168 pages, with 16 illustrations. Cloth, $1.50.
The author of this monograph is a man of posi- This work will derive value from the high stand-
tive convictions and vigorous style. This is iusti- : ing of its author, aside from the fact of its passing
fied by his experience and by hisstudy, which has so rapidly into its second edition. This is, indeeci,
gone hand in hand with his experience. In regard ! a book that every physician will be glad to place
to the various organic and functional disorders of in his library to be read with profit to himself,
the male generative apparatus, lie has had ex- and with incalculable benefit to his patient. Be-
ceptional opportunities for ob.servation, and his sides the subjects embraced in the title, which are
book shows that he has not neglected to compare i treated of in their various forms and degrees,
his own views with those of other authors. The spermatorrhoea and prostatorrhcea are also fully
result is a work which can be. "^afely recommended considered. The work is thoroughly practical in
to both physician? and surgeons as a guide in the ; character, and will be especially useful to the
treatment of the disturbances it refers to. It is general practitioner.— iVetiicai Record, Aug. 18,
the best treatise on the subject with which we are i 1883.
acquainted. — The Medical JVews, Sept. 1, 1883.
CULLFBIEB, A., & BU3ISTFAI), F. J., M.JD., LL.D.,
Surgeon to the Hdpital du Midi. Late Professor of Venereal Diseases in the College of Physicians
and Surgeons, New York.
An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum-
stead, IVI.D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates,
containing about 150 figures, beautifully colored, many of them the size of life. Strongly
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts.
HILL ON SYPHILIS AND LOCAL CONTAGIOUS FORiMS OP LOCAL DISEASE AFFECTING
DISORDERS. In one 8vo vol. of 479 p. Cloth, 8:?.2.5. PRINCIPALLY THE ORGANS OF GENERA-
LEES LECTURES ON SYPHILIS AND SOME TION. In one 8vo. vol. of 246 pages. Cloth, e2.26.
26 Lea Brothers & Co.'s Publications — Diseases of Skiu.
HTDE, J, NBVINS, A, M., M. D.,
Pi-ofes$or of Dermatology and Venereal Diseases in Rnali Medical College, Chicago.
A Practical Treatise on Diseases of the Skin. For the use of Students and
Pnictitioners. In one liandsome octavo volume of 570 pages, ^vith 66 beautiful and elab-
orate illustrations. Cloth, $4.25 ; leather, $5.25.
The author has given the student and practi- j cian in active practice. In dealing with these
tioner a work admirably adapted to the wants of • questions the author leaves nothing to the pre-
eaeh. We can heartily commend the book as a I sumed knowledge of the reader, but enters thor-
valuable addition to our literature and a reliable j oughly into the most minute description, so that
guide to students and practitioners in their studies one is not only told what should be done under
and practice.— .■l»'i. Journ. of Med. Sci., July, 188.S. given conditions but how to do it as well. It is
Especially to be praised are the practical sug- therefore In the best sense "a practical treatise."
gestions as to what may be called the common- \ That it is comprehensive, a glance at the index
sense treatment of eczema. It is quite impossible will s\u'\v.— Maryland Medical Journal, July 7, 1883,
to exaggerate the judiciousness with which the , Profes.sor Hyde has long been known as one of
formula' for the external treatment of eczema are the most intelligeni and enthusiastic represent*-
seleotod, and what Is of equal importance, the full i lives of dermatology in the west. His numerous
and clear instructions for their use.— Ixjndon Jtfetii- contributions to the literature of this specialty
cal JSmes and Gazette, July 28, 1883. have gained for him a favorable recognition as a
The work of Dr. Hyde will be awarded a high • careful, conscientious and original observer. The
position. The student of medicine will find it remarkable advances made in our knowledge of
Seculiarly adapted to his wants. Notwithstanding diseases of the skin, especially from the stand-
le extent of the subject to which it is doTotod, I point of pathological histology and improved
yet it is limited to a single and not very large vol- 1 methods of treatment, necessitate a revision of
ume. without omitting a proper discussion of the the older textrbooks at short intervals in order to
topics. The conciseness of the volume, and the , bring them up to the standard demanded by the
setting forth of onlv what can be held as facts will ] march of science. This last contribution of Dr.
also make It acceptable to general practitioners. Hyde Is an eflTort in this direction. He has at-
— Cincinnati Medical A'eics, Feb. 188.S. I tempted, as he informs us, the task of presenting
The aim of the author has been to present to his ] In a condensed form the results of the latest ob-
readers a work not only expounding the most servation and experience. A careful e.\aminatiod
modern conceptions of his subject, but presenting of the work convinces us that he has accomplishen
what is of standard value. He has more espoeially his task with painstaking fidelity and with a cred-
devoted its pages to the treatment of disease, and Itable result. — Journal of Ottatieous and Venereal
by his detailed descriptions of therapeutic meas- ; Diseases, June, 1883.
ures hits adapted them to the needs of the physl- j
FOX, T,, M.n., F.M. C. JP., and FOX, T. C, B.A,, 3I.B. C.S„
Physician to the Department for Skin Diseases, Physician for Dissases of the Skin to the
Univasity College Hospital, London. Westminster Hospital, London.
An Epitome of Skin Diseases. "With Formulse. For Students and Prac-
titioners. Third edition, revised and enlarged. In one very handsome 12mo. voliune
of 23S pages. Cloth, $1 .25.
The third edition of this convenient handbook ! manual to lie upon the table for instant reference,
calls for notice owing to the revision and expansion \ Itsalphabetical arrangement is suited to this use,
■which it has undergone. Thearrangement of skin , for all one has to know is the name of the disease,
diseases in alphabetical order, which is the method and here are its description and the appropriate
of classification adopted In this work, becomes a ■ treatment at hand and ready for instant applica-
positive advantage to the student. The book is | tion. The present edition has been very carefully
one which we can strongly recommend, not only ■ revised and a number of new disea.^es are de-
to students but also to practitioners who require a scribed, while most of the recent additions to
compendious summary of the present state of dermal therapeutics find mention, and the formu-
dermatoJogj'.— J5n7i;.7i Medical Journal, July 2, 1883. lary at the end of the book has been considerably
We cordially recommend Fox's Epitome to Xhoi^e 1 augmented. — The Medical News, December, 1883.
whose time is limited and who wish a handy |
MOBBIS, MALCOLM, 3L n..
Joint Lecturer on Dermatology at St. Mary's Hospital Medical School, Lorulon.
Skin Diseases ; Including their Definitions, Symptoms, Diagnosis, Prognosis, Mor-
bid Anatomy and Treatment. A Manual for Students and Practitioners. In one 12mo.
volume of 316 pages, with illustrations. Cloth, $1.75.
To physicianswho wouldlike toknowsomething for clearness of expression and methodical ar-
about skin diseases, so that when a patient pre- rangement is better adapted to promote a rational
senfs himself for relief they can make a correct conception of dermatology — a branch confessedly
diagnosis and prescribe a rational treatment, we difficult and perplexing to"the beginner.— S<. Z<ouw
unhesitatingly recommend this little book of Dr. Courier of Medicine, April, ISSO.
Morris. The affections of the skin are described ' The writer has certainly given in a small compass
in a terse, lucid manner, and their several charac- ' a large amount of well-compiled information, and
teristics so t.lainly set forth that diagnosis will be 1 his little book compares favorably with any other
easy. The treatment in each case is such as the \ which has emanated from England, while in many
experience of the most eminent dermatologists ad- i points he has emancipated himself from the stub-
vises.— Cifinnr.ari Meiiical yews, April, ISSO. bornly adhered to errors of others of his country-
This is emphatically a learner's book; for we i men. There is certainly excellent material in the
can safely say, that in the whole range of medical i book which will well repay perusal. — Boston Med.
literature there is no book of alike scope which t and Surg. Journ., March, 1880.
WILSOy, EBAS3IUS, F. B. S,
The Student's Book of Cutaneous Medicine and Diseases of the Skin.
In one handsome small octavo volume of 535 pages. Cloth, $3.50.
HILLIEB, THOMAS, 31. D.,
Physician to the Skin Department of University College, London.
Handbook of Skin Diseases ; for Students and Practitioners. Second Ameri-
can edition. In one 12mo. volume of 353 pages, with plates. Cloth, $2.25.
Lea Brothers & Co.'s Publications — Dis. ot Women.
27
A^ AMERICAN SYSTEM OF GYNJECOLOGT,
A System of Gynaecology, in Treatises by Various Authors. Edited
by Matthew D. Maxx, M. D., Professor of Obstetrics and Gynaecology in the Uni-
versity of Buffalo, N. Y. In two handsome .octavo volumes, richly illustrated. In active
•preparation.
LIST OF CONTRIBUTORS.
WILLIAM H. BAKER, M. D.,
FORDYCE BARKER, M. D.,
ROBERT BATTEY, M. D.,
SAMUEL C. BUSEY, M. D.,
HENRY F. CAMPBELL, M. D.,
HENRY C. COE, M. D.,
E. C. DUDLEY, M. D,
GEORaE J. ENGELMANN, M. D.,
HENRY F. GARRIGUES, M. D.,
WILLIAM GOODELL, M. D.,
EGBERT H. GRANDIN, M. D.,
SAMUEL W. GROSS, M. D.,
JAMES B. HUNTER, M. D., '
A. REEVES JACKSON, M. D.,
EDWARD W. JENKS, M. D.,
WILLIAM T. LUSK, M. D.,
MATTHEW D. MANN, M. D.,
ROBERT B. MAURY, M. D.,
PAUL F. MUNDE, M. D.,
C. D. PALMER, M. D.,
WILLIAM M. POLK, M. D.,
THADDEUS A. REAMY, M. D.,
A. D. ROCKWELL, M. D.,
ALEX. J. C. SKENE, M. D.,
R. STANSBURY SUTTON, A. M., M. D.,
T. GAILLARD THOMAS, M. D.,
ELI VAN DE WALKER, M. D.,
W. GILL WYLIE, M. D.
TH03IAS, T. GAILLABJy, M. D.,
Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y.
A Practical Treatise on the Diseases of Women, Fifth edition, thoroughly
revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266
illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Eussia, raised bands, $6.50.
The words which follow " fifth edition" are in ; vious one. As a booli of reference for the busy
this case no mere formal announcement. The i practitioner it is unequalled.— Boston Medical any
alterations and additions which have been made are \ Surgical Journal, April 7, 1880.
both numerous and important. The attraction I It has been enlarged and carefully revised. It is
and the permanent character of this book lie in a condensed encyclopsedia of gyntecological m edi-
the clearness and truth of the clinical descriptions cine. The style of arrangement, the masterly
of diseases ; the fertility of the author in thera- manner in which each subject is treated, and the
pentic resources and the fulness with which the i honest convictions derived from prohatily the
details of treatment are described; the definite ; largest clinical experience in that specialty of any
character of the teachins;; and last, but not least, in this country, all serve to commend it in the
the evident candor which pervades it. We would
also particularize the fulness with which the his-
tory of the subject is gone into, which maltes the
boolc additionally interesting and gives it value as
a work of reference. — London Medical Times and
Gazette, July 30, 188L
The determination of the author to keep his
highest terms to the practitioner. — Nashville Jour.
of Med. and Surg., Jan. 1881.
That the previous editions of the treatise of Dr.
Thomas were thought worthy of translation into
German, French, Italian and Spanish, is enough
to give it the stamp of genuine merit. At home'it
has made its way into the library of every obstet-
booli foremost in the rank of works on gynrecology rician and gynfecologist as a safe guide to practice,
is most gratifjing. Recognizing tlie fact that this No small number of additions have been made to
can only be accomplished by frequent and tlior- the present edition to make it correspond to re-
ough revision, he has spared no pains to make the cent improvements in treatment. — Pacific Medical
present edition more desii-able even than the pre- I a7id Surgical Journal, Jan. 1881.
EDIS, ARTBTUB IF., 3i7jy., Zand., F.B. C. JP., M, R. C. S.,
Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital.
The Diseases of Women. Including their Pathology, Causation, Symptoms,
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00.
It is a pleasure to read a book so thoroughly i The greatest pains h^ve been taken with the
good as tins one. The special qualities which are \ sections relating to treatment. A liberal selection
conspicuous are thoroughness in covering the j of remedies i.-; given for each morViid condition,
whole ground, clearness of description and con- i the strength, mode of application and other details
ciseness of statement. Anotlier marked feature of being fally explained. The descriptions of gynse-
the book is the attention paid to the details of ' cological manipulations and operations are full,
many minor surgical operations and procedures, clear and practical. Bluch care has also been be-
as, for instance, the use of tents, application of ' stowed on the parts of the book which deal with
leeches, and use of hot water injections. These diagnosis — we note especially the pages dealing
are among the more common methods of treat-
ment, and yet very little is said about them in
many of the text-books. The book is one to be
warmly recommended especially to students and
general practitioners, who need a concise but com-
plete resume, of the wnole subject. Specialists, too,
will find many useful hints in its pages. — Boston
Med. and Surg. Journ., March 2, 1882.
with the difl^erentiation, one from another, of the
different kinds of abdominal tumors. The prac-
titioner will therefore find in this book the kind
of Icnowledge he most needs in his daily work, and
he will be pleased with the clearness and fulness
of the information there given. — The Practitioner,
Feb. 1882.
BARNES, ROBERT, M. D,, F. R. C. JR.,
Obstetric Physician to St. Thomas'' Hospital, London, etc.
A Clinical Exposition of the Medical and Surgical Diseases of Women.
In one liandsome octavo volume, with numerous illustrations. New edition. Preparing.
WEST, CHARLEsTM.n,
Lectures on the Diseases of Women. Third American from the third Lon-
don edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75.
28 Lea Brothers & Co.'s Publications — Dis. of Women, Mldwty.
EMMET, THOMAS ADDIS, M. D., LL. D,,
Suryton to the Woman's Hospital, Kew York, etc.
The Principles and Practice of Gynaecology ; For the use of Students and
Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5 ; leather, $6.
{Just ready.)
We are in doubt whether to congratulate the' The time has passed when Emmet's G.i/ncenoJojfi/
author more than the profession upon the appear- was to be reearded as a book for a single country
ance of the third edition of this well-known work, or for a single generation. It has always been his
Embodying, as it does, the life-long experience of aim to popularize gymecology, to bring it within
one who has conspicuously distinguished himself easy reach of the general practitioner. The orig-
as a bold and successful operator, and who has inality of the ideas, aside from tlie perfect con-
devoted so much attention to the specialty, we fidence which we feel in the author's statements,
feel sure the profession will not fail to appreciate compels our admiration and respect. We may
the privilege thus offered them of perusing the well take an honest pride in Dr. Emmet's work
views and practice of the author. His earnestness i and feel that his book can hold its own against the
of purpose and con.scientiousness are manifest. ] criticism of two continents. It represents all that
He gives not only his individual experience but is most earnest and most thoughtuil in American
endeavors to represent the actual state of gynse- [ gyniecology. Emmet's work will continue to
cological science and a,rt.— British Medical Jfour- retieet the "individuality, the sterling integrity and
no'. May iri, 1885. ] the kindly heart of its honored author long after
No jot or tittle of the high praise bestowed upon I smaller books have been forgotten.— .imerican
the first edition is abated. It is still a book of Journal of Obstetrics, ll'la.y,lSSo.
marked personality, one based upon large clinical i Any work on gynsecology by Emmet must
experience, containing large and valuable ad- always have especial interest and value. He has
ditions to our knowledge, evidently written not [ for many years' been an excecdinglj' bu.sy prao-
only with honesty of purpose, but with aconseien- j titionerln this department. Few men have had
tious sense of responsibility, and a book that is at his experience and opportunities. .\s a guide
once a credit to its author and to .■Vmerican med- either for the general practitioner or specialist,
ical literature. We repeat that it is a book to be it is second to none other. No one can read
studied, and one that is indispensable to every Emmet without pleasure, instruction and profit,
practitioner giving any attention to gynrecology.— 1 —Cincinnati Lancet and Clinic, Jan 31, 1885.
American Journal of the Medical Scietues, April, 1885.
DVNCAN, J, MATTHEWS, 3I.D., LL. D,, F, JR. S, E., etc.
Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar-
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50.
They are in every way worthy ol their author ; stamp of individuality that, if widely read, as they
indeed, we look upon them as among the most I certainly deserve to be, they cannot fail to exert a
valuable of his contributions. They are all upon ' wholesome restraint upon the undue eagerness
mattersof great interest to the general practitioner. I with which many young physicians seem bent
Some of them deal with subjects that are not, as a
rule, adequately handled in the text-books; others ^
of them, while bearing upon topics that are usually .Journal, Marcn, 1880,
treated of at length in such works, yet bear such a
upon following the wild teachings which so infest
the gynfecology of the present day. — N. Y. Medical
MAY, CHARLES H., M. D,
Late House Surqeon to Mount Sinai Hospital, yew Yerk.
A Manual of the Diseases of Women. Containing a cpncise and systematic
exposition of theory and practice. In one 12mo. volume of about 350 pages. In pre»'.s.
HODGE, HUGHE., M. D.,
Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania.
On Diseases Peculiar to Women; Including Displacements of the UteruB.
Second edition, revised and enlarged. In one beautifully printed octavo volume of 519
pages, with original illustrations. Cloth, $4.50.
By the Same Author.
The Principles and Practice of Obstetrics. Illustrated with large litlio-
graphic plates containing 159 figures from original photographs, and with ntimerous wood-
cuts. In one large quarto volume of 542 double-columned pages. Strongly bound in
cloth, $14.00.
* ^(. * Specimens of the plates and letter-press will be forwarded to any address, free by
mail, on receipt of six cents in postage stamps.
BA3rSBOTHAM, FRANCIS H., 31. D.
The Principles and Practice of Obstetric Medicine and Surgery;
In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised
by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc.,
in the Jefferson Medical College of Philadelphia. In one large and handsome imperial
octavo voluiue of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain-
ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7.
ASHWELL'S PRACTICAL TREATISE ON THE I AND OTHER DISEASES PECULIAR TO WO-
I'lSEASES PECULIAR TO WOMEN. Third MEN. In oneSvo. vol. of 4t;4 pases. Cloth, 82.50.
American from the third and revi.«ed London MEIOS ON THE NATURE, SIGN.S AND TREAT-
edition. In one 8vo. vol., pp. 520. Cloth. ?3.50. MENT OF CHILDBED FEVER. In one 8vo.
CHURCHILL ON THE PUERPERAL FEVER volume of 34G pages. Cloth, S2.'K).
\
Lba Brothers & Co.'s Publications — Midwifei*y. 29
PZAYFAIM, W, S,, 31. D., F, B, C. jP.,
Professor of Obstetric Medicine in KitKj's College, London, etc.
A Treatise on the Science and Pi-actice of Midwifery. New (fourth)
American, from the fifth English edition. Edited, with additions, by Robert P. Har-
ris, M. D. In one handsome octavo volume of 654 pages, with 3 jjlates and 201 engrav-
ings Cloth, $-i ; leather, $5 ; half Russia, $5.50. Jiist ready.
This excellent work needs no commendation.
For many 3'ear.s it lias maintained a deservedly
high repiitation among teaclier^; as a text book,
and in the profession as a guide to the practical
experiences which attend tlie obstetrician. The
present edition, under the supervision of Dr. Har-
ris, has been carefully revised, and many portions
rewritten, and the whole work has been adapted to
the wants and circumstances of this continent. —
Buffalo Medical and Surgical Journal, Aug. 1885. q.
In the short time that this excellent and highly
esteemed work has been before the profession it
has reached a fourth edition in this country and a
fifth one in England. This fact alone speaks in
high praise of it, and it seems to us that scarcely
more need be said of it in the way of endorsement
of its value. As a text book for students and for
the uses of the general practitioner there is no
work on obstetrics superior to the work of Dr.
Playfair. Its teachings are practical, written in
plain language, and afford a correct understanding
of the art of midwifery. No one can be disap-
pointed in it. — Cincinnati BIcdical News, June, 1885.
BARNES, ROBEItT, 31. J>., and FANCOUBT, 31. D.,
Phys. to the General Lying-in Hasp., Land. Obstetric Phys. to St. Thomas' Hosp., Lond.
A System of Obstetric Medicine and Surgery, Theoretical and Clin-
ical. For the Student and the Practitioner. The Section on Embryology contributed by
Prof. Milnes Marshall. In one handsome octavo volume of about 1000 pages, profusely
illustrated. Cloth, %o ; leather, |6. In a few days.
BABKBIt, FORDYCF, A. 3f., 31. Z)., XX. D. Edin.,
Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College,
New York, Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc.
Obstetrical and Clinical Essays. In one handsome 12<ao. volume of about
300 pages. Pi-epariny.
KING, A. F. A., 31. Jy.,
Professor of Obstetrics and Diseases of Women m the Medical Department of the Columbian Univer-
sity, Washington, D. C, and in the University of Vermont, etc.
A Manual of Obstetrics. Second edition. In one very handsome 12mo. volume
of 331 pages, with 59 illustrations. Cloth, $2.00.
It must be acknowledged that tliis is just what ! densed style of composition, the writer has pre-
it pretends to be — a sound guide, a portable epit- sented a great deal of what it is well that every
orne, a work in which only indispensable matter ! obstetrician should know and be ready to practice
has been presented, leaving out all padding and • or prescribe. The fact that the demand for the
chaff, and one in which the student will find pure 1 volume has been such as to exhaust the first
wheat or condensed nutriment.— A'eu; Or/ea)ii>J/ed- | edition in a little over a year and a half speaks
teal and Surgical Journal, May, 1884. I well for its popularity. — American Journal of the
In a series of short paragraphs and by a con- | Medical Sciences, April, 1884.
LANJDIS, HENRY G., A. M., 31. D.,
Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, 0.
The Management of Labor. In one handsome 12mo. volume of about 300
pages, with 30 illustrations. Shortly.
BARNES, FANCOURT, 31. D.,
Obstetric Physician to St. Thomas^ Hospital, London.
A Manual of Midwifery for Midwives and Medical Students. In one
royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, $1.25.
PARVIN, THEOPHILUS, M. I)., LJL. I).,
Professor of Obstetrics and the Diseases of Women and Children in the Jefferson Medical College.
A Treatise on Midwifery. In one very handsome octavo volume of about 550
pages, with numerous illustrations. In press.
FARRY, JOHN S., 31. D.,
Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia.
Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and
Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50.
TANNER, TH03LAS HAWKES, M. D.
On the Signs and Diseases of Pregnancy. First American from the second
English edition. Octavo, 490 pages, with 4 colored plates and 16 woodcuts. Cloth, $4.25.
WINCKEL, F.
A Complete Treatise on the Pathology and Treatment of Childbed,
For Students and Practitioners. Translated, with the consent of the Author, from the
second German edition, by J. R. CnADWiCK, M. D. Octavo 484 pages. Cloth, $4.00.
30
Lea Brothers «& Co.'s Publications — JVndwfy., Dis. Childn.
LEISHMAJSr, WILLIAM, M, J>.,
Regius Professor of Midieiferxi in the University of Olasgow, etc
A System of Midwifery, Including the Diseases of Pregnancy and the
Puerperal State. Third American edition, revised bv the Author, with additions by
John S. Parry, M. D., Obstetrician to the Philadelphia hospital, etc. In one large and
very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather,
$5.50 ; very handsome half Kussia, raised bands, $6.00
The BUthor is broad in his teachings, and dis-
cusses briefly the comparative anatomy of the pel
vis and the mobility of the pelvic articulations.
The second chapter is devoted especially to
the study of the pelvis, while in the third the
female organs of generation are introduced.
The structure and development of the ovum are
admirably described. Then follow chapters upon
the various subjects embraced in the study of mid-
wifery. The descriptions throughout the work are
plain and pleasing. It is sufficient to state that in
this, the last edition of this well-known work, every
recent advancement in this field has been brought
forward. — Phtjaieian and Surgeon, Jan. 18S0.
preparation of the present edition the author has
made such alterations as the progress of obstetri-
cal science seems to require, and we cannot but
admire the ability with which the task has been
Eerformed. We consider it an admirable text-
ook for students during their attendance upon
lectures, and have great pleasure in recommend-
ing it. As au exponent of the midwifery of the
present day it has no superior in the English lan-
guage. — Canada Lancet, Jan. 1880.
To the American student the work before us
must prove admirably adapted. Complete in all its
parts, essentially modern in its teachings, and with
demonstrationsnoted for clearness and precision,
We gladly welcome the new edjtion of this ex- it will gain in favor and be recognized "as a work
former edi- of standard merit. The work cannot fail to be
celleut text-book of midwifery. The
tions have been most favorably received by the ! po
In the I iW<
profession on both sides of the Atlantic.
opular and is cordially recommended. — N. O.
'ed. and Surg. Journ., March, 1880.
SMITH, J. LEWIS, M, !>.,
Clinical Professor of Diseases of Cliildren in the Bellevue Hospital Medical College, N. Y.
A Complete Practical Treatise on the Diseases of Children, Fifth
edition, thoroughly revised and rewritten. In one handsome octavo volume of 836 pages,
with illustrations. Cloth, $4.50 ; leather, $5.50 ; very handsome half Russia, raised bands, $6.
This is one of the best books on the subject with which we venture to say will be a favorable one. —
which we have met and one that has given us . Dublin Journal of Medical Science, March, 1883.
satisfaction on every occasion on which we have ] There is no book published on the subjects of
consulted it, either as to diagnosis or treatment. | which this one treats that is its equal in value to
It is now in its fifth edition and in its present form | the physician. While he has said just enough to
is a very adequate representation of the subject it impart the information desired by general practi-
treats of as at present understood. The important ', tioners on such questions as etiology, pathology,
subject of infant hygiene is fully dealt with in the prognosis, etc., he has devoted more attention to
early portion of the oook. The great bulk of the the diagnosis and treatment of the ailments which
work is appropriately devoted to the diseases of he so accurately describes ; and such information
Infancy ana childhood. We would recommend is exactly what is wanted by the vast majority of
any one in need of information on the subject to , " family physicians." — Va. Med. Monthly, Feb. 1882.
procure the work and form his own opinion on it, i
KEATING, JOHWM., M. I>.,
Lecturer on the Diseases of Children at the University of Pennsylvania, etc.
The Mother's Guide in the Management and Feeding of Infants. lu
one handsome 12mo. volume of 118 pages. Cloth, $1.00.
Works like this one will aid the physician im- ' the employment of a wet-nurse, about the proper
mensely, for it saves the time he is constantly giv- ' food for a nursing mother, about the tonic effects
ing his patients in instructing them on the sub- of a bath, about the perambulator I'ersuvi the nurses,
jecls here dwelt upon so thoroughly and prac- arms, and on many other subjects concerning
tically. Dr. Keating has written a practical book. , whicn the critic might say, "surely this is obvi-
has carefully avoided unnecessary repetition, ana ; ous," but which experience teaches us are exactly
successfully instructed the mother in such details ! the thingsneeded tobe insisted upon, with therich
of the treatment of her child as devolve upon her. i aswellas thepoor. — London inneef, January, 28 1882.
He has studiously omitted giving prescriptions, | a book small in size, written in pleasant style, in
and instru-ts the mother \vhen to call upon the 1 language which can be readily understood by any
doctor, as his duties are totally distinct from hers. ! mother, and eminently practical and safe; in fact
—Amenean Journal of Obstetrics, October, 1881. I » book for which we have been waiting a long
Dr. Keating has kept clear of the common fault i time, and which we can most heartily recommend
of works of this sort, viz., mixing the duties of | to mothers as the book on this subject.— JVeio York
the mother with those proper to the doctor. There i Medical Journal and Obstetrical Review, Feb. 1882.
Is the ring of common sense in the remarks about 1
OTTEJV; EDMUJ^n^M. b], F. B. C. S.,
Sunjeon to the Children's Uospital, Great Ormond St., London.
Surgical Diseases of Children. In one 12mo. volume.
of Clinical Manuals, page 3.
Preparing. See Series
WEST, CHARLES, M, !>.,
Physician to the Hospital for Sick Children, London, etc.
Lectures on the Diseases of Infancy and Childhood. Fifth American
from 6th English edition. Inone oct avo volum e of 686 pages. Cloth, $4.50 ; leather, $5.50.
By the Same Author.
On Some Disorders of the Nervous System in Childhood. In one small
12mo. volume of 127 pages. Cloth, $1.00.
CONDIE'S PRACTICAL TREATISE ON THE
DISEASES OF CHILDREN. Sixth edition, re-
vised and augmented. In one octavo volume of
779 pages. Cloth, $5.25 ; leather, 86.25.
Lea Brothers & Co.'s Publications — Med. Juris., Miscel.
31
TIDY, CHABLES MEYMOTT, 31. B., F, C. S.,
Professor of Chemistry and of Forensic Afedirine and Public Health at the London Hospital, etc.
Legal Medicine. Volume II. Legitimacj'^ and Paternity, Pregnancy, Abor-
tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asph}'xia,
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc-
tavo volume of 529 pages. Cloth, $6.00 ; leather, $7.00.
Volume I. Containing 664 imperial octavo pages, with two beautiful colored
plates. Cloth, $6.00 ; leather, $7.00.
The satisfaction expressed with the first portion I tables of cases appended to each division of the
of this work is in no wise lessened by a perusal of subject, must have cost the author a prodigious
the second volume. We find it characterieed by
the same ftilness of detail and clearness of ex-
pression which we had occasion so highly to com-
mend in our former notice, and which render it so
Taluable to the medical jurist. The copious
amount of lalsor and research, but they constitute
one of the most valuable features of the book,
especially for reference in medico-legal trials. —
American Journal of the Medical Sciences, April, 1884.
TAYLOB, ALFBED S,, M. !>.,
Lecturer on Medical Jurisprudence arid Chemistry in Otiy's Hospital, London.
A Manual of Medical Jurisprudence. Eighth American from the tenth Lon-
don edition, thoroughly revised and re^vritten. Edited by John J. Reese, M. D., Professor
of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one
large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00 ; leather, $6.00 ; half
Russia, raised bands, $6.50.
^'[he American editions of this standard manual
tave for a long time laid claim to the attention of
the profession in this country; and the eighth
comes before us as embodying the latest thoughts
and emendations of Dr. Taylor upon the subject
to which he devoted his life with an assiduity and
success which made him jacile princeps among
English writers on medical jurisprudence. Both
the author and the book have made a mark too
deep to be atfected by criticism, whether it be
censure or praise. In this case, however, we should
only have to seek for laudatory terms. — American
Journal of the Medical Sciences, Jan. 1881.
This celebrated work has been the standard au-
thority in its department for thirty-seven years,
both in England and America, in botli the profes-
sions which it concerns, and it is improbable that
it will be superseded in many years. The work is
simply indispensable to every physician, and nearly
so to evei-y liberally-educated lawyer, and we
heartily commend the present edition to both pro-
fessions. — Albany Law Journal, March 26, 1881.
By the Same Author,
The Principles and Practice of Medical Jurisprudence. Third edition.
In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ;
leather, $12. Just ready.
For years Dr. Taylor was the highest authority
in England upon the subject to which he gave
especial attention. Hia experience was vast, liis
j'udgment excellent, and his skill beyond cavil. It
is therefore well that the work of one who, as Dr.
Stevenson says, had an "enormous grasp of all
matters connected with the subject," should be
brought up to the present day and continued in
its authoritative position. Tc accomplisli this re-
sult Dr. Btevensou has subjected it to most careful
editing, bringing it well up to the times. — Ameri-
can Journal ^ the Medical Sciences, Jan. 1884.
By the Same Author.
Poisons in Relation to Medical Jurisprudence and Medicine. Third
American, from the third and revised English edition. In one large octavo volume of 788
pages. Cloth, $5.50 ; leather, $6.50.
JPEFFEB, AUGUSTUS J., M.J.^^. B., F. B. C. S.,
Examiner in Forensic Medicine at the Univeisity of London.
Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Students^
Series of Manuals, page 3.
LEA, HENBY C,
Superstition and Force : Essays on The Wager of Law, The Wager of
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one
handsome royal 12mo. volume of 552 pages. Cloth, $2.50.
This valuable work is in reality a history of civ-
ilization a.s interpreted by the progress of jurispru-
dence. . . In "Superstition and Force" we have a
philosophic survey of the long period intervening
between primitive barbarity aha civilized enlight-
enment. There is not a chapter in the work that
should not be most carefliUy studied ; and however
well versed the reader may he in the science of
jurisprudence, he will find much in Mr. Lea's vol-
ume of which he was previously ignorant. The
book i.9 a valuable addition to the literature of so-
cial science. — Westminster Review, Jan. 1880.
By the Same Author.
Studies in Church History, The Rise of the Temporal Power— Ben-
efit of Clergy — Excommunication
octavo volume of 605 pages. Cloth, $2.50.
The author is pre-eminently a scholar. He takes
up every topic allied with the leading theme, and
traces it out to the minutest detail with a wealth
of knowledge and impartiality of treatment that
compel admiration. The amount of information
compressed into the book is extraordinary. In no
other single volume is the development of the
New edition. In one very handsome royal
Just ready.
I primitive church traced with so much clearness,
and with so definite a perception of complex or
conflicting sources. The fifty pages on the growth
of the papacy, for instance, are admirable for con-
• ciseness and freedom from prejudice. — Boston
I Traveller, May 3, 1883.
Allen's Anatomy . •,,£,■,
Americau Journal of the Medical Sciences
American System of Ciyna>colof:v - .
American System of Practical Medicine
*Asliluirsfs'Siii(,'ery .
Asliwoll on Diseases of Women
A tlfleM's Chemistry . .
Ball on the Keitnm and Anus .
Biirkers (ilistetricul and Clnucal Essays,
Barlo\v"s Practice of Medicine
Barnes' Midwifery
♦Barnes (in Diseases of Women .
Barnes' System of Obstetric Medicine
BarthoUiw on Klectricity
Bashuin on Renal Diseases . . •
Bell's Connianitiye I'liysiology and Anatomy
Bellamy's Operative Surgery
Bellamy's Surgical Anatomy
Blandford on fnsanity
Bloxam's Chemistry . . • •
Bowman's Practical Chemistry
♦Bristowo's Practice of Medicine .
Broadbenl on the Pulse
Browne on the Onhtluilmoscope .
Bro>yne on tlie Throat .
Bruce's Materia Mcdica and Therapeutics
Bruntons Materia Medica and Therapeutics
Brvant on the Breast . . . •
»Bnants Practice of Surgerj-
♦Bunistead on \'enereal Diseases .
♦Burnett on the f'jir . . . •
Bullin on theToiiKue - . • ,- , • ,
C«ri)enter on the Use and Abuse of Alcohol
♦Carpenter's Human Physiology .
Carter on the Kye . . .-
Centura- of American Medicine
aiambers on Diet and Kegimen . _ .
Charles' Physiological and PatUological Cliem.
Churchill on Puerperal Fever . .
Clarke and Lockwood's Dissectors' Manual
Classen's Quantitative Analysis
Cleland's Dissector ....
Clouston on Disanity
Clowes' Practical Chemistry
Coals' Pathology . . ■ •
Cohen on the Throat . . . •
Coleman's DenU\l Surgery .
Condie on Diseases of Children
Cooper's Lectures on Surgery
Cornil on Syphilis . . . ;—.•,
♦Cornil and Kanvier's Pathological Histologj-
CuUericr's Atlas of Venereal Diseases
Curnow's Medical .Vnatomy
Dalton on the Circulation
♦Dalton's HumiuiPhysiologj' •,.^ • .
Daltou's Topographical Anatomy of the Brain
Davis" Clinical Lectures
Draper's Me<lical I'hysics
Drum's Modern Surgery
Duncan on Diseases of Women
♦Dunglison's Meilieal Dictionary .
Edis on Diseases of Woiiien .
Kills' Demonstrations of Anatomy
Emmet's Oyiiiecology
♦Eriohsen's System of Surgery . .
Esmarcbs Earlv Aid In Injuries and Accid ts
Farquhai-son's '^herapeutics and Mat. Med.
Fenwick's Medical Diagnosis
Finlavson's Clinical Diagnosis
Flint on Auscultation and Percussion
Flint on Phthisis . • , • ^ •
Elint on Plivsicail Exploration of the Lungs
Flint on Respiratory Organs
Flint on the Heart . . .
♦Flint's Clinical Medicine
Flint's Essavs . . • '
♦Flint's Practice of Medicine
Folsom's I.aws of U. S. on Custody of Insane
Foster's Physiology ....
♦Fothergill s Handbook of Treatment .
Fowne.f' Elementary Chemistry
Fox on Diseases of the Skin .
Frankland and Japp's Inorganic Chemistry
Fuller on the Lungji and Air Pas-sages .
Galloway's Analysis ....
Gibiiev's Ortlioptedic Surgery
Gibson's Surgery . . . ■
Glugc's Patho'.oiiical Histology, by Leldy
Gould's Surgical Diagnosis .
♦Grav's .Anaiomv ... .
Greene's Medical Chemistry .
Green's Patliology and Morbid Anatomy
Grillilh's I'niveisal Foriinilary
Gros.son foreign Bodies in Air-Passages
Gross on Impotence and Sterility .
Gross on Urinary Organs
•Gros.s' System of Surgery
Habershon on the Abdomen
♦Hamilton on Fractures and Dislocations
Hamilton on Nervous Diseases
Hartshorne's .Anatomy and Physiology .
Hartsliorne's Conspectus of the Med. Sciences
Hartshnrne's F.s.sentials of Medicine
Hermann s Experimental Pharmacology
Hill on Syphilis .....
Hillier's Haiull)ook of Skin Diseases
Hohlyn's Medical Dictionary
Hodge on Women ....
Hodge's Obstetrics
6 Hoffmann and Power's Chemical Analysis
3 I Holden's Landmarks . ....
•>: Holland's Medical Notes and Reflections
15 I *Holmes' System of Surgery
20 ' Horner's .-Vnaioniy and Histology
ib Hudson on Fever
9 i Hutchinson on Syphilis . .
21 i Hvde on the Diseases of the Skin .
29 Jo'nes I.C. Handlield) on Nervous Disorders
17 i Juler's Oi)hihalmic Science and Practice
29 I Keating on Infants . .
27 I King's Jfur.ual of Obstetrics .
29 I Klem's Histology
17 i Landis on Labor :..,•.,•.
"I 1 La Koche on Pneumonia. Malaria, etc. .
3 7 La Roche on Yellow Fever .
3 20 ' Laurence and Moon's Ophthalmic Surgery
' 6 ' Lawson on the Eye, Orbit and Eyelid
l«i ! Lea's Studies in Church History
9 Lea's .Superstition and Force
«) Lee on Syphilis
ULehmanns Chemical Physiology .
3, li; I *Leishman's Midwifery
2:1 Lucas on Disease.s of the Urethra .
IS Ludlow's Manual of Examinations
U I Lyons on Fever . . . • •
11 Jfaiscli's Organic Materia Medica .
3,21 i Marsh on the Joints
21 j May on Diseases of Women .
2.5 Medical News . ...
2-1 Meigs on Childbed Fever
3,21 Miller's Practice of Surgery .
ft : Miller's Principles of Surgery
5 ISIitclieli's Kervous Disea.ses of Women .
23 Morris on Diseases of the Kidneys
n i Morris on Skin Diseases . ,i, ^ •, .
17 I Neill and Smith's Compendium of Med. bci.
10 i Nettleship on Diseases of the Eye .
28 Owen on Diseases of Children
6 *Parrisirs Practical Pharmacy
10 I Parrv on Extra-Uterine Pregnancy
.i i Parvins Midwifery . .
19 Pavy on Digestion and its Disorders
10 ' I'epper's Forensic lledicine .
13 Pepper's Surgical Pathology
15 Pick on Fractures and Dislocations
2^Pin■ie•s System of Surgery . . ..
SO I Plavfair on Nerve Prostration and Hysteria
20 *Plavfair's Midwifery .
25 I Politzer on the Ear and its Diseases
13 I Power's Human Physiology .
25 I Ralfe's Clinical Chemistry
3, C Ramsbotham on Parturition
7 Reiusens Theoretical Chemistry .
8 *Reynolds' System of Medicine. .
7 i RiciJardson's Preventive Medicine
16 I Roberts on Urinary Disea,ses
7 ! Roberts' Principles and Practice of Surgery
21 , Robertson's Physiological Physics
28 Rod well's Dictionary of Science
4 ! Ross on Nervous Diseases
27 ' Sargent's Minor and Military Surgery .
7 Savage on Insanity, including Hysteria .
28 Schafer's Es.sentials of Histology,
21 Schiifer's Histology
21 Schreiber on Massage . . „ • ™ •
12 • Seller on the Throat, No.se and Naso-Pharynx
16 I Series of Clinical Manuals . . • •
IG Simon's Manual of Chemistry
15 Skev's Operative Surgery ....
18 1 Slaflo on Diphtheria . .. ■
18 I Smith lEdward) on Consumption . . ■
18 Smith (H. H.) and Horner's Anatomical Atlas
18 *Smith 1 J. Lewis'i on Children
Ifi Stlllf on Cholera . •. • , •
16 ' -sstilli? A- Maisch's National Dispensatory
14 *Stillt!'s Therapeutics and Materia Mcdica
19 ' Stimson on Fractures . . . • ■
S StimsonsOper.ative Surgery
16 ; Stokes on Fever . . •
» 1 Students' Series of Manuals . . . •
26 Sturges' Clinical Medicine • , „•
9 ' Tanner on Signs and Diseases of Pregnancy .
18 '■ Tanner's Manual of Clinical Medicine .
S Taylor on Poisons . . . . •
20 \ *Tavlor's Medical Jurisprudence .
20 Taylors Prin. and Prac. of Med. Jurisprudence
ir. i *Tiiomas on Diseases of Women .
3, 20 ; Thompson on stricture . . . •
5 Thompson on Urinary Organs
1" Tidy's Legal Medicine . . . . •
Todd on Acute Diseases
10
5
17
22
6
14
3,25
28
18
23
90
29
3,13
29
18
14
23
23
31
31
Treves' .Applied Anatomy
In' - = - ' '-■-•-
Treves on Intestinal Obstruction • „ •
Tukeon the Iniluence of Mind on theBody
Walshe on the Heart . . • • •
Watson's Practice of Phj-sic .
*Wellson tlM? Eye . ■ •
West on Diseases of Childhood
West on Diseases of Women „ .,-^ ■
West on Nervous Disorders in Childhood
Williams on Consumption . . .•
Wilson's Handbook of Cutaneous Medicine
Wilson's Human -Anatomy . . ,^ •., „ :
-„ Winckel on Pathol, and 'fteatment of Childbed
26 Wohler's Organic Chemistry
4 Woodhead's Practical Pathologj- .
2i Year-Book of Treatment . . . •
23
•24
25
30
3,24
3
14
U
3,22
28
1
28
20
20
19
3,24
26
3
23
3,30
11
29
29
17
3,31
3,13
3,22
20
19
29
24
3,8
3,10
28
9
15
17
20
3,7
4
19
20
3,19
13
13
16
18
3
9
20
18
18
5
30
16
12
12
22
20
14
3
16
29
16
31
31
31
27
24
24
31
17
3,6
3,21
19
18
14
23
30
27
30
18
26
Books marked * are also bound in half Russia.
LEA BROTHERS & CO., Philadelpbia.
VFR«i" Y r "^ r frr^"v
FAQLITY
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