*EW FINDINGS 
 'HTHALMOLOGY 
 AND OTOLOGY 
 
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 BERKELEY 
 
 LIBRARY 
 
 UNIVERSITY OF 
 CALIFORNIA 
 
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THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 GIVEN WITH LOVE TO THE 
 
 OPTOMETRY LIBRARY 
 
 BY 
 
 MONROE J. HIRSCH, O.D., Ph.D. 
 
NEW FINDINGS 
 
 IN OPHTHALMOLOGY 
 
 AND OTOLOGY 
 
 A MONOGRAPH. 
 
 WITH A DESCRIPTION OF TWO NEW INSTRUMENTS. 
 
 ILLUSTRATED. 
 
 SECOND EDITION. 
 
 By 
 E. H. HAZEN, M. D. 
 
 Lecturer on Ophthalmology and Otology Medical Department State 
 University from 1870 to 1874. Emeritus Professor of Ophthal- 
 mology and Otology, College of Physicians and Surgeons, 
 Medical Department of Drake University, Des Moine 
 IoiL-a. Member of the American Medical Associa- 
 tion, Iozva State Medical Society. Et , 
 
OPTOMETRY 
 
 COPYRIGHTED 1911 
 
 By 
 
 E. H. HAZEN, M. D., 
 
 Des Moines. 
 
PREFACE. 
 
 Rt is 
 
 HI/ 
 
 or 
 
 He who essays to write a book in these times, should 
 have a reason. 
 
 The incentives to authorship may be various — -a desire 
 to exercise a talent in expressing thoughts already pro- 
 mulgated by others; a desire for recognition in his own 
 field of work; or a desire to make known the result of his 
 labor in original investigation. 
 
 These are all legitimate motives, and the merits of his 
 labor are always tested by the life of the book. 
 
 It is not my purpose to write a Text book, but a Mono- 
 graph of the subject of the treatment of the Muscles of 
 the Eye. 
 
 It is particularly gratifying, to be enabled, as I think, 
 to contribute to the profession, some improvement in 
 the science of Ophthalmology, in which I have spent 
 the most of a long life. 
 
 I take the liberty of dissertating, in the introduction, 
 on some of the late movements, in the handling of a class 
 of cases, to which I contribute my method of treatment. 
 
 I have presented the history of this subject and the 
 views of writers down to the present time, in excerpts 
 from the authors, instead of appropriating their thoughts, 
 and expressing them in my own words. I hope 1 have 
 done no violence to these writings. 
 
 I believe that the means. I have devised for the testing 
 of the muscles, not only add to the good management of 
 those cases already recognized as having muscular 
 troubles, but they include relief for a large percentage, 
 which are now supposed to be outside the work of the 
 Ophthalmologist. 
 
INTRODUCTION. 
 
 A great division in the world's work is the combatting 
 of disease. While the forces of nature are constantly 
 propelling toward the higher and better samples of im- 
 provement, there is an antagonizing force which dete- 
 riorates this impulse. The first we call good and the second 
 evil. 
 
 The mind of man attempts to grapple with the problem 
 and abets, aids, directs and cultivates the one and prunes, 
 hunts, cuts off and destroys the other. It is one of the 
 wonderful products of nature that the mind of man, 
 which itself has come up out of nature, should tower over 
 nature and presume to direct its growth. 
 
 Nevertheless, when we compare rude nature and the 
 work, which man is enabled to show as his, we are puzzled 
 to decide which is the most wonderful. 
 
 We do not detract from the Creator in admiring, with 
 awe, the direction which man has given to the many 
 things on which he has put his finger, for he is but a 
 servant of nature and must work by her laws and in 
 contemplating the direction he has given to nature, and 
 to that which he has wrought, he but glorifies the maker of 
 himself, and the echo of achievement reverberates from 
 generation to generation, and man becomes more civilized, 
 lives in luxury and sings more praises to his God. 
 
 With the enumeration of all the benefits of civilization, 
 there are elements of evil. The higher organization of 
 man and that which enables him to have dominion over 
 
HAZEN'S NEW FINDINGS 
 
 nature consists of the develop menl oi his nervous system. 
 With culture comes disease. Many are the examples in 
 nature, where impulses have proceeded that seemed to 
 be good, but have gone up and on until that very element 
 has wrought its own destruction. 
 
 'This development oi the brain and nervous system, 
 which enables man to do the work that shows itself on 
 every hand, has, in the majority of mankind, refined, 
 cultured and made more powerful and strenuous each 
 succeeding generation, until in our own, we may estimate 
 its capabilities as greater than any that have gone before, 
 and we may anticipate that in the generations to come, 
 there will be greater masters than in the present. 
 
 But these advances are made at a great cost; the stren- 
 uousness, the ambitions, the requirements of the habits 
 of industry to attain the coveted goal draw upon the 
 vitality of the nervous system, and the nature of man's 
 physical and anatomical system is not prepared for the 
 demands, which he makes upon it. When carried too 
 far, pain comes as a warning, and when not heeded a 
 break-down is the consequence and death of the unfit 
 is the result. 
 
 Xo better example can be given of the exceedingly 
 great demand upon the civilization of the day than that 
 made upon the organ of vision. Not only is this organ 
 continuously and excessively exercised in acquiring an 
 education for the start in life, but it is upon this organ that 
 we depend mainly for existence in the struggle of life, 
 and upon it for the success of the greater ambitions 
 which comes to the few. 
 
 The manual labor of the generality of mankind is 
 becoming more and more narrowed down to the need of 
 a limited action of the muscles of the eye, and but a few 
 of the other muscles of the body; the necessities of 
 many, indeed most of the occupations, require but little 
 variety of motion, and this limited motion is more ex- 
 
[NTRODUCTION 
 
 haustive on the nervous system than the occupations 
 of our forefathers, which usually called upon the action 
 of the whole muscular system in the performance of their 
 duties. 
 
 The consequence is that we have a generation of abnor- 
 mal hyperaesthenic nerve development, that is on the 
 road to asylums and has for its end insanity. 
 
 Poor humanity resorts to alcohol, narcotics, opiates 
 and sedatives to dull the disturbance. The require 
 ments of an exhausted nervous system demand an abnor- 
 mal excitement and stimulant; the already tired organ 
 of vision seeks amusements other than those requiring 
 further exercise of sight, and the social enticements lure 
 them, and their environment is not always the best, and 
 so bad habits are acquired, and waste of time and a lower 
 or indifferent life is the consequence. 
 
 The type of American physique is a nervous organiza- 
 tion and the attention of the American physician is par- 
 ticularly directed to this class of disorders. 
 
 From experience in these affections, and contact with 
 others whom I have been teaching, it is my conviction 
 that this disease is the most prevalent one in America. 
 American people read more than any others. Her people 
 develop faster because of those occupations, requiring 
 near sight. Their ancestors used their eyes but little in 
 convergence, and therefore had not cultivated a physiolog- 
 ical condition toward the necessities of the new 
 civilization, and had not transmitted them by 
 heredity. These people, thus wanting in the advantages 
 of heredity, have to cope with a disadvantage, in strange 
 occupations, and are apt to break down in the race for 
 life in the new environment. 
 
 The frequent appeal to the eye specialist, of those 
 with nervous systems, for relief, and the growing impor- 
 tance of this work, which the oculist has gradually 
 learned, in relation to the nervous diseases, and also, as 
 
8 HAZEN'S NEW FINDINGS 
 
 the author believes that he has a further contribution 
 in this line, he takes the liberty df dissertating broadly 
 upon the situation as he sees it, hoping that his thoughts 
 may be considered, and weighed and turned out onto the 
 tide, that flows in and out and purifies and improves the 
 humanitarian's labors. 
 
 \ i withstanding that the pathology of nervous troubles 
 has made some progress in the profession as to differen- 
 tiation, when presented, by sufferers, to their friends, 
 the troubles are, as a whole, about alike in character. 
 
 It makes a great difference upon which road they seek 
 advice regarding them. If the patient has been to the 
 Oculist, he emerges with a saddle and bridle on his face. 
 If he is switched off to the Nervous Disease man, he is 
 relegated to a Sanatorium and put to "rest." If to the 
 Hydropath, he is massaged, soaked and washed inside 
 and out. If to the Faith cure, he is persuaded, cajoled and 
 hypnotized. Neither Specialist seems to have know- 
 ledge of any better method of relief. Some of them at- 
 tempt to cure the symptoms by improving the general 
 health, and others will take medicine and a vacation 
 to build up the constitution, with the expectation that the 
 symptoms (which the physicians say are caused by 
 constitutional diseases) will depart. Others claim that 
 the theories of disease are a delusion and a snare. 
 
 Each specialist is trained to believe that he is able 
 to cure by his particular method. There is not that 
 linking together of methods, that one would expect from 
 these men, who have generally been educated in the same 
 colleges, and belong to the same Medical societies — 
 nevertheless, the Specialists represent a different Tribe 
 and think on the lines of the particular specialty of their 
 choice. 
 
 There is need of a combination of the knowledge 
 attained in the world's work — unprejudiced, disinter- 
 ested and philanthropic in its spirit to apportion its 
 
INTRODUCTION 9 
 
 application. The desirability of this has been seen of 
 late, and some of the religious organizations have at- 
 tempted to supply the necessity by a fusing of religion 
 and medicine. 
 
 The movement takes up a different method of bene- 
 fitting mankind from that heretofore practiced. It is 
 a combination of the institutions that have been the 
 closest to the social nature of man — the religions and 
 medicine. The church, ostensibly, has been instituted 
 to direct man in attaining to the best in this life and 
 beyond the grave, and, to a certain extent, it has pro- 
 moted a moral life, but of late years there has been more 
 attention paid to matters of this life. The church is a 
 social institution, and more than any other, looks after 
 the welfare of its members. This mission is becoming 
 more and more the work of the church. There is no 
 other institution that affords such opportunities to guard 
 and teach the social and moral phases of life. All com- 
 munities need a corps of intelligent men and women, 
 who will interest themselves in each others' temporal 
 welfare and attend to the social up lift; associated with 
 them should be the disinterested scientific man, who 
 understands disease and sanitation. His education 
 should be broad — a graduate in medicine — one who un- 
 derstands, not only the diagnosis of disease, but sanita- 
 tion in all its branches — architecture- — plumbing — land- 
 scape gardening — bacteriology and chemistry — physical 
 culture etc., but he should not be a practitioner of medicine. 
 This limit would place him at once before the people, 
 as an unbiased adviser and as one, who would devote 
 his energy to the combatting of the causes of disease. 
 The Science of Sanitation would grow in the hands of 
 such a promoter, for he would be an independent ad- 
 visor in all branches. 
 
 The Minister, through his profession, enters into that 
 field of labor, which gets closer to the social aspect of 
 
10 HAZEN'S NEW FIX DINGS 
 
 civilization and comes in contact with the sympathetic 
 
 and brotherly nature of man, more than any other. 
 His education touches upon the finer and more esthetic 
 nature and reaches man through impulses, that we classify 
 as belonging to the heart. His training of mind and 
 habits of thought fit him better than any other class of 
 men to get to and direct social and domestic matters. 
 \\\> purposes and aspirations adapt him to win the confi- 
 dence of his fellow men who toil and have not had or 
 have not laid hold of opportunities to become educated 
 or enlightened in the progress of the age. 
 
 These people need the helping hand of those, better 
 educated, to enable them to adjust themselves to modern 
 methods and thoughts, and to advise them where aid 
 can be obtained. \\ ith the council of the man, scien- 
 tifically educated, many of the difficulties and troubles, 
 on the road to success, may be made smooth and com- 
 fortable. 
 
 Behind these two persons, who would come directlv in 
 contact with the public, might be a board composed of 
 business and professional men, w r ho would constitute a 
 financial council and referee. This is not too formidable, 
 in the light of what is already organized in some of the 
 churches of the east. 
 
 The weakness of these organizations that have at- 
 tempted this combination, is in the association of the 
 church with specialists of Nervous diseases, and they 
 practitioners of medicine. 
 
 The Advisory board would have a distinctive work 
 that would be accepted as most free from sinister motive, 
 and would be more free from suspicion of graft than any 
 other source from which to get advice. It ought to be 
 mostly supported by the benevolent contributions, but 
 not wholly, for the best charities of the day require of 
 the person benefitted, some remuneration for time and 
 service. 
 
INTRODUCTION 11 
 
 The majority of the people need the council of the educa- 
 ted, the experienced, the broad-minded, honest, true 
 philanthropic friend. Many men and women, who pass 
 for intelligent people, place their expectations of success 
 on a wrong basis for results. They do not understand 
 the laws of nature nor of society, and when in trouble, 
 or when being carried away by emotion or passion, make 
 mistakes that wreck their lives. 
 
 The Missionary spirit of the church and the accumula- 
 tion of moral ethics, which it has stored away, and the 
 reputation it has for true philanthrophy ought to be 
 directed more to the mundane relations of men and the 
 direction of their purposes — the building up of the 
 physical man — enlightening his mental and moral nature 
 — clarifying society and directing the rearing of the coming 
 generation. 
 
 From our experience in the past, shall we not look for 
 a scientific solution of all the problems with which we 
 seek to benefit mankind, mentally, morally, and physically, 
 and shall we not put our faith in this method to bring 
 about our happiness and thrift: 
 
 The Alchemist, in former generations, with a sordid 
 motive it is true, dissipated a mystery and found nature's 
 well defined laws in the atoms, which are so small that 
 they have not yet been seen, and the result is, that the 
 beautiful and practical science of chemistry has been 
 established. 
 
 Pathology groped its way in superstition for ages, 
 until the Microscopist increased the convexity of his 
 object lens and immersed it; when the science of Bacteri- 
 ology was instituted and sanitation was born again; 
 salvation for millions was guaranteed; fevers are now 
 harnessed, and climates are habilitated, and man's plans 
 are made possible when before they failed. 
 
 Accoustics, as a science, was a mystery. Edison, 
 following the wave theory and taking the pattern of the 
 
12 HAZEN'S NEW FINDINGS 
 
 ear, put a needle into an artificial drum and we record 
 the sounds in wax. The telephone is half brother to 
 this and again mystery is materialized. 
 
 We have now, on our hands, the theory of mind over 
 matter. Whispers of solutions load the printing presses. 
 The subject is so mysterious that superstition envelopes 
 it as it did other questions of yore, but if it is ever solved, 
 science will do it. But, some will ask. what has this 
 to do with eye strain? 
 
 We have, in this subject, phenomena that are wide- 
 spread, and the syndromes of the particular groups 
 are so different in manifestation, and some so remote 
 from the organ of vision, affecting the system so differently 
 and implicating the mental, moral and physical nature 
 of man, so that all the"pathys and ologies"take it up, 
 and build into their doctrines an explanation of and a 
 remedy for them. Some of the theories open out a way 
 toward a proper basis for their solution, and others are 
 but stumbling blocks. 
 
 The nervous organization of man, which has so far 
 out-reached that of other species, becomes more and more 
 intricate, and most of the troubles with which we have 
 to deal, being symptomatic, functional and phenomenal 
 and so far from our instruments of precision, that opinions 
 regarding them must necessarily be various. 
 
 Many a problem has been delayed in solution, because 
 of a wrong direction being taken for its mastery, and at 
 last it was conquered by a simple method. 
 
EYE STRAIN AND ASTHENOPIA. 
 
 DEFINITIONS AND DESCRIPTIONS. 
 
 One of the most interesting histories in medicine is 
 that of the growth of, and advancement made in the 
 understanding of the functional troubles of the organ 
 of vision. There is no other organ of the body (unless 
 it be the brain) that is so intricate, subtle and so slow in 
 being understood. 
 
 We have had in science, some of the brightest ge- 
 niuses, who have given us the fruits of their labors; among 
 them, Young, Helmholtz, Donders, Von Graefe and Xoyes, 
 who have worked in this particular field and others who 
 are still alive and have not finished their work. To 
 the fruits of the labor of these men, the world is indebted 
 for the means by which it is enabled to do the work 
 which civilization and new methods of labor have entailed. 
 The}' have furnished the treatment that relieves a greater 
 number in the realms of suffering humanity, than any of 
 the other specialists in medicine, and yet there is room 
 for progress. The pendulum will swing from one side 
 to the other in the emphasis of theories and practices, 
 but it will be in the hands of men still alive, and if they 
 have the metal of those whom we mention as having 
 died, ere another generation will have passed, they too 
 will hand in valuable contributions and make advance- 
 ment in this beautiful science. 
 
 Denouncements and indifferent attitudes, will always 
 be the reception given by many, to departures from 
 
] I HAZEN'S NEW FINDINGS 
 
 staid methods and authority; however, when the new 
 principles come to men who have courage, and who avow 
 them, there are sometimes those, who take hold <>t the 
 new ideas with great avidity and enthusiasm, but, very 
 often many o\ them are so imperfectly demonstrated, 
 thai other minds do not understand them as the author 
 did and hence, those attempting to practice them do 
 not get the same results. This truth cannot be better 
 illustrated than in the intricate physiology and pathol- 
 • >t the eye. and a single step forward in this science 
 deserves attention. 
 
 \\ e will, as far as possible, examine the authors of the 
 day, regarding the main points of the functions of the 
 organ of vision, and endeavor to get at the status of the 
 subject of disorders connected therewith, and as held 
 by the profession at the present time. We will examine 
 the position taken by the authors of our day, in the order of 
 the date of their writings. In the examination of the 
 subject by the inquiries adopted, we can best set forth 
 the development of the science and show the steps taken 
 therein, and thus be enabled the better to compare them 
 with what is here offered as a new contribution. 
 
 INQUIRIES. 
 
 1st. Terms. Eye strain, Asthenopia, both ace emmedative and mus 
 cular, as words to encompass disorders of the function 
 of sight. 
 
 2nd. The doctrine of Insufficiency of the Muscles. 
 
 3d. The Relation of Ametropia to Muscular Anomalies. 
 
 4th. The Theories of Balance and Equilibrium and the Relation 
 of Imbalance to Eye disorders. 
 
 5th. Dynamics of the eye muscles and gymnastics in the treat- 
 ment of them. 
 
 6th. As to Epilepsy, Chorea, Hysteria, Migraine etc., to Asthen 
 opia. 
 
 7th. The Relation o! Eye strain <>r Asthenopia to Constitu ticna 
 symptoms. 
 
PART I. 
 
 EXCERPTS FROM SPECIALISTS 
 IN OPHTHALMOLOGY. 
 
The thoroughness with which Prof. Donders of Utrecht 
 systematized the subject of Refraction, would be difficult 
 to parallel in the history of the science of Medicine. 
 
 Its importance, and the benefit accrued to the world, 
 and that yet to come, cannot be estimated. He wrote 
 out of chaos, mystery and ignorance, a beautiful science 
 and habilitated it with art, order and precision. He put 
 it forth on the road to exactness, and with becoming 
 modesty, bid it improve. 
 
 1864. 
 
 F. C. DONDERS, M. D. 
 
 Professor of Physiology and Ophthalmology in the University of 
 
 Utrecht. 
 
 Translated by 
 WILLIAM DANIEL MOORE, M. D. 
 
 ANOMALIES OF ACCOMMODATION 
 AND 
 REFRACTION OF THE EYE. 
 
 Asthenopia. — Prof. Donders' early history of asthenopia tells 
 us, that it received a variety of names, which but covered up ignor- 
 ance of the phenomena. "Dimness of vision" — "Affection of the 
 retina from execssive employment" — Disposition to fatigue" — 
 "Slowly adjusting sight" — Impaired vision from overwork. "It 
 is evident that in a condition such as this, there was great difficulty 
 in sketching a typical picture, so long as the cause of the leading 
 feature of the affliction, and therefore its nature was unknown".... 
 
is HAZEN'S NEW FINDINGS 
 
 "The well defined lineaments of the picture were obliterated by un- 
 ential phenomena, and mixed up with those of amblyopia.... 
 and were generally Bought in the retina or in the choriadea." 
 
 Early Idea. \s to the affection beingcaused by accommodation 
 
 in the time of Mackenzie, it was met by the theory of Bohm 
 
 ascribed it to the external muscles of the eye, and was the first 
 
 -com mend the use of convex glasses for the trouble of asthen- 
 
 . but lie gave too weak ones. 
 
 Ruete adopted Bohm's theory and concluded that the "proxi- 
 mate cause , as proved by Bohm, was a weakness of the motor 
 nerves of the eye." From the fact noticed, that complaints were 
 made by persons, who were almost constantly occupied, with close 
 work, and who, on its suspension, showed immediate improvement 
 — it was asked, should not the affliction be considered as a purely 
 acquired condition, and the cause of it be sought in excessive ten- 
 sion?" Although at first, asthenopia lay concealed in amblyopia, 
 it gradually emerged from its obscurity, and without the partici- 
 pation of the retina being as yet denied, its seat was sought more 
 and more, in the organs of accommodation, until, at last the retina 
 was almost completely excluded, and the condition was looked 
 upon as a disease of the motor nerves and of the organ of motion 
 of the eye." 
 
 At this time the source of the power of accommodation had not 
 yet been discovered. There was as much reason to assign the 
 principal part in that function to the external muscles of the eye. 
 This led to the supposition that asthenopia was to be sought in 
 a spasmodic contraction of some external muscle of the eye." 
 "The cause of asthenopia was sought in the external muscles of 
 the eye, and the results obtained on division of the latter were 
 supposed to furnish a fresh proof of the correctness of the views 
 of those who referred it to them." 
 
 After Discovery of Accommodation. — After the discovery of the 
 principal of accommodation, nothing more was said of the principal 
 of abnormal pressure of the muscles of the eye, nor of dividing 
 the latter as a remedy for asthenopia." 
 
 Yon Graefe, "assigning to asthenopia only a symptomatic sig- 
 nification, demonstrates the existence of asthenopia muscularis, 
 proceeding from insufficiency of the musculi recti intend." 
 
 Discovery of Hypermetropia. — "Our knowledge had reached 
 this point, when I discovered the cause of asthenopia in the hyper- 
 metropic structure of the eye. The supposed anomaly of accom- 
 
' PROF. F. C. DOXDERS 19 
 
 initiation then became an anomaly of refraction. The connection 
 of asthenopia with the circumstances under which fatieuc is mani- 
 fested was made most clear; the necessity of complete relief by 
 spectacles was proven, while at the same time, the hope of a radical 
 cure of asthenopia was extinguished forever." 
 
 The exaggerated attention to the external muscles, during the 
 period of operation for strabismus, before his time, he thinks caused 
 the pendulum of progress to swing too far that way. 
 
 "We must beware of mistaking apparent for true asthenopia." 
 Then he describes a case of undoubted asthenopia or akinesis, in 
 which he finds hyperesthesia outside and in. and puts on dark 
 glasses. 
 
 ASTHENOPIA. 
 
 Accommodation and Refraction. 
 
 Symptoms. — "A peculiar morbid condition of the eyes has long 
 attracted the attention of Ophthalmologists. The phenomena 
 of which it is composed are highly characteristic. The eye has a 
 perfectly normal appearance; its movements are undisturbed; 
 the convergence of the visual lines presents no difficulty; the power 
 of vision is usually acute; nevertheless, in reading, writing, and other 
 close work — especially by artificial light, or in a gloomy place, the 
 objects after a short time, become indistinct and confused, and a 
 feeling of fatigue and tension comes on — especially above the eyes, 
 necessitating a suspension of work. The person so affected often, 
 involuntarily, closes his eyes, and rubs his hand over the forehead 
 and eyelids. After some moments' rest, he once more sees dis- 
 tinctly, but the same phenomena are again developed more rapidly 
 than before." (Sunday interval-rest.) 
 
 "The tension above the eyes gives place to actual pain, some- 
 times even slight redness and a flow of tears ensue. Everything 
 is diffused before the eyes, and the patient no longer sees at first 
 well, even at a distance. After too long continued tension, he is 
 obliged to refrain for a long time from any near work. It is remark- 
 able that pain in the eyes themselves, even after continued exertion, 
 is of rare occurrence." "At first this condition was considered as 
 a sort of amblyopia. It was called i habitudeo vises'."' 
 
 Congenital Predisposition Explained. — "By decrees the cause 
 was sought, more and more in the organ of accommodation — ;at 
 first in the action of the external muscles, subsequently, in that of 
 the internal muscular elements, and in the same measure, the impor- 
 tance of the retina was thrown into the shade. Excessive ten- 
 
SO HAZEN'S NEW FINDINGS 
 
 of the accommodation was looked upon as a satisfactory cause of 
 the troublesome symptoms, which, it was hoped, might be overcome 
 by rest." "Since the same cause does not produce, in every one, 
 the same deviation, writers are accustomed to take refuge in a pe- 
 culiar predisposition. Thus the difficulty is set aside, but, if the 
 foundation of this peculiar predisposition be dark and obscure, 
 pathogeny has gained but little from the adoption of this course. 
 I therefore felt called upon to propose to myself the question, on 
 what the so-called predisposition to asthenopia (so the condition 
 was now more generally called) might depend upon, and I soon 
 became convinced that a congenital deviation, namely, a moderate 
 degree of hypermetropia was at the bottom of it. The hyperme- 
 tropia is here, however, more than predisposition. The asthe- 
 nopia — I mean the tendency to fatigue in looking at near objects, is 
 already included therein. Every hypermetropia, which, with refer- 
 ence to the range of accommodation, has attained a certain degree, 
 is, at the same time, asthenopia. If the symptoms, sometimes do 
 not manifest themselves until twenty-five years of age, or even later, 
 this is to be ascribed merely to the fact, that previously, the range 
 of accommodation was sufficiently great, to easily overcome the 
 existing degree of hypermetropia." "We should beware of con- 
 founding the exciting circumstances of the phenomena which con- 
 sist in continued tension in looking at near objects; the cause, on 
 the contrary, is the hypermetropic structure of the eye. In fact, 
 asthenopia is not fatigue itself, but the want of power through 
 which the fatigue occurs. The distinction, made here, is appli- 
 cable to other conditions — for example, climbing a hill. "I have 
 already asserted that hypermetropia is usually at the bottom of 
 asthenopia. The truth of this assertion has been doubted. I 
 now, however, go a step farther, and venture to maintain, that in 
 the pure form of asthenopia, hypermetropia is scarcely ever wanting." 
 '*\\ hen inconvenience was felt on continued exertion, this appeared 
 to some, sufficient to justify the inference that asthenopia existed. 
 On this account, different forms of irritation, congestion in myopic 
 eyes, hyperesthesia of the eye, with increased pain or exertion, dif- 
 ferent affections of the retina and of the choroid, nay. even the 
 beginning of trachoma, and foreign bodies in the sac of the con- 
 junctiva, might all be united under one denomination, but I cannot 
 concur in the adoption of such a punitive, semiotic method. It 
 leads inevitably to confusion of ideas and conditions. "The con- 
 dition for the occurence of asthenopia may now be still more gen- 
 erally formalized; it is the presence of a rather considerable, but yet 
 at the same time, insufficient ranee of accommodation. Xow. in 
 
PROF. F. C. DONDERS 21 
 
 general, this insufficiency is attributable to Hypermetropia, as has 
 been fully explained, but it may proceed also from want of energy. 
 This last occurs exceptionally — especially in general weakness, 
 from loss of blood or otherwise, and in paresis. In both of these 
 conditions there is this peculiarity, that a brief but rather powerful 
 muscular exertion is possible, but that the energy employed is 
 almost immediately lost. We observe this in all muscles, and 
 it is true also of those of the eye." "There arc still other morbid 
 states, whose symptons have some resemblance to those of asthen- 
 opia. To those belong especially, insufficiency of the external 
 recti muscles, which Yon Graefe has studied with such excellent 
 results — myopic eyes, where this insufficiency is more particularly 
 apt to occur." 
 
 "This form was distinguished by Von Graefe, under the name of 
 asthenopia muscularis, from that here described which may be 
 here called the accommodative asthenopia." 
 
 MUSCLES. 
 
 Fatigue. — "The phenomena of asthenopia proceeds from nothing 
 else than from fatigue of the muscular system of accommodation. 
 In what this fatigue consists, deserves to be more closely examined." 
 "In my investigations respecting the elasticity of muscles, I have 
 distinguished two forms of fatigue." "One form proceeds from 
 the actual energy produced by the muscle. The work consists 
 in the moving of a load. The load may be the body itself or some 
 part of the body, which is moved, or, in addition thereto, an object 
 external to the body." "Distinguished from this is the fatigue, 
 which is the result of the simple extension of an elastic muscle in 
 state of contraction. This takes place when a burden is held 
 without being moved, as for example, when, with the arm bent at 
 a right angle at the elbow joint, the hand is loaded with a weight; 
 the arm and the weight remain in the same place and yet fatigue 
 soon occurs." "It has ,in fact, been proved that, according as the 
 muscle becomes fatigued, its extensibility increases, and this in- 
 creasing extensibility requires augmenting contraction, in order, 
 under the extending action of the same load to keep the muscle 
 as short as it was." "There was continually some actual energy 
 in the oscillations of the electric currents, and most likely converted 
 into heat." "I therefore think the fatigue proceeding from the 
 performance of labor, must be distinguished from that arising from 
 simple extension." "In explanation of the fatigue, which is the 
 result of the performance of labor, we may take refuge in an accumu- 
 
22 HAZEN'S NEW FINDINGS 
 
 lation of products of metamorphosis of matter in the muscular 
 tissue, which really goes hand in hand with it. The fatigue pro- 
 ceeding from extension, under the influence of a load not further 
 moved, may, partly at least .have another source. Thus the exten- 
 sion might give rise to pressure on the nerve filaments in the mus- 
 cle." "Probably, however, it depends partly also on an increase 
 of the products of the metamorphosis of matter in the muscular 
 tissue, produced, not so much, by the accelerated formation, as by 
 retarded elimination." "Now, to which form of fatigue does that 
 belong, which arises from persistent accommodation for accurate 
 vision in the hypermetropic eye?" 
 
 Muscular Asthenopia.— He describes Asthenopia Muscularis 
 under the head of Myopia. "Diverging Strabismus'' is generally 
 combined with Myopia." He says, "in cases of astigmatism, 
 physical fatigue is soon created, with which, under some circum- 
 stances, as the result of the excessive tension of accommodation, 
 phenomena of asthenopia are combined." 
 
 Under Myopia, he refers, to Von Graefe's operation for insuf- 
 ficiency of the interni. He had no knowledge of prisms as a means 
 of exercise, but refers to them as used by Yon Graefe, as a disagree- 
 able means of correcting diplopia by wearing them. 
 
 Insufficiency of Interni. — "If the one eye, so soon as it is 
 covered, preceptibly deviates outward, and on removing the hand 
 again turns inward, in order to resume its former direction, we may 
 suspect the occurrence of asthenopic muscularis. It is often 
 difficult enough to decide what is to be done in such cases, for the 
 rules applicable to insufficiency of the internal muscles in non- 
 myopes, by no means hold good in asthenopia muscularis in myopic 
 individuals. In the former, the condition referred to is, in the 
 first place, free from danger, and it is even allowable to try, by 
 systematic practice with prismatic glasses to excite energy of the 
 external muscle. In myopia on the contrary, cure of the insufficiency 
 of the internal recti muscle is not to be thought of. Once begun, the 
 insufficiency developes itself, more and more, in double proportion 
 when, as is usual, the myopia is progressive. Often no other result 
 is possible, than the exclusion of the one eye, with diverging stra- 
 bismus. In the worst cases the mobility is even so limited, that 
 it is insufficient both inwardly and outwardly." 
 
There was a notable meeting of the American Ophthal- 
 mological Society which it would be a great omission 
 to leave out of a history of the subject, which we arc 
 endeavoring to elucidate. This paper and its discussion, 
 was the initiative of muscular discipline, as a remedy 
 for eye strain, and awakened a new idea on the subject 
 of asthenopia in this country. 
 
 The paper was given in a full meeting at which many 
 prominent eye men were in attendance and took part 
 in the discussion. 
 
 The description of the condition of these cases showed 
 that those present had met with similar experiences, 
 and the discussion was animated and interesting. (This 
 is but a synopsis of the paper and its discussion.) 
 
 June, ISO"). 
 
 MEETING OF THE AMERICAN OPHTHALMOLOGICAL 
 SOCIETY, NEW YORK CITY. 
 
 DR. EDWARD DELAFIELD, President, in the Chair. 
 
 DR. HENRY D. NOYES, Secretary. 
 
 "ASTHENOPIA NOT CONNECTED WITH HYPERMETROPIA." 
 
 By 
 E. DYER, M. D. 
 
 Asthenopia with no Hypermetropia. — Dr. Dyer said, "In 
 
 these cases, there was no hypermetropia, latent or apparent." 
 '"The majority of his cases were myopic; good accommodation; 
 did not complain of words becoming indistinct, but had absolute 
 pain, so disagreeable that they ceased to use their eyes; rest did 
 
24 MAXK.VS NEW FINDINGS 
 
 not relieve; pain or sensation lasted for several hours, sometimes, 
 
 • night and next day; some intolerance of light; could go to 
 
 theater or opera if excited, no feeling of discomfort at any time, but 
 
 the next day or two would suffer the penalty; the pain produced 
 by indiscretions of this kind was almost exactly like that brought 
 on by using the eyes;" (near point) is mostly found in persons 30 
 years of age, and almost restricted to persons of the better class 
 of society; have never seen it in strabismus convergens, but some- 
 times in strabismus divergens; have seen only one case complicated 
 with astigmatism. The Ophthalmoscope generally, shows nothing 
 abnormal; frequently, the optic nerve is not clear." He was led 
 to the conclusion that there was some trouble with the accommoda- 
 tion that caused the pain, but in emmetropia and in myopia both 
 complain of asthenopia. He did not detect insufficiency of conver- 
 gence, but thought there might be a discrepancy between the 
 power of the ciliary muscle and the an^le of convergence. 
 
 Discussion. 
 
 Dr. Dei. afield. — Dr. Delatield. said, "He had. in forty years, 
 seen so much of asthenopia of this kind, that he must describe 
 some that had come to his notice. One case, the wife of a class- 
 mate of his, had not read or written since 1812; another of the same 
 kind, 80 years of age, with the same effect: the disease generally 
 occurs in young people, but no aee is exempt from it; the common 
 direction is, "to rest your eyes." He never knew one to get well 
 by resting the eyes. The difficulty occurs very largely in girls' 
 boaiding schools where hysteria is seen, and bad hygienic measures 
 are found; symptoms are very much alike; the variety is not mate- 
 rial; has not found a large proportion with myopia; after using 
 eyes, "the eye sight blurs." 
 
 Dr. Derby divides the conditions of cases of asthenopia into 
 two clasess — 1st. those where continued use of eyes is optically 
 impossible. 2nd. Those where the same is physically impossible. 
 The description of Donders suffices for the first, and the symptoms, 
 indistinctness of vision from effort, with pains in head, flow of tears 
 and disposition to close the eyes, the second. Under one or other 
 of these classes, every case of asthenopia can be brought. The 
 physical division is as little understood, as in 1858, when Donders 
 first wrote, and when firmly fixed, is as little amenable to treatment; 
 often absent in the invalid, and present along with the most vig- 
 orous health — a complete enigma as to its seat, its cause or cure; 
 more common in this country than in F.urope, and more common 
 on the Atlantic seaboard than in the West* 
 
NEW YORK OPHTHALMOLOGICAL SOCIETY 25 
 
 The ocular class, generally congenital, is reducible to two causes, 
 hypermetropia and insufficiency of the internal recti. Out of the 
 1800 cases in genera! practice, 369 were asthenopic; of these '_' 1 1 
 belonged to the physical and 125 to the ocular; nearly all the latter 
 were dependent on hypermetropia. 
 
 In true asthenopia, the eye is, to all appearances, botli exter- 
 nally and internally, absolutely normal; no hypermetropia; interni 
 of normal strength; general health may be satisfactory, but often 
 is not. Sometimes, under the influence of alcoholic stimulus, or 
 the excitement of important business, the eyes are used with appa- 
 rent ease, and when excitement ceases, they relapse into their old 
 condition. The affection may last weeks or a lifetime, and, in the 
 majority of cases, resist any and all therapeutics. 
 
 Dr. Williams of Cincinnati. — Dr. Williams of Cincinnati, 
 during a number of years, has found a great many of this kind ol 
 cases, that, after repeated examinations, have excluded all idea of the 
 usual cases of asthenopia, such as myopia, hypermetropia, astigmatism 
 or paralysis of accommodation; that with sight perfect; range of 
 accommodation normal and ophthalmoscopically perfectly natural; 
 the patients were unable to use their eyes an}' length of time without 
 feeling great inconvenience. These cases had often been told that 
 they were threatened with amaurosis and must not use their eyes. 
 This apprehension I try to remove, by telling them, they could not 
 get blind if they were to try. From much reading and study, my 
 own eyes became asthenopic, and I became apprehensive that I 
 might lose my sight, and Yon Graefe, on examination of them by 
 the Ophthalmoscope, assured me that there was but a little nervous 
 irritation, and I have done nothing for them, except to use my 
 eyes a little more reasonably. One case, coming to me, had not 
 read five lines at a time for twenty years. I fitted the Presbyopia 
 and she has been using her eyes as much as she pleased, with very 
 little inconvenience. 
 
 Dr. Williams of Bostox. — Dr. Williams of Boston. "My 
 attention was drawn to these cases, (before I had anything to do 
 with them) which were called, 'morbid sensibility of the retina;' 
 they were subjected to rather an active treatment, local depletion 
 and low diet, and directed to absolutely refrain from the use of their 
 eyes. These patients suffered from dread that they were to be 
 blind, and they had readily taken advice to refrain absolutely from 
 using their eyes, so as not to 'strain them." and sometimes, they 
 would shut themselves into a dark room. A charlatan oi the early 
 days, with a good deal of tact, too!; these hysterical patients, and 
 
26 HAZENS NEW FINDINGS 
 
 by putting them to bed for a day, with strong alkaloids on their 
 eyes, and changing the diet to roast beef and stimulants, with fre- 
 quent drives about the country, taking away all their old associa- 
 tions, caused his patients to do extremely well, and the quack was 
 considered a prophet. He ascribed much more importance to the 
 general treatment than to local applications, which were of an 
 haracter, and were used to make an impression on the 
 patient rather than on the disease, but it answered the purpose in 
 making an impression on the disease psychologically." 
 
 *'In Ophthalmological examination of such cases, I did not often 
 rind the slightest tendency to amaurosis, and I encouraged my 
 patients to use their eyes all they possibly could. I prescribed 
 tonics and placed them in cheerful surroundings, instead of having 
 their minds constantly filled with morbid fear, and I sometimes 
 gave them convex glasses, which I found to be good in some cases, 
 not knowing, at that time, much about hypcrmetropia. as we now 
 know it. 
 
 Dr. Sands. — Dr. Sands reported a case of the '"Optical variety," 
 coming under his observation. "A young man at 17 years of age, 
 living in Xew England had been sent abroad to complete his educa- 
 tion, and also to spend a couple of years in Europe. He was in 
 perfect health; after spending two or three months about the Rhine 
 and in Switzerland, he returned to Paris and began to experience 
 pain on use of his eyes. He had never been a very hard student 
 and he was very much surprised at the occurrence, and went to 
 a well known oculist in Paris, who told him, 'that he was suffer- 
 ing from hyperesthesia of the retina.' The physician created an 
 immense amount of alarm in the mind of the boy, and placed him 
 under treatment of a complicated character; remedies external and 
 internal; told him to avoid use of his eyes, and under no circum- 
 stances to apply himself to work, in less than a year. His parents 
 sent for him to come home, and he consulted me. I found a slight 
 myopia, accommodation 1-4, vision good, no blur; the pain was in 
 the ball; could discover no disease by ophthalmoscopic examination, 
 excepting capillary hyperemia in the optic nerves; vision above nor- 
 mal; physicial health good; mental depression on account of the 
 advice given by the Paris oculist. He suffered no pain when looking 
 at distant objects, but only when the ciliary muscle was brought 
 into play during accommodation. Following Donders in 'inordi- 
 nate contraction of the ciliary muscle,' I prescribed convex glasses 
 of 20 inch focus, but when the optic lines were made to converge 
 upon near objects, it was about as painful as it had previously been 
 to exert it without glasses. 
 
NEW YORK OPHTHALMOLOGICAL SOCIETY 27 
 
 Dondcrs suspended the accommodation by atropine, and used 
 convex glasses in place of the accommodation, and thus cured the 
 spasmodic contraction. These facts lead us to look for an expla- 
 nation of asthenopic symptoms in the apparatus of accommoda- 
 tion in the ciliary muscle and the nerves that supply it, rather 
 than in the errors of refraction or any disturbance relating to gen- 
 eral health. 
 
 Dr. Noyes. — Dr. Noyes led the discussion, which thus far related 
 chiefly to one class of asthenopia. "I think it will not be amiss, 
 cursorily, to run over some of these diseases, which, in the general 
 classification of medical men, are included under the name of Asthe- 
 nopia. Mackenzie, I find to be, "Incapability of sustaining the eye 
 in adjustment for near objects." Lawrence, "An affection of the 
 retina from excessive employment, commonly called, "weakness of 
 sight" — Mackenzie grouping symptoms around adjustment, and 
 Lawrence grouping the symptoms around a morbid condition of 
 the retina — Stellwag Von Corion, "The inability to keep the dioptric 
 system on the visual lines, for a long period, directed to near objects; 
 and secondly, in close pathological relation to the condition hyper- 
 aesthesia of the retina and ciliary nerves." 
 
 "This definition of asthenopia is unquestionably the definition, 
 which we would be most likely to adopt, but there is a tendency to 
 exclude from the definition of asthenopia, all those cases of re- 
 fractive errors and muscular disturbances, which are not properly 
 disturbances of the ciliary muscle, but include cases in which 
 neuralgic symptoms predominate. This is the meaning which the 
 term is gradually assuming. Such was not formerly the under- 
 standing of asthenopia, and we all know perfectly well that, at least, 
 two or three well recognized sub-divisions can be made — 1st. 
 Errors of refraction, principally hypermetropia and astigmatism. 
 
 2d. Insufficient power of the internal recti muscles; they, 
 cannot perform their work of converging the visual lines, when the 
 eyes are engaged upon near objects. 3d. Characterized by exces- 
 sive irritability of the retina, accompanied by ciliary disturbance 
 or neuralgia of the eye, extreme intolerance of light, with no lesion, 
 no organic change, with vital powers, normal standard. Enough 
 has been said on the subject of hypermetropia, astigmatism, and 
 myopia. I desire to recall these facts. The insufficiency of the 
 internal recti muscles has a nearer relation to the subject of asthen- 
 opia, in the aspect in which we are now disposed to view it, than to 
 the simple errors of refraction, because this muscular part requires 
 to be exerted in all use of the eyes upon near objects. The accom- 
 
28 HAZEN'S NEW FINDINGS 
 
 modation and muscular convergence arc inseparably connected. 
 The correction of this difficulty is accomplished in one of three ways 
 — division of the external recti muscle; by use of prisms or what 
 has recently been suggested, the employment of electricity to the 
 internal recti muscle (Here Dr. Noyes introduced a readier method 
 of detecting insufficiency). 
 
 In regard to cases to which the term hyperesthesia of the retina 
 may properly belong — Case — A physician, a surgeon in the Navy, 
 who had been stationed on the African coast, and subjected to the 
 intense light of the tropics; extremely sensitive to light; he not only 
 could not use his eyes but was rarely free from neuralgia. He 
 had subjected himself to all sorts of treatment; had almost poisoned 
 himself with strychnine. After about five years, he came under 
 my observation. There was no departure from normal structure; 
 no deficiency of accommodation or any other function. I assured 
 him there was no danger of becoming blind, and that he would 
 probably be better. Out of door exercise, Avith blue glasses and 
 avoidance of the use of his eyes, resulted in benefit, and after about 
 six months on shore, away from the irritating influences to which 
 he had been subjected, he recovered the use of his eyes and again 
 went to sea. 
 
 Another case — That of a physician with the same misfortune — 
 Ophthalmoscopic examination, with as little gas light as I could get 
 along with, produced agonizing pain for 24 to 48 hours; attempts 
 to read or fix eyes on distant objects, as well as near, provoked 
 extreme pain. There was no error of refraction, impairment of 
 vision, or muscular disturbance; general health fully up to the 
 average. I could regard this case in no other light than one of 
 extreme irritability, whose starting point was the retina, and which 
 was reflected upon the ciliary muscles and nerves. 
 
 These several categories of Asthenopia, will hereafter, be known 
 by their proper designation of errors of refraction, debility of the 
 internal recti, hyperesthesia retina. The term Asthenopia is, at the 
 present time, when used to designate a distinct disease, and not 
 merely a symptom, being narrowed down to cases of ciliary spasm 
 or neuralgia." 
 
 TREATMENT. — Dr. Dyer seems to be the first one, who intro- 
 duced a system of gymnastics for the muscles of the eye, which 
 he added to the general course of tonics and hygiene. He ''changed 
 the relation of the accommodation to the angle of convergence of 
 the axes by glasses," by giving them a light convex glass. He 
 gave them explicit directions to never use their eyes without glasses, 
 
NEW YORK OPHTHALMOLOGICAL SOCIETY 29 
 
 and never use them except as directed. Taking the clear type of 
 medium size, the patient must read at first, from 3 to 15 minutes 
 (according to the case) morning, noon, and evening (before sunset) 
 adding a minute to each sitting; if pain arose, which lasted to the 
 time of the next reading, make the time a minute less, but always 
 read at the stipulated time. A point will soon be found at which 
 the patient can read without pain — then, to the time, he can add 
 a minute a day, and when he gets to 30 or 40 minutes, three times 
 a day, he may use his eyes at other work, but not until then. When 
 he reaches an hour of reading, the glasses may be dispensed with. 
 
 The explanation, the rational and the new hope held out, together 
 with the mental discipline and interest, gives to these cases, who 
 have been told that they must rest, and that there is danger of their 
 becoming blind, renewed energy. Out of forty of these cases, the 
 results have been highly satisfactory. 
 
 The necessity of persevering and following directions is emphasized. 
 If they become careless and read too much or irregularly, they will 
 be sure to be thrown back and have the whole ground to go over 
 again. The treatment of these cases extends over months, and 
 they often relapse from indiscretion. 
 
 Dr. Delafield considers the principle of Dr. Dyer's method a 
 correct one and has applied it for years — that is — in general dis- 
 eases, he insists on exercise. He says, "The cure of the patient's 
 general health is the foundation of everything. I am specific in 
 direction as to this. Locally, I apply a sol of veratria or aconite 
 to the nape of the neck, and from this application, urge them to 
 read fifteen minutes. I sometimes use ammonia and alcohol, 
 applied to the forehead, temples and neck. Each day one of these 
 is used. I have used a solution of a grain of veratria to the ounce, 
 dropped into the eye, in obstinate cases of asthenopia. It is painful 
 and I get along without when I can." The exercise, instituted by 
 Dr. Dyer, called for the forced use of the eyes not stopping because 
 of pain. 
 
 Dr. Derby. — The original method of treating asthenopia, was 
 neutralizing the manifest hypermetropia and keeping pace with 
 the manifest, until all became manifest. Much stress was laid 
 on the necessity of making the neutralizing glass part and parcel 
 of the eye, and only laid aside when the eye ceased to see. It is 
 now proved that the assumption that accommodation cannot be 
 used on distant objects without injury, is fallacious. We may 
 therefore, allow the patient, who sees distant objects fairly well, 
 to use his glasses only for the near. 
 
30 HAZEN'S NEW FINDINGS 
 
 Dr. WILLIAMS of Cincinnati, believed in exercising the eyes and 
 had used Dr. Dyer's system, without exactly knowing why. He 
 I, "I have tried it in two cases. I used moderately convex 
 g'asses and applied a solution of the sulphate of morphia — two 
 grains to ounce — dropping three or four drops into the eyes, three 
 or four times a day. Gave tonics constitutionally, and douched 
 the eye with cold water twice a day." 
 
 Dr. \\ illiams of Boston — .Constitutional medicine, tonics and 
 moderate exercise. No use of eyes when ill. Found glasses were 
 of benefit in hypermetropia. Encouraged patients to use eyes, 
 increasing their use gradually. 
 
 Dr. Noyes, considered the system of Dr. Dyer, in using a convex 
 glass required a little greater effort of the internal recti, by bringing 
 the near point nearer, while a systematic training developed their 
 strength. He says, "I have seen benefit from wearing weak prisms 
 when I did not feel certain that the interni were at fault. A com- 
 bination of -f- 1. D. C 2° prism has relieved a troublesome asthen- 
 opia. \\ ith these contrivances, there occurs a change in the 
 relative accommodation — not as by use of convex glasses, yet 
 the eyes accommodate, under conditions, unlike those to which 
 they have become accustomed. 
 
 It was brought out in the discussion, by inquiry, that Dr. Dyer 
 had no particular method, besides those commonly used, to deter- 
 mine whether his patients had insufficiency of the interni. He was 
 satisfied to change the relation beiween accommodation and con- 
 vergence, and endeavored to establish a more perfect relation 
 between the two. He said, "I have doubted whether the benefit 
 derived from prisms, was because of the relief to the internal recti, 
 and not rather because of the modification in the condition of accom- 
 modation." 
 
 Dr. Althof had seen a great deal of the application of electric- 
 ity to the eyes, but had never seen any benefit, whatever, derived 
 from the use of it. As far as the treatment of these cases of asthen- 
 opia, by glasses was concerned, it was becoming more important 
 and if the providing of glasses were facilitated, there would be less 
 of asthenopia. High degrees of insufficiency do not always show 
 diplopia with red glass. 
 
The early history of the specialty of Ophthalmology 
 in this country, received much of its impetus through 
 the labors of Charles Bader, as shown in the following 
 named book — although it was published in England. 
 
 1868. 
 
 THE NATURAL AND MORBID CHANGES 
 
 OF THE 
 HUMAN EYE AND THEIR TREATMENT. 
 
 By 
 
 CHARLES BADER, 
 Ophthalmic Assistant Surgeon to Guy's Hospital. 
 
 Asthenopia. — Weak sight, impaired vision, slowly adjusting 
 sight, affection of the retina from excessive employment. The 
 two groups of muscles, which, from want of power, may give rise 
 to asthenopia, are the ciliary muscle and the external muscles of 
 the eye ball. 
 
 The term, Accommodative Asthenopia has been used by some to 
 distinguish asthenopia, which is due to want of power of the ciliary 
 muscle. Many symptoms accompanying asthenopia, do not essen- 
 tially belong to it. In true asthenopia, when engaged in "near 
 work," letters or finer details become "dim" or disappear. After 
 rubbing or closing the lids, they can resume work for a short time; 
 attacks of dimness vary in frequency; they appear sooner in ill 
 health; they may continue for years without interfering with 
 acuteness of vision. In hypermetropia, dimness is preceded by 
 sensations of tension over eyebrows, amounting sometimes to pain. 
 It has been stated, that the age at which asthenopia appears, is 
 about equal to the denomination of the fraction (inch system) 
 which expresses the deeree of hypermetropia. Only the true asthen- 
 opia, as a rule, is cured by convex glasses. 
 
32 HAZEN'S NEW FINDINGS 
 
 Apparent, Not True Asthenopia. — Patients, at near and dis- 
 tant vision, complain of pain, aching, watering, pain in ciliary 
 region and back of eyes. Pain may he permanent and increased 
 when attempt is made to work. Tension, smarting, photophobia 
 and occasionally phosphenes, dimness of vision arc felt, but it is 
 the pain etc., which compels the patient to desist from work, often 
 tor months. Apparent Asthenopia often occurs in Myopia, and 
 occasionally in hyperemia of the optic disc and retina, and is termed 
 hyperaesthesia of the retina if no organic changes are discernible. 
 Asthenopia arising from weakness ("insufficiency") of the internal 
 recti muscles — by some termed muscular asthenopia, is often met 
 with in Accommodative Asthenopia, and is sometimes mistaken 
 for it. 
 
 Insufficiency of the Internal Recti Muscles. 
 
 Insufficiency of the Converging Power of the Eyes — Asthen- 
 opia Muscularis. 
 
 ''In Insufficiency, the associated movements of both eyes are 
 normal — not so in Paresis." Insufficiency of the internal recti 
 muscles signifies want of power in these muscles. The sub- 
 jective symptoms of the insufficiency are, in a great measure, those 
 of asthenopia, and in every case of asthenopia, Ave should ascertain 
 the power of the internal recti muscles. The asthenopia caused 
 by insufficiency, is termed muscular asthenopia. The weaker eye 
 diverges first. We suppose the insufficiency to be pretty equal, 
 if, at one moment one, at another the other eye, diverges. 
 
 Screen Test. — If we find that the excluded eye diverges, we 
 infer that the converging power of that eye is insufficient. By 
 Von Graefe's test, it is further established. If, before the prism 
 with the angle upward (which causes the dot and line to double) 
 a second prism with the refracting angle outward, will measure the 
 degree that will unite the two images. For Insufficiency at a dis- 
 tance, use the flame of a candle and determine the prism that can 
 be overcome by convergence, and what prism can be overcome by 
 divergence. The power of divergence, in these cases, is generally 
 greater. Weakness of these muscles is often congenital and 
 hereditary. 
 
 Treatment. — "Asthenopia, whether true or apparent, is a 
 symptom, which, as a rule, subsides under proper treatment of 
 its cause. 
 
CHARLES BADER 33 
 
 Correction of the Refraction. — In Insufficiency, we often 
 succeed in removing the asthenopia, caused by it, through optical 
 or surgical means or by combining of the two. In case the refrac- 
 tion is normal and the eyes are otherwise healthy, if divergence 
 exist to the extent of l°or 1^°, we recommend prismatic spectacles 
 with refracting angle turned outward. "The external recti must 
 be made to contract, and the internal ones to relax. "Tf, as in 
 paresis of the internal recti muscles, it is desirable to excite and 
 practice contraction of these muscles, we reverse the position 
 of the prisms." We give prisms of equal strength to both eyes. 
 If the strength of the correction exceeds 10° or 12°, we divide 
 the external rectus of the eye, which diverges most on exclusion." 
 We divide both external recti muscles, if, in each eye, the outward 
 movement exceeds 60°. He explains decentering of lenses. 
 
 Operation. — The object of operation is to facilitate the con- 
 traction of the internal recti muscles. 
 
The prominence of the German works in former years, 
 and especially those translated by our well known Amer- 
 ican, Dr. Roosa, makes it necessary that their thought 
 on the sunbject of Astheopia, in relation to the Function 
 of Vision, should be represented in its history. 
 
 1868 
 
 CARL STELLWAG VON CARION, M. D. 
 
 Professor of Ophthalmology in the Imperial Royal University of 
 
 Vienna. 
 
 TREATISE ON THE DISEASES OF THE EYE. 
 
 Translated by 
 
 CHARLES E. HACKLEY, M. D. 
 
 Surgeon to the New York Eye and Ear Infirmary, Physician to the 
 New York Hospital, Fellow of the New York Academy of Medi- 
 cine, etc. 
 
 D. B. ST. JOHN ROOSA, M. D. 
 
 Clinical Professor of the Eye ansd Ear in the Medical Department 
 of the City of New York, etc. 
 
 Asthenopia. — "By Asthenopia, we understand the inability of 
 maintaining the adjustment of the dioptric apparatus, or the 
 visual axis for short distances, for a length of time, and the hyper- 
 aesthsia of the retina and ciliary nerves accompanying this inabil- 
 ity." 
 
 The cause of the disease is sometimes an absolute or a relative 
 deficiency of energy in the muscle of accommodation; at others 
 it is a similar affection of the internal recti on which depends the 
 convergence of the optic axes. Accommodative Asthenopia is most 
 frequently seen. When the functional stamina has much decreased, 
 and pain arises with swimming, they announce themselves by a 
 feeling of fullness in the eye, with peculiar tension in the forehead, 
 then over the eyes; soon dizziness, headache, malaise and even 
 
36 HAZEN'S NEW FINDINGS 
 
 nausea, almost always injection of the conjunctiva; episclera as 
 well as lachrymation. Muscular asthenopia is much less frequent. 
 The subjective symptoms are similar to those of the accommo- 
 dative form; only the retina does not have to contend with circles 
 of dispersion. Patients complain more of the neighboring letters 
 running together and through each other; this is preceded by a 
 straining sensation. Double vision occurs, assistance comes by 
 removing objects to a greater distance. Many patients prefer 
 to shut the weaker eye or move the object to the affected side, 
 diminishing the amount of action required of it. '"In muscular 
 asthenopia a long interruption of work, or nightly rest does not 
 suffice to produce an increased duration of function; the energy of 
 the internal recti, once decreased, is again aroused with much more 
 difficulty, and more slowly than that of the muscle of accommo- 
 dation." On fixing at a near point, one eye becomes uncertain and 
 finally turns outward. In tests of double image caused by prisms, 
 there are crossed images produced. In emmetropes myopes, ac- 
 commodative asthenopia rarely occurs, but such eyes are not 
 perfectly safe when there is muscular insufficiency. The internal 
 r ecti are most called on in high grades of myopia, hence muscular 
 asthenopia principally affects the near sighted. Muscular asthen- 
 opia occurs more rapidly if there is also a congenital or developed 
 deficiency of energy of the internal recti. These insufficiencies 
 often occur and, as they are not combined with great myopia, it 
 shows that muscular asthenopia may also, under certain circum- 
 stances, occur in slightly myopic or even emmetropic or hyper- 
 metropic persons. This would be practically liable to occur, when 
 an unaccustomed strain of the muscle of convergence offered the 
 opportunity. At first, symptoms appear w r hen the affected muscle 
 is subjected to unaccustomed straining. With continued forced 
 work, the nervous symptoms soon become permanent — dazzling 
 even, in slight use of the eye as in distant vision, exciting severe pains 
 in and around the eye. The asthenopia acquires, more and more, 
 the character of retino ciliary hyperaesthesia. 
 
 Causes of Asthenopia. — Among the causes of asthenopia, he 
 gives the doctrine of Von Graefe. "The overburdening of the mus- 
 cle of accommodation or of the internal recti. Frequently such 
 insufficiences are congenital, or even hereditary — hence affect 
 unproportionally, members of the same family, and unfavorable 
 circumstances almost always occur if the patient strain his eyes 
 too soon. Hypermetropia furnishes by far the greatest number 
 of cases of accommodative asthenopia. Muscular asthenopia 
 
CARL STELLWAG VON CARION, M. D. 37 
 
 principally affects the near sighted, because the near approach of 
 the object and the position of the point of rotation overburdens 
 the converging muscles. This excessive work, imposed on the 
 interna! recti of very short sighted persons, who are employed with 
 small objects, does not always produce muscular asthenopia, because 
 the error of refraction generally increases and the energy of the 
 muscles increases as the tendency to asthenopia diminishes. Later 
 in life, posterior staphyloma increases rapidly. Muscular asthenopia 
 occurs in congenital or developed deficiency of energy of the inter- 
 nal recti. These insufficiencies often occur, under certain circum- 
 stances, in slightly myopic or even emmetropic or hypermetropic 
 persons. Evertion seems to be limited from parallelism; voluntary 
 adduction always remains in excess. If there is insufficiency of 
 one or both internal recti and consequent asthenopia, abduction 
 is favored. At the distance of the ordinary occupations, much 
 stronger prisms can be overcome, when the angle is outward than 
 when it is inward. Even when the distance is greater the abduction 
 still preponderates, so that quite strong prisms can be overcome, 
 when the angle is outward, while even weak ones, with the angle 
 inward, excite unbearable diplopia. A prism of 24°, angle inward, 
 overcomes at ten inches, but with this angle outward 30°, 
 and if the lateral deviation were 80°, there would be only a 
 slight tendency to muscular asthenopia, as the insufficiency is only 
 one third of the abduction. 
 
 "Among the special causes of muscular asthenopia, are sudden 
 and powerful disturbances of the associations existing between the 
 innervation of the muscle of accommodation and the lateral muscles 
 of the eye ball." They will arise with some, who are accustomed 
 to glasses and take them off; or in putting them onto those not 
 accustomed to any. The muscle of adaptation is compelled to 
 exert or relax quite differently, than was formerly required, with 
 equal convergence of the optic axes. The disproportion is not 
 endured and fatigue comes and soon asthenopia. 
 
 "It is a probable supposition and confirmed by careful observation, 
 that insufficiency of the external recti, with asthenopia, may also 
 occur." 
 
 Course and Results.. — Asthenopia is capable of cure. It is 
 especially true of those cases in which it is not so much an actual 
 want of energy, that causes the disease, as an absolute excess of 
 required action, and of those cases in which diseases and the general 
 and local weakness they cause, have diminished the working power 
 of the eye, and so placed the cause of the asthenopia in connection 
 
38 HAZEN'S NEW FINDINGS 
 
 with overburdening. Where a certain deficiency of energy is the 
 cause of the development of asthenopia, the eye never returns to 
 normal duration of function. Throughout life it requires certain 
 helps, which in ordinary occupations, diminish the amount of work 
 to the existing power. 
 
 The translator adds, "that under the belief that in asthenopia 
 there was often a discrepancy between the power of the ciliary 
 muscle and the angle of convergence, it was concluded that there 
 was — 1st. Some disturbance of the relative accommodation. 
 2d. There seems to be a want of tone or power of the ciliary 
 muscle for continued action. 3d. Want of mental energy, the 
 patient having lost confidence in his power to use his eyes. 
 
 He then describes Dr. Dyer's method of discipline, explained 
 in this digest. 
 
The work of J. Soelberg Wells, has figured largely, 
 for a certain period, in Ophthalmology in this country. 
 The clear and easily comprehended expressions of the 
 text is one of the valued remembrances of its use, and 
 the advanced course in the particular subject, which is 
 our present study, is another cause for finding a niche 
 for it in our history. 
 
 1869 
 
 A TREATISE ON THE DISEASES OF THE EYE. 
 
 American Edition. 
 
 J. SOELBERG WELLS. 
 
 Professor of Ophthalmology in Kings' College, London. Ophthal- 
 mologic al Surgeon to King's College Hospital, and Assis- 
 tant Surgeon to the Royal Ophthalmic Hospital, 
 Moors fields. 
 
 ASTHENOPIA. 
 
 Accommodation. — Hypermetropia is a very frequent cause of 
 asthenopia. This accommodative form of asthenopia must be 
 distinguished from the muscular, which depends upon the weakness 
 of the internal recti muscles, and also from the retinal asthenopia. 
 The latter is generally due to hyperesthesia and irritability of the 
 retina, accompanied by hyperemia of the optic nerve and retina." 
 "It mostly occurs in feeble, nervous and excitable persons — espec- 
 ially females." 
 
 Muscular Asthenopia. — This affection is of common occurrence, 
 and is characterized by very marked symptoms of Asthenopia, 
 which sometimes prove so irksome and harassing to the patient as 
 to incapacitate him for reading etc. Such patients complain, that, 
 after they have been working or reading for a certain length of time, 
 the letters become confused and run into or overlap each other. 
 
40 HAZEN'S NEW FINDINGS 
 
 This is generally preceded by a feeling of tension or weight, in the 
 and over the brow, and some patients distinctly feel how the 
 one eye becomes unsteady and wavering, and then moves gradually 
 outward. They also anticipate these symptoms by closing one eye. 
 Alter resting for a short time, reading may be resumed, to be, 
 however, again interrupted by the same train of symptoms. 
 
 He measured the deviation of the lateral muscles, at a distance 
 as well as near, by the use of a prism, with axis vertical, This, 
 he says is a much more delicate test than that of covering one eye 
 with the hand, for it will enable us to detect degrees of deviation 
 of the optic axes, which are too slight to be appreciated by the eye. 
 He gives the dot and line test of Von Graefe. After the presence 
 of insufficiency and its degree have thus been determined, he tests 
 the relative strength of the external recti of each eye, by ascertaining 
 the strongest prism, which it is able to overcome at a distance of 
 from G to 10 feet. He says, "Place prisms of various strength before 
 one eye, turning the base, first outwards in order to find the strong- 
 est, with which a patient sees singly, and this gives the strength 
 of the internal rectus. The external rectus of the same eye is 
 to be tried, and the other eye should be examined in the same man- 
 ner. Insufficiency of the internal recti is most frequently met with 
 in cases of considerable myopia, but a temporary insufficiency of 
 the internal recti may also be produced by severe constitutional 
 diseases, which greatly weaken the system. It may co-exist 
 with hypermetropia, and it should always be suspected if the 
 symptoms of asthenopia persist, in spite of the use of convex lenses. 
 
 "The internal recti may be strengthened by frequent exercises 
 with prisms (whose base is turned outward). The object (a lighted 
 candle, white wand, etc.) is to be placed at a distance of 6 to 8 
 feet and a prism with its base outwards should be held before one 
 eye. Crossed diplopia will be produced, and in order to overcome 
 this the patient will squint inwards. The strength of the prism 
 may be gradually increased but should not be too strong at first, 
 otherwise the internal rectus will be weakened by over-exertion." 
 
 Strabismus. — The nature of strabismus is totally different from 
 that of the paralytic. In the latter, the innervation of one or more 
 of the muscles of the eye ball is impaired; whereas, concomitant 
 squint is due to a change — an increased degree of tension in the 
 muscles in the direction in which the squint occurs, but its inner- 
 vation is normal, as is at once proved by the perfect mobility of 
 the eyeball in this direction, and by the fact that the secondary 
 
J. SOELBERG WELLS 41 
 
 deviation exactly equals the primary, and does not exceed it, as 
 in the case of paralysis. 
 
 Treatment. — As Hypermetropia is the most frequent cause of 
 convergent squint, Myopia is the most frequent cause of divergent 
 squint. He advocated operation, and recommended prismatic 
 lenses to aid the internal recti; correction of hypermetropia with 
 convex lenses, and corrected myopia with concave lenses, and decen- 
 tering of lenses to aid the muscles. 
 
Dr. Noyes of New York was a conspicuous figure in 
 the dissemination of the science of Ophthalmology by 
 his writings, teachings, and clinical work. He added 
 many devices and improvements in instruments and 
 facilities in ophthalmological work — and displayed a 
 genius in systemization and the making of new applica- 
 tions to conditions, which he differentiated in his study 
 of cases. 
 
 1875—1890 
 HENRY D. NOYES, A. M., M. D. 
 
 Professor of Ophthalmology and Otology in Bellevue Hospital Medi- 
 cal College; Executive Surgeon to the New York Eye and Ear In- 
 firmary, etc. 
 
 PAPER IN THE TRANSACTIONS OF THE INTERNATIONAL 
 OPHTHALMOLOGICAL CONGRESS. 1876. 
 
 Asthenopia. — In his analysis of 1079 cases of Ametropia and 
 Muscular weakness with deductions respecting asthenopia, at the 
 Congress, he notices the difficulties of authors in cases of asthenopia, 
 which do not come under the category of Donders' or Graefe's 
 systems, but are thrown out as "apparent" or "false" asthenopia. 
 He uses the "word asthenopia as a generic term and not as being 
 itself a disease." The cases of opacity of the cornea, incipient 
 cataract, posterior synechia, a turbid vitreous or any slight retinal 
 or charoidal affection may cause asthenopic symptoms, but these 
 are placed in their true category. As in Amaurosis, Asthenopia 
 is a generic term. "The word has become current as a general- 
 ization to distinguish those cases in which the use of the eyes causes 
 pain or difficulty, and this when there is no ideopathic inflammation 
 nor any opacity of media." 
 
44 HAZK.VS Xi:\V FINDINGS 
 
 We condense his recital of the symptoms. — 
 
 SYMPTOMS. — 1st. The cardinal symptom is pain, acute or dull, 
 on efforts of use of eyes, near or remote, aggravated by bright 
 light; it may be called by different names; "aching," "a tired feel- 
 in-:." "weariness," "soreness," "inability to look at anything," 
 a horror of print," "acute pain," "dull pain," etc. The seat 
 may be in the eyeballs, supra-orbital or deep in the orbit; in the 
 inner or outer angles, forehead or face, headache; sometimes any 
 movement or fixation of the eyes is painful. Looking at rapidly 
 moving objects, either when passing or riding. The most common 
 occasion of pain is looking at near objects. Pain is produced by 
 moving the eyes across the page, and by looking up or down to 
 extreme lateral positions. 
 
 2d. Next in frequency comes smarting of the eyes as of foreign 
 body under the lids; sometimes lachrymation. To relieve the feel- 
 ing, patients rub or press on the eyeballs and often suppose the 
 slight inflammation to be the cause of distress. Physicians, too 
 often, so regard it, and prescribe without making deeper inquiries. 
 This irritation has been noted by Donders and others. In my 
 practice I find it noted in 158 cases. Under conjunctival irritation 
 is included blepharitis ciliaris, blepharitis angularis, hordeola, 
 cystic tumors and phlyctenule as well as congestion of the pal- 
 pebral or ocular conjunctiva; all these conditions are extremely 
 prone to attend upon asthenopic troubles, which, sometimes, will 
 not yield to any treatment, local or general, until the asthenopic 
 symptoms (causes) are removed. These symptoms should be a 
 sufficient presumption to cause inquiry into the functions of the eye. 
 
 3d. Blur or confusion or indistinctness in reading, writing, 
 etc. Blur or indistinctness characterizes refractive and accommo- 
 dative asthenopia and double vision, muscular asthenopia. 
 
 4th. There is always inability for or discomfort under sustained 
 effort at near objects. 
 
 5th. Headache. In refractive errors — especially in astigmatism, 
 it may be of constant or frequent occurrence and independent of 
 use of the eyes. In other cases, it is caused by near work, and 
 this is the most frequent in the two divisions of asthenopia. There 
 are concurrent signs of congestion of the brain and spinal cord, 
 such as dizziness, a sense of fulness and oppression, slight numbness 
 of the upper extremities, tenderness over the spinous processes, 
 etc. 
 
HENRY D. NOYES, M. D. 45 
 
 6th. A symptom, correlated to headache is nausea; noted in 
 four cases. They were instances of both refractive and muscular 
 errors. 
 
 7th. Intolerance of light varies in every degree. Extreme 
 cases are apt to be adjudged to have acute retinitis and grave vatio- 
 cinations are given. He details several cases of intense photo- 
 phobia. He had had six with twitching of lids, seven facial spasms, 
 and eight vertigo. 
 
 8th. Irregular muscular action in the muscles of the face. 
 Sometimes, the ocular disability was found in ammetropia, and 
 sometimes muscular. The ocular disabilities were relieved but 
 the nervous spasms continued. He had not been able to discover 
 any casual connection between asthenopia and chorea. 
 
 9th. Strabismus convergens, as one of the symptoms of asthen- 
 opia, may be considered illogical, because it is commonly a device 
 in which the painful action is avoided. The hypermetropic, who 
 squints, voluntarily thereby uses his eyes without fatigue, but if 
 he does not squint he speedily becomes tired. He finds seven 
 cases of strabismus convergens with myopia. 
 
 10th. Twice I find it noted that there were attacks of total 
 darkness, lasting but a few minutes. 
 
 11th. Objective examination interiorily, showed, almost as a 
 matter of course, there was hyperemia of the optic nerve and 
 retina. There is a state of the nerve which could be pounced upon 
 by "cebro oscopiats" as evidence of head trouble, unless there are 
 signs of infiltration and swelling and opacity of the nerve, the fact 
 of hyperemia counts for very little. 
 
 12th. The acuity of vision in asthenopia may be perfect or im- 
 perfect: does not exclude refractive error, nor in imperfect vision 
 does not always admit of full correction. 
 
 Etiology. — As to the etiology of asthenopia, he says, old writers 
 dwelt upon the influence of impaired health exerted upon the work- 
 ing powers of the eyes and this must be recognized in some cases 
 as the essential and only cause, but in a great majority of cases, 
 the ill health is but the exciting, and not the essential cause. The 
 controlling cause lies in local disturbances; of these the larger part 
 is refraction and muscular errors; they are found in conjunction; 
 there are cases, however, of pure refraction and also cases of pure 
 muscular trouble; a few paresis of accommodation. Another 
 class of cases is found with irritation of the cervical part of the 
 
46 HAZEN'S NEW FINDINGS 
 
 spinal cord and base of the brain. Another subdivision, the sequel 
 of nasal catarrh. In an immense majority of cases of asthenopia 
 an adequate and intelligent cause can be found. 
 
 I have found hypermetropic astigmatism in small degrees, of 
 importance to correct. 
 
 Muscular. — In muscular trouble, I have been helped out of 
 perplexity by finding small deficiences in the externi or in the 
 movement of the globe in a vertical direction, in maintaining an 
 extreme position; so too, the fact that there is a rotary motion on 
 the horizontal movement, unsteady and jerky. There need be 
 nothing like nastigmus or diplopia and there may or may not be 
 refractive errors. 
 
 Hyperaesthesia. — He believes that a few cases of hyperesthesia 
 of the retina are too often assigned as the primary lesion in undue 
 sensibility of the retina, or the neuralgia of the nerves of sensation 
 are used to cover up imperfect examinations. The correction of 
 small errors is not always attended with happy results. Repose 
 is needful, sometimes entire discontinuance of work for a time. I 
 very rarely give this advice; the moral effect is not good. 
 
 All oculists practice the advice of Dr. Dyer. It takes from one 
 to six months to cure, and very many have been cured by this pro- 
 cess. 
 
 Muscular Asthenopia. — The muscles recti interni are so fre- 
 quently the pair at fault, that the occurrence of weakness on other 
 muscles is liable to be overlooked. 
 
 Next, in order of frequency, come cases in which all the muscles 
 are deficient. Next come the recti externi, and lastly, cases in 
 which the movements of the eyes, up and down, are irregular — 
 excluding nastigmus. 
 
 Tests. — He uses Graefe's test for insufficiency, but prefers a 
 white dot on a black surface to the dot and line. Of late had been 
 taking the power of adduction and abduction at 20 feet, it being 
 more reliable than in the association with accommodation. Among 
 the emmetropic, the muscular power is much below standard and 
 varies as the tone of the general health. 
 
 "It has been my observation that very few persons can get along 
 comfortably with less than 20° adduction for 20 feet distance and 
 4° to 6° abduction. "These cases have been little regarded, 
 because the share which the muscles contribute to the dis- 
 comfort of myopes, has absorbed the ophthalmic attention." 
 
HENRY D. NOYES, M. D. 47 
 
 Association of Accommodative and Muscular Asthenopia. — 
 As a rule, patients with hypermetropia suffer from accommodative 
 asthenopia alone, but the combination with muscular asthenopia 
 is not impossible. The addition of a glass to the eye changes the 
 muscular equilibrium and usually developes a higher degree of 
 insufficiency than without glass, but the inaptitude may soon dis- 
 appear." 
 
 Spasm of Accommodation. — He gives a series of cases of spasm of 
 accommodation, provoked by weakness of the interni, associated 
 with Myopia and Astigmatism. He also gives a number of cases, 
 whose external recti are at fault, with asthenopia with no converg- 
 ing strabismus; some with pain, some intolerance of light, others 
 conjunctivitis. He found a few cases where the failure of equilib- 
 rium was from verticals. His means of diagnosis was not that 
 which we have. He reports a large number of cases where all the 
 muscles were enfeebled. Half were emmetropic. Fixation and 
 movement showed tremor, and they exhibited the symptoms of 
 asthenopia in an exquisite degree. Some had a horror of looking 
 at objects, and mind especially morbid. Some were emmetropic; 
 some had equilibrium. 
 
 Dr. Noyes finds, that out of 227 cases of muscular asthenopia 
 172 were of the recti interni; 24 of all the muscles; 16 of recti externi; 
 15 of oblique, supra and infra. 
 
 There was insufficiency of recti interni with 60 of E.; 30 of H.; 56 
 of M.; and 26 of astigmatism. 
 
 TREATISE ON THE DISEASES OF THE EYE (WOOD'S 
 LIBRARY). 1881. 
 
 A TEXT BOOK ON THE DISEASES OF THE EYE. 1890. 
 
 Asthenopia. — In Dr. Noyes' "Diseases of the Eye" — Woods' 
 Library Edition (18S1) he uses the word asthenopia, but he does 
 not head a chapter with it or make it a distinct disease, and the 
 word does not appear under Accommodation, but it is made promi- 
 nent in his later work, "Diseases of the Eye" (1890) where he devotes 
 20 pages to it, in two of which Accommodative Asthenopia is des- 
 cribed, and in the subject of refraction it is mentioned, and not 
 many of the symptoms are ascribed to the ciliary muscle. 
 
 Causes. — Among the causes of asthenopia, he says, "refractive 
 errors — especially myopia which inclines to weakness of adduction, 
 and hyperopia which inclines to weakness of abduction, and astig- 
 
48 HAZEN'S NEW FINDINGS 
 
 autism, arc frequent and obvious causes. There may, however, 
 be small errors, too trifling to account for the asthenopia, and the 
 persons enjoy good health and good use of eyes until, without 
 explanation, an acute breakdown occurs. "The person may be 
 ot exceptional vigor, and not have attempted more eye work than 
 may be justly called reasonable, yet have severe pain in the eyes 
 and head, sometimes vertigo and a sense of oppression and much 
 ocular irritation." "The refractive error may be very small, and 
 the only statement to be made is, that certain muscles, say the 
 externi or the interni, are intrinsically weak. Frequently, operative 
 causes are, depreciation of general health by chronic or acute 
 diseases, pressure on the nerve twigs by inflammation, or thicken- 
 ing of their sheath, by growths, by injuries, or by congenital dis- 
 orders; heredity is not infrequent. Overtaxation of the eyes is 
 the important factor, and is brought about by reading on railway 
 trains and in carriages; by reading when lying down, which con- 
 valescents and chronic invalids often find out too late, they should 
 not do, by attempting difficult work, such as embroidery, sewing 
 on black, fine painting, decoration of china, etc.; bending over work 
 and bringing it too near the eyes; by the study of languages whose 
 text is intricate, such as Greek, German, Hebrew, etc. Want 
 of vigor, whether from congenital conditions of health; by too rapid 
 growth, by malaria, by any debilitating causes, by shock, grief, 
 etc. — all are to be duly considered — especially too, all forms of 
 uterine diseases, hemorrhage, fevers, chronic anaemia, instigate 
 muscular asthenopia. It will often happen that the depressing 
 agencies mentioned are simply exciting causes of a disorder, whose 
 real progenitor is an essential muscular weakness, which may long 
 have been latent, but is now made potential." 
 
 Muscular Insufficiency. — "It is important to make a dis- 
 tinction in cases of muscular insufficiency and those which are 
 purely local, and those in which the defect is associated with gen- 
 eral ill health. Symptoms of eye trouble may be simply the effect 
 of remote disorders, on the other hand, eye defects can excite 
 remote reflex troubles, and these quite disappear when the eye 
 defects are corrected." 
 
 Under Muscular Asthenopia, he details most of the symptoms 
 that are so graphically described by some writers, under eye strain. 
 
 "Cases of apparent congestion of the base of the brain, and 
 
 enderness over the middle and upper cervical vertebrae." To 
 
 the previous enumeration of symptoms in the report at the Congress, 
 
 he mentions the relief obtained by pressing the eye balls. Pain 
 
HENRY D. NO YES, M. D. 49 
 
 in using or fixing the eyes is the conspicuous symptom. This 
 appears in all kinds of near work, reading, writing, etc.; it may 
 also exist in distant vision, in looking at a crowd, or at a stage in 
 a theater, looking out of a carriage or from the window of a railway 
 car, etc. There may be great photophobia. Pain is generally 
 in the eyeball, but is often temporal, frontal, occipital or at vertex. 
 In truth, not a small percentage of obstinate headaches, "especially 
 ache on first awaking from sleep in the morning." Dizziness, and 
 when the general health is feeble, or the subject neurotic; we may 
 have the most erratic and intense remote symptoms; aphonia, 
 palpitation of the heart, pain in the ovaries, diarrhoea, rectal irri- 
 tation, etc. He here speaks cautiously of the hysteria, chorea, 
 epilepsy and says, "I cannot deny that, in a few cases, eye strain 
 may have been demonstrated to be an exciting cause or occasion, 
 but there has been behind it a deep lesion of the general nerve 
 system. " 
 
 Spasms of Accommodation. — Under Spasms of Accommodation, 
 (Wood's Library Edition 5) " It will very likely be found that the 
 extrinsic muscles of the eye are also weak, they belong in the same 
 reduced state as the ciliary muscle." "Moreover, the supposition 
 of spasm is not to be excluded because of general debility. It 
 also appears, together with other spasmodic afflictions, such as 
 blepharospasm and nastigmus and again in cases of hyperesthesia 
 retinae." 
 
 "Spasms of Accommodation accompany many functional and 
 refractive disorders of the eye." "It is the immediate cause of 
 the discomfort of the great body of workers upon small objects, 
 who complain of eye troubles." "In my view, many cases of Mus- 
 cular Asthenopia are not evidences so much of the defective power 
 of certain muscles, as of continued and excessive action or spasms 
 of opposing and dominating muscles. Only in this view, can many 
 cases of recovery by spasms and by slight tenotomies, be accounted 
 for." 
 
 Objective Symptoms. — Under Objective Symptoms, after 
 observation of the manner in which eyes behave under the test, 
 with card first over one, then over the other eye, as to tremulousness 
 and deviation from the median line, and carrying the object 
 looked at close to the nose, and also their behavior in extreme 
 positions to the right and to the left, and pronouncing these tests 
 only suggestive, he begins with the real examination, correction of 
 the refractive errors, visual acuity." Next the muscular conditions. 
 
50 HAZEN'S NEW FINDINGS 
 
 Regarding a candle flame at 6 meters with prisms, he makes the re- 
 mark, "that it is decidedly preferable to take the muscular condi- 
 tions at this remote point." Experience proves that the moderate 
 rees of Ametropia do not interfere with muscular tests. Begin- 
 ing with abduction, he uses a battery of a series of square prisms, 
 one above the other, with interval of 2°, one series with odd 
 numbers and another with even numbers, 9 in each (prefer- 
 ring this to the revolving double prism as more reliable and less 
 misleading) to ascertain capacity of the muscles. Besides this, 
 'or one eye, one may hold in the other hand a 5° interval, over 
 each eye for adduction, and when this is exhausted, place 10° 
 over each eye in spectacle frames and proceed with the bat- 
 teries in front of them; can thus attain to 62°. 
 
 The strongest prism which can be overcome, that is despite of 
 which the flame appears single, measures the duction of that pair. 
 Less than 5° abduction is pathological. Adduction is made by 
 reversing the base outward, being careful to avoid obliquity. 
 Adduction should reach 25° to 50°, but the physiological limit 
 is not well defined. More than one examination is necessary to 
 decide what may be the patient's capacity. Next put before 
 one eye a 5° or a 10° prism base [axis] vertical. Two flames 
 appear, which ought to be perpendicular to each other. When 
 prism is over L. E. w 7 ith base upward, the lower image corresponds 
 to L. E. If this appears to the left of the other as well as below, 
 the condition indicates homonymous diplopia and weakness of 
 abduction or of the interni. If the lower image goes to the patient's 
 right, this means weakness of adduction or of the interni. The 
 prism placed so as to bring the images into a vertical line measures 
 the displacement, which Von Graefe called the insufficiency of the 
 muscles, whether of the externi or interni. This phrase has ac- 
 quired this technical meaning and is, to some extent, misleading 
 
 He gives place to Dr. Stevens' terms in muscular anomalies. 
 He had not found any absolute standard for adduction and ab- 
 duction, nevertheless, a certain ratio must not be exceeded; and for 
 distance for adduction 36° to 42°, abduction, 60° or adduction 40° 
 to 45°, and abduction 70° which is about 6 to 1. For near 13 
 inches, adduction 40° and abduction 20° suffices for comfort. 
 
 Examination at working distance. Instead of Von Graefe's 
 dot and line test, he uses a white dot on a black surface placed on a 
 carrier on a central stem. Near the eye is a box containing three 
 cells before each eye, into which square lenses can be dropped, 
 which is more convenient than the trial frame. Sometimes a patient 
 
HENRY D. NOYES, M. D. 51 
 
 cannot put forth his real energy when looking into an apparatus. 
 Let him make a few trials without — holding the prisms in one hand 
 and the test card in the other. Beginning with Von Grade's equil- 
 ibrium test, place a 10° with base (axis) vertical. Jf images do 
 not stand vertically above one another, there is deviation in the 
 sense of abduction. When about 5° only, this cannot be called 
 abnormal, and directs suspicion upon the externi. Next try 
 the abduction and the adduction suitably placed. Great 
 diversities will appear, according to conditions of refraction; espec- 
 ially will weakness of adduction appear with myopia. On the 
 other hand, abduction will more frequently be found in emmetro- 
 pia hypermetropia, and astigmatism. Spasms of accommodation 
 may be detected by slipping into the holder a 5° prism combined 
 with a plus 3. D. base inward before each eye ; placing Xo. 1 
 Snellen at 13 inches; if not read by emmetropes until it approaches 
 to 9 inches, spasm may be inferred. With myopes, spasm sum- 
 cent to vitiate the test is not common, while w r ith other ametropes 
 proper corrections will be made. 
 
 A small number of cases exhibit symptoms of muscular asthenopia, 
 which do not betray any notable fault of the externi or the interni, 
 nor, if there be errors of refraction does its correction remove the 
 symptoms. In such, search for errors in action of the muscles, 
 which move the globe up and down. With correction of refraction 
 on, light at 20 feet, use a prism base inward of 10° or 15° (be 
 careful that the axis is perfectly horizontal) If the two images 
 are not on a horizontal line, inquire which is the higher. The 
 images are homonymous images because the visual lines are rela- 
 tively convergent, and if the left is above the other the fault is in 
 the L. E. and vice versa. If there is no vertical error, try what power 
 the patient possesses for overcoming prisms with vertical axes. 
 Begin with one degree and go up until the limit is reached. I have 
 found them able to overcome 3° to 8° with no apparent de- 
 viation of visual lines. If a prism of 3°, with the base up be- 
 fore the eye, is easily overcome, it should cause very wide dip- 
 lopia if its base is reversed; by thus testing each eye, we may 
 succeed in determining which is at fau.t. For persons, who do not 
 habitually and invariably practice binocular vision, as in some 
 myopes and in cases of great anisometropia, etc.; this fault of ver- 
 tical displacement of one visual axis, is exceedingly common, and 
 does not occasion asthenopic symptoms. For them it is difficult to 
 recognize double images, and if they do catch them, it may be only 
 for an instant, even when they are brought into close contiguity. 
 When the candle flame is seen obliquely, it indicates a fault with 
 
52 HAZEN'S NEW FINDINGS 
 
 one of the oblique muscles. We have six general muscular weak- 
 nesses for all distances. 
 
 \Yc have symptoms of muscular asthenopia most frequently 
 in cases where muscular groups are not properly balanced or pro- 
 portioned. We may also have it when there is debility of the whole 
 muscular apparatus without special disproportion among the oppos- 
 ing groups. It is not, however, an invariable rule, that general 
 weakness of the eye muscles, of necessity,causes asthenopia. A 
 large margin must be allowed for what may be called nervous 
 excitability or activity. Those of quick, eager and vivid per- 
 ceptions, whose mental processes are always lively and ready, 
 are the persons most liable to complain. The torpid or deliberate 
 persons are less often sufferers from muscular asthenopia. The 
 young often suffer from this trouble. 
 
Dr. Landolt of Paris, France has figured largely in 
 contributions to American Ophthalmic literature during 
 the last decade. He comes nearer to the views of Dr. 
 Noyes of New York than other authors on the subject, 
 in his conception of the relation of the focal apparatus 
 and the motor apparatus, but did not reach Dr. Noyes' 
 practical treatment of the muscular anomalies, which 
 he found so abundant. 
 
 1886. 
 
 E. LANDOLT, M. D., PARIS, FRANCE. 
 
 THE REFRACTION AND ACCOMMODATION OF THE EYE. 
 
 Translated by 
 
 C. M. CULVER, M. A., M. D. 
 
 1900. 
 
 E. LANDOLT, M. D., PARIS, FRANCE. 
 
 ANOMALIES OF THE MOTOR APPARATUS OF THE EYE. 
 IN SYSTEM OF THE DISEASES OF THE EYE. VOL. IV. 
 
 Translated by 
 
 C. M. CULVER, M. A., M. D. 
 
 Ophthalmic Surgeon to the Albany Orphan Asylum, Albany , N. Y. 
 
 REFRACTION AND ACCOMMODATION. 
 
 He explains the effect of glasses on accommodation and conver- 
 gence as follows: 
 
 Convex glasses modify the relations between accommodation 
 and convergence. A sudden exclusion of accommodation in order 
 to fix the near object binocularly, he is obliged to make a consider- 
 
54 HAZEN'S NEW FINDINGS 
 
 able effort at convergence, while the accommodation must be totally 
 released. At first the object is seen with crossed diplopia, because 
 "the sudden exclusion of the accommodation disposes the eyes 
 to assume a parallel direction, or at least renders convergence 
 difficult." "They diverge therefore, relatively to the position 
 of the object. Even when one has succeeded in uniting the double 
 images, a certain disagreeable feeling often persists in the forehead 
 and eyes and proves that the latter perform only with difficult}', 
 this unusual and anti-physiological function." 
 
 Now' since the elasticity of the crystalline lens is diminished 
 throughout life, the accommodative effort ought to increase pro- 
 portionally, in order to produce the same number of dioptries, 
 and, inasmuch as the amplitude of convergence, essentially depend- 
 ent upon the strength of the muscles, does not diminish with the 
 accommodation, but remains nearly stationary, the individual is 
 forced to vary, in a physiological state, the effort of accommodation, 
 which he associates with a given effort of convergence. "The 3 
 dioptries of accommodation, which an emmetrope must have, 
 when fixing an object 33 C. M. distant, will require from him a 
 much greater muscular effort at the age of forty than at the age 
 of twenty years, while the effort of convergence will remain the 
 same — 3 meter angles. The difference is still more perceptible 
 in the cases of hyperopes, especially of the medium or high degree; 
 in the defect, static refraction of itself, determines a branch of the 
 equilibrium between the two functions." "Convex glasses render 
 inestimable service by relieving the accommodative muscle of a 
 quota of its work by establishing between convergence and accom- 
 modation the relation most agreeable to the individual. Convex 
 lenses can also exercise a direct influence upon convergence, by 
 regarding them as two prisms with their bases joined. "An eye 
 looking through a convex glass will see objects in their real position, 
 only when looking along the axis of the lens, while they will appear 
 displaced along the periphery of the glass on the side "through 
 which the eye looks, when its gaze is directed away from the center, 
 and they will appear displaced toward the periphery of the glass 
 exactly as if they were seen through a prism." With a pair of specta- 
 cles for distance, when they look through the center, the object 
 is not deflected, but if used for near visions the prismatic action is 
 apparent, for on converging the eyes, the eyes look through a por- 
 tion of the lens to the apices toward the nose and, in order to see 
 without diplopia, the prism effect has to be overcome by an extra 
 effort, and if the muscles are somewhat weak, it makes itself felt 
 
E. LANDOLT, M. D. 55 
 
 even in lower numbers. "From four dioptrics on, their influence 
 on convergence ought never to he disregarded." In afakia the 
 trouble is common. We must confess that our knowledge, as re- 
 gards muscular asthenopia, and insufficiency of convergence is 
 still in its infancy. The observation of the results of operations 
 with a view to cure it, have been neither numerous nor in accord 
 with each other. 
 
 Insufficiency. — "Insufficiency of the power of convereence is 
 quite a wide spread affection and a frequent cause of asthenopia. 
 It is not by any means peculiar to myopes only, even if they do, 
 from necessity, at a near point, suffer more from it than others, 
 and are, on account of the conformation of the eyes, more inclined 
 to it." He distinguishes two forms — 1st. "Muscular asthenopia 
 in the true sense of the word, depending upon the absolute or rota- 
 tive weakness of the adduction or upon their insertion." "The 
 second has its origin in the central organ, and depends upon a dis- 
 turbance of the innervation or upon the weakness .of the power 
 of fusion." "The excursions of the eyes, the monocular fields 
 of fixation and the associated movements, may, with all this, be 
 quite normal, while the amplitude of convergence is much reduced, 
 even, at times, equal to zero. With a negative convergence or di- 
 vergence, where spontaneous binocular vision does not exist, vision 
 at a near point" can only be accomplished with the aid of abduct- 
 ing prisms. In all cases where the positive convergence does not 
 reach nine meter angles, asthenopic troubles may develop, when 
 the eyes are not used for near vision. The ideal correction would be 
 realized by a lens large enough, that its periphery would reach 
 over both eyes, or better, by cutting out the periphery, which 
 would thus impinge over each eye for insertion into spectacles. 
 The prismatic effect of spherical glasses also affects the vertical 
 meridians — the position as to the base line is important. 
 
 Just as in the case of convex lenses, concave ones act as prisms 
 if one does not look through their optical center. The lens being 
 thinner in the center than at the periphery, the prism effect is opposite 
 to that of the convex lenses. The prism effect, when the lines of 
 fixation pass externally to the axes, will increase the effect of con- 
 vergence (adducting prisms) the object being deflected outward, 
 and the eye in correcting it, converges to get the image on the fovea 
 centralis. On the other hand, when the eyes look through the inner 
 halves of concave glasses, the latter will act like prisms with apices 
 
56 HAZEN'S NEW FINDINGS 
 
 turned toward the temples. Thus it is that the prismatic effect 
 of concave lenses, by decentcring, may render real service. 
 
 When the insufficiency of convergence has resisted hygienic 
 measures, general strengthening treatment aids in gaining repose of 
 the eyes, and when it is too great to be corrected by optical means, 
 we may think of remedying it in a surgical way. 
 
 For paresis of accommodation, there is constitutional treatment, 
 electricity, and the fitting of lenses. 
 
 Treatment. — Orthoptic training consists in the use of a "Wheat- 
 stone's Stereoscope." Upon the resistance of these methods, 
 tenotomy of both external recti, advancement of the interni, or 
 even a combination of both these operations is explained. In cases 
 of "neurasthenic insufficiency," when amplitude of convergence 
 is very narrow," we ought to be guarded in operating as well as 
 in making our prognosis." An exercise is given in which the patient 
 is seated, at least 5 meters from a lighted candle and directed to 
 turn the head to the point, w r here there is a tendency of the lights 
 to separate and he is directed to keep them fused. "The patient 
 will, in this way, succeed in extending the domain of single binoc- 
 ular vision" after some weeks or months. Prisms may have to be 
 resorted to. 
 
 "When insufficiency of the adductors has given way to a true 
 divergent strabismus, and when the latter is still periodic, it may 
 sometimes be remedied by prismatic and concave glasses, but such 
 cases are very rare. The divergent strabismus which we meet 
 with in practice has ,long since, far exceeded the degrees that are 
 corrigible by optical means,." The surgical treatment is indeed, 
 the only efficacious one in high degrees of insufficiency of conver- 
 gence, and with all the more reason, in divergent strabismus. 
 
 ANOMALIES OF THE MOTOR APPARATUS OF THE EYE, 
 IN SYSTEM OF DISEASES OF THE EYE. 
 
 After consideration of the ocular muscles, one by one, with 
 reference to the movements of the globe and the phenomena which 
 result from the paralysis of these muscles, he devotes a section to 
 -i Xon-paralytic Strabismus." 
 
 A correct notion of the ocular movements "will be had by con- 
 sidering all the muscles, as together forming one motor apparatus." 
 It can be seen that "each movement, given to the eye, encounters 
 an opposite regulating movement." "There is no direction that the 
 
E. LANDOLT, M. D. 57 
 
 eye cannot easily take, and in which it cannot remain without 
 fatigue." The mechanism is more marvelous, "when combined 
 movements of the two eyes are considered." Binocular vision 
 requires that the two eyes be directed simultaneously toward the 
 object looked at, so that it may fall on the fovea centralis of each 
 eye, when the objects are fused into a single one. The impression 
 is thus made vivid and a certain impression of distance and relief 
 is given to it. The eyes diverge in a state of rest, but without an 
 appreciable difference in height. Convergence is not an act among 
 the lower mammals. When both eyes are not simultaneously 
 directed toward the point to which the possessor directs his atten- 
 tion, strabismus is present. It is association between accommoda- 
 tion and convergence which can impress a proper direction upon 
 an eye which is not fixing. If this association is not present the 
 eye deviates, but will not, however, abandon the level of its fellow. 
 Now, paralytic strabismus, sursum or dorsum vergins, is very rare, 
 and never attains a degree comparable to that with which one 
 usually meets in lateral strabismus. Unless muscular paralysis 
 be present, one eye never moves alone but the second eye takes an 
 active part in the motion and there is no divergence of one eye, as 
 in paralysis of the internal rectus or convergence of one eye, as in 
 paralysis of the abducens but there is divergence or convergence 
 between the two eyes in the same degree. One eye fixes and the 
 other eye takes position out of line, and this gives the appearance 
 of a monocular deviation. The expression correctly made, would 
 be — "the eyes diverge or converge — the right eye performing the 
 fixation." 
 
 Strabismus. — "Strabismus is not always manifest. In its 
 early stages especially, it sometimes remains latent, and shows 
 itself under conditions of fatigue of the eyes or body; under influen- 
 ces of emotion or when binocular vision is suppressed by the exclu- 
 sion of one eye." "When the vision of each eye is good, strabismus 
 often passes from one eye to the other," the eyes alternating in 
 fixing and yet do not see double. Generally, by using red glass 
 over one eye, the patient can be made to see two images. By 
 provoking diplopia in the vertical meridian by means of a prism 
 (base down) he may be made to see two images, but it may be 
 difficult for him to determine whether they are homonymous or 
 crossed. In paralysis this is not the case. "The image of the 
 deviating eye is sometimes systematically disregarded by the 
 visual center." One can discipline himself into the same analogous 
 condition, as in the use of the ophthalmoscope or microscope — 
 
58 HAZEN'S NEW FINDINGS 
 
 having both eyes open in the use of these instruments, and ignoring 
 the image received by the eye to which he is directing his attention. 
 This phenomena is called, "suppression or exclusion" of the ims 
 of the deviating eye. 
 
 REGIONAL EXCLUSION. — There is such a thing as regional exclu- 
 sion — a part of the retina only in which there is suppression, and 
 by imposing a prism of double vision, it can be provoked and can 
 then be measured. In the horizontal direction stronger prisms are 
 required than in the vertical direction, to accomplish this. The 
 entire retina may have exclusion over its whole surface and this is 
 total exclusion. 
 
 Not rarely, a kind of new indentity between the two retince is 
 established. The part of the retinae of the affected eye, which 
 receives the image of the object, assumes the function of the macula 
 and the visual impression is fused with that of the healthy eye. 
 Weak prisms suffice to produce diplopia in these cases even when 
 prisms or mirrors are placed to throw the image on the mascula 
 of the deviating eye, double images are produced. 
 
 The long duration of strabismus is the cause of the change in the 
 correspondence of the retina, and after correction of the strabismus, 
 the diplopia produced by the change, through operation, almost 
 always disappears. The stereoscopic effect may be restored if 
 the patient will patiently carry out the necessary exercises. 
 
 NON-PARALYTIC DIVERGENT STRABISMUS. 
 
 After describing the different etiologies, held by authors in 
 regard to Convergent Squint, Landolt says, "Examination of the 
 field of fixation has taught us the fact, already pointed out by Don- 
 ders, that the temporal excursion of both eyes is almost always 
 restricted in convergent strabismus. "This defect in motility, 
 which is often not very pronounced in recent cases, is the rule for 
 cases of long standing. It is always found in both eyes, and often 
 in the same degree. Frequently, it is more developed in the devi- 
 ating one than in the fixing one." "Those who are given to the 
 performance of muscular advancement, have abundant occasion 
 to verify the weakness of the external recti muscles in cases of con- 
 vergent strabismus. These muscles are thin and flabby, especially 
 in comparison with their antagonists." We have to inquire whether 
 it is primary or secondary. It seems to us that this defective 
 development of the abductors is due to a lack of use. The excur- 
 
E. LANDOLT, M. D. 59 
 
 sions of the eyes, before we change directions of our faces, are in 
 R. or L., 3° or 4° — elevation 3°, lowering 5°. This shows that no 
 demand is made at all comparable with that made on the internal 
 recti in convergence. 
 
 Causes of Malformation*. — Enumerating causes of malfor- 
 mation as local changes in the muscle, (congenital weakness, vici 
 insertion, anatomical shortening) spasms due to Keratitis, which 
 many authors consider the cause of convergent as well as divergent 
 strabismus, Landolt thinks has been exaggerated, but does not 
 deny the possibiltiy of such malformations, yet why should the 
 ocular muscles be exempt from the infirmities, which are met with 
 in all the other muscles of the human body: 
 
 After reviewing the different authors as to the cause of the devia- 
 tion in convergent strabismus, he expresses it thus, "By contract- 
 ing too much, the internal recti have become unable to relax en- 
 tirely, or exaggerated convergence becomes habitual." Thus, 
 on account of secondary anatomical changes, muscles, which at 
 the outset were normal, become altered in their functions. 
 "Nothing, " he says, "is more difficult than to determine the posi- 
 tion of minimum innervation of the ocular muscles." "It would be 
 of no great advantage if we could." It is the consequence of the 
 influence of a number of factors, which act upon the relative di- 
 rection of the eyes." 
 
 "The inanity of the muscular theory of squint having been 
 shown long ago, one hears it said, upon different sides, that it has 
 been replaced by a new theory, "the central or nervous theory." 
 These words have no significance of themselves. Donders' theory 
 of the intimate relation of convergence and accommodation, in 
 their connection, in the central nervous system, where the fusion 
 of the two muscular impressions takes place, in the sensation of 
 binocular vision, has the great merit of its explanation here." In 
 the light of more recent physiology, he says, "the attempts to 
 localize strabismus in the central organ, do not mean that it is to 
 be considered as a cerebral affection, although, in some general 
 diseases, there are changes in the centers of innervation. If one 
 squints toward the nose without being the victim of paralysis of 
 the abductors, it is because his abductors are not held in equilibrium 
 by these muscles — because the former contract too much — the latter 
 too little, and since they contract only under the influence of a 
 nervous impulse, it is evident, there must be an absolute or relative 
 excess of the innervation for convergence. If'hy, the center of 
 
60 HAZEN'S NEW FINDINGS 
 
 convergence shows itself so exuberant in convergent strabismus, 
 and why, in divergent, the center fails to do its duty, is to be ex- 
 plained. "Donders answers this question satisfactorily in the 
 immense majority of cases of strabismus" — mentioning the occa- 
 sional cause of its development, he discusses fixation at the near 
 point, when they sometimes accidently discover that they can 
 secure distinctness of vision by sacraficing the use of one eye. 
 He gives instances of persons curing themselves of strabismus by 
 acting on the contrary muscles through the will. 
 
 Hyperopic, convergent strabismus, generally commences by 
 being periodic or alternating. It is often, at the outset, also rela- 
 tive — localizes itself in one eye, generally the weaker one. 
 
 Landolt's Treatment of Convergent Strabismus. 
 
 "When due to defects of refraction, which necessitates an exaggera- 
 ted effort of accommodation. Conner's glasses are indicated and 
 mydriatics. The necessity of correcting the vision of the inferior 
 eye by correcting the astigmatism and restoring it to visual power 
 by exercising it, and still more important are the exercises, which 
 bring into action both eyes simultaneously for the purpose of stim- 
 ulating or re-establishing binocular vision. The principal cause of 
 strabismus and the greatest obstacle to its cure, being the absence 
 of binocular vision — it is evident that anything, which tends to 
 re-establish the fusion of the retinal impression of the two eyes, 
 constitutes a valuable therapeutic agent in the treatment of the 
 infirmity. To secure relaxation of accommodation, it is necessary 
 to have recourse to Mydriatics. He advocates the use of Javal's 
 stereoscope in the fusion of images for the cure of strabismus. 
 
 Surgical Treatment of Convergent Strabismus. 
 
 He advocates advancement instead of tenotomy. It is best to 
 continue orthoptric treatment for a long time. The most perfect 
 surgical correction is not always sufficient, even if the vision is good 
 in both eyes. The eyes have forgotten — if they have ever learned — 
 to fuse the impression of their foveas. 
 
 In divergent strabismus, the false image is carried toward the 
 temple — homonymous — and treatment is required for this, after 
 operation. 
 
E. LANDOLT, M. U. 61 
 
 NON-PARALYTIC DIVERGENT STRABISMUS. 
 
 As a rule, the eyes diverge in complete repose considering the 
 divergence of the orbits. The function of convergence is only 
 found in the higher order of vertebrates, diverging the more as 
 we descend in the examination until we find in fishes that they are 
 90° to each other. "Convergence in man is so intimately 
 associated with accommodation, that, under normal circum- 
 stances, an effort of accommodation suffices to provoke a conver- 
 gent movement." Without either of these, divergence almost 
 invariably takes place, and this explains why, an amblyopic eye 
 deviates toward the temple, and why myopes, who exercise their 
 accommodation much less than emmetropes, and hyperopes, fur- 
 nish the large majority of divergent strabismus. The ellipsoidal 
 form of the myopic, favors this position. In high degrees of myo- 
 pia, from the necessity of bringing the object so close they are apt 
 to give up convergence, and allow the eye, not used, to diverge. 
 Binocular vision is not developed and the visual impression is sup- 
 pressed in the eye, not fixing, in order not to be troubled with 
 double vision. Divergence is mostly absolute, existing for all 
 directions of the gaze. This condition very often occurs in cases of 
 myopia of less degree. The alteration of accommodation and 
 convergence undergoes considerable change from that in emmetro- 
 pia. He sees without any effort at accommodation, at a distance 
 for which he is obliged to use a great amount of convergence. There 
 exists an insufficiency of convergence. Up to 5. D. of myopia, 
 the independence of convergence relatively to accommodation, 
 can be estimated, if the amplitude of convergence is sufficiently 
 developed for binocular clear vision. If there be added to defec- 
 tive development, enfeebled motor muscles, from debilitating 
 illness, the individual will only too promptly abandon convergence, 
 and let the inferior eye turn out. "Thus we see that typical con- 
 vergent strabismus — that of Hyperopes — is an active — a spastic 
 strabismus." "Divergent strabismus is an essentially passive 
 strabismus, due to a relaxitive or a lack of development of conver- 
 gence." 
 
 "Although myopia, for the reasons stated, furnishes the largest 
 proportion of divergent squint, yet it is also found in other states 
 of refraction." Any cause which abolishes binocular vision pre- 
 disposes to strabismus. Divergence is found in the position of re- 
 pose. "It is for this reason that divergence is the rule in monoc- 
 ular amblyopia or amaurosis." Fixing with the best eye, the devia- 
 tion manifests itself in the amblyopic one. "Divergent strabismus 
 
62 HAZEN'S NEW FINDINGS 
 
 is a binocular strabismus, just as is convergent strabismus." "In 
 the same way, as the examination of the field of fixation denotes, 
 in convergent strabismus of long standing, a limitation of the 
 temporal excursions of both eyes, so the excursions toward the 
 nasal side are always found limited in both eyes, although only 
 one, and always the same one, is the victim of divergent strabismus." 
 
 "This defect in motility is, in both cases, and in the majority 
 of instances, not the cause but the consequence of strabismus." 
 In divergent strabismus, it is due to a lack of use of the abductor 
 muscles, for which convergence contributes an exercise much more 
 powerful than do the associated lateral movements. Considering 
 that "there is nothing absolute in the relations between accommoda- 
 tion and convergence," "one cannot admit a single center of inner- 
 vation as ruling them simultaneously." "This independence of re- 
 lation is shown by the fact that the amplitude of accommodation 
 gradually diminishes, as age advances, until it becomes nil, while 
 convergence remains almost invariable during the whole lifetime — 
 hence the relations between the two functions must be continually 
 modified, otherwise binocular and distinct vision would not be 
 possible, even for emmetropic eyes." "The individual must learn 
 how to associate the same degree of convergence with a greater 
 and greater (less and less) degree of accommodation." 
 
 As long as the emmetrope fuses well the visual impressions of 
 his two eyes, accommodation causes him to converge so correctly 
 that he directs even the eye that has been excluded from vision, 
 toward the object fixed by the other, but if he loses the sight of one 
 of the eyes, he learns equally well to abandon the effort of conver- 
 gence," and as the insufficiency is no more troublesome than when 
 he had double vision, it is natural that convergence should be almost 
 entirely lost. It may equally happen with hyperopes, which 
 augments convergence in order to facilitate accommodation. "Not 
 all, however, have convergent strabismus. Some of them, deprived 
 of binocular vision, squint outward and furnish a certain con- 
 tingent of (5 per cent) of divergent strabismus." "As in conver- 
 gent strabismus, local circumstances have been given as a cause; 
 vicious insertion, a defective development, an insufficient power 
 of the abductor muscles or the excessive separation of the orbits, 
 and smallness of the angula gamma." 
 
 Stilling and others say, "certain eyes ought to be predisposed to 
 divergent strabismus by their position of equilibrium, which in 
 this case is divergence." "Another theory holds that it is a pr-i- 
 
E. LANDOLT, M. D. 63 
 
 mary lesion of the centers controlling the symmetrical movements 
 of the eyes." 
 
 Concomitant divergent strabismus, which it is necessary to dis- 
 tinguish from paralytic strabismus — The first is equality of the 
 conjugate movements of the eyes, and the gradual development of 
 the deviation, etc. There is a well defined diplopia increasing 
 in one direction and diminishing in the other, leaving no doubt 
 of paralysis. This diplopia is the most striking symptom of para- 
 lytic strabismus, but in it there may be amblyopia in one eye ? 
 which excludes diplopia and the certainty of diagnosis is made by 
 other symptoms. In this concomitant divergent strabismus, 
 the divergence manifests itself only under certain circumstances 
 ("relative"). On looking into infinity the eyes may be in equilib- 
 rium and they may follow the object as it is brought nearer, but 
 at a certain point they stop converging, the eyes waver and if 
 brought still closer, one eye diverges, and double vision is the con- 
 sequence, although the patient may describe it as confusion. The 
 beginning of divergence or insufficiency may be accompanied 
 with asthenopia, headache, vertigo and visual disturbances. This 
 initial stage of divergent strabismus may endure for months or 
 years. In myopia of high degree, especially with amblyopia 
 in one eye, the relation becomes absolute strabismus. 
 
 INSUFFICIENCY OF CONVERGENCE. 
 
 There has been a recognition of asthenopia caused by insuffi- 
 ciency of the interni, but Krenchel in 1S73 clearly established that 
 convergence must be considered a function by itself, which can be 
 altered without lesion of the muscles which produce it. He and 
 others gave support to it so that insufficiency of convergence is 
 now considered as a well defined entity. 
 
 Landolt here defines, "convergence as the faculty of directing 
 the two eyes toward the object of fixation, whether the object be 
 situated at a definite distance or infinite, or even beyond infinity" — 
 that is to say, whether its fixation requires actual convergence, 
 parallelism or divergence." He describes the system of Nagel 
 of the meter angle. He has a method of representation of maxi- 
 mum and minimum, both positive and negative. See figure. Eyes 
 can diverge one meter angle — about 3.5°, or 3.5 centimeters. 
 The negative convergence is above the zero line, and the positive 
 below the line. The normal amount of convergence ought to by 
 9 M. a. 
 
•;l 
 
 HAZEN'S NEW FINDINGS 
 
 - I- 
 
 0- 
 + I- 
 
 2- 
 
 B 
 
 D E F 
 R 
 
 H I K 
 
 8 — 
 9 
 
 10- 
 11- 
 12- 
 13- 
 
 14" 
 
 Fig. 1. 
 
 In figure Amplitude is represented; the full horizontal line in- 
 dicates zero or parallelism; the part above the horizontal line 
 represents the negative convergence and the part below the posi- 
 tive convergence. 
 
 In A there is normal negative and positive. In B there is a 
 total of 10 M. a. and yet there is insufficiency of convergence — 
 that being but 7 M. a. — the 3 M. a. are negative. In C there is 
 the same negative and less positive. In D there is only a little 
 short of the positive. In E the amplitude is all positive. In F, 
 C and K, convergence is all negative. His adduction does not 
 bring him to his parallelism. 
 
E. LANDOLT, M. D. 65 
 
 The punctum proximum represents the maximum of convergence 
 of which an individual is capable, but he can maintain neither 
 accommodation nor convergence more than an instant at this 
 point. This then is not the distance at which the individual can 
 work. He must have a certain amount of force in reserve for his 
 working point. 
 
 The quota of convergence in reserve should be twice as great as 
 the convergence required for the work. To work at 3 M. a., there 
 should be 6 M. a. in reserve — 9 M. a. in all. In spite of the normal 
 amplitude, convergence may be insufficient for exceptionally near 
 work, and those defficient in it will find fatigue, because there is 
 diminution of the positive part. The negative has to be expended 
 to get parallelism and the remainder of the amplitude the positive. 
 The punctum proximum is too far away and convergence gives rise 
 to those symptoms of asthenopia, which are encountered in the 
 early stages of divergent strabismus — viz., the fatigue of the eyes, 
 crossed diplopia, pains in the head, having their seat especially 
 in the forehead, vertigo, and general malaise. 
 
 Insufficiency may have a cause in lesion of the brain or spinal 
 cord — tabes dorsules locomotor ataxia and affections of the nervous 
 system. A different form of insufficiency is that which accompanies 
 neurasthenia. He finds it as a cause in women and men, and that 
 in men of s-plendid and remarkable strength — with two good eyes 
 but not able to use them at short distance. It also accompanies 
 anaemia, the sequel of typhoid influenza, accouchement, etc. This 
 form he denomininates as central because of lack of energy. In 
 those from lack of use, as in myopia, divergence coming because 
 one of the stimulants, accommodation, is lacking. Although they 
 may have amplitude of convergence it. is inferior to emmetropes' 
 and there is excess of abduction, and lack of exercise, but there 
 is in no wise a paralysis. 
 
 As in the case of an equestrian, who is not in practice and is 
 easily thrown because he cannot cling with his legs, the adductors 
 are weak and we encourage strengthening of the muscles by their 
 innervation. 
 
 Convergence is defective because it is not exercised, but he does 
 not think this form of convergence is of central origin, for this term 
 is generally understood to imply a material cerebral lesion. 
 
 Still another form of insufficiences is where the muscles are really 
 weak, in which the field of fixation shows a limitation on the nasal 
 
66 HAZEN'S NEW FINDINGS 
 
 si.lc. It is the muscular insufficiency, which gives rise to asthen- 
 opia with or without binocular vision. The existence of muscular 
 insufficiency has been denied, as if the ocular muscles could not 
 become incompetent in their work, just as in the cases of other 
 muscles. Thorough examination would dispel such theories and 
 prevent such statements — notably the field of fixation. 
 
 There are cases where the convergence is rudimentary and the 
 muscles are weak, as in myopes, where the excursion laterally is 
 limited to a very few degrees and has no duration. This is account- 
 ed secondary. There is also a primary insufficiency due to con- 
 genital defects. Such conditions are met with in other muscles, 
 wliv not the eve? 
 
 Diagnosis of Convergence. 
 
 "To know one's power of convergence, determine the distance 
 of the nearest point to which one can converge," and compare 
 with value found in the same way in healthy persons. 
 
 The Ophthalmo dynamometer consists of a cylinder blackened 
 outside, and in which a candle forms the light. There are slits 
 and circular holes, covered with ground glass, furnishing luminous 
 apertures. To measure, a tape line is attached, which is rolled 
 up by a spring. The tape is graduated in centimeters and meter 
 angles. To determine the maximum of convergence, use the luminous 
 slit, one third of a millimeter in breadth for fixation, placing it in 
 the median line. It is then drawn up until there is diplopia (crossed). 
 This is the near point of convergence. One eye, with a red glass, 
 will sometimes enable the patient to perceive the second image. 
 To measure accommodation, there are the fine openings to let 
 the light through small punctures. 
 
 With a maximum of 9 M. a. to 10 M. a., Landolt says, "that he 
 has rarely met insufficiency of this function, among persons capable 
 of converging to a point 10 centimeters distant. Since two thirds 
 of the convergence must be kept in reserve, 9 M. a. would suffice 
 for a distance of 33 centimeters. 25 centimeters 4 M. a. would 
 demand 8 M. a., hence 12 M. a. altogether. This is not rare but 
 less for this point, he would soon tire. If, in case of only 8 
 M. a. the work must be removed further away, or a frequent inter- 
 val of rest is necessary, or asthenopia follows after a mixing up of 
 the objects. The parties often have a distinct sensation that one 
 of the eyes has deviated outward. With some, the phenomena 
 
E. LANDOLT, M. D. 67 
 
 of insufficiency, is a difficult}' in directing the gaze from one point 
 to another where distances vary. These successful fixations are 
 not executed with the facility of healthy exes. Objects before 
 being fixed are double or indistinct, and in the movement of the 
 eyes there is a feeling of annoyance. A closing of the eyes, or a 
 gaze into the distance rests the muscles but the fatigue becomes 
 more intense and necessitates repose. Asthenopia increases to 
 such a degree as to render all work impossible, or a production 
 of cephalalgia, hemicrania nausea, vertigo, etc. A short objective 
 examination shows the behavior of the eyes; when directed to a 
 near point, there is a recoil, a withdrawing from the object, oscilla- 
 tion and at last a divergence. The phenomena will manifest itself 
 in only one of the eyes, one fixing and the other turning outward. 
 This behavior will be similar in all eyes as we approach their maxi- 
 mum of convergence, but the pathological conditions will be seen 
 earlier in some, according as the deficiency is developed. The 
 maximum of some cases is on the negative side of zero, and at a 
 distance, and the amount is measured by abducting prisms. \\ e 
 are to measure the excursion of the eyes by the perimeter. The 
 state of the mobility will then be completed by the determination 
 of the equilibrium. The point of absolute pose, which he proceeds 
 to find on the distance, is more difficult. The examination must 
 be objective. The eyes are so mobile, the inner value of the motor 
 apparatus is both so complex and so delicate, that even a semi- 
 conscious thought suffices to modify their relative direction. Only 
 narcosis or death brings about an absolute relaxation of the ocular 
 muscles. 
 
 To withdraw the patient from influences that would give direction 
 of the eyes. 1st. At a distance accommodation is not required. 
 2nd. Making the images dissimilar by means of a colored glass 
 over one eye, the tendency to fusion is less. 3d. With prisms by 
 which insurmountable diplopia is produced there is even less ten- 
 dency. Some are led into the dark and then required to open their 
 closed eyes and say, at the moment of opening, whether the lu- 
 minous object is single or double, or they take position in an abso- 
 lutely dark room, with their eyes open and a light flashed at a dis- 
 tance. The Maddox rod that is mentioned is good. 
 
 Landolt has most confidence in Yon Graefe's method of placing 
 before one eye a vertical prism. He does not advocate its appli- 
 cation for short distances, in which Yon Graefe used it. Abduction, 
 at a distance, is the negative of the amplitude of convergence, and 
 1 e says, "to the same extent that investigation of absolute divergence 
 
C8 HAZEN'S NEW FINDINGS 
 
 18 rational and useful, so is the opposite attempt (by means of abduct 
 ing prisms) devoid of sense, utility and accuracy." He regards the 
 exercise of abduction and adduction," without changing the accom- 
 modation places the patient in conditions of vision which 
 
 are entirely abnormal/' These investigations of the equilibrium 
 and latent deviations of the eyes, in no wise inform us, either of 
 the amplitude of the eyes for work or of the nature of the asthenopia." 
 He gets but little in the study of equilibrium. Where there is 
 divergence there may be no insufficiency of convergence. The 
 tendency to diverge or converge gives us the position the eyes 
 would take if binocular vision was lost. 
 
 He has devised the Kinothalmoscope, an adjustment made of 
 a plate of glass with handle on which he places objects, as reading, 
 upon which the eyes are fixed, and the observer, looking through 
 the interstices of objects, can observe the behavior of the eyes in 
 doing so. 
 
 Treatment of Insufficiency of Convergent and of Diver- 
 gent STRA3ISMUS. 
 
 These are so intimately related to each other, that the treatment 
 of both may be combined under one head. The constitutional 
 etiology is made prominent, physical, moral, and intellectual; 
 out of door exercise, hydrotherapy, change of environment, travel, 
 etc. The exercise of the impotent function, more than anything 
 else will render them service." He takes up the controversy on 
 the exercise of the muscles, wherein there are directly opposite 
 opinions. Xoyes recommended exercise, but Von Graefe advised 
 the opposite. Exercise would only fatigue and weaken them still 
 more, but Landolt sees that both may be right in different condi- 
 tions. When the infirmity is ascribed to a lack of exercise, and 
 after surgical intervention, the exercise is recommended on the near 
 objects. In cases of commencing divergence, when binocular 
 vision exists, but where one is amblyopic or amaurotic these are 
 excluded. Where binocular vision is lacking, but sight of both 
 eyes is fairly good the treatment should begin by stereoscopic exer- 
 cise. In most instances, orthoptic treatment should be preceded 
 by tenotomy. All these treatments, general or orthoptic, even 
 under the most favorable circumstances, demand much time, 
 hence it has been sought to solace the victim of asthenopia or in- 
 sufficiency of convergence by means of palliatives, until the infirmity 
 shall have disappeared. In short, it has been sought to diminish 
 the convergence required for the work." Thus, he proposes, first 
 
E. LANDOLT, M. D. 69 
 
 to remove the object to a greater distance or necessity of holding 
 close by placing a concave glass, which would stimulate conver- 
 gence, or put prisms on to take the place of convergence. 
 
 The decentering of the lenses, that are necessary to be worn, 
 c onvex or concave, is spoken of. He says, "great hopes are enter- 
 tained as to the efficacy of prisms in the treatment of motor asthen- 
 opia." These hopes have not been entirely realized. 
 
The following work is another of the translations of 
 D. B. St. John Roosa, M. D., L. L. D., Professor of Dis- 
 eases of the Eye and Ear, in the New York Post Graduate 
 Medical School, and Surgeon to the Manhattan Eye and 
 Ear Hospital. 
 
 1889. 
 
 DR. HERMAN SCHMIDT-RUMPLER. 
 
 Professor of Ophthalmology and Director of the Ophthalmologic al 
 
 Clinic, in Marburg. 
 
 OPHTHALMOLOGY AND OPHTHALMOSCOPE, 
 Translated and Edited by 
 D. B. ST. JOHN ROOSA, M. D., L. L. D. 
 
 Asthenopia.— Dr. Herman Schmidt-Rumpler, under the head of 
 "Insufficiency of the Internal Recti," defines Asthenopia to be," 
 "want of endurance in close work." For example, when the pa- 
 tient reads, the letters become indistinct after a time and are even 
 seen double. In addition, there is pressure in and above the eyes; 
 headache and nausea may also be observed. These symptoms 
 depend upon the insufficient activity of the internal recti, which 
 soon grow tired. At first both eyes are accurately adjusted in read- 
 ing; after a while the power of the interni relaxes, and the eyes 
 assume a position of divergence. At the same time crossed double 
 images appear, of which, the patient usually is not fully conscious; 
 they produce, merely, the phenomena of "swimming" or "blurring." 
 If he again attempts to adjust properly, by a new impulse of con- 
 vergence, the letters again become indistinct. The repeated 
 relaxation and tension of the muscles is a source of the compli- 
 cating nervous phenomena." 
 
 Under Asthenopia Nervosa, (Retinal Asthenopia) complaints of 
 deficient endurance in working, with darkening and swimming of the 
 objects looked at, occur in cases in which, after exclusion of errors 
 of refraction and accommodation, insufficiency of the interni, 
 etc., we can assume only nervous causes. In these cases, thcr? 
 
72 HAZEN'S NEW FINDINGS 
 
 arc usually pains in the eyes and head, which continue, even after 
 the work is abandoned. There is often great sensitiveness to light. 
 The affection is due, partly to general nervousness, and partly to 
 a local hypcracsthia of the retina. 
 
 Dr. Rempler quotes Dr. Noyes, where he states that, "insuffi- 
 ciency of the internal recti" may also give rise to asthenopia. He 
 eives the equilibrium, "that is made for a distance, which corres- 
 ponds to the individual reading distance." Asthenopia, "weak 
 sight," is found in hypermetropia. The translator explains, "that 
 the author, evidently, takes the view of the relations of asthenopia 
 to general disease, taken by the vast majority of oculists throughout 
 the world, that is, that while certain forms of headaches, neuralgias, 
 quite frequently depend upon ocular defects, there is no large 
 class of constitutional diseases such as chorea, epilepsy, or even 
 migraine in any large proportion, that may be cured by the use of 
 glasses." The balance or equilibrium is not discussed, and there 
 is no handling of divergent squint. (Under hyperopia.) " If 
 asthenopic symptoms develop, convex lenses must always be re- 
 sorted to. 
 
 Treatment. — Should be chiefly directed to the cure of the con- 
 stitutional anomalies, on account of the obstinacy, which is often 
 manifested by the disease ; complete cessation of work and a trip 
 to the country or the mountains are sometimes necessary. Opera- 
 tions on the muscles consist in Strabotomy of either the internal 
 or external recti. He had no success in the "stereoscopic exercises." 
 
There has not been a more active or industrious man 
 in the sphere of medicine in this country, or one who 
 has done more for the advancement of his profession 
 than the late Dr. Roosa of New York. 
 
 He has written more in his particular branches of med- 
 icine, including his translations of German works, in 
 the specialties of Eye and Ear", than any other man of 
 his time. He was active in the organization of Schools, 
 Hospitals, and Societies — especially in Diseases of the 
 Ear, he was considered in the front rank of his profession. 
 
 1894. 
 
 D. B. ST. JOHN ROOSA, M. D., L. L. D. 
 
 Professor of Diseases of the Eye and Ear in the New York Post Grad- 
 uate Medical School and Hospital; Surgeon to the Manhattan 
 Eye and Ear Hospital; formerly Professor of Diseases of the 
 Eye in the University of the City of New York, and in the 
 University of Vermont. 
 
 A CLINICAL MANUAL 
 
 OF 
 
 DISEASES OF THE EYE. 
 
 Asthenopia. — Since we have such high authority for considering 
 a hypermetropic formation of the eyeball, as being at the founda- 
 tion of most cases of true asthenopia. I fully adopt the opinion, 
 including hyperopia and astigmatism. 
 
 Asthenopia may be divided into true or local, and the false or 
 symptomatic. I regard true asthenopia as that which depends 
 upon a refractive anomaly, and I consider that, as symptomatic 
 or false, which depends upon some error in the general nutrition, 
 neurotic constitution, nervous exhaustion and the like. These 
 have been very much confounded in the discussions, which have 
 obtained in this country on this subject. There has been a great 
 deal written, avowedly not on the basis of Donders' investigations, 
 
71 HAZEN'S NEW FINDINGS 
 
 but claiming to involve new ideas on this subject, which seems to 
 me, in many instances, to he but a going back to the erroneous 
 ; rines, which Donders undertook to combat. Asthenopia 
 means an inability to continue to use the eyes on near objects, 
 without involving painful consequences. Some of those conse- 
 quences are at once appreciable, and cause the patient to stop 
 his occupation, indeed, compel him to do so." Here he adds to 
 the list of other writers, "inflammation of the edge of the lids, 
 peculiar headaches." Certain constitutional conditions that 
 involve accommodative fatigue of the ciliary muscles, may pro- 
 duce symptoms simulating true asthenopia, but these should be 
 carefully distinguished from those resulting from errors of refraction. 
 Epilepsy, chorea, etc., have been thought to result from these 
 conditions. With that doctrine, I have no sympathy. Latent 
 errors of refraction have very little to do, as a rule, in my opinion, 
 even in the causation of asthenopia, and nothing whatever in the 
 production of constitutional disease. 
 
 Muscular Asthenofia. — Although I formerly accepted the 
 ordinary classification of an asthenopia, dependent upon insuffi- 
 ciences of the external ocular muscles, I have finally come to reject 
 it altogether. Of course, I do not deny the existence of insufficien- 
 ces of the interni, chiefly in myopia, and the externi, principally in 
 hypermetropia, nor do I deny that there are many eyes, whose exter- 
 nal muscles are not capable of doing the average degree of work, 
 but I hold that all these conditions depend on static fixed condi- 
 tions of the eyeball; that they are direct consequences of these 
 conditions and should not be denied a special nomenclature, but 
 should be classed under the head of asthenopia occurring in Myopia, 
 Hypermetropia, Hypermetropic Astigmatism, etc., from faulty 
 conformation of the eye. I formerly measured the relative power 
 of muscles; this relative power varies in different individuals, 
 who have no trouble with their eyes, and I, therefore, no longer 
 measure it. Physiologically, it may be interesting, but it can do 
 nothing toward the proper treatment. Then Myopia, being 
 rarely asthenopic. its congestion or inflammation, which is thought 
 to be asthenopia, is not true asthenopia; neurotic invalids, suffering 
 from neurasthenia, often have great difficulty in using their eyes, 
 but they also have difficulty in performing many other functions 
 of the body. No adaptation of glasses will materially assist such 
 persons, except by what may be termed suggestion. 
 
 Roosa says, "that Donders mentioning muscular asthenopia in 
 his book was "owing to his reverence for the opinions of Graefe," 
 
D. B. ST. JOHN ROOSA, M. D. 75 
 
 and further on he says, "I believe that if we set aside sentiment as 
 to Graefe's discoveries and preconceptions, and examine asthenopia 
 in the light of Donders' work upon hypermetropia and that of 
 Javal upon astigmatism, we shall have no occasion to look to in- 
 sufficiences as faults needing correction, except when they cause 
 deformity or destroy binocular vision, when, if possible, they are 
 to be removed by operations. The sources of true asthenopia 
 and its results are, in my judgment, to be found in Ametropia. 
 
 Treatment. — His treatment is by attention to ametropia only. 
 He remarks that, in his opinion, the very best that can be done for 
 them is to make rather light of their troubles, and correct their 
 astigmatism. This accomplishes more than any other system of 
 treatment, and If the practitioner is firm with them and informs 
 them that this is the best that can be done, they go on with their 
 work and do it with very little inconvenience. The examinations 
 are not extended to the inquiry of balance or equilibrium, but the 
 thought is that the equilibrium or imbalance has no significance. 
 He has abandoned tenotomy and use of prisms for the correction 
 of muscular anomalies, and believes, "that the nomenclature to 
 describe weakness of the muscles should disappear." He has found 
 astigmatism to be the cause and its correction the cure. "The 
 Asthenopia with us in the U. S. is directly traceable to the weakened 
 constitutional conditions." 
 
The voluminous and Encyclopedic method of compiling 
 "System of Diseases of the Eye," and its extensive in- 
 troduction into the libraries of the Oculists of this country, 
 gives weight and authority to any part of the subject 
 of Ophthalmology. As this division of the work is 
 handled by one of the editors of this system, it draws a 
 closer attention to the views taken by its writer than 
 if apportioned to another. We therefore give it much 
 space. 
 
 1900. 
 
 CHARLES A. OLIVER, A. M., M. D. 
 
 Attending Surgeon to the Wills' Eye Hospital; Ophthalmic Surgeon 
 to the Philadelphia Hospital, Philadelphia, Penn. 
 
 AMETROPIA: ITS ETIOLOGY, COURSE AND TREATMENT 
 SYSTEM OF DISEASES OF THE EYE. VOL. IV. 
 
 That the eye of the savage differed from that of the civilized 
 man is made manifest, when the modes of livelihood are con- 
 trasted. 
 
 The savage gazed for brief periods of time, at near things, and 
 educated his visual power for distant objects both day and night. 
 
 The civilized man engaged in in-door pursuits; his visual organs 
 had to be adapted to near work. 
 
 The wear and tear, in this latter type, is greater and is so often 
 abused that there is structural impairment. 
 
 These are the physical penalties of increased mental force, and the 
 consequence is, that man must accept the conditions, so that he 
 may enjoy the fruits of civilization and culture. 
 
 The overtaxed visual function is manifest among the professions, 
 the artizans, seamstresses, weavers, and even the house-wife. The 
 newborn may be given an inheritance unstable, and not able to 
 withstand any ordinary amount of use. It signifies a transmitted 
 fault, expressing itself through physical or physiological impair- 
 ment. 
 
7^ HAZENS NEW FINDINGS 
 
 i laminations show, that the ordinary shape of the unemployed 
 eye of the human species, presents a short diameter to the entering 
 rays of light. Similar peculiarities of structure exist in the eye, 
 such as differences in cephalic configuration and facial contour. 
 
 The "normal eye" is not one with the findings mathematically 
 correct or that of the emmetropic standard, but that in which the 
 perfect visual result is obtained. It is doubtful whether the ideal 
 one exists. The emmetropic eye is the transitional stage between 
 hypermetropia and myopia. It is one which focuses distant par- 
 allel rays on its foveal plane without muscular effort, giving dis- 
 tinct images of distant objects. "It is a refractive halt in an 
 asthenopic eye." Practically, it should always be sought for. 
 "The condition artifically obtained, is however, not always the best 
 for the well being of the organ." 
 
 "There are two end organs, each of which receives a sensory 
 impression, which it is necessary to combine into a single perception- 
 binocular single vision." 
 
 "Though ametropia is as wide spread as the world itself, yet 
 asthenopia is the bane of the civilized minority." It is dependent 
 on many interrelated and interdependent conditions," for example, 
 ametropia and asthenopia make their appearance or heterophoric 
 asthenopia is provoked. The first is that which includes in its 
 etiology both the sensory and motor disturbances, that have their 
 origin in badly shaped eyeballs. The second has for its cause 
 ideopathic or functional errors in muscle eqilibrium, that may 
 be independent of the shape of the eyeball and the condition of 
 the refraction." 
 
 "Heterophoric Asthenopia is not so rare as may be supposed, 
 be the ametropia ever so slight or undisturbing, or even if emmetro- 
 pia be found, asthenopic symptoms of heterophoric type may be 
 present. Moreover, ideopathic or primary heterophoria, par- 
 ticularly hyperphoria, may not only produce a heterophoric asthen- 
 opia, but may also provoke an ametropic one from a latent ame- 
 tropia, which would not have been brought into evidence had there 
 not been a normal equilibrium and action of the ocular muscles" 
 
 Asthenopia. — "Considered broadly, Asthenopia or eye-strain 
 is a complex grouping; as a rule, it is expressive of the combined 
 workings of the two ocular end bulbs and their accessories." 
 "What may be considered the normal state of the visual apparatus 
 today need not be that of tomorrow. "Normality can be assumed, 
 no matter what inequality may exist, as long as the two series 
 of ocular muscular groupings are in balance and continue so during 
 activity." 
 
CHARLES A. OLIVER, M. D. 79 
 
 "It is the heterophoric type of asthenopia, particularly the 
 hyperphoric variety of minor degree, more than it is the ametropic 
 one, which gives rise to so many reflex neuroses. It is this type 
 of disorder that dizziness, gastric disturbances, with, for example, 
 urticaria, vertigo, migraine, nervous irritability, mental confusion, 
 insomnia, etc., all of which are so prone to interfere with general 
 nutrition, come into existence." 
 
 "In this category are to be found the many changes of vaso- 
 motor type. In this group are to be seen the characteristics of 
 the vicious circle of cause and effect; eye strain, with its pain and 
 nervous disturbances, producing interference with assimilation and 
 nutrition, which, in its turn, so reduces the general physical condi- 
 tion as to induce an increase of the asthenopia." 
 
 Nerve Storms. — "The nerve storms that are produced by heter- 
 ophoria (as also ametropia) may produce a rapid discontinuance of 
 near work, so that the more distant reflexes may never be given an 
 opportunity to manifest themselves. There may be so strong 
 nerve tone that the excitation may never make an impression — 
 just as ametropic and heterophoric asthenopia may produce far 
 reaching and injurious symptoms that cannot be removed in any 
 other way than by correction of the local defects" — so must general 
 disturbances be remediable by therapy, "directed to the casual 
 factors." 
 
 In the neurotic, toxaemic and anaemic, small errors sooner mani- 
 fest their presence. Some of the functional nervous diseases and 
 some of the morbid processes, named neurasthenia, chorea, epilepsy 
 "may be indirectly dependent upon disturbed binocular action." 
 
 Neurasthenia. — Neurasthenia produces Asthenopia; Functional 
 Paresis of the motor apparatus; irregularity of pupils; lachryma. 
 tion; congestion; sensation of foreign material in the conjunctival 
 sac from want of tone and localized dilation of the vascular 
 walls, with a sense of weight and a tendency to drooping of the 
 upper eyelids, hyperesthesias, and irregular spasmodic actions. 
 
 Heterophoria. — "It is the minor and unequal degrees of hetero- 
 phoria (particularly hyperphoria) that produce the most disturbing 
 r eflex symptoms. This is especially so, if there be some peculi- 
 arity of angle of muscle-deviation or fault}' muscular tendency." 
 
 "Neuralgia, the functional expression of a disturbed nerve, is 
 one of the most common signs of ametropia." 
 
 "In the trifacial and second cervical groupings, on use of eyes, 
 it manifests itself, especially when the system is below par. Low 
 
SO HAZEN'S NEW FINDINGS 
 
 grade of compound hypermetropic astigmatism, mixed astigmatism, 
 etc., produce the greatest amount of headache; anisometropia, 
 and antimetropia, increase the frequency of cephalalgia. 
 
 Differential Diagnosis. — "As yet, the differential diagnosis 
 between the cephalalgia of ametropia, and that of heterophoria is 
 uncertain, though it is probable that when the pains are associated 
 with dizziness, and car "sickness," that abnormal balance is the 
 more to blame. As a rule, however, the two conditions are asso- 
 ciated and interdependent." 
 
 Local Reflex Eye Strain. — Asthenopia may be produced by 
 conjunctival and pulpebral irritation and inflammation, associated 
 with pterygia, chalazia and abnormal adhesions of lids. Whether 
 naso-pharyngial disturbances can be included in this category is 
 uncertain, although the removal of adenoids has directly relieved 
 cases in which the correction of the ametropia and the heterophoria 
 has availed little or nothing. Nasal reflexes and dental caries 
 must also be considered. Many subjects, suffering from frontal neu- 
 ralgia and complaining of eyestrain on rising in the morning, may 
 be dependent upon congestion of nasal cavities, conjunctival 
 irritation, that has been provoked the evening before by improper 
 use of the eyes. 
 
 Spastic. — "In the spastic or overacting types of heterophoric 
 asthenopia, particularly, when there is hyperhoria and the interior 
 muscles are also affected, migrainous attacks are common." "In 
 the forced or over acting exophoria, the more general signs ,such as 
 vertigo, incoordination, mental peculiarities, and even insomnia, 
 and neurasthenia are noticeable." 
 
 "Undue action of the interior muscles (sphincter irides and the 
 ciliary) being supplied by the third nerve affects all the related 
 exterior muscles and produces a departure of the globe from ortho- 
 phoric equilibrium." 
 
 Paretic — The paretic or underacting form of heterophoric 
 asthenopia, found so frequently in the aesthenic is dependent on 
 weakness of the muscles of the third nerve. The symptoms vary 
 in all forms of cephalalgia from mere frontal to fronto-occipital 
 pain; the greatest disturbance always being found in the positions 
 of the weakest groupings or combinations of muscles. In a mixed 
 type (underacting and paretic) where the extrinsic and intrinsic 
 muscles are weak from general debility, there is a subnormal ciliary 
 action, associated with dilated pupils and exophoria, during near 
 vision in which there is both ametropia and heterophoric disturb- 
 
CHARLES A. OLIVER, M. D. 81 
 
 ance, with an inability for prolonged focusing, imperfect fixation, 
 visual confusion, dizziness, and gastric disorders. Xot only the 
 muscles supplied by the oculo-motor, but those of the fourth 
 and sixth become lowered in action. 
 
 Climate. — Climate as an etiological factor, as a cause of astheno- 
 pia, is discussed, in that, in one section, there is more strenuousnes 
 required to obtain the necessities of life than in the other, where 
 nature supplies the fruits to appease the appetites with less labor. 
 
 Life Struggle. — Then, added to the struggle of life for sub- 
 sistence, the procuring of the necessities, and those living in the 
 more rugged climates, set standards of skill, education and profi- 
 ciency, all of which "cause wear and tear of the structural organs," 
 and in the case of the eye"" are, unremittingly, and often injur- 
 iously brought into play" — hence it is not possible to consider the 
 functions of the visual organs as dominated by any mathematical 
 laws, but the adoption of anatomic elements subserve the purpose 
 for which they were intended. 
 
 Muscle E( uilibrium. — Among the etiological causes of hetero- 
 phoric disturbances, the great majority of faulty muscle equilibrium 
 is the result of a transmitted over stimulation, given to the ciliary 
 muscle, the consequence of ametropia; it is an associated error, 
 the effect of individual imperfection. "In the vast majority of 
 cases, muscle disturbance is the result of unlike degrees of minor 
 amounts of ametropia in two organs that are found to work as 
 one organ." Comfortable vision may be with heterophoria, both 
 manifest and latent. It may be the result of a spastic condition 
 of one muscle and a paretic condition of another. 
 
 Astigmatism. — As one of the causes of astigmatism is the tonic 
 contraction of the exterior ocular muscle groupings, a spastic 
 condition of a series of extra ocular muscles, as is occasionally seen 
 in some types of nerve disease. Both surfaces of the cornea and 
 of the lens, as well as the density of the different portions of the 
 two masses, must be taken into consideration. 
 
 The astigmatism, determined in examination of each eye separa- 
 tely, is often different in amount; when the examination is made 
 with the eyes simultaneously, the angles of the meridians likewise 
 change. This is possibly accounted for by the extra ocular muscles, 
 producing different degrees of tension in their combined functioning. 
 
 Heterophoria. — Muscle equilibrium is pronounced in cases of 
 one or even two degrees of deviation, (exophoria in myopes and 
 
82 HAZEN'S NEW FINDINGS 
 
 horia in hypcrtropcs) for five or six meters distant and slight 
 exophoria at reading distance. Jt is seen in cases in which the 
 gmatic axes arc at 'JO degrees. The deviation in the vertical 
 direction is much inure troublesome. 
 
 "Heterophorias soon become apparent with the minor degree 
 of ametropia, particularly of the astigmatic variety. Latent 
 ezophorias are often made manifest by the use of prisms and the 
 repeated performance of the so called graduated tenotomies." 
 
 •'IIvperaesophorias are quite common in young, highly hyper- 
 metropic and astigmatic subjects, while hyperexophorias, with 
 slightly dilated pupils, are the rule in the middle and the high 
 grade myopes. The extra ocular muscle imbalances are the greatest 
 in antimetropic and anisometropic subjects." 
 
 Like ametropia, heterophoria is divisible into manifest, latent 
 and total. 
 
 The local symptoms of external deviations are frequently those 
 that have been shown to be dependent on underaction and paresis. 
 
 "'An odd symptom is the sensation of a sudden impact against 
 the eye ball, produced, probably, by a simultaneous action of two 
 or more of the recti muscles;" ptosis may be caused by hyperme- 
 tropic disturbances, tilting of the head away from the shoulder 
 corresponding with the hyperphoric eye; palpebral hyperemia 
 with watering of the eye; diminished vision, and comprising double 
 vision as seen in car sickness, with all manner of general reflexes 
 that are more or less distantly related, constitute some of the other 
 signs of heterophoria. 
 
 Cyclophoria is an imbalance of equilibrium and action of the 
 exterior ocular muscles. It is most frequently seen in oblique 
 astigmatism and is mainly connected with the oblique muscles. 
 
 Facial wrinkles, corrugations and even grimaces are sympto- 
 matic of heterophoria. 
 
 A variety of general symptoms are not noted until the ametro- 
 pia or heterophoria are corrected, thereby getting rid of an expendi- 
 ture of nervous energy, which would have, if continued, been an 
 injurious influence upon the general health. 
 
 It must not be forgotten that general organic lesions, particu- 
 larly those of neural structures, may give rise to similar signs. 
 
 Prognosis. — With proper care and rest, work can be secured 
 from the visual organs. "Mischief manifests itself when friction 
 begins, and if not recognized and corrected, is apt to produce 
 
CHARLES A. OLIVER, M. D. 83 
 
 physical disorders." Ametropia has no major place in the statistics 
 of blindness, but it slowly extends its harmful impulses, which 
 frequently are but imperfectly recognized, and so imperfectly 
 corrected that its evil consequences become more widely spread." 
 In the sedentary lives of asthenopes, "the weakened sight is but 
 one of the evidences of general nerve tire." 
 
 In a country where myopia was increasing, attention was called 
 to asthenopia two decades ago, and America profited by the object 
 lesson, and reform has been the result, through her optical estab- 
 lishments as in other hygienic measures. Notwithstanding the 
 "want of harmonious binocular action," until the last decade and 
 a half, it has generally remained untreated. 
 
 Owing to the general strenuousness of our people, where so much 
 nerve energy is wasted, we find asthenopia at its worst. 
 
 "Such a complex organ, so situated, as its work continues, must 
 cause harmful influences on distant related organs." 
 
 The private schools, whose pupils are from the well to do classes, 
 with less rugged constitutions, afford illustrations of the causes and 
 effects of asthenopia; physical unfitness, and inadequate strength 
 for the performance of their real life work, especially among brain 
 workers are some of the results; neurasthenia becomes manifest 
 and the eyes are among the earliest organs to become involved. 
 The effects of impaired vision on the intellectual development 
 and physical growth of the subject are marvelous, often unrecog- 
 nized until too late, when the disturbance becomes increasingly 
 harmful. 
 
 Theoretically, the emmetropic have the fewest injurious influences; 
 practically, there cannot be any ocular ideal, and an emmetropic 
 eve cannot be expected to remain so, when its dioptric media is 
 so changeable, and its muscular movements so indeterminate. 
 Lens Therapy should be subject to legal regulation. 
 Municipal statutes should be enacted for the examination of 
 pupils. 
 
 Correction of ametropia, particularly astigmatism, has lessoned 
 myopia; disastrous intraocular changes, associated with myopia, 
 are not so frequently seen at the present. 
 
 Myopia is a direct accompaniment of advanced civilization, but 
 cannot be attributed to embryologic causes. Mental pursuits 
 require prolonged near vision from early life, and therefore the best 
 sight attainable. Uncomplicated Myopia is rare and the lower 
 grades of the schools present but little asthenopia. 
 
 Minor degrees of ametropia and heterophoria produce impair 
 ment of nerve energy, by abnormal expenditure of nerve force; 
 
84 HAZEN'S NEW FINDINGS 
 
 early correction leaves fewer chances of nervous impairment or 
 organic disturbance'. 
 
 Treatment, —"A normal eye is one that has healthy tissues and 
 is functioning properly." '"It need not be emmetropic nor neither 
 need it be exactly like its fellow. By over use, however, pain is 
 produced and rest, orthopedy by lenses and prisms must be applied. 
 \\ hile improvement in vision is brought about, ocular disease is 
 the main condition to be improved. The uncomfortable vision 
 before inflammation and acuteocular pain are theprincipalsymptoms 
 that send the ametrope for relief," and the almost universal belief 
 that all defective vision can be relieved by lenses acts disastrously 
 on the welfare of the organ." 
 
 The science of prescribing for ametropia is not a mechanical 
 art. It is the work of the educated, who understand the signifi- 
 cance of the eye strain on the general health. The end organ is 
 improperly compared to a camera — it is a living mechanism. The 
 employment of a correcting lens is medical therapy. Like other 
 therapeutic aid, its virtues have been exaggerated. 
 
 Eighty per cent of Opthalmic work is for the correction of ame- 
 tropia. Unlike our ancestors, people of the present day need not be 
 doomed to pursue lives of uselessness, out of doors; on the contrary, 
 scientific medicine would be criminal!}' negligent to give such advice, 
 
 \\ e cannot expect to cure "static" ametropia without surgical 
 procedure, but "dynamic" can be cured, both by local and general 
 methods. The orthopedic therapy is a lens and acts as a crutch, 
 and it cannot be expected to remain efficient without changing. 
 
 Lenses should not be used, merely to benefit vision, but to pre- 
 vent disturbing causes and disordered mechanism. It is not the 
 amount of ametropia, which determines their necessity. A cylin- 
 drical lens of 12. D. has frequently done more good as a thera- 
 peutic measure, in changing muscle imbalance than general treat- 
 ment, or so called "rest lenses." 
 
 "All refractive errors, especially minor degrees of astigmatism, 
 should be carefully estimated for, at least as low strength as one 
 eighth of a diopter." 
 
 The total error, particularly the astigmatic one, must be found, 
 before the proper orthopedic help to the combined organs can be 
 established. In all subjects under 45 years there must be full 
 paralysis of ciliary muscles. 
 
 Select a cycloplegic that is deemed best adapted to the particular 
 case and get full effect of control of accommodation. 
 
CHARLES A. OLIVER, M. D. 85 
 
 "To relieve asthenopia, it is just as important to obtain definite 
 data of heterophoric changes;" artificial control of the extra ocular 
 muscles; we do not have to determine the amount of heterophoric 
 action, particularly the latent in any definite position," though 
 clinically, the muscle equilibrium, for distance, may often be ad- 
 vantageously tried, while the ciliary muscle is artificially paralyzed." 
 
 Prismatic corrections have their limitations. "During their use, 
 there should be definite modifications of power for every finite 
 point used. Unfortunately, in such corrections, there are the most 
 troublesome factors of identical points, that are situated throughout 
 the associated fields of vision." 
 
 No therapy of any kind should be applied to the extra ocular 
 muscle until the ametropia is relatively corrected; the powers of 
 the combined muscle action, in the four principal directions, must 
 be learned and the inter-relationship of the two ciliary muscles 
 must be studied. "It is a series of motor impulses in unstable 
 muscular apparatus of dual type, independent of set mathemat- 
 ical rules and fixed certainties." 
 
 Optometry, the science of measuring the optical powers of the 
 eye, in practice, divides itself into objective and subjective; 1st. 
 Opthalmoscopy-Keratometry and the Fundus Reflex test are em- 
 ployed. 2nd. Test Lenses. For determining related muscle 
 imbalance, both objective and subjective tests should be applied 
 both for distance and working point, and also for other focusing. 
 
 "The methods of testing heterophoria, are as a rule, very im- 
 perfect." The muscular condition should be gotten repeatedly, 
 in order to gain averages of muscle balance. "The duction powers 
 of muscle combinations that produce the various combined ocular 
 movements, must always be tested." 
 
 Prescribing lenses brings into consideration a whole series of 
 dynamic forces, situated in and around two closely related eyeballs. 
 It is one of the most difficult problems, given a physician, and is 
 one of the most important therapeutic agents that has been offered 
 to the profession. 
 
 Xo case of binocular ametropia has been properly treated until 
 the disturbances of both the related extra ocular and intra ocular 
 muscle groupings (which are brought into almost momentary 
 play) are gotten rid of as nearly as possible. 
 
 "The production of an artificial ametropia is not infrequently- 
 necessary, in order to obtain a pair of comfortably working and 
 non-irritating visual organs." 
 
 The secret is to bring about as close a proper relation between 
 the two conditions (extra and intra ocular premises) in each in- 
 
86 HAZEN'S NEW FINDINGS 
 
 dividual case as possible, hoping only to approach the ideal state. 
 "'As a rule, a total correction of binocular ametropia (particularly 
 the minor types) not only removes a false tendency of the globes, 
 in some definite direct ion," but "restores the extra ocular and the 
 intra-ocular series of muscles to a normal inter-relational balance, 
 thus permitting proper equipoise, without undue or harmful in- 
 nervation impulses to take place, when moved into associated 
 positions. 
 
 "In the majority of cases, the question is to get the two eyes to 
 work together harmoniously ,for the generally employed, distant 
 or near working points; to reduce the optical and the muscular 
 strains to a minimum, in agreement with what it is expected of 
 the organs to perform." "Normality and emmetropia need not 
 be the same; it may not be the best practical basis." 
 
 In heterophoria, when amblyopia is threatened, correction of 
 ametropia, stereoscopic exercises, periodic use of the organs should 
 be carefully attended to. If vision remains below normal, radical 
 procedures may be resorted to. Each form of therapy has its 
 limitations and operation as an ultimatum. 
 
 "Orthopedic treatment of ametropia should really be frequently 
 considered as to removal of the etiological factors in asthenopic 
 symptoms." "Prisms combined with sphericals instead of cylin- 
 ders signify uncorrected muscle balance, which might be remedied 
 by sphero-cylinder." 
 
 Ideopathic, that is anatomic, is the only type of heterophoria that 
 legitimately permits operation, and this is the only remedy. "It 
 must be "structural" or "insertional" in character." 
 
 "For removal of reflex disturbances, reflex irritants or the offending 
 relationship must be sought." 
 
 In functional forms, after correction of ametropia, there should 
 be hygienic attention to general nerve tone. "Rythmic exercises, 
 not carried to excess, and in some instances innervation impulse 
 tests are of use. 
 
 "These two types of heterophoria are distinctly separated," 
 and the two procedures can be accomplished only by the scientific 
 medical man. 
 
 "If the external groupings are suffering from the secondary 
 exhaustion, much good can be done by obtaining and retaining a 
 normal working balance between the two related series." Never 
 in heterophoric or heterotropic errors should attempts be made 
 to weaken any set or sets of muscles. Find the weak and strengthen 
 them by orthopedic measures. 
 
CHARLES A. OLIVER, M. D. 87 
 
 The paretic type is evidently dependent on general systematic 
 disturbance. Hygiene and internal medicine are indicated. Forms 
 of strychnia, hypodermatically administered. Local therapy is 
 useless without general treatment. 
 
 In the neurasthenic types, frequently seen among the intellectual, 
 optical and musculo-dynamic correction are of but little value. 
 
 Prolonged and absolute change, rest and properly taken exercise, 
 both physical and mental, can alone effect a cure. 
 
 A partial correction of astigmatism, or even omission of the 
 astigmatism found in cycloplegia, and in others, a frequent change 
 of axes may be of value. 
 
 For slight esophoria, for distance, prisms are not best. In low 
 degrees of exophoria for near vision, base in, prisms can be put 
 before the helping eye. If later, muscle equilibrium be again dis- 
 turbed, as it frequently is, "hygiene of eye employment, temporary 
 cessation of work, spherical and prismatic correction and genera) 
 constitutional remedies are employed. 
 
 Theoretically, "the cure of asthenopia is the artificial production 
 of emmetropia and orthophoria, yet practically, such ideals are 
 rarely preserved," "nothing more can be expected in the removal 
 of asthenopic conditions than to approach as near to a refraction 
 and muscular ideal as possible." 
 
 Some cases of "spasm of accommodation" are so persistant as to 
 require months of active treatment. 
 
 "Migraine is one of the main causes of ocular disturbance." 
 Clinically, get the eyes into a normal state, and hygienically treat 
 generally associated neurotic conditions, which are probably one 
 of the principal casual factors in the production of the affliction." 
 
 Habit Chorea of refractive origin, has a tendency to invade other 
 muscular groupings besides those of the eye-lids and face, and is 
 bettered by correction of ametropia and heterophoria. 
 
 Headache. It would be well to estimate the refraction in all 
 cases of functional neurosis, situated around the eyes. 
 
 Presbyopia. The ametropia of each eye must be considered. 
 This done, the artificial combined points for near work can readily 
 be obtained. Properly centering should have the same care. 
 
 "In the placing of prisms in lenticular corrections, it is best to 
 put the bulk of the prismatrc action before the helping eye, which 
 is generally the left one." 
 
The contribution to the science of Ophthalmology by 
 Dr. Stevens, in instruments of precision in Diagnosis 
 and his new nomenclature in Muscular Anomalies, and 
 the new views in which he presented the relation of the 
 extra-ocular muscles to the subject of Functional \ ision, 
 together with his method of relief of asthenopia by "grad- 
 ual tenotomy" marks an epoch in the history of Oph- 
 thalmology. 
 
 1906. 
 
 GEORGE T. STEVENS, M. D., Ph. D. 
 
 A TREATISE ON THE MOTOR APPARATUS OF THE EYES. 
 
 MOTOR APPARATUS OF THE EYE. 
 
 This work follows his book of "Functional Nervous Diseases,"' 
 published in 1884. The central doctrine in this, he states in the 
 preface, is difficulty of adjustment of eyes, which is a source of ner- 
 vous trouble, and more frequently than other conditions, consti- 
 tutes a neuropathic tendency. 
 
 He gives an interesting history of how the ancients regarded 
 deviation of the eyes, and states that the opinions expressed as to 
 cause, were copied by subsequent writers and thus handed down 
 nearly to our own day. 
 
 In the history of muscular anomalies that are less than strabismus, 
 he discusses Von Graefe's Insufficiency of the interni and the sacra- 
 fice he made of single vision, for a distance, for convergence, for 
 reading distance; by an operation he made that condition, declaring 
 that his doctrine of obtaining fusion at one point at the expense of 
 another point, would not be tolerated in these days. 
 
 He holds that in the introduction of his system of heterophoria, 
 he gave expression to new facts by new terms. In a series of cases, 
 reported to the Royal Academy of Medicine in Belgium, 1883, for 
 which he received the award in a competition. His proposition 
 was; that" difficulties of the adjustment of the eyes are a source 
 of nervous trouble, and more frequently than other conditions, 
 constitute a nervous tendencv." 
 
90 HAZEN'S NEW FINDINGS 
 
 The difference between Von Graefe's practice on adjustment of 
 the eyes, and his, was that the former did not establish equilibrium 
 for all points, but he sought that result. Jn seeking this, the practice 
 ot tenetomy under it became more refined and more scientific, lie 
 regards his instrument, the Tropometcr, in these cases, as sheddinir 
 a flood ot [ighl on the subject, and, for a time, it seemed as though 
 a key had been found to unlock secrets. The anomalous position of 
 the plane of vision was first shown by it. With all the investiga- 
 tions of Helmholtz, he shows that the true investigations of the sub- 
 ject of the muscular apparatus had not yet been made. His in- 
 struments for technical physiological investigation enabled him 
 to make a class of examinations better than all that had gone before. 
 
 The maintaining of the uprightness of objects seen by the eye, 
 is one of the important impulses. The construction of the muscles, 
 which roll the eye upon its optic axis, is an element of cause in 
 exophoria; that when the rotation of the eyes, in its full extent, is 
 understood, it will no longer be necessary to perform tenotomy for 
 convergence or divergence squint. The full understanding of 
 heterophoria and its bearing on the nervous system fairly con- 
 stitute a science. 
 
 He sees that oculists will, in the future, hold a closer relation 
 to the physical well being of patients in correcting bodily postures, 
 which go far to produce ailments from pose of the head and eyes. 
 
 In the section of Physiology of the eyes, he makes a close study 
 of torsion, the w^heel like movement on and around the plane of 
 regard, making a distinction between this and declination. "The 
 angle of torsion is the angle of displacement of the vertical meridian, 
 when the eye passes from a primary to a secondary position." 
 Displacement to the temporal side is positive; to the median side 
 negative. The rotation of the eye is about a fixed point, practically 
 the center of the eye; the muscles performing it are divided into 
 three pairs; each pair, the axis of which cuts the center of rotation, 
 acting alone. It is also to be remembered that neither eye acts 
 independently, but the two eyes are in definite relations and asso- 
 ciation with each other. The attachments of the different muscles 
 to the eye ball in front, being varied from a right angle to the axis 
 of action, caused deviations from the normal meridians. The 
 conclusion is that the action of the muscles upon the eyeball cannot 
 be uniform. In the associated movements of the two eyes, there is 
 also often a noncomformity of motion from mal-insertion of the mus- 
 cles. In the combined action of two muscles or pairs of the two 
 eyes, the vertical lines are thrown out of parallelism. 
 
GEORGE T. STEVENS, M. D. 91 
 
 In the combined action of the two pairs, displacements may be 
 detected. 
 
 A turning of the eye upon its own antcro-posterior axis by direc- 
 tion of the traction of the superior and inferior recti and the oblique 
 muscles is called torsion. The torsion which tilts the upper end of 
 the vertical meridian to the nasal side is negative and that which 
 tilts the upper end outward is positive. The compensating action 
 of the muscles, when in health, prevents torsion. 
 
 With the Clinoscope the vertical lines may be made to rotate 
 20° with the two eyes. The horizontal lines cannot be rotated 
 to this extent. 
 
 ANOMALOUS CONDITIONS OF THE MOTOR MUSCLES OF 
 THE EYES, CONSISTENT WITH THE PHYSIO- 
 LOGICAL STATE. 
 
 Euthyphoria. — A passive adjustment of the normal plane of 
 vision, such that this visual plane is coincident with the plane of 
 the horizon, or very nearly so. 
 
 Axophoria. — A passive adjustment of the normal visual plane, 
 at an angle distinctly above the plane of the horizon. 
 
 Katophoria. — A passive adjustment of the visual plane at an 
 angle distinctly below the plane of the horizon. 
 
 Anotropia. — An adjustment in which the visual line of either 
 eye deviates upward when the other is in fixation. 
 
 Katotropia. — An adjustment in which the visual line of either 
 eye deviates downward when the other is in fixation. 
 
 Orthophoria. — A tending of the visual lines in parallelism. 
 
 Heterophoria. — A tending of these lines in some other way. 
 
 Esophoria. — A tending of the visual lines inward. 
 
 Exophoria. — A tending of the visual lines outward. 
 
 Hyperphoria. — R. or L. — A tending of the right or the left 
 visual line in a direction above its fellow. The term does not imply 
 that the line is too high, but that one is higher than the other. 
 
 Tendencies in oblique directions are expressed: 
 
 Hyperesophoria. — A tendency of one visual line above the other, 
 with a tendency of the lines inward. 
 
 Hyperexophoria. — A tendency of one visual line above the other, 
 with a tendencv of the line outward. 
 
92 HAZEN'S NEW FINDINGS 
 
 1 1 1 terotropia. — R. or L. — A deviation of the visual lines. 
 
 Esotropia. — A deviation of the visual line inward. 
 
 Exotropia. — A deviation of the visual line outward. 
 
 Hypertropia. (R. or L.) — A deviation of one visual line above 
 the other. 
 
 IIyperesotropia. A deviation of one visual line inward and 
 above the other. 
 
 Hyperexotropia. — A deviation of one visual line out and above 
 the other. 
 
 Declination. — He tests the extent of the rotation of the eyes 
 by his Tropometer and claims that before this instrument there 
 had been no reliable method of arriving at approximate measure- 
 ments of all the rotations. He gives standards of rotation. On 
 the degree of anomalous condition depends the amount of disturb- 
 ance of the nervous system. The recognition of declinations will 
 mark the advance in the character of the results. The science of 
 declination cannot well be compared with that of heterophoria as 
 they are intimately associated. When the meridian of the retina 
 deviates from the meridan of external space inwardly or outwardly, 
 that is, when the ball rolls upon its visual axis, it is a declination. 
 When the top of the retinal meridan leans towards the temple it is 
 positive (plus) declination; Avhen toward the nose, negative (minus) 
 declination; sometimes these declinations occur in eyes physiolog- 
 ically correct, and are as various as errors of refraction and as 
 important in tenotomies. 
 
 Among the distinctive symptoms named in declinations, are 
 chronic hyperemia with smarting and dryness, caused by pressure 
 of the lids against the ball in the endeavor to resist the tendency to 
 roll; habitual pain in and over the brow, of one or both eyes; arching 
 of the brow. He calls his detecting device, "The Lens Clinoscope." 
 
 With Myopia, there is usually a high degree of declination. 
 Declinations give contour to the expression of the face, in arching 
 brows. It is easy, not only to recognize the class of declination but 
 to tell the direction of the leaning of each eye. The habitual pose 
 of the head and indeed that of the body, is in a large measure 
 influenced by peculiarities of adjustment of the eyes. 
 
 He dissents from the doctrine of Donders, so generally accepted, 
 that of the association of the two functions, accommodation and 
 convergence that an excess of the action of one should cause an 
 excess in the function of the other. "The affections of the ciliary 
 
GEORGE T. STEVENS, M. D. 33 
 
 muscles are not essential factors of the anomalies of the motor 
 muscles, and need not be considered beyond the reciprocal influences, 
 which may arise from habitual associations." Heterophoria may 
 be regarded in general a resultant of declination. As the accuracy 
 of estimation of distance and form is made by the muscular move- 
 ments of the eye, bringing into position the different meridians 
 over retinal spaces in their relation to the maclea, and that these 
 adjustments are made with inconceivable rapidity and frequency, 
 it is important to know the degree which a pair of eyes has to make 
 up by its want of equilibrium, thereby estimating the nervous 
 force expended in ariy particular occupation. Heterophoria, 
 in one person might not produce disturbance, but, under different 
 circumstances cause trouble; another person with very little devia- 
 tion might suffer severely when called upon in duties that demand 
 unusual hours; so that a certain degree of fault in the associated 
 movements will not denote the degree of nervous disturbance, or 
 that when there has been no inconvenience from the use of eyes, 
 that there is a well balanced adjustment. 
 
 This would indicate that the time to correct anomalies is before 
 the disturbance occurs and if there is such a condition that entails 
 great expenditure of nervous energy, it should be corrected before 
 a breakdown is brought about. 
 
 Tests. — Among the ''Auxiliary Tests of the Phorometer," he 
 cites duction. This he calls overcoming difficulties in the fusion of 
 images. The measure of it is the strength of prism, which the eyes 
 can overcome. Von Graefe named adbuction and adduction, and 
 sursumduction, right and left, which is overcoming prisms base 
 down over R. E. and is Right sursumduction; the same position 
 over L. E. is Left sursumduction. The same terms apply if prism 
 is reversed before the opposite eye. 
 
 The ability in adduction with orthophoria is 50 base out. Prac- 
 tice and acquiring a "knack" will give such ability but there is no 
 fixed standard. It is necessary that the prisms be placed equally 
 before the two eyes. Not so in abduction with base in, but may be 
 placed over either eye. He placed a standard of 8 in ab- 
 duction. These collateral tests are less in demand, since the dis- 
 covery of the Clinoscope, yet are not to be ignored. He regards 
 the vertical diplopia test at the reading distance of no absolute 
 value. He depends much upon the screen and the parallax test 
 of Duane. 
 
 Esophoria "is not to be regarded a disease or as a weakness, 
 nor yet a spasm." "It is a physiological state, depending upon 
 
94 HAZEX'S NEW FINDINGS 
 
 anatomical peculiarities of the course and the insistence of the 
 motor muscles, by which.. ..the balance of tension is normally 
 toward the median plane." In exophoria as in esophoria the habit- 
 ual visual state is the union of the images of the two eyes. When 
 diplopia occurs the deviating tendency has passed to actual devia- 
 tion, and then exotropia. Exophoria in accommodation, which 
 is a condition analogous to insufficiency of the intern i of Von Graefe 
 — not a condition of true exophoria. 
 
 In hypcrophoria single vision is assumed although, when a single 
 degree exists, subjects of the affection surrender to it. Xo hete- 
 rophoria exerts more disturbing injurious influences, giving rise to 
 fatigue, perplexity and it exaggerates all other tendencies. It has 
 a slight deviation effect on type and its doubling effect causes 
 inordinate muscular tension or a suppression of the images of ,qne 
 of the eyes. Amblyopia is not only common in hyperphoria but it 
 is uncommon to find hyperphoria without amblyopia. 
 
 Expression of the face and the bodily pose are sufficient indica- 
 tion, in some forms of anaphoria, to indicate a restricted chest and 
 that the respiratory passages are partly shut in a valve like fashion. 
 Although they may not acquire phthisis, the pains in the back of 
 the neck, in the middle dorsal region, and even in the lumbar 
 region are often the physical protest against tension upon the mus- 
 cles of these parts 
 
 "Weakness" of certain muscles is not the cause of different forms 
 of heterophoria. The most conspicuous cause is in the vertical 
 meridian. Declinations are peculiarities of tendon insertions. 
 
 The following is the method given for the manipulation of prisms 
 in effecting direction of the muscles. The simplest and easiest, 
 and indeed the most effective way of making these tests is by help 
 of prisms, taken from the trial case. For abduction, take a prism, 
 for example of 5° from the box, and place it with its base toward the 
 nose, close to one eye of the patient, and ask him to unite the 
 images, if two result. If this can be done, proceed to the next 
 grade or pass over one or two grades and try again. In a very few 
 trials the limit will be reached. On the other hand, if the 5° cannot 
 be overcome, a lesser grade is tried, and, if necessary, other lesser 
 ones until a union of images can be found. The strongest prism 
 that can be overcome is the measure of abduction. If there is 
 actual convergence it may require a prism, base out, to enable the 
 patient to unite the images. Then there is homonymous diplopia 
 of the degree of the weakest prism that will unite the images. 
 Prisms of much less grade are usually required for sursumduction. 
 A prism of one, two or three degrees is usually sufficient. Place 
 
GEORGE T. STEVENS, M. D. 95 
 
 the prism, with the base down, before one eve. If this can be 
 overcome, present a stronger one, until, with no stronger one will 
 the images unite. In most cases, a prism of not more than 3° may 
 be overcome. In myopic caess with high declinations, prisms of 
 9° or 10° may be overcome. After determining the sursum- 
 duction in one direction, in a few minutes the prisms can be placed 
 over the other eye, base down as before, or over the first eye with 
 base reversed. 
 
 After thus testing in the different forms of heterophoria, tests 
 are made of the rotation by his Tropometer, then the Clinoscope. 
 
 Esophoria, which occurs in the proportion of more than three to 
 one of exophoria, plays an important role as a cause of neurosis. 
 When the strain in adjusting the eyes, in close work, may be ex- 
 pressed in the orbit and localized in the muscles in case of exophoria. 
 The reaction, in case of esophoria, is found after direction on a 
 distant point, as upon attending church, theatre or picture gallery, 
 when the eyes have been directed, during a considerable time, in 
 parallelism. The pain is at the back of the head and upper part 
 of the neck, causing a general malaise and sense of illness. 
 
 The amount of deviation is not commensurate with the irritating 
 result. 
 
 The suppression of the false image gives relief, afforded at ex- 
 pense and perplexity of another sort. Of a large number of cases, 
 which go from one oculist to another, in hope of relief, and submit 
 to an almost endless change of spectacles with 1 ittle advantage, a 
 very considerable number have slight grades of esophoria. These 
 moderate cases of esophoria may represent declinations, and it is 
 this to which nervous perplexity is due rather than the esophoria. 
 In a certain proportion of cases, accommodation is feeble, pupil 
 sluggish and dilated. Attention is to be turned to the declination, 
 which may induce the esophoria. 
 
 Amblyopia is rather the rule than the exception in hyperphoria. 
 In esophoria at least, it is quite common to have but one third of 
 the visual power in one eye. 
 
 Nutrition of the eye is interfered with in heterophoria; the 
 crystalline lens and tunics of the eye are affected. The discovery 
 of causes, which induce perverted nerves, is more practical than 
 volumes of profound ambiguity. Muscular anomalies are etiolog- 
 ical factors in many forms of eye diseases; blepharites, conjuncti- 
 vitis, corneal ulcers. A large class of people, who are suffering 
 from "malaria," "biliousness", "nervous prostration," "dyspepsia," 
 "constipation," etc., are simply paying the penalty of uncorrected 
 heterophoria. 
 
96 HAZEN'S NEW FINDINGS 
 
 The influence of Anaphoria, Kataphoria and declination in dis- 
 eases of the eyes, as trachoma, and in respiratory diseases is dis- 
 cussed at length. Facial expression, taken on from condition of 
 the eye muscles in heterophoria, and declination occupies consider- 
 able space in analyzation. 
 
 TREATMENT. 
 
 TREATMENT OF DECLINATION. Under certain circum- 
 stances, spherical and cylindrical glasses, prismatic lenses will 
 have an influence in correcting declinations; no practical use oJ 
 them can be made in the treatment of this class of anomalies. 
 Strong convex lenses in neutralizing declination may have temp- 
 orary effect as in strabismus but not in the relief of the ciliary 
 muscles. Gymnastics are not, in any sense, curative. 
 
 Surgical Treatment of Declination. — Treatment. 1st. Gen- 
 eral. All the heterophoric conditions are depending on anatomical 
 peculiarities, and cannot be changed by medical or other treatment, 
 directed to general physical conditions, but temporary benefit 
 may result from treatment of this nature. Often the expense of 
 ocular adjustments is greater than the victim can afford, and the 
 result is, economy of nervous energy — rest. During this suspen- 
 sion the general physical tone may so greatly improve that dis- 
 turbances to health may be lost sight of for a time. The anomaly 
 is not removed. Tonics, change of air, abundant wholesome food, 
 to establish the general vigor of the nervous organization, consti- 
 tute the principal means for re-establishment of the nervous organi- 
 zation. 
 
 Electricity as a local stimulant, may induce a change of nutri- 
 tion. 
 
 He condemns the coal tar preparations, as chloral, sulphoral, etc. 
 
 They are paralyzers of the nuclear region, supplying the nerves 
 of the eye muscles and give temporary relief at the expense of more 
 lasting injury. 
 
 As direct agents for the relief of functional disturbances, prisms 
 are used, both as a means for gymnastics and in spectacles. He 
 says he formerly gave much attention to exercise of the muscles 
 and it was the means of relieving many of my earlier reported cases. 
 The method of using prisms in gymnastics is thus described. A 
 patient, looking at the flame of a candle at 20 feet distant, a weak 
 prism is placed, base out, before one eye — as soon as the images 
 unite, an equal prism, with its base out, is placed before the other 
 
GEORGE T. STEVENS, M. D. 97 
 
 eye. As fast as images are united this alternate addition of prisms 
 is continued, until it is no longer convenient to add them, or until 
 the patient fails to unite, Then, if union cannot take place, the 
 prisms are removed and the same process is repeated until more 
 can be accomplished if possible. If the patient is able to unite 
 these weak prisms, the surgeon begins with those of higher grade, 
 adding alternately until the images are no longer united. This 
 also, is repeated several times, and thus adding ability can be raised. 
 A similar method can be used in overcoming by abduction, the prism 
 being placed with its base in. In this case, it is rarely required 
 to add one prism above another before both eyes — a single prism 
 before one eye serving the purpose. 
 
 Gymnastics for declination can be done by use of Maddox rod 
 twisted from a horizontal position, but to get at the rotations, the 
 Clinoscope is necessary. The use of low degrees of prisms in spec- 
 tacles, correcting only a portion of the deviation, was carried on 
 by him to a large extent, at one time, but he found a very few who 
 derived important relief, and a smaller number still who found 
 permanent relief. He found better success in cases of anaphoria 
 and kataphoria, using prisms of equal strength on both sides. 
 Strabismus occurs because one or more of the muscles of the eye is 
 disabled or because there is some mechanical obstruction of the 
 free movement of one or both eves in certain directions. 
 
We have given much space to the review of Dr. Howe's 
 two volumes on the muscles of the eye. 1st. Because 
 it is a late production. 2nd. — Because the principal 
 characteristic of the work is the thorough analyzation 
 of the subject and classification of its minute subdivi- 
 sion and their presentation. 3rd. — It thoroughly repre- 
 sents the general status of the subject, in our time. 
 
 1907. 
 
 LUCIEN HOWE, M. A., M. D. 
 
 Professor of Ophthalmology, University of Buffalo, etc. 
 
 THE MUSCLES OF THE EYE. 
 2 Volumes. 
 
 After considering the anatomy of the eye, he gives the plan of 
 study of the physiology of the organ, and comes to the conclusion 
 that for "comfortable binocular vision, especially at the working 
 distance, a relation within certain limits must be maintained 
 between accommodation and convergence and torsion." The geome- 
 try of the globe is considered. Listing's plane the center of motion; 
 the angles, Alpha, Delta and Gamma and their clinical importance. 
 The relation of the visual acuity of the action of the eye. "The 
 position that the globe assumes is determined by the sensibility 
 at the fovea is so much greater, there is an instinctive desire to turn 
 the eye that the central part of the image shall fall just at that 
 point." "The smallest space between the points, which can be 
 perceived, must subtend an angle of about 55 seconds" — a fact 
 on which Test Type is constructed. For testing at this near point, 
 "it is desirable to use types for expression in meters or fractions 
 of a meter, if we are to make this part of Ophthalmology accord 
 with the rest." 
 
 "The normal eye is accustomed to suppress those images, which 
 do not fall on the fovea to such an extent that we are unconscious 
 of it." "It is sometimes the images of one eye that predominate, 
 
100 HAZEN'S NEW FINDINGS 
 
 sometimes those of the other, and so .long as wc can see in a part 
 of the \ isual tic-Id images of one eye, those of the other eye are com- 
 pletely suppressed." 7 'scheming. 
 
 "This lias an important bearing upon some forms of deviation 
 with which we have to deal." "Observations indicate that the 
 tendency of a single eye, when at rest, is to swing from the primary 
 position — sometimes inward, or more frequently outward, or out- 
 ward and upward." "We constantly find ,in practice, a slight 
 degree of latent convergence or esophoria." "In sleep, the eye 
 assumes a position of up and outward." Blind eyes, it is said, 
 "almost invariably turn outward," but this is not quite true. The 
 examination of 21 pupils of the N. Y. State school. for the blind, 
 showed that there were almost as many of abnormal convergence 
 as of divergence. "We must conclude therefore, that the mono- 
 cular position of rest seldom corresponds to the primary position." 
 
 Accommodation. — Range of accommodation indicates "the 
 amount of accommodation of which an eye is capable." When 
 Test Letters are well constructed and reduced to proper size, it 
 is much more convenient. The many methods of investigation 
 of the pupillary reaction are so poorly adapted to clinical use that 
 practitioners do not avail themselves of them. In youth, 15 to 
 20 years, the pupil is about 4.1mm and at 50 years, about 3mm. 
 The main causes which produce changes in its diameter are — 1st. 
 Intensity of illumination. 2nd. Act of accommodation contracts. 
 3d. Size relates to respiration and circulation. 4th. "Varying 
 conditions of the nervous system — especially those involving the 
 sympathies, fear, surprise, emotion" and the more lasting changes 
 from lesions of the motor oculi. He uses a modified miscroscope 
 with a micrometer eye-piece. 
 
 ASTIGMATIC. 
 
 Irregular Contraction of the Ciliary Muscle. 
 
 From the irregular action may be established — 1st. Facts of 
 anatomical arrangement — 2nd. In other muscles exact measure- 
 ments show a different degree of tension of different fibres — 3rd. 
 "Certain branches of the 3d nerve are sometimes paretic or 'in- 
 sufficient, leaving muscles supplied by other branches in an entirely 
 normal condition." 4th. The action of the ciliary to overcome 
 astigmatism in the consulting room, contradiction is found between 
 the declaration of the patient, on looking at the charts, and what 
 is found by scientific examination. 5th. Sensation of the patient, 
 headache, and its relief on correction. 
 
LUCIEN HOWE, M. D. 101 
 
 ONE EYE IN MOTION. 
 
 Nomenclature. 
 
 Adduction. Intorsion. 
 
 Abduction. Extorsion. 
 
 Superduction. True torsion. 
 
 Subduction. False torsion. 
 
 Cirsumduction, or Cycloduction. 
 
 Ophthalmotropes are models of mechanisms to produce the motions 
 of the eyes and in great variety. It assists the teachers in con- 
 veying the fundamental ideas concerning the movements of the 
 balls by the ocular muscles. "All the points, which an eye can see 
 or fix, while the head remains immovable, constitute the field of 
 fixation or the motor field." "Most physiologists and clinicians 
 have depended on the perimeter for measuring this. "It is impor- 
 tant to remember that the limit of the field of fixation is not to 
 be judged entirely by the number of degrees which an eye can turn 
 in any given direction. Much also depends upon the manner 
 in which that motion is made." We wish to know, for instance, in 
 abnormal convergence: 
 
 1st. Does any deviation of one or both eyes exist? 
 2nd. Which eye — if either, is specially affected? 
 3d. Exactly which muscle or group of muscles is affected? 
 4th. Is the deviation due to excessive contraction of the adductors, 
 (action esotropia) or to paresis of the abductors (passive eso- 
 tropia) or is it due to both causes?" 
 As to the 1st. Deviations are not always apparent — they may 
 be latent and this is shown sometimes by the behavior of the eye 
 as it approaches the limits. 2nd. "Most of the tests with double 
 
 images do not show which eye" has the difficulty. 3rd. 
 
 The limits of field assist in locating the group of muscles or even 
 the principal muscle. 4th. It is difficult to decide and require 
 aid in other ways. The lifting power of the adductors, when looking 
 at a distance, averages about 18 grams. This should not be con- 
 fused with the tensile strength — that is the weight which a muscle 
 will sustain without breaking — 2 to 2 and 14 -Kilos which is several 
 times greater than that of the ordinary muscular fibre." The 
 rapidity of the lateral motion of the eye as found by photograms 
 is that it requires fifty to sixty thousandths for 30 degrees, and 
 about 100 thousandths for one 100th of a second for 100 degrees. 
 In the act of reading from left to right, the eye stops four or five 
 times for perhaps 5 or 10 thousandths of a second. The movements 
 of the eye, while reading, are shown by the photogram — at the 
 
L02 HAZEN'S NEW FINDINGS 
 
 end of the line the eye rests for a varying length of time, then 
 swings back to the left and begins again. 
 
 In winking the average time taken is about a half second. The 
 time of remaining closed is about two to three tenths of a second. 
 The lid is raised more slowly than it is closed — occupying from 
 one i" two tenths of a second. When one eye is slower than the 
 other in its movements, it may be the first indication of a muscular 
 paralysis. A wheel motion of one eye only is possible, but is un- 
 usual and is of no practical importance. Contrary to Maddox 
 in regard to the silence of the eye muscles when in motion, Herring 
 is quoted as saying, "that several proficient auscultators were 
 able to tell when the eyes were looking at a distance or converging, 
 by the sound produced." 
 
 DIVISION 1. 
 BOTH EYES AT REST. 
 
 The relation of one eye to the other and the fundamental prin- 
 ciple, which controls all associated action, must be taken into ac- 
 count. As nature abhors a vacuum, so is the desire for single vision. 
 "The associated motion of two eyes requires, first of all, that the 
 image of an object looked at, shall fall on parts of the two retinas 
 which correspond to each other. "The measurement of the inter- 
 ocular base line, which is the distance between the centers of the 
 eyes, or pupils of the eyes, is a practical necessity for several reasons. 
 The Primary position is when the visual axes of the horizontal 
 plane are parallel to each other and perpendicular to the line joining 
 the centers of the two eyes. The different forms of heterophoria 
 are, "essentially, passive conditions." When we "disassociate 
 the retinal image in one eye, from its fellow eye, each globe tends 
 to swing into the position most natural to it." Then if single 
 vision is maintained in heterophoria, it requires a constant effort 
 of one or more groups of muscles to maintain single vision. 
 
 The essentials for examination are — room, of six meters in length, 
 darkened, and light placed at six meters or more. A candle flame 
 s inconvenient and inaccurate, but if used, should be inclosed in 
 an opaque cylinder, with circular spring on one side, and a head 
 rest to keep the head in proper position. The Maddox rod is an 
 admirable test in many respects. A Phorometer in connection 
 with head rest is necessary for exactness. 
 
LUCIEN HOWE, M. D. 103 
 
 DIVISION II. 
 
 CLASSIFICATION OF TESTS. 
 1st. Group. 
 
 1st. Displacement of the clear image of one eye, up or down. 
 
 (a) As Von Graefe's single prism, base up or down. 
 
 (b) Stevens, Savage and others — two prisms, one base up, and 
 the other down — one over each eye. 
 
 (c) Maddox double prism, bases joined. 
 
 2nd. Group. 
 
 The image is clear in one eye, but in the other is so disturbed or 
 blurred that the desire for vision is abolished. 
 
 (a) Maddox rod. (b) Stenopaic Lens. (c) Cobalt glass. 
 
 3rd. Group. 
 
 The Screen test — blinding one eye and noting whether the eye screened 
 swings away to another point of rest. 
 
 Instruments must be constructed so that they can be arranged 
 exactly in the same position. Much greater exactness is necessary 
 before we can lessen materially the existing confusion concerning 
 muscular statics. The ciliary muscle is an important factor in 
 determining the position of the visual axis. In hypermetropia 
 there is some tension of that muscle in seeing distant objects clearly. 
 Results will be less conflicting if atropia is used and a correction 
 of the refraction is made. "The recti muscles influence the static 
 condition of the visual axes, for after atropia and correction of 
 ametropia there is movement. The condition of the retina in- 
 fluences this also, for it is sometimes difficult for individuals to 
 perceive the image." 
 
 The so called "Position of Rest" is either apparent, which is 
 simply a relaxation, more or less complete, of the extra ocular- 
 muscles, or actual .which is relaxation of both intra-ocular and 
 extra-ocular muscles. The results obtained in examination of large 
 numbers of persons were striking in showing that orthophoria was 
 by no means necessary to comfortable vision as had formerly 
 been supposed. The methods ordinarily used for determining 
 the static position of the visual axes are not altogether satisfactory. 
 
 DIVISION III. 
 POSITION OF THE VERTICAL AXES. 
 
 There may exist a tendency of the vertical axes to revolve about 
 the anterior-posterior axes. When the eyes arc in a primary 
 
104 HAZEN'S NEW FINDINGS 
 
 posiii"ii the vertical axes tend to diverge upward, at an angle with 
 each other of about three degrees. The fact that the vertical 
 axes do revolve about the anterior-posterior axes is important and 
 what is called true torsion. 
 
 Tl sis. 
 
 The double prism and elaborated by Savage. 
 
 The Steven's Clinoscope & Yolkmann's Disks. 
 
 The adaption of Yolkmann's Disks to Converging Clinoscope. 
 
 Test for Cyclothoria. 
 
 The double prism is the simplest and the most easily understood 
 but it is not exact. The Clinoscope, with intelligent patients, is 
 most exact. (One and one-half to two degrees, each eye.) By 
 tipping the upper radius out four degrees to allow for the normal 
 outward tipping — then count any variation as real cyclophoria. 
 It is better to use the terms, outward and inward, than plus and 
 minus. 
 
 Both Eyes — Associated Movements. 
 
 The motions of one eye alone include much which relates to 
 both. The two eyes may be regarded as the halves of a single 
 organ. In order to avoid double vision, each eye instinctively 
 turns its visual axis to the point to which attention is directed. 
 Although the theories of the mechanism of the motor impulses 
 relating to both of the eyes in the same direction, have been dis- 
 carded, our knowledge of the functions of the cells in the muscles 
 in different portions of the brain, has grown more exact. There 
 are at least six conjugate innervations. 
 
 Classification of Associated Movements. 
 
 1st. A torsional movement is made about the visual axis, which 
 is the hub of the wheel motions. These motions are very limited 
 but must be considered in connection with true torsion, which 
 accompanies convergence. They are a cycloduction-active. Man}' 
 devices have been made to measure. The method of Herring is 
 described as simple — Donders' Isoscope — his own, using the Mad- 
 dox rod principle. The Maximum and Minimum extorsion and 
 intorsion is found to be in a limited number examined — Maximum 
 extorsion 4° and Minimum intorsion 2 1 /?. The Maximum extorsion 
 and intorsion are often more than twice as much as the Minimum, 
 and vary greatly in different persons. The importance of this 
 studv is variouslv estimated. "The evidence is abundant where 
 
LUCIEN HOWE, M. D. 105 
 
 the axes of astigmatism approach each other, but are still suf- 
 ficiently divergent to produce this effect at torsion. That condition 
 is a very important cause of asthenopia, although the degree of 
 astigmatism be slight." 
 
 2nd. "The parallel visual axes move in one of the principal 
 meridians to the right, left, up or down. There is no torsion. 
 The clinical bearing in this connection is with the double images 
 in paralysis." 
 
 3rd. The parallel visual axes move obliquely. The vertical and 
 horizontal axes appear to change their position, called "false torsion, 
 by Maddux. Before him, it was described simply torsion. It 
 is not a true wheel motion, as shown by detailed descriptions by 
 different authors. This also has a bearing in cases of paralysis. 
 
 4th. The visual axes do not remain parallel but converge. In 
 doing so the upper end of each vertical axes rotates slightly outward, 
 producing true torsion. 
 
 Convergence is the most important group of motions with 
 which we have to deal, as it is accompanied with a certain amount 
 of Accommodation, and of true torsion. We now estimate it by 
 the meter angles of Nagel. He gives a table of the degrees of con- 
 vergence expressed in meter angles of the different pupillary dis- 
 tances from one to twenty degrees. 
 
 The Relative Fusion Power of the Muscles. 
 
 The power of the abductor muscles is found by placing prisms, 
 base out, before one or both eyes, the effort being to avoid double 
 vision. One or both eyes turn in. As this effort is one exerted 
 in relation to the opposing groups of muscles, we can properly call 
 it the relative power of adduction. It depends upon two factors; 
 the actual strength of the recti muscles and the so called instinctive 
 desire for fusion. Both of these vary in different individuals. 
 The same principle applies to all ductions. 
 
 How To Measure Fusion Power. 
 
 If the parallel visual axes are directed to a distant object, and 
 a prism is held before the right eye with the base out, then, as the 
 ray from the light passes through the prism is deflected towards 
 its base, the image of the light falls not on the fovea of the rit'ht 
 eye, but on its outer side and crossed diplopia results; with an in- 
 stinctive desire to overcome it, the eye turns far enough inward 
 to overcome the diplopia; with a stronger prism the eye turns 
 
106 IIAZK.VS NKW KIN DINGS 
 
 in. and still more until the strongest prism is reached which the 
 adductors can overcome., which is said to represent the power of 
 adduction of that pair ot eyes. We are very far from agreeing on 
 the interpretation of the data obtained by this simple procedure. 
 We have most confused the idea of how the power of adduction 
 should be measured — what its amount is in normal conditions, and 
 what its value is clinically, and indeed whether such examinations 
 have any value at all. 
 
 Methods of Examinations. 
 
 Let us begin by placing a prism of five degrees ,base out before 
 the right eye. Suppose the eye overcomes this prism and others 
 of gradually increasing strength, as they are selected from the trial 
 case until we find at last that one of nine degrees represents the total 
 abducting power, or we may begin with prisms of 12 or 14 , 
 taken again from the test case and decreasing from that point, 
 find again that one of nine degrees is the strongest which the adduc- 
 tor muscles can overcome. If however, we vary that method of 
 testing, by gradually increasing the strength of the prism, without 
 allowing the eye an interval in which to rest — the result is different. 
 If we use the prisms in series, the adduction can be brought to ten 
 or twelve, and if we use rotating prisms, adduction can be brought 
 to fifteen or eighteen, and occasionally greater. Evidently, we 
 have different results, dependent upon different methods. 
 
 1st. The Minimum relative of fusion power of a group of muscles, 
 is that which w r e obtain by placing different prisms before the eye, 
 leaving a considerable interval between the tests, or it is that 
 which is found when we pass from a prism strong enough to pro- 
 duce diplopia to one which can be overcome. 
 
 2nd. The Maximum relative of fusion power of a group of mus- 
 cles is that which we obtain when we pass, by gradual increment, 
 from a prism, which is not strong enough to produce diplopia to 
 one which cannot be overcome. It may be observed that this 
 "development" of the latent heterophoria is something which may 
 be done by almost any one who has abnormal eyes, if he will take 
 the trouble to use prisms of increasing strength, regularly and pa- 
 tiently, even for a comparatively short time. Such experiments, on 
 normal or abnormal eyes, show how readily the muscular power 
 can be increased, and indeed, np limit within the bounds of cre- 
 dulity, seems to have been placed on the power of fusion. In a 
 word, the maximum of fusion power is of some interest for the 
 sake of comparison, but certainly is not of as much importance 
 in itself, as many writers on the subject would have us think. 
 
LUCIEN HOWE, M. D. 107 
 
 Balance of Power. 
 
 It should not be inferred that relative weakness in a certain 
 group of muscles, as measured in terms of prisms, is an indication of 
 inability of that group of muscles to do its work in a physiological 
 manner. In different individuals whose eyes are practicallv nor- 
 mal, the minimum power of adduction, for example, may be quite 
 small, occasionally only half the average, but in these individuals 
 we find, ordinarily, that the minimum power of the opposing group 
 is also less than normal,, and often in a corresponding degree. On 
 the other hand, there are individuals who have a minimum power 
 of adduction largely in excess of the average, and in these we are 
 apt to find a correspondingly large amount of abductive power. 
 In other words, it is certain that in the normal condition, we may 
 have decided variations in the relative strength of different individ- 
 uals, but that the balance between the opposing groups of muscles 
 remains, a in general way, the same. A pair of scales will balance 
 whether there is a weight of the grains or a hundred grams on 
 either side. 
 
 Test of Balance With Convergence. 
 
 For distance heterophoria is as frequent as orthophoria. That 
 is not the case when accommodation and convergence is brought 
 into action. 
 
 Test of Von Graefe — dot and line. When the individual sees 
 only one vertical line with two dots in its course, we say that "mus- 
 cle balance exists for that point, whether it be three, four or five 
 meter angles of convergence. This condition is often described as 
 orthophoria at the near point. That term, however, is both con- 
 tradictory and indefinite. If orthophoria is a "tendency of the 
 visual lines in parallelism, evidently that cannot occur in conver- 
 gence If the two dots are not in the same vertical line, 
 
 they can be made to appear so by placing a second prism at right 
 angles to the first, as when correcting a heterophoria. The position 
 and strength of the second prism then shows the kind and degree 
 of heterophoria, which exists with convergence at a certain num- 
 ber of meter angles, whatever that may be. 
 
 Stereoscopes. The Stereoscope is of decided assistance in 
 treating certain forms of muscular difficulties. 
 
108 HAZEN'S NEW FINDINGS 
 
 DIVISION III. 
 
 I'm Relation of Accommodation to Convergence and 
 Relative Accommodation. 
 
 The range of Accommodation — the relative accommodation — 
 — the plotting of relative accommodation — how the range of 
 relative accommodation is influenced by age is minutely handled 
 and described. 
 
 DIVISION IV. 
 
 Relation of Convergence to Accommodation — Relative 
 Convergence. 
 
 The Clinical Importance of the Relations of Accommodation 
 and Convergence will be met at every turn and no phase of our 
 subject is worthy of more careful study. 
 
 DIVISION V. 
 
 Relation of both Accommodation and Convergence to 
 Torsion or True Torsion with Convergence. 
 
 The relation of Torsion is elaborately defined and the measuring 
 is fully described. Torsion is one of the three factors which con- 
 tribute to comfortable vision at the near point. Relation of both 
 Accommodation and Convergence to Torsion with Convergence. 
 "Torsion with convergence is the tipping outward of the upper 
 ends of the vertical axes (true torsion) which accompanies con- 
 vergence. 
 
 Appliances. — "It is necessary to distinguish different instru- 
 ments for measuring the tipping of the vertical axes." Those 
 which measure the cyclophoria, which is a passive condition — tor- 
 tometers which measure the cycloduction. "Most of the Tor- 
 tometers are also Clinoscopes, but all Clinoscopes are not Tor- 
 tometers." 
 
 The determination of the plane in which the visual axes lie is 
 desirable. Le Contes' method is the simplest. The tipping out- 
 ward of the upper end of the vertical axes usually increases as the 
 plane of the axes of vision is elevated and not in proportion to the 
 amount of convergence. It is relative. The object of torsion is 
 not clearly understood. When torsion is disturbed artificially — 
 the effort at torsion, which the eyes make to fuse these lines, gives 
 a sense of discomfort. It will be seen that torsion must be taken 
 into account together with accommodation and convergence. 
 Muscle Balance is (as defined) the condition in which, with comfor- 
 table binocular vision, accommodation, convergence, and torsion 
 
LUCIEN HOWE, M. D. 109 
 
 bear their normal relations to each other. We need a physiolog- 
 ical standard, with which to compare nervous forms of muscle 
 balance ,or unbalance as it is sometimes called. Muscle Balance 
 is relative. It should not be confused with orthophoria. 
 
 Muscle Balance (Eukenesis). 
 
 1st. Relates to extrinsic and intrinsic muscles. 
 
 2nd. Visual lines parallel or converging. 
 
 3d. Binocular vision must exist. 
 
 4th. Comfort is essential. 
 
 Relation of the "General Strength" to the Physiological 
 Action of the Ocular Muscles. 
 
 The power of the eye muscles is given in terms of prisms, whereas 
 the condition of the muscles of the body is given in foot-pounds. 
 
 "When we take into account both the minimum and maximum 
 power of different groups of the ocular muscles — for example, 
 adduction and abduction — each measured by different methods, 
 we have at least an approximate expression of the strength of the 
 ocular muscles in that individual." "The muscular tone does not 
 
 refer to the strength or lifting power it is the ability of a 
 
 muscle or a group of muscles to perform the amount of work nor- 
 mally devolving upon them without the development of fatigue 
 . . . .there can be no question though, but that this normal tone of 
 the ocular muscles is also in proportion to the tone of the muscles 
 in other parts of the body of that individual. ... It is true that 
 we often find invalids, who can read and work all day under adverse 
 circumstances." Where we find an imbalance or fault of the mus- 
 cles, we should not be satisfied with local means only, but the 
 strength or tone of the muscles of the body should be improved . 
 
 HOWE, VOL. II. 
 
 PART I. 
 
 Ocular Muscle Imbalance. 
 
 The three primary forces in the act of comfortable vision have, 
 each, a secondary one — "resistance". Balance is rare as perfect 
 health, but it does exist. Where the primary and secondary fac- 
 tors bear their normal relations, we have balance or eukenesis. The 
 range of variation without a sensation of real discomfort has been 
 called, "The area of comfort." Imbalance is the condition in which 
 accommodation, convergence and torsion do not bear their normal 
 relations, called dyakinesis. 
 
lie HAZEN'S NEW FINDINGS 
 
 In the time ol Von Graefe, what is now called hcterophoria was 
 called latent convergence and divergence. All latent abnormalities 
 gradually came to be described by English and American writers as 
 imbalance. It should be remembered that in all forms of eye 
 strain — the ultimate cause of uncomfortable svsmptoms is the in- 
 stinctive effort to obtain and to maintain perfect vision, and also 
 binocular vision when that is possible. Of the various forms of 
 imbalance, it is customary to speak of them as varieties of asthenopia. 
 This is wrong and unfortunate — and "we shall attempt to dispense, 
 when we can. with the term asthenopia." We have a lack in our 
 nomenclature, which includes anomalies of accommodation. 
 
 Intra-Ocular. 
 
 According to our modern nomenclature of the external muscles, 
 this has nothing to do with the ciliary muscle. There is evident 
 need and the single word, heterocykinesis, hereto (varied) cycle 
 (as in cyclites) Kinesis (strength or tenacity) but we have the English 
 terms, anomalies of accommodation, spasm and paresis (abnormal 
 action of the intra-ocular muscles.) 
 
 Extra-Ocular. 
 
 Imbalance of — We know these as latent deviations or heterophoria 
 
 Is esophoria due to excessive contradiction of the adductors or 
 associated with excessive accommodation — that is — is it active 
 esophoria an actual excessive convergence, or is it the tendency 
 to deviation, dependent on some abnormal relaxitive of the ab- 
 ductors — that is — is it passive esophoria? If so, it would be a 
 relative excessive convergence, so, in a similar manner with the 
 other deviations, and of this proposition, he makes eleven groupings. 
 Besides these, there are compound forms of imbalance — mixed 
 simple imbalance, and an associated compound imbalance. Sim- 
 ple Imbalance, "is one in which there is an abnormal condition 
 of only one of the principal forces or a pair of forces, which enter 
 into the act of normal binocular vision." Compound Imbalance, 
 "is one in which there is an abnormal condition of two or more 
 principal forces or pairs of forces. A large majority of all cases 
 of imbalance are of the compound forms." Imbalance should not 
 be confused with its results. 
 
 "Eye strain is a result of ocular imbalance. A person may 
 or may not be conscious of strain." "Asthenopia is a group of 
 symptoms — also a result of a muscle imbalance. The patient 
 is conscious of it, often to a painful degree. We shall deal only 
 
LUCIEN HOWE, M. D. Ill 
 
 with those few symptoms, which all practitioners agree, do frequently 
 accompany imbalance. These may be called the cardinal symp- 
 toms. 
 
 Blurring, frequently due to insufficient focusing. 
 
 Headache — varieties almost innumerable. 
 
 Location of — frontal, vertex, occiput, extending down the neck, 
 even to the back. 
 
 Hyperemia of the conjunctiva. 
 
 Increased Lachrymation. 
 
 At the first visit, we should enter only a provisional diagnosis. 
 
 SIMPLE IMBALANCE INVOLVING ONLY THE INTRAOCULAR 
 
 MUSCLES. 
 
 DIVISION I. 
 
 " Actual Excessive Accommodation." 
 
 In actual excessive accommodation, he unqualifiedly answers 
 affirmatively that it is desirable to make a really exact correction 
 of ametropia. In some cases, a persistent use of belladonna for 
 months — even to six. 
 
 DIVISION II. 
 
 "Relative Excessive Accommodation," the treatment of this 
 simple imbalance is by correcting the ametropia. 
 
 DIVISION III. 
 
 "Actual Insufficient Accommodation/" find the cause and 
 treat that and give a guarded prognosis. Bodily exercise is recom- 
 mended, but ocular exercise is not mentioned. 
 
 DIVISION IV. 
 
 Relative Insufficient Accommodation. It is the most 
 important simple imbalance. 
 
 The insufficient accommodation is dependent upon, or relative 
 to the resistance offered by the lens. 
 
 The range of accommodation is either normal or its action is 
 limited — the positive part small — the negative large. 
 
 A sharp line of distinction cannot always be drawn between 
 actual and relative insufficient accommodation — causes — Pres- 
 byopia — Hypermetropia — Astigmatism — Treatment is obvious — 
 If discomfort continues — rest and Dverism. 
 
112 HAZEN'S Xi:W FINDINGS 
 
 DIVISION V. 
 
 I nequal Refraction 'Anisometropia) Treatment-Correction. 
 Simple Imbalance Involving the Extraocular Muscles Only. 
 (Simple heterophoria) 
 
 EXTRA OCULAR MUSCLES. 
 
 DIVISION I. 
 
 Latent Deviations Produced by the Horizontal Muscles. 
 
 (Anomolies of Convergence.) 
 
 SL B-DIVISION I. — -Active esophoria or actual excessive conver- 
 gence, excessive action of adductors rather than relaxation of ab- 
 ductors. We frequently have, in normal eyes, a tendency of the 
 axes to converge or diverge, when the individual looks into the 
 distance, but when converging and accommodating, we have 
 muscle balance, (eukinesis) Symptoms given are objective. 
 Among the subjective are feelings of tension and panoramic fa- 
 tigue. 
 
 Causes — -Anatomical, Physiological, Central. 
 
 SUB-DIVISION II. — Passive Esophoria [Relative excessive 
 convergence.) Visual axes tend to turn inward from lack of resis- 
 tance of abductors. The abductors are easily fatigued. Fre- 
 quency is not as great as the active form. The positive relative 
 convergence — large and often irregular at different points and also 
 different times. Causes may be anatomical — often paralysis, 
 paresis. 
 
 SUB-DIVISION III.— Active Esophoria {Relative Insufficient 
 Convergence.) 
 
 This is a rare condition. Cause — some imperfect action of the 
 abductors. Test — Von Graefe's dot and line test. Treatment — - 
 Rest is not here indicated, but strengthening convergence. The 
 problem is how to make the adductors stronger than normal, in 
 order to balance the excessive power of abduction. That is not 
 easy to accomplish. A gymnast can develop the muscles of the 
 arm, but with some difficulty and only to a limited degree. Some 
 temporary relief from the discomfort can usually be obtained by 
 abductive process, but when continued too long it makes matters 
 worse. In this form of exophoria, advancement is warrantable. 
 General treatment — medication and hygiene. 
 
LUCIEN HOWE, M. D. 113 
 
 SUB-DIVISION IV.— Passive Kxophoria {Actual, Insufficient 
 
 Convergence.) 
 
 The visual axes tend to diverge because of insufficient action of 
 the adductors. This is next to insufficient accommodation in 
 frequency. A differential diagnosis from the active, in many cases, 
 is impossible. Objectively, the differential diagnosis can be made 
 with the perimeter, tropometer, photograms. Subjective — there 
 are abundant and varied forms of eye-strain — the cardinal 
 symptoms always present. Sometimes we have an imperfect 
 knee-jerk. Causes — anatomical — analogous to those in relative 
 insufficient accommodation — disturbance of the nervous system — 
 over correction of strabismus. 
 
 Treatment — Exercise of the ocular muscles — Wall and wall 
 exercise — Occasional strong prisms for a distance — ditto for near- 
 stereoscope — weak prisms for constant use — decentering lenses — 
 gradual and frequent strengthening of the wearing prisms. 
 
 DIVISION II. 
 
 Latent Deviations Produced by the oblique Muscles. 
 
 (Anomalies of Torsion) Cyclophoria. 
 
 SUB-DIVISION I. — Excessive Torsion. The frequency seems 
 to be rather rare — perhaps because exact measurements of it are 
 comparatively few. They are more frequent in relation to astig- 
 matism, and more important than is usually supposed. Causes — 
 Astigmatism. Treatment. — Co.rection of ametropia. As to exer- 
 cise of the oblique muscles, thus fai the results obtained have been 
 of rather doubtful value. 
 
 SUB-DIVISION II. Insufficient Torsion. 
 
 The upper end of the vertical axis does not tend to turn outward 
 as far as it should normally. Treatment. — Same as division I — 
 with modifications. 
 
 DIVISION III. 
 
 SUB-DIVISION I. — Latent Deviations Produced by the 
 Vertical Muscles Hyperphoria and hypophoria. 
 
 When Hyperphoria is a tendency of one eye to turn up while the 
 other fixes the distant object. Hypophoria is the tendency of the 
 other to turn downward. To make a definite diagnosis between 
 the two is not possible, and in the matter of treatment is of slight 
 importance. The vertical symmetry of the face can be seen in 
 
114 HAZEN'S NEW FINDINGS 
 
 some — the eyes arc not on the same horizontal plane and it is often 
 rectified by tipping the head. We do not know whether the upward 
 tendency is <>f an active or of a passive nature. Treatment. — 
 Local consists in use of prisms, and not knowing whether the ten- 
 dency to turn up is dependent on undue contraction of the levators 
 or upon relaxation of the depressors — the placing of prisms is em- 
 pirical. Operation is to be considered only as a last resort. 
 
 SUB-DIVISION II. Anophoria and Katophoria. 
 
 Their number is exceedingly small and have not yet been studied 
 with the care, which they perhaps deserve. The tendency to lower 
 the chin and raise the eyes; the deleterious position of the head in 
 its effect on respiration, (which Stevens gives) he thinks "is un- 
 worthy of serious consideration." he considers it a bad habit and 
 shows a lack of proper training. He suggests a prism, with base 
 down, over each eye. Repetition is unnecessary in the opposite 
 position of Katophoria. 
 
 COMPOUND IMBALANCE. 
 
 Anomalies of two or More Groups of Muuscles. 
 DIVISION I. 
 
 There are two varieties — associated and disassociated. "As a 
 disturbance of a single one of the three pairs of factors is apt to 
 also disturb the relation of one or more of the other factors, we may, 
 apparently, have as man}' different forms of compound imbalance 
 as there are permutations of six." But. disheartening as the con- 
 ditions may be at first glance, the treatment problem is not so com- 
 plicated, for, "when we correct the principal abnormal element, 
 the others associated, tend to correct themselves." "Compound 
 imbalance is not a disease, but only the name of two or more abnor- 
 mal muscular conditions, each of which, is by itself distinct from 
 the other." One is called the excesssive or spastic type — excessive 
 accommodation and an esophoria or sometimes an excess of torsion. 
 We should determine, if possible, the relative importance of each 
 element in the compound imbalance. The imbalance of the intra- 
 ocular muscles is usually more important than that of the extra- 
 ocular. "A decided imperfection of torsion is usually of more 
 importance than an imperfection of convergence." 
 
LUCIEN HOWE, M. D. 115 
 
 DIVISION II. 
 
 SUB-DIVISION I. Effects of the Intraocular Muscles 
 on the Intraocular Structures. 
 
 Prolonged effort of accommodation produces Cycletes, Iritis, 
 pathological changes in Choroid, in Retina, Macula, Optic nerve. 
 Eye-strain as a cause of Glaucoma is doubtful but it is claimed by 
 some, it causes peripheral opacities in the lens. 
 
 SUB-DIVISION II. — Effects of the Extraocular Muscles 
 
 ON THE GLOBE. 
 
 No one can study the aspect without being convinced that the 
 extra-ocular muscles do affect the form of the globe. It is generally 
 agreed that astigmatism can be developed. The broad tendons 
 of the recti and especially of the two obliques might press upon the 
 globe to impede the return of venous blood and thus increase the 
 ocular tension. 
 
 SUB-DIVISION III. Effects of the Ocular Muscles on 
 Neighboring Structures. 
 
 Hyperemia of the Conjunctiva; associated with it a feeling of 
 discomfort, itching or distant pain, which causes the person to 
 close the lid and rub the eyes; increased lachrymation; corneal 
 inflammation; blepharitis, associated with astigmatism. 
 
 Headaches. — Our ignorance on this subject is almost as great 
 as it was a half century ago, depending on imperfect nomenclature. 
 The locality of pain, its area, and whether that pain is accompanied 
 by tenderness. "As there has been a decided looseness in using 
 the term headache, so there has been a similar laxity in using the 
 term eye-strain when related to that headache. " We wish to know- 
 kind and degree of ametropia — imbalance." It is divided into three 
 groups. 
 
 1st. Headache, the result of contraction of accessory muscles of 
 accommodation. 
 
 2nd. Those which are directly the result of imbalance. 
 
 3d. Those which are a reflex from disorders of the stomach or 
 other parts of the body. 
 
 Torticollis occur in some forms of imperfect action of the ocular 
 muscles. Such an enforced position of the head, maintained for 
 a long time, results in the condition we recognize as Torticollis or 
 Scoliosis. 
 
IK- HAZEN'S NEW FINDINGS 
 
 SI B-DIVISION IV. Effects of the Ocular Muscles ox 
 thi mm k parts of the Body. (Indirect Effects of Imbalance.) 
 
 They arc probably produced through the sympathetic nervous 
 system. Their importance has been unduly exaggerated — usually 
 called, "reflexes of eye strain.'' 1 
 
 "Donders," and for some time after him, no one suspected that 
 the action of the muscles would produce much inconvenience 
 beyond the cardinal symptoms, which were then called asthenopia." 
 "Gradually, increasing clinical experience has modified our idea of 
 asthenopia." Symptomatology is enlarged beyond the cardinal 
 systems, to "pain extending upon the neck and shoulders," nausea 
 including many reflexes of a neurotic type, dependent upon the 
 the use of the eyes. Many of these symptoms may result directly 
 from an imperfect action of the ocular muscles, and also disturbances 
 of the general system, acting on a primary cause, may affect the 
 ocular muscles and are called asthenopia." 
 
 Reflexes. — The criterion to determine whether a given symptom 
 is the result of muscle imbalance — we should establish — (a) "a 
 relation in time — should follow the imbalance or be coincident 
 with it;" (b) "there should be a relation in degree; ordinarily the 
 amount of imbalance is in some proportion to the severity; the 
 severity of the reflex is sometimes entirely out of proportion to the 
 amount of imbalance;" (c) "the partial or total correction of the 
 imbalance should produce a corresponding effect upon the reflexes;" 
 (d) "everything which may be considered a contributing cause in 
 producing reflexes should be eliminated." "The frequency of such 
 reflexes — especially in America, is noted by many." Americans 
 use their eyes in a careless manner. The hurry and mental strain 
 make unusual demands on the nervous system. "Reflexes are due 
 to difficulties of digestion." "Heat and dryness of the atmos- 
 phere in our homes cause Conjunctivitis and thus give rise to 
 symptoms of imbalance." 
 
 SUB-DIVISION V. — Effect of the Ocular Muscles on the 
 Nervous System. 
 
 Headaches. — Indirectly the result of Imbalance. 
 
 Sick Headache (migraine) belongs to this group. The litera- 
 ture of late years has grown large in which the remedy has been 
 correction of the refraction. Fatigue, easily brought on by use 
 of eyes.. 
 
 Neurasthenia. — Imbalance of the ocular muscles, with the 
 resulting eye strain, is one of the causes which we class together 
 
LUCIEN HOWE, M. D. 117 
 
 under that one name. That eye-strain is usually a prominent 
 cause, and occasionally the only cause, is an extreme view. 
 
 Hysteria. — The limbo of Neurotics, and the unreliable state- 
 ments of them is depicted. 
 
 Chorea. The off-hand statement, frequently made, that chorea 
 is always or even usually due to ocular imbalance, "is not supported 
 by fact." There are a few cases in which the relation between 
 eye-strain and chorea is, apparently, that of cause and effect. To 
 condemn any patient to glasses, the evidence must be as conclusive 
 as possible. 
 
 Epilepsy. — The term means nothing exact. "It is certain that 
 some cases show a distinct relation between muscular imbalance 
 and epilepsy." In a small number of cases, the attacks are 
 lessened by suitable glasses. 
 
 Other Neurotic Conditions. — The literature is abundant. The 
 nervous effect on the mental and moral conditions, the chain of 
 circumstances is far from complete. 
 
 SUB-DIVISION VI. Effects of the Ocular Muscles on 
 Parts of the Body other than the Nervous System. 
 
 On the teeth; on the mucus membrane of the nose; on the stomach. 
 The effect of extra effort at focusing or movement of the eyes, as 
 in a car, swing, or with some, when at sea, or use of glasses on nor- 
 mal or abnormal eyes, affecting the stomach, is in evidence. It 
 was proved by a case of gastric fistula, that the acerbity of the 
 stomach was affected by certain glasses. On certain parts of the 
 body; the heart, the liver, the kidneys, it is doubtful whether the 
 glasses, which were thought to improve these condition, did more 
 than relieve some existing eye-strain, and thus directly comforted 
 the patient. 
 
 EXAGQERATED OPINIONS OF THE EFFECT OF EYE STRAIN. 
 
 If we admit that certain reflexes can be produced by imbalance' 
 the question arises why all reflexes do not come from the same 
 cause. Some of these cases of nervous reflexes are cured by the 
 adjustment of glasses or by certain operations, but in most cases 
 they are not. Exaggerated statements have been made in late 
 years to prove, that well known authors have been sufferers from 
 eye-strain, and that their misanthropic views, indigestions or ill 
 temper, were due to imperfection of the ocular muscles. It seems 
 a little hasty, to say the least, thus to jump at a diagnosis when the 
 
US HAZEN'S NEW FINDINGS 
 
 patient has been dead for many years. Such literary diversions 
 arc clever and popular of course, but let us not call them, even 
 semi-scientific or attempt to treat them seriously. 
 
 DIVISION III. 
 Reflexes to the Eye from Disturbances ix other parts 
 
 OK THE BODY. 
 
 These have been called "Central Asthenopia." There is nothing 
 to show that any of these reflexes arc "central" in the sense that 
 they arc due to changes in the brain. 
 
 SI 15-DI VISION II. Reflexes to yhe eye. Shown as Symp- 
 toms of Imbalance. 
 
 Conjunctivitis. — We must not allow our knowledge of refrac- 
 tion or of muscle imbalance to make us forget that these symptoms 
 may be the result of a simple conjunctivitis and is to be treated as 
 Mich. Ocular headaches are of entirely reflex character. These 
 are not dependent upon muscle imbalance. Ocular headaches 
 cause disturbances of the stomach, as for instance, a distinct dis- 
 comfort just above the eyes, when cold is taken into the stomach. 
 In some cases the gastric condition produces, not simply reflex 
 symptoms, but also a distinct imbalance. 
 
 From disturbance of the intestinal canal. 
 
 From imperfect nutrition and from toxaemias. 
 
 In anaemic or chlorotic cases. 
 
 Headaches from toxaemias. 
 
 When a patient complains of ocular headache, which glasses 
 fail to relieve promptly, it becomes the duty to have a reliable 
 examination made of the blood or of the contents of the stomach, 
 or have the urine tested, and ,if necessary, an examination made 
 of the blood pressure. 
 
 Reflex to the eye from the nose. 
 
 Reflex to the eye from the ear. 
 
 Symptoms of Imbalance after injury. 
 
 Non-Traumatic Nerve Lesions. 
 
 Splanchnoptosis. 
 
 SUB-DIVISION II. Reflexes to the Eye from Imperfect 
 Nutrition, Intoxication, etc Shown as Actual Muscle 
 Imbalance. 
 
 Distinct Imbalance is produced by imperfect nutrition, intoxi- 
 cation or by some disturbance of the function in another part of 
 the bodv. 
 
LUCIEN HOWE, M. D. 119 
 
 DIVISION IV. 
 SUB-DIVISION I. Treatment of Compound Imbalance. 
 
 A. Correct any Intra Ocular Imbalance. 
 
 B. The correction of any imbalance of the Extra Ocular Muscles 
 by prisms or by decentered lenses, affords, at least, temporary 
 relief by placing them in such a position as to favor the affected 
 muscle. Usually, it is preferable to turn the prism in the opposite 
 direction if the best ultimate results are desired. 
 
 C. ''In Associated Compound Imbalance, if \vc correct the 
 function or feature of the imbalance, then the muscle balance oi 
 at least improvement follows." 
 
 D. "In some cases of associated and in nearly all cases of dis- 
 associated compound imbalance it is necessary to deal with each 
 compound function or feature of the imbalance according to the 
 principles of simple imbalance." 
 
 SUD-DIVISIOX II. Recognition and Treatment of Gen- 
 eral Causes of Imbalance. 
 
 Anaemia and Tests of the Blood. 
 
 Auto-intoxications and tests of the Urine. 
 
 Auto-intoxications — especially with sick-headache and tests of 
 the stomach contents. 
 
 Headaches and other symptoms of Imbalance and Tests of the 
 Blood Pressure. 
 
 SUB-DIVISION III. Simple Forms of Gymnastic Exercise. 
 
 (Condition of the muscular system as a whole and Ocular Muscles.) 
 
 SUB-DIVISION IV. The Optical Treatment of Muscle 
 Imbalance by the Optician or by the Ophthalmologist. 
 
 PART II. 
 
 ACTUAL DEVIATIONS DUE TO LESIONS OF THE EXTRA 
 OCULAR MUSCLES OR IN THE GLOBE. 
 
 Definitions. 
 
 "When the visual axis of one eye fixes a certain point, the fellow 
 eye is directed to some other point. This describes an Actual 
 and Manifest deviation as distinguished from forms of heterophoria, 
 in which there exists only the tendency to deviation. These actual 
 deviations, usually called "Strabismus" or "squint" arc now termed 
 "Heterotropia.". This we use as a synonym for "deviation. 
 Deviations are paralytic or non-paralytic. 
 
120 HAZEN'S NEW FINDINGS 
 
 SYMPTOMS AND DIAGNOSES. 
 
 DIVISION I. 
 
 Deviations and their Measurement. 
 
 The Linear Strabometer. 
 
 The Strabometer of the author. (Howe) 
 
 Corneal Reflexes. Maddox Rod. 
 
 With Flattened Perimeter. 
 
 The Tripometer. 
 
 The Production of Diplopia. 
 
 Photographs. 
 
 DIVISION II 
 
 Symptoms of Non-Paralytic or Active Deviations. 
 
 One in which there is no evidence of a subnormal action of the 
 muscle or group of muscles, away from which the visual axis deviates 
 . . . .due more to excessive action of one muscle or group of muscles 
 than to insufficient action of the opponents." The degree varies 
 greatly. It may be primary or secondary. It may be permanent 
 or variable. 
 
 DIVISION III. 
 
 ARRANGEMENT OF DATA AND PLAN OF STUDY. SINGLE 
 LESION WHICH PRODUCE ACTUAL NON- 
 PARALYTIC DEVIATIONS. 
 
 (Simple Heterophoria.) 
 
 DIVISION I. 
 
 Deviations Due to Abnormal Muscles. 
 
 Muscular heterotropia is an abnormal condition of the Extra 
 Ocular muscles, which produce deviations of the globe, but in the 
 majority of cases, the original cause of the deviation is not an 
 excessive or insufficient action of the muscles, but is owing to some 
 imperfection of the globe. "Typical examples are rare." 
 
 Symptoms. — These are neither numerous nor reliable. By 
 exclusions' process we may say, there is an hypertrophy or shortening 
 of one group of muscles or atrophy or lengthening of the opposing 
 group. Often there is little or no ametropia. To assume that 
 these cases are from a defect of the fusion faculty "is simply begging 
 the question." There are certain facts w r hich indicate that these 
 deviations are caused by anatomical variations, from the normal 
 type. 
 
LUCIEN HOWE, M. D. 121 
 
 Treatment. — Determine whether active or passive. Then if 
 good vision is present, muscle exercise can be practiced to advantage. 
 When such exerciseis not practicable, operation is the only treatment 
 available. 
 
 DIVISION II. 
 
 Deviations Due to Ametropia. 
 
 SUB-DIVISION I. Hypermetropic Esotropia. 
 (Strabismus or Squint.) 
 
 As Donders taught, and others subsequently have proved beyond 
 question, ametropia is a cause of deviations inward. By separating 
 this group from others, the pathological conditions can be well 
 defined and treatment better understood. 
 
 SUB-DIVISION II. Myopia Exotropia. 
 
 Resulting from a myopia, with or without Astigmation. 
 Pure types, rare. Usually secondary changes in the retina. 
 
 DIVISION III. 
 
 Deviations Due to Imperfections of the Retina. 
 Defect of the Fusion Faculty-Amblyopia in the Retina or 
 
 in the Brain. 
 
 DIVISION IV. 
 
 Deviations due to Imperfections of the Refractive Media. 
 
 Opacity of Cornea. 
 
 Superficial Cicatrix from Ulceration, etc. 
 
 DIVISION V. 
 
 Some Secondary Causes, which may contribute with any 
 Single Lesion to produce a Deviation. 
 
 Occupation, Irritation, Anisometropia, Heredity. 
 
 DEVIATIONS DUE TO TWO OR MORE LESIONS. 
 
 (Compound Heterotropia.) 
 
 Muscular Lesions. Abnormal condition of the Extra-ocular, 
 is in many cases the underlying cause. .. .Ametropia, Imperfect 
 Retinal Perfection 
 
 Treatment. For the non-operative it is to correct the ametropia, 
 improve the amblyopia, and strengthen the weaker muscles, but 
 to follow this as a routine plan, we found neither scientific nor 
 satisfactory. 
 
122 HAZEN'S NEW FINDINGS 
 
 PART III. 
 
 ACTUAL DEVIATIONS DUE TO LESIONS, IN THE BRAIN 
 OR IN THE NERVES. 
 
 Paralytic. — Ophthalmoplegia (Hutchinson). 
 
 Ophthalmoplegia interna-paralysis of all the nerve fibers, sup- 
 plying the tissues on the interior of the globe, while the term Oph- 
 thalmoplegia externa was used to designate those cases in which 
 "all or most of the muscles which move the globe" were affected. 
 
 DIVISION I. 
 
 Symptoms and Diagnosis. 
 Summary. (Compare with Landolt.) 
 
 DIVISION II. 
 
 Aids to Diagnosis. 
 
 DIVISION III. 
 
 Differential Diagnosis is between the Xon-Paralytic, 
 (active) and the paralytic (passive) Deviations. 
 
 In view of an operation, it is necessary to know how to decide, 
 whether a tenotomy or an advancement. 
 
 PARALYSIS OF THE THIRD NERVE. 
 
 I. Cerebal Lesions. 
 
 II. Basilar Paralysis. 
 
 III. Orbital Paralysis. 
 
 IV. Peripheral Paralysis. 
 Peripheral Paralysis of the Third Nerve. 
 Paralysis of the Fourth Nerve. 
 Paralysis of the Sixth Nerve. 
 Paralysis of branches of the Sympathetic. 
 Causes of Ocular Paralysis. 
 Prognosis. 
 
 Treatment. 
 
LUCIEN HOWE, M. D. 123 
 
 PART IV. 
 
 ATYPICAL MOVEMENTS OF THE EYE. INFLAMMATIONS 
 AND INJURIES OF THE MUSCLES. 
 
 Atypical Movements. 
 
 DIVISION I. 
 
 1st. Definition. — Movements which do not seem to be related, 
 in any way, to the deviations we have considered. 
 2nd. Voluntary Movements of one eye. 
 3d. Refraction Movements of the Eyes. 
 4th. Atypical Associated Muscle Action. 
 5th. Hysterical Deviations. 
 
 DIVISION II. 
 
 Inflammations and Injuries of the Muscles. 
 
 Rheumatism, Myosites, Progressive Atrophy, Injuries of the 
 Extra-Ocular Muscles. 
 
 PART V. 
 Operations on the Muscles. 
 
PART II. 
 MONOGRAPH 
 
 BY 
 
 E. H. HAZEN, M. D. 
 
ASTHENOPIA AND EYE STRAIN. 
 Philology. 
 
 The Philology of a subject often gives the best history 
 of its development and leads toward an understanding 
 of its nature. 
 
 The gradual change in the definition of the word 
 asthenopia from an "affection of the retina," as it was 
 regarded when Donders came upon the stage, and his 
 transferring the mystery of the phenomena to the function 
 of accommodation as a cause, is an epoch in the science. 
 From his time until near the present, the word designated 
 a disease and it was placed at the heads of chapters and 
 then belonged to the glossary of disease, (as by Stellwag 
 and Noyes) but it did not stay there long for the word 
 as it appeared in the later writings of the time, was 
 used, as it now is, to designate a symptom. The most 
 modern writers now use it thus and some do not dignify 
 it with a definition, but use it as they do the words 
 "pain and discomfort," 
 
 Of late years, the term "eye-strain"has arisen and has 
 become more general in use and it now, not only, conveys 
 the idea of pain or discomfort but points to the under- 
 lying cause, and this substitution of the description of 
 the cause of the trouble complained of, has come into 
 quick use because of its less scientific ring than that of 
 asthenopia. Many writers use the terms synonymously. 
 The definition of these words by different authors, as 
 they have come down to the profession, will show the 
 insight its members had into this most prominent affection 
 of all eve troubles. 
 
ll> HAZEN'S NEW FINDINGS 
 
 In addition to what we have already laid out in the 
 synopsis of asthenopia, we add the following: 
 
 Howard (1850) defines it as amblyopia or weakness of 
 sight. He considers it as arising from constitutional 
 causes. 
 
 Mackenzie, (1855), Asthenopia is "an incapability of 
 sustaining the adjustment to near objects." 
 
 Jones, (1863), Asthenopia is "weakness of sight;" 
 "debility of apparatus of adjustment to near objects." 
 
 Macnamara, (1876), A feebleness of vision from defec- 
 tive or irregular muscular action; the internal rectus 
 being at fault in motor asthenopia, and ciliary muscle 
 in the accommodative form of disease. 
 
 Schell, (1881), Asthenopia is a word used to express 
 forms of pain. There is Muscular Asthenopia, in Myopia 
 from strain of internal recti during forced convergence. 
 
 Mettendorf, (1881), "After using the eyes for near 
 objects for some time ,a weakness of one or both internal 
 recti muscles becomes manifest. The weakness may be 
 caused by efforts of convergence, especially from change 
 of shape of the eyeball, or it may result from severe con- 
 stitutional disease." 
 
 Ranney. Nervous Diseases. (1888), "Asthenopia is 
 that condition of visual apparatus which entails suffering 
 in consequence of defective equilibrium in the muscular 
 power exerted upon that organ, when a fixed position of 
 the eye is maintained for any length of time. The patient 
 may or may not have refractive error." 
 
 Ranney, in Eye Strain — (1897), In this work he does 
 not define the word. 
 
 Swanzy, (1897), uses the word in a general sense — 
 hurting on use of eyes at near work. Conjunctival, 
 Insufficiency, Nervous, Muscular — Muscular is caused 
 by insufficiency and is a disturbance of the equilibrium. 
 
HAZEN'S NEW FINDINGS 129 
 
 De Schweinitz, (1892), uses the word without special 
 definition. He recognizes Accommodative, Muscular and 
 Neurasthenic Asthenopia. 
 
 Fuchs, (1899), recognizes Accommodative, Muscular 
 and Nervosa, associated with near work, and "panorama" 
 asthenopia" distant. 
 
 Jackson, (1900), does not define asthenopia or eye 
 strain. He uses them synonymously in describing symp- 
 toms of disordered function and names eye strain "as 
 cause of many diseases and confines the term of asthenopia 
 to the pain and discomfort of the eye in functioning. 
 
 Fox, (1904), defines asthenopia as "a technical name 
 for a group of symptoms resulting from eye strain due 
 to errors of refraction or fatigue of the ocular muscles." 
 
 Berry, (1905), "Asthenopia is a name generally given 
 to the inflammatory pain associated with the use of the 
 eyes, which literally means a want of power in the eyes 
 to perform their functions." 
 
 Ball, (1904), uses the word asthenopia as a symptom 
 and recognizes accommodative, Muscular and Neuras- 
 thenic asthenopia. 
 
 Eye Strain. The use of the term "Eye Strain" is 
 becoming almost universal in describing affections of the 
 eyes, resulting from the functional use of these organs. 
 Some of the former authors, however, ignore the word 
 and use asthenopia instead, and some use them inter- 
 changeably. 
 
 The term, "Eye Strain," is not in the vocabulary of 
 Mackenzie, Donders, Howard, Stellwag, Wells, Metten- 
 dorf, Schmidt, Rumpler, Macnamara, Williams of Boston, 
 Schell, Fuchs, Landolt, Roosa, Berry, Ball, de Schweintz, 
 nor in Billings' dictionary. 
 
 Gould says, "Eye strain is the name given to any 
 unphysiologic, i. e., pathologic ocular action or function 
 which is wearing, excessive or unnatural. Popular 
 Science Monthly. Dec. 1905. 
 
130 HAZEN'S NEW FINDINGS 
 
 It seems at present that t he consensus of opinion is to 
 regard Eye strain as expressive of the trouble of the eye 
 in functioning, and Asthenopia as the principal symptom 
 of pain and discomfort connected therewith. 
 
 If the word Asthenopia is held closely to mean the 
 symptom of pain or discomfort arising from the eye, 
 wheresoever that symptom is located, we have a very 
 expressive and satisfactory word. 
 
 In the synopsis which I have given on this subject, 
 and which I have attempted to elucidate, by quoting 
 freely from well known authors, it can easily be detected 
 that authors are drifting away from the former method 
 of studying the phenomena we now call Eye Strain. 
 
 They have, in these latter days, gradually dropped the 
 descriptions of the numerous symptoms connected 
 therewith, as we find them in Donders and Noyes and 
 seek other methods as a guide to ferret out the mischief 
 these disorders present. 
 
 Since Donder's doctrine that the physiological cause of 
 asthenopia existed in the ametropic condition of the accom- 
 modative apparatus, and especially since the admission 
 that the motor apparatus of the extrinsic muscles par- 
 ticipates, and since it is conceded by some that they 
 may wholly be the seat of the trouble, there has been 
 built an extensive theory of a mechanical nature rather 
 than a physical condition to account for the departure 
 of this apparatus from the normal. 
 
 In other words, the attention is directed to the position, 
 direction of movement, results of action, deviations 
 from standards of position and action, and the measure- 
 ments of all these, instead of a study of the causes that 
 have brought these conditions about. They seek to 
 remedy these wayward "end organs" by adjusting them 
 to their ideals, rather than by the consideration of the 
 psychical forces that control and bring into creation 
 
HAZEN'S NEW FINDINGS 131 
 
 the sense of sight and keep it in repair for the best ser- 
 vice. 
 
 The method of study, so long practiced in general 
 medicine of noting symptoms and grouping these to 
 direct the course of investigation is being dropped and 
 the foot rule, the scale, the motion indicator and the 
 balance are used to explain. These modern methods 
 which call in the miscroscope and the test tube in many 
 diseases, do not seem applicable to the diseases which 
 we are now considering, for these belong to the nervous 
 system and their connection is with the brain; they 
 produce phenomena of a disordered action and a mental 
 outlook that is difficult to understand, and is beyond 
 measurement and borders on mystery, and though it 
 takes such a hold on life and is so intangible in character, 
 is yet exceedingly veritable, amd afflicts a large per- 
 centage of the intelligent part of the community. 
 
 BALANCE AND EQUILIBRIUM. 
 
 We see by reference to our coterie of Authors, that 
 up to the time of 1890 when Dr. Xoyes wrote his last 
 large work, there had not been anything said about 
 imbalances. 
 
 About this time, Dr. Stevens gave to the profession 
 his nomenclature with its system of measurements of 
 the relation of the two balls to each other, and his in- 
 struments of precision. He also made more emphatic 
 the importance of the strength and action than had been 
 made before his time and that of Dr. Xoyes. 
 
 Ranney, (1888), who was a student of Dr. Stevens, 
 used the word balance in a foot note in defending their 
 doctrine of "latent insufficienc^' ,, and he uses the word 
 equilibrium in a general sense but not in so specific a 
 sense as it has been used of late. 
 
132 HAZEN'S NEW FINDINGS 
 
 From about this time for a decade. Ophthalmology 
 has been re-written on the basis of what Stevens gave to 
 the subject. 
 
 The direction thus taken was that of considering the 
 cause of trouble in this organ to be in the findings there- — 
 mal-adjustmcnt, misfit muscles and corkscrew motions 
 of the balls. 
 
 It is perfectly logical to consider symptoms as a minor 
 and subordinate matter if this way of looking at it is 
 the true one; symptoms will vanish when the ideal 
 equilibrium is restored and balance is brought about. 
 But in this conception of the situation we are losing 
 the guide of symptoms to a physiological regulator. 
 
 A number of books have appeared which deal with the 
 subject in this way. Since muscular disorders have been 
 acknowledged to be a cause of asthenopia, a system of 
 interrelation of the intrinsic and extrinsic muscles has been 
 well worked and the principal physiological phenomena 
 found in this conception is, that the abnormal imbalance 
 of the extrinsic muscle has, for its explanation, the 
 abnormality of the intrinsic muscles. This gets no 
 farther than Donders. 
 
 At the risk of being considered "prolix," let us examine 
 this doctrine of "balance", "equilibrium" and some 
 other associated ideas that have relation to the motor 
 apparatus and its anomalies. 
 
 The work of Dr. Stevens, which gave us a system with 
 a definite basis on which to found a proper examination 
 of the muscles of the eyes and their relations to each 
 other, was a master stroke on this subject. 
 
 Before that, the study was prosecuted at the near point, 
 entangled with the ever varying relation of accommoda- 
 tion and convergence. 
 
 Examination at a distance of 20 feet gives the best 
 point at which to obtain rest of the organ in its functional 
 action. At this point from which, practically, the rays 
 
HAZEN'S NEW FINDINGS 133 
 
 of light come parallel, it is seen that the eye must be 
 examined to ascertain whether there are departures 
 from this ideal point of rest. 
 
 The eyes do not always remain at rest, for it is difficult 
 "for individuals to permit the eye muscles to become 
 entirely passive." "Notwithstanding the imperfection 
 of the theory, we possess no method of investigation 
 better than producing diplopia of the image at this 
 distance." "No just appreciation of the muscular 
 balance can be arrived at, while the accommodation is 
 considerably exercised or while convergence is required." 
 (Stevens). 
 
 The new conception of "balance or equilibrium" took 
 hold of the profession in the decade of the '80's and 
 writers on Ophthalmology hurried to re-write their papers 
 and books on this new basis. 
 
 Dr. Stevens says, "equilibrium should signify a con- 
 dition in which all the muscles of the eyes are so pro- 
 portioned and adjusted in respect to their dynamic 
 conditions that, with the least expenditure of nervous 
 energy, when the gaze is directed to an object in the 
 median plane at the level of the eye and at infinite dis- 
 tance, while the head is in the primary position, the 
 visual lines should be parallel and in the same horizontal 
 plane." 
 
 He does not use the term "balance" in his "Motor 
 Muscles" but in his contribution to System, the title of 
 which is, "The Principles of and Methods for the estima- 
 tion of the Balance of the Extra-ocular Muscles." In this 
 article he says, "the best muscular equilibrium, that is 
 the condition in which parallelism of the visual lines is 
 maintained with the minimum of nervous effort, the con- 
 dition is known as Orthophoria. (\ol. II.) 
 
 Landolt, in "Refraction and Accommodation" does 
 not use terms balance or equilibrium, but in System ( 1900) 
 says, "The position of equilibrium is used to designate 
 
134 HAZENS NKW FINDINGS 
 
 the direction taken by the eyes when in a state of minimum 
 innervation or of absolute repose.'" Nothing is more 
 difficult than to find this position." On further at- 
 tempting to get his idea of equilibrium, it is found that 
 he defines it to mean the point of rest in any (even) 
 heterophoric conditions, for he says, " the Maddox rod 
 is a good method of determining the position of equili- 
 brium or latent deviation of the eyes," and further on 
 he says, "that in profound narcosis or death the eyes are 
 turned outward." 
 
 Dr. Howe does not use the word equilibrium in Vol. 
 I. but defines Muscular balance as "the condition in 
 which, with comfortable binocular vision, accommoda- 
 tion, convergence and torsion bear their normal rela- 
 tions to each other. He sets his definition of balance 
 against Dr. Stevens' Orthophoria of Equilibrium thus: — 
 
 Orthophoria. Muscle Balance. (Eukenesis.) 
 
 1. Relates to extrinsic muscles 1. Relates to extrinsic and in- 
 only, trinsic muscles. 
 
 2. Visual lines tend to paral- 2. Visual lines parallel or con- 
 
 lelism. verging. 
 
 3. Binocular vision may or 3. Binocular vision must exist, 
 may not exist. 
 
 -1. Comfort may or may not 4. Comfort is essential, 
 exist. 
 
 Other differences might be named in the definitions 
 of the conditions in which the term Balance is used by 
 one, and Equilibrium by the other. 
 
 Stevens. How 
 
 e. 
 
 1. There is a definite point of 1. The ever shifting condition 
 departure for a standard. requires a standard for 
 
 each of his numerous sub- 
 divisions. 
 
 2. There is a common standard 2. The normal can never be 
 for all departures of the found for it is in action ib 
 normal. manv directions. 
 
HAZEN'S NEW FINDINGS 135 
 
 If the point of rest and parallelism of Stevens is not 
 adhered to as a standard, we have none from which the 
 abnormal is a departure. 
 
 The Strength of the Muscles. 
 
 Another consideration in the study of the subject of 
 eye strain is that of the strength of the extrinsic muscles 
 (Eukenesis) and their facility of action. Donders and 
 Von Graefe had no idea of their place in the problem of 
 asthenopia. 
 
 The turning of the visual gaze from one point to another 
 and the fixation, adjustment or projection of an eye 
 upon an object are of course muscular efforts. Accom- 
 modation is a muscular act of the ciliary muscle and con- 
 vergence is an extra effort of the adductors. 
 
 They recognized weakness of these muscles, but at- 
 tributed the manifestations of it to errors of refraction, 
 which gave the muscles extra labor, from which fatigue 
 and symptoms of pain arose. 
 
 When there was no ametropia the asthenopia was 
 termed, by Donders, "false asthenopia," and rather than 
 attribute it to affections of the muscles themselves, a 
 cause was sought in constitutional disturbances. 
 
 When it was found that asthenopia occurred in cases 
 of emmetropia or that it continued when they had been 
 made emmetropic by glasses, they still relegated the pa- 
 tient to rest, constitutional treatment or change of occu- 
 pation which gave them less activity in the use of their 
 
 eyes. 
 
 As late as 1000 when, through the writings of Xoyes, the 
 profession had come to believe in Muscular Asthenopia 
 and to recognize, in theory at least, that when there was 
 weakness of the extrinsic muscles, they should be treated 
 by discipline to strengthen them— the directions for 
 doing this were still of the most vague and unsystematic 
 sort. 
 
136 HAZEN'S NEW FINDINGS 
 
 Dr. Noyes developed a practical method for disci- 
 plining these muscles, and showed much patience in this 
 particular necessity as he found it. 
 
 Landolt saw the weakness of muscles and compared 
 it to the condition of an equestrian, out of practice and 
 liable to he thrown from his horse and recommended 
 discipline of leg convergence, that he might be able to 
 stick to his animal. 
 
 But for the weak convergence of the recti, he merely 
 suggested discipline without exercising his usual acumen 
 in inventing apparatus, as he did for diagnosing. 
 
 All along, for a couple of decades, the opinions of writers, 
 pro and con, in regard to the question, whether there 
 was such a thing as Muscular Asthenopia, and whether 
 the discipline of the muscles was of any avail, were freely 
 given. 
 
 "Insufficiency" 1 was regarded a weakness, yet remedies 
 for weakness were not used to strengthen. Dr. Dyer, 
 as we have seen, was the first to institute measures of 
 relief according to the laws of physical culture. His 
 system was empirically applied and consisted in dis- 
 ciplining the ciliary as well as the recti in convergence, 
 and to so change the relation between the two that there 
 was a new environment, or a new order of things — he 
 did not know what or how r — but discipline was insti- 
 tuted for the muscles, for the first time in Ophthalmic 
 history. 
 
 This system was taken up throughout the land and 
 much was said of it. A few cases were restored, after 
 months of severe trial and watching, and infinite labor 
 and pains. 
 
 It was not long before Dr. Noyes developed his ideas 
 in relation to eye strain, and accepting Dr. Stevens' 
 system of appealing to the muscles for diagnosis and treat- 
 ment free from the accommodative act, he was able to 
 lay before the profession the most clear and well balanced 
 
HAZEN'S NEW FINDINGS 137 
 
 analyzation of the subject that had yet been published. 
 His writings show infinite pains taken in the subject, 
 with study clinically made and with a mind free from 
 prejudice and dogmatism. 
 
 He gave much hope and encouragement to those fol- 
 lowing out the lines of his procedure. There has not 
 been sufficient attention paid to his emphatic assertions, 
 contrary to the doctrine of Prof. Donders, regarding 
 the relation of Asthenopia and Hypermetropia. 
 
 About this time, there were two modes of dealing with 
 that perplexing disease, asthenopia; they were antago- 
 nistic to each other, one regarding the muscles as the seat 
 of a high percentage of causes, and attention was directed 
 to its relief through this avenue, the other believing 
 that the whole trouble lay in errors of refraction and that 
 if the muscles were implicated, it was from ametropia. 
 
 Dr. Stevens was an active worker in the former method, 
 and he, with Dr. Ranney, was an exponent of tenotomy, a 
 shortening or lengthening of the muscles to obtain 
 equilibrium. They mention orthoptic treatment but 
 relied on surgery to a great extent. 
 
 They taught the doctrine of "latent heterophoria"- 
 a condition where, in the ordinary means of examination 
 the full amount of heterophoria is not manifest. Dr. 
 Ranney uses the word "insufficiency" synonomously 
 with heterophoria, and says, "it seems to him to be a 
 congenital defect in most cases, probably all." The 
 "latent insufficiency" of the internal recti he makes 
 manifest, by putting on a pair of prisms, bases in, in 
 spectacles, and has the patient wear them a few days. 
 After the latent becomes manifest, he is enabled to judge 
 of the effect he wants to produce in his tenotomy. 
 
 Eyes that show orthophoria or a slight amount of 
 heterophoria before wearing the prisms, will show a 
 considerable amount of heterophoria. This is but in- 
 
138 HAZEN'S NEW FINDINGS 
 
 dulging i he muscles, which, very naturally, take the 
 position that is the easiest for them. 
 
 There was a large faction in the profession, who, from 
 natural conservative tendencies — perhaps having tried 
 the radical method of tenotomy, and not having found 
 what was expected, fell back upon the doctrines of Don- 
 ders and relied upon the correction of ametropia. Some 
 have gone so far as to hold that if relief was not had, it 
 was because they had not skill enough to find the error. 
 All saw a deficiency of strength in the muscles, but held 
 that the cause of such a condition was the uncorrected 
 ametropia. 
 
 A few prominent men did not believe in Muscular 
 Asthenopia. But Dr. Noyes re-discovered what Bohn 
 and Rueta promulgated before Donders but which was 
 obscured and set in the background by the brilliancy of 
 the Professor's System of Refraction. The patience and 
 systematic analyzation shown in Dr. Noyes' work; his 
 devising of means to discipline the muscles by a suc- 
 cession of prisms, and the true estimate he made of 
 tenotomy have just begun to be appreciated in the 
 settling of a rational view to be held in the future regard- 
 ing this wide spread affliction. 
 
 Most authors now suggest orthoptic exercise of the 
 muscles, but there is evidently but little faith in its 
 efficacy as practiced by them This is easilv accounted 
 for in the inefficiency and awkwardness of the method. 
 Two authors from whom I have quoted say, "that the 
 prisms from the Test Case are sufficient to carry out this 
 treatment." These prisms are generally ground rouind 
 edge and are to be held in the hand of the practitioner, 
 or slipped into the trial frame found in the case. When 
 we realize that the manipulation of lenses and the putting 
 on and taking off of prisms from the faces of these patients 
 is a severe ordeal to them, and that the axis of the lens 
 cannot always be right, and that too the strength of the 
 
HAZEN'S NEW FINDINGS 139 
 
 lens is augmented from 2° to 6° above the index of 
 the lens (varying in amount by the position of the plane 
 of the lens and the strength of it) we can easily see the 
 inaccuracy of the act and the unscientific method of the 
 manipulation. However dextrous the manipulator may 
 be, he will increase the nervousness of the patient and 
 will not get the accurate information that is needed. 
 
 The touching of the eye lashes or eyebrows in handling 
 lenses before the eyes of these patients, whether the lenses 
 are single or put in prisms or in batteries with a succession 
 of lenses, is extremely annoying and irritating. These 
 patients are generally nervous and motion is the bane 
 of their existence. The most careful manipulator will 
 often cause nausea and headache or irritability, and 
 either the patient or the surgeon will give it up in disgust. 
 Therefore, the practice of presenting a lens before the 
 the eye for correction — then laying it down and taking 
 up and presenting another, and so on, is entirely wrong. 
 The practice of parting the light and asking the patient 
 to fuse it, and if unable to do so, to present another, is 
 another mistaken manipulation. The information re- 
 quired in getting the duction pow r er of a muscle cannot 
 be obtained in this way. 
 
 There is much stress put upon ascertaining the devia- 
 tion of the muscles from parallelism (Heterophoria) and 
 many tests and trials are made, and repeated on different 
 days, to get the balance. When gotten, the information 
 is of little value towards a solution of the case. 
 
 The latest writers have so developed the imbalance 
 theory as to give it a different meaning from that on the 
 basis of heterophoria, which we have had for some time, 
 so that now the definition has become obscure, and almost 
 lost in the development of this theory of equilibrium. 
 
 Equilibrium seems now to be an imaginary fulcrum, 
 situated somewhere between the eyes, behind the balls 
 and with some six points extending through the aria of 
 
L40 HAZKN'S NKW FINDINGS 
 
 motion of the eyes, and subject to as great variation as 
 an aeroplane. The whole object to be obtained in the 
 treatment of the disorder of this function is a balance 
 of equilibrium. 
 
 If Tenotomy is not resorted to immediately, a process 
 is adopted of changing the load to another muscle, or 
 giving it more or less action by changing the denomina- 
 tion of the lenses or decentering them, or putting the 
 cylinders at a different axis, expecting by this means to 
 counterbalance this imaginary plane to an equilibrium. 
 
 \\ hen these appeals to the refraction part of the eye 
 prove of no avail in curing the asthenopia, tenotomy is 
 resorted to, or at least that dernier resort is presented 
 to the patient with emphasis — a six months' vacation, 
 travel and rest to build up the constitution is recom- 
 mended. 
 
 That the delicate and intricate apparatus of adjust- 
 ment of the balls should not have troubles of their own, 
 per se is contrary to our experience and observation of 
 the human frame. This apparatus in the function of 
 vision is as complicated, and shows as many contin- 
 gencies in its participation as the focal act, and when we 
 consider the demand upon this organ in the work of our 
 civilization, we must expect and look for trouble in these 
 parts themselves. It is reasonable to expect to find it. 
 
 The investigation of the muscular system commenced 
 in the necessities of the internal recti, for the severity 
 of their work in convergence was noticed. By the 
 giving out of the convergence muscles, attention was 
 called to the opposing muscles and the abductors became 
 a study and so the lateral pairs were fully brought into 
 notice, but the verticals and the obliques were yet in 
 the undiscovered physiological world. Those who brought 
 into training the laterals let the verticals go untrained, 
 and whereas the laterals were voked and "broken'' the 
 
HAZEN'S NEW FINDINGS 141 
 
 verticals received no attention or were handled very 
 differently. 
 
 This failure to get results in the vertical muscles may 
 be accounted for in that there was an attempt to treat 
 them with the same denomination of prisms as were used 
 in the cases of the laterals, and not getting response, 
 these muscles were prismed and sometimes clipped or 
 let alone and considered outside of the general laws of 
 extrinsic muscles. 
 
 THE AUTHORS FINDINGS. 
 
 In a practice of the Specialty of Eye and Ear for over 
 forty years, and adjusting Compound glasses since 1869 
 in the State of Iowa, I may be pardoned for considering 
 my experience as of some weight and value in the relief 
 of Eye Strain. 
 
 With the best facilities to be had during this period, 
 and with as close and skillful attention as I could command, 
 there were many cases that were not relieved to the 
 extent that one, doing such work, would naturally desire. 
 
 The subject of the muscles, during this period, was an 
 obscure one but my study of it resulted in the belief that 
 there were a great many suffering from nervous troubles, 
 which could be accounted for in eye deflections, and that 
 if there was a trouble of the extra ocular muscles, which 
 explained the want of its relief by correction of the 
 refraction, gymnastics ought to be of some service in the 
 restoration of the disability. 
 
 The directions of the books to acomplish gymnastics 
 were tried, but the labor of it was sufficient to deter one 
 from carrying out the directions, and the patients would 
 drop off before accomplishing what was set out to be done, 
 and, as a natural consequence, the practice of muscular 
 discipline for asthenopic symptoms gradually fell into 
 disuse. 
 
142 HAZEN'S NEW FINDINGS 
 
 Still believing in the principle, although the practice 
 in it failed, I had batteries etc., made, upon principles, 
 which 1 thought, from my experience with them, were 
 necessary. 
 
 This apparatus was in my hands for seven years 
 before I found the systematic use of it in these cases of 
 Functional troubles. Two or three cases fell into my 
 hands in 1896, which had been glassed and carefully 
 treated according to the doctrine of Refraction and not 
 relieved. I commenced, and carried out empirically the 
 treatment, which is essentially that which I have followed 
 ever since with gratifying results. I have deduced and 
 worked upon the following principles. 
 
 1st. The diseases presented, formerly designated 
 asthenopia and now termed eye strain, are disordered 
 junctions and consist in weakness or insufficiency of the 
 eye muscles, intrinsic and extrinsic, and the chief symptom 
 is asthenopia. 
 
 2nd. This weakness is found in cases of emmetropia 
 or orthophoria as well as in ametropia or hetrophoria; 
 caused from overwork of the eyes, or from the general 
 need of tone, refractive error or the absence of proper 
 nourishment by aliment for assimilation. 
 
 3rd. When the refraction is hypermetropic, unless 
 there is an extra compensation of muscular strength in 
 the ciliary, focusing becomes a burden; or when there is 
 heterophoria, a like compensation is wanting, the excur- 
 sion of the extrinsic adjustment is lengthened and made 
 difficult, and the eye balls lag and mal-position is the 
 consequence. In either case fatigue is experienced and, 
 unless there is great apathy asthenopia sets in. 
 
 4th. This weakness may be from obstruction in the 
 eye tissues; it may be from an imperfect conducting 
 quality of the nerves supplying the muscles; it may be 
 from a want of nervous force; lastly, it may be in a defect- 
 
HAZEN'S NEW FINDINGS 143 
 
 ive brain (central). All of these causes of weakness may 
 be considered as weak innervation. 
 
 5th. The indications are (if this theory be true) to 
 overcome the weakness by administering those aids 
 which strengthen muscles and innervate them. 
 
 6th. The principal aid in strengthening muscles is 
 gymnastics. The effect gained by this means remedies 
 the various pathological conditions mentioned, and makes 
 the muscles effective. All the extrinsic muscles are 
 equally amenable to this appeal, when a proper varia- 
 tion is made under the general laws governing all of them. 
 
 Nature-Aids. 
 
 In view of the conditions which we pronounce depart- 
 ures from the normal or from the standards we set up, 
 the most rational conception seems to be that nature 
 strives to mend or correct these defects that interfere 
 with the action for which eyes are made, or re-constructs 
 or fits them for the work which their environment has 
 put upon them, and it is the business of the Doctor to 
 aid Nature in accomplishing this. 
 
 Science tells us that in the progress of the species, the 
 orbits have been brought around toward the median 
 line from 90°, found in the fishes and most of the 
 birds, to man whose orbits diverge but 24° or 30°, and 
 we know that the eyeballs can be maintained at paral- 
 lelism within these diverging sockets, and not only that, 
 but under the necessity of convergence, man, to do his 
 tasks, is enabled to converge 50° inside the median line. 
 
 From this history of the organ of sight in the past 
 ages and the conditions we rind in our study of the human 
 eye, we can draw a lesson. 
 
 It is safe to regard the functions of the organ with 
 which we are dealing, as well as those of many others of 
 the human system, as under our control under the laws 
 
144 HAZEN'S NEW FINDINGS 
 
 of development, and to note that changes are contin- 
 ually going on for better or for worse; that man's do- 
 minion oil the earth shows a wonderful power in directing 
 and fashioning the species, and in regulating and im- 
 proving the functions and moulding the good qualities 
 in his own race, or in animals over which he has control. 
 
 Then it is reasonable, in the present application, to 
 remove those things which prevent good action in this 
 function; to administer to the weakness, and tone up 
 the innervation, and use any other means that will 
 strengthen, giving Nature a chance to right up all im- 
 balances if these interfere with proper functioning. 
 
 But, if after this attention, the eye balls do not take 
 the position, which is found necessary, it may be advis- 
 able to shorten or lengthen muscles, so that there may be 
 less expenditure of nerve force in accomplishing the 
 excursion needed for adjustment, but not before the 
 orthoptic treatment has been well tried. 
 
 There has not been a proper recognition of this con- 
 dition and very poor treatment of i*. If the theory, 
 that Nature is bending her forces to th<„ accomplishment of 
 the demands of environment is true, there will be but few 
 cases for such interference, for she is wonderful in the 
 adaptation of means to ends. My experience is, that 
 surgical interference is not required in exophoria at all, 
 if there is vision or even perception of light in the devia- 
 ting eye. I have operated by advancement, on these 
 cases, for years. 
 
 CLASSIFICATION BY POSITION. 
 
 Heterophoria. 
 
 Heterophoria is most likely to be one of the conse- 
 quences of weakness or of pathological conditions, and 
 not heterophoria the cause of asthenopia. In Hetero- 
 phoria the excursions of the eye balls to prevent dip- 
 
HAZEN'S NEW FINDINGS 145 
 
 lopia for distance, is greater than in Orthophoria. This 
 requires more expenditure of nerve force, and weari- 
 ness is apt to show itself, and perhaps pain. The func- 
 tion act starts with a deficit, as Donders said of Hyper- 
 metropia. If the nerve supply is sufficient, the work not 
 protracted beyond limit of capacity, or the heterophoria 
 not too great, there is but little inconvenience. 
 
 Exophoria. 
 
 Hypermetropia causes weakness of the ciliary from 
 overwork, and we have accommodative asthenopia. 
 This condition is properly helped by convex glasses, but 
 the former stimulus given to convergence by the excessive 
 accommodation, is removed by the glass, and, unless 
 there was formerly excessive convergence, the internal 
 recti are now relieved of this stimulus and they are thrown 
 into an independent condition. This developes weak- 
 ness and muscular asthenopia often arises from it, 
 and exophoria is developed. This course of reasoning 
 is properly applied to the insufficiency of the internal 
 recti and to the causes of exophoria in hypermetropia, 
 of which the writer has found a large number. \\ here 
 there was but little weakness at the beginning, this brought 
 on exophoria and for every degree of divergence, there 
 was additional necessity for effort and nervous energy 
 to cover the gap, that was continually widening as 
 exophoria was developed, and until the patient could 
 learn to suppress the image of the deviating eye, there 
 was continual labor and pain. Asthenopia, however, 
 subsides as the effort to fuse the images is given up, 
 but this is at a great cost of useful vision to that ball 
 and to the patient's ability to avoid danger to his person, 
 and I may add — to the looks of his face. 
 
 It is not yet established that all eyes should be made 
 emmetropic by glasses. Besides, the interference con- 
 vex glasses have with convergence, it is quite certain 
 
14C HAZEN'S NEW FINDINGS 
 
 that hypermetropia, if not' great, is a better condition for 
 a healthy development of the eye in children than em- 
 met ropia. 
 
 ESOPHORIA. 
 
 In esophoria the external recti have the load in respect 
 to distant vision, but if of moderate degree, say 8° or 
 less, when there is abduction sufficient, there is an advan- 
 tage in the act of convergence — that is, if there be no 
 undue action or spasm of the internal recti. The ball 
 is in or near the position for near vision, without the 
 necessity of the convergence act. Nevertheless, in these 
 esophoric cases there is weakness of adduction, with as 
 high degree of esophoria as 8°, and to cure the asthenopia, 
 adduction has been given, but abduction should also 
 be attended to before discharging the case. The 
 esophoria may increase, but long before adduction has 
 been brought to the standard, the asthenopia will have 
 vanished. Often the esophoria increases in exercise 
 of the adductors even as high as 14° and the patient 
 is discharged in this condition, but in a short time, the 
 lateral muscles will be found to be towards orthophoria. 
 If the abductors are strong, the needful movement is 
 easily made to parallelism. 
 
 Hypirihoria. 
 
 The verticals have been the last of the muscles to be 
 recognized as participating in this w r ide spread affliction. 
 Although Drs. Stevens and Noyes found hyperphoria 
 and, with it, severe trouble — the remedy was to put prisms, 
 with base up or down, into spectacles. These of course 
 relieved for a time, but soon a greater degree of hyper- 
 phoria developed and stronger prisms were prescribed, 
 until the indulged muscles allowed the ey r e to hide under 
 the lid, and a delicate, uncommon and skillful graduated 
 tenotomy is consented to, by the patient. 
 
HAZEN'S NEW FINDINGS 147 
 
 Having discovered the right denomination of lenses 
 and the proper interval between them, I found that 
 orthoptic treatment was as efficacious on one pair as 
 any other pair, and that they all responded equally well 
 and were equally amenable to the general laws of eye 
 muscles. 
 
 Cycloj hor a. 
 
 The oblique muscles have command of the torsion 
 or wheel motions of the eye. The normal position of rest 
 — the vertical axis of the upper end — is said to be about 
 three degrees outward of the vertical line. "Every 
 motion of an eye from the primary to an oblique posi- 
 tion is accompanied by torsion as an essential com- 
 ponent of the motion." Maddox. This was recognized 
 by Donders, Helmholtz and developed in Lystings' 
 Law. 
 
 In oblique astigmatism the oblique muscles are called 
 upon to correct it, so that the axis of vision may cor- 
 respond to the vertical and horizontal lines, of which 
 print and objects generally are made up. 
 
 To Dr. Savage, we owe the discovery of the "Ineffi- 
 ciency of the oblique muscles." and a method of clearly 
 and easily detecting it. I have not had satisfactory 
 results in treating it with cylinders, as he recommends. 
 We, of course, correct astigmatism that may cause the 
 overwork of the oblique muscles, and treat for strength- 
 ening the obliques the same as we do the verticals. It 
 often disappears, without direct appeal, in treating the 
 recti. 
 
 My observation and experience in treating these cases 
 of eye strain is, that it may come in the emmetropic 
 and orthophoric eye as frequently as in the ametropic 
 or heterophoric eye, and weakness of the ciliary muscle 
 or of the external muscles may come as well in one as 
 in the other, accommodation becoming difficult and con- 
 
L48 NAZI-: N • S X K W PI N DINGS 
 
 mergence painful; soreness, nervousness and inability 
 for protracted work are present, but accommodation 
 may show normality and there be no, or very little, 
 deviation of the muscles. The inclination is to favor 
 the muscle, and the common idea is to rest and avoid 
 use when they hurt, and there is developed, "insufficiency" 
 and in many cases exophoria. When a phoria is devel- 
 oped, it adds labor to the muscle of adjustment; the 
 excursion of the eyeball to accomplish a fixation becomes, 
 more and more, an extra task. That the trouble 
 should be supposed to be in the deflections or the heter- 
 ophoria, seems to me a great mistake. For the classi- 
 fication of these cases, we will group them differently. 
 
 CLASSIFICATION BY PATHOLOGICAL CONDITIONS. 
 Vascularity. 
 
 Prof. Donders, in speaking of the fatigue of the mus- 
 cles, mentions as the result of the performance of labor, 
 "the products of metamorphosis of matter in the muscle 
 tissue." 
 
 This physiological condition may be the explanation 
 of a pathological state, which we find in a group of cases 
 with symptoms of eye strain. This group, which is 
 characterized by a hyperemic condition, is of wide extent. 
 The patient may have this hyperemia for years without 
 the characteristic of inflammation, (the sticking together 
 of the lids in the morning) which shows the dividing 
 line between hyperemia and inflammation. With some, 
 there is a tearing and with others a dry hot sensation. 
 There is a general vascularity inside (opthalmoscopic- 
 ally) and out. In the advanced or chronic stage, 
 stys and pterygium may be developed. The patient 
 soon learns to school himself to avoid motion of the eye 
 balls because of the pain in friction of the balls and lids; 
 the eye takes on a dull sunken and soggy appearance, 
 
HAZEN'S NEW FINDINGS 149 
 
 and the individual mopes and subdues all impulses to 
 animation, and looks disconsolate and spiritless. Every 
 act of fixation blurs and most sufferers pass the fingers 
 or knuckles across the lids every few minutes, they take 
 off their glasses to press, or squeeze the balls by strong 
 closing of the lids, which press upon the balls and take 
 off the tension of the muscles for a moment and perhaps 
 accelerate the circulation to absorption. They school 
 themselves not to fix upon an object, and allow motions 
 and other things to happen before their eyes without 
 notice, and in walking on the street avoid observation. 
 For this purpose, they wear black glasses and attribute 
 their pain to intolerance of light. These cases are not 
 characterized by great nervousness, excitableness or 
 sleeplessness. 
 
 I believe they may be classified as reflection of eye 
 strain on the Yaso-Motor System. It is remarkable 
 how quickly these cases respond to proper treatment by 
 gymnastics. 
 
 Neuralgia and Neurasthenia. 
 
 Another group of asthenopic symptoms is found when 
 the patient suffers through reflex on the fifth nerve sys- 
 tem. Ranney in "Nervous Diseases" says, "The causes 
 of neuralgia may be classified — (1) The predisposing — 
 (2) modifying — (3) exciting," and says under the first, 
 "I believe, from somewhat extended research, into the 
 probable factors which tend to induce the neuropathic 
 tendency, that the eye strain and abnormal eye tension 
 are, perhaps, more closely related to the obscure and im- 
 perfectly understood conditions than any other factors, 
 which have yet been observed." 
 
 "As a rule, it may be stated that neuralgias are seldom 
 dependent upon pathological changes. In a few excep- 
 ional cases, however, the nerves and the nerve centers 
 ma>' reveal, in a variety of ways, the existence of a mor- 
 
150 HAZEN'S NEW FINDINGS 
 
 bid state." "We are forced to admit that the pathology 
 of neuralgia is not yet understood." 
 
 "All the later observations of Dr. Stevens and myself,'' 
 he says, "go to show that neuralgic attacks are curable 
 in a large proportion of cases, when treated by the relief 
 of eye strain" .... "Like other purely functional neuro- 
 sis, the detection of the cause and the removal of the 
 irritation (generally of a reflex type) results in the per- 
 manent benefit of the .patient, and a more or less com- 
 plete cessation of the attacks. 
 
 Dr. Joseph Collins (J. A. M. A. Jan'y '09) says, "Ner- 
 vous Diseases are looked upon as mysterious in their mani- 
 festations, incomprehensible in their display, unamenable 
 to treatment and therefore unworthy of profound effort 
 at interpretation." Functional or Organic? There are 
 diseases in which no characteristic anatomic alterations 
 are found after death, and yet, we believe these to be 
 organic diseases. Among these are paralysis agitans, 
 grave myasthenia and hyperthyroidism. There are 
 other diseases commonly spoken of as diseases of degener- 
 acy or deviation such as tic, hysteria, idiopathic epilepsy 
 and psychosthenia, possibly migraine, which are not 
 likely to be found associated with anatomic alteration. 
 
 Dr. Collins further says, "There seems to be something 
 about functional nervous diseases, which is decidedly 
 repellant to many members of our guild ... .Another 
 feature of his attitude is the belief, feeling or assumption, 
 that these diseases are not real, that they are more or 
 less assumed, that they are manifestations of weakness 
 of contumacy, that they are a sort of splotch on the 
 escutcheon of health and of moral dignity, that they are 
 evidences of stubborn perverseness, which excite a min- 
 gling of sympathy and contempt, that they are products 
 of disordered imagination." 
 
 "This is a distinct sequel of the view which looked on 
 functional nervous diseases as manifestations of demon- 
 
HAZEN'S NEW FINDINGS 151 
 
 iacal possession, and it is much less prevalent than it 
 was a generation ago." 
 
 It is not to be wondered at that nervous diseases are 
 so little understood and that their phenomena are a 
 mystery. \\ hen we remember what the system of 
 refraction has done in the last fifty years, in relieving 
 headache, we marvel that even in our time, books have 
 been written on headache, without a mention of Eye 
 strain as a cause. Dr. David Webster saved the credit 
 of Dr. J. Leonard Comings' work (1894) on "Headache 
 and Neuralgia," in an appendix on eye strain. Francis 
 E. Anstie on "Neuralgia" (1872) has not a word to say 
 about the part that eye troubles have in producing 
 Neuralgia. 
 
 Taking the relation of Nervous Disease men, and 
 oculists, they seem to be as far apart as two religions. 
 Although they graduate at the same schools and study 
 the human system together, they have but little con- 
 sultation over those diseases in which both should be 
 familiar with each other's experience, if they would 
 master all difficulties. 
 
 If one half of what that indefatigable writer, George 
 M. Gould, says in regard to eye strain and the benefits 
 derived from glass fitting be true , and if to this, there 
 can be added the additional cause of affection of the mus- 
 cles, we may truly believe that the specialist of the "Eye" 
 has, within his grasp, the majority of the neuralgic 
 ailments of civilized man. 
 
 Reflexes. 
 
 The power of eye strain for making mischief in remote 
 parts by reflex action, is hardly recognized anywhere in 
 general medical literature, yet, there have been reports 
 of surprising relief by the fitting of glasses or the correc- 
 tion of muscular anomalies. 
 
152 HAZENS NEW FINDINGS 
 
 People who had been unable to read a book for twenty 
 years have been restored. Some, who had suffered from 
 migraine for a quarter of a century, have been almost 
 miraculously cured by skillful manipulation about the 
 eye, but the Medical profession is so slow to accept, that 
 the pressure to its recognition will have to come through 
 the education by popular reading, and advertisements 
 among the less educated, rather than through the teach- 
 ing of those who are the best judges and who are able to 
 test the experiences of their own confreres. 
 
 There are people dying in every community from asthen- 
 opia as a first cause. Young people, who are driven to 
 desperation by it, sometimes lose command of them- 
 selves and go to the bad, because they are unable to work 
 as others do, and often they are drawn to the use of drugs 
 or stimulants. 
 
 \\ e are unable to properly judge of criminality or the 
 cause of a suicide, until we inquire about the nervous 
 symptoms and learn the source of that desperation. 
 
 Nervous diseases, most of which are not organic, have 
 been classified as Neurasthenia, Hysteria, Chorea, Epilepsy, 
 Psychosis, Insomnia, Brain fag, Migraine, Nervous 
 prostration, Sick headache. There are those in every 
 community, who are counted invalids and who are un- 
 able to contribute to the work of society; they are unable 
 to read; to attend church or theater; they often spend 
 half of the day in bed. There are others who are on the 
 go,- — travel and work off the surplus vitality by activity, 
 fearing to enter the arena that calls for near work. There 
 are many others, who are assigned to sanitariums — in- 
 stitutions to be amused and to rest — some to asylums, 
 unlabeled. I believe a great percentage of these have 
 asthenopia as a first cause. 
 
 The effect of asthenopia is exceedingly variable. One 
 may have only eye symptoms, perhaps only headache 
 of a neuralgic character. It may occur in people who have 
 
HAZEN'S NEW FINDINGS 153 
 
 an extraordinarily good physique. I have found it in 
 athletes who had good digestion. The direction taken 
 in the reflex contiguous nerves, depends upon the power 
 of resistence these nerves have to repel an attack. In 
 some cases, the Fifth nerve, the ophthalmic branch will 
 succumb to the irritation and neuralgia sets in and mi- 
 graine developes. Then reflections upon the general 
 nervous system, denominated neurasthenia and symp- 
 toms become widely spread, and thus require a more 
 definite classification, familiar to all — named nervousness, 
 hysteria, chorea, nervous prostration, sick headache. 
 
 Sometimes the spinal nerves show the direction or 
 course and there is pain at the occipit or base of the brain, 
 and through the cervical vertabrae, and there is tender- 
 ness of the spine and numbness of the extremities. 
 
 When the pneumo-gastric succumbs to the attack, we 
 have a train of symptoms that may wreck a life. Aphonea 
 ma}' be the only evidence of the weakness, but the heart 
 is often affected; with migraine, the stomach and other 
 digestive organs are often the seat of the most severe 
 symptoms to which the human being is subjected. When 
 this incubus settles upon an individual, life, as witnessed 
 by the observer of it, does not seem worth the living, 
 and were it not that there were intervals of cessation 
 and a clearing away of the clouds, and the sunshine of 
 existence breaking in occasionally, it would seem that 
 an ending would be preferred. Such a life, covering a 
 period of 30 or 40 years — half of it spent in bed with 
 intense suffering, is a marvel of tolerance. 
 
 Mental. 
 
 Yet another tangent for this reflex is upon the mental 
 faculties. Included under this head, some might, with 
 propriety be named, "the perverted senses." These 
 attacks often come suddenly, a wave of confusion, a 
 
154 HAZBN'S NEW FINDINGS 
 
 sudden blindness, dizziness, an unaccountable fright, 
 insomnia, melancholia, etc. 
 
 That the diseases named in this category, and that 
 8} mptoms difficult to be explained, have their origin in 
 eye strain, is fast being admitted and proved, and that 
 attention to the eyes tor their relief is not to be ignored. 
 The relief sometimes comes so quickly, that it has been 
 explained as having some relation to "suggestion" — 
 mind-cure or psycho-therapy. 
 
 The many groups of symptoms that have been devel- 
 oped by reflexes generally have the history of eye trouble, 
 but not always. The secondary effect becomes of pre- 
 dominant importance and the eye as the leading factor, 
 is forgotten; the secondary disease becomes the primary 
 one, and the attention of the practitioner is wholly 
 taken up in combatting the symptoms of it without 
 recognizing its genesis. 
 
 Xot many are now holding out against the assertions, 
 that sometimes chorea, hysteria, epilepsy ,etc, are cured 
 by correcting the cause of eye strain. 
 
 TREATMENT. 
 
 The principal relief that has been reported in cases of 
 reflex eye strain, is that of the correction of refraction 
 and tenotomy of the muscles. Dr. Noyes has more 
 fully recognized the part the extrinsic muscles take in 
 asthenopia, than any other author with whom I am 
 acquainted. With his apparatus, he was enabled to 
 demonstrate the efficacy of orthoptic exercise, but his 
 appliances, although an improvement on those before 
 him, lacked very many essential elements to meet the 
 indications. 
 
 My experience, though limited considering the very 
 broad field which I am led to believe is spread by this 
 octopus of human ills, has but partially developed the 
 
HAZEN'S NEW FINDINGS lo5 
 
 possibilities, that I believe exist, in an intelligent and 
 systematic treatment of the motor apparatus. 
 
 I find that this apparatus is the seat of the trouble 
 in over half the functional difficulties; and the cause of 
 many other eye troubles; that a very high percentage, 
 if not all of those cases of asthenopia, which are attributed 
 to constitutional causes, are eye affections causing the 
 disturbance of the whole economy. When the muscles 
 receive as much attention as the refraction, it will dispose 
 of as many sufferers in addition, as has the fitting of glasses. 
 
 I find that the excessive emphasis put upon the appli- 
 cation of glasses in asthenopia, is beyond good judgment 
 and honesty. 
 
 There was a time when it was almost impossible to 
 get the consent of the parent for the child to wear glasses, 
 but the people are now so well educated that spectacles 
 are sought when complaint is made of the eyes, and if 
 relief is not obtained at the first fitting, a second is tried 
 by the same practitioner, or the patient goes to another, 
 and so much faith is put in glasses that there are many, 
 who have been fitted a dozen times or more. 
 
 By following up these cases, it is often found that the 
 variation in the prescriptions is infinitesimal; a quarter 
 dioptra on the medium, one side or the other, or a slight 
 change in the axis of the cylinder. The craze for fitting 
 glasses onto every one, complaining of his eyes and putting 
 on as low as .25 D. spherical, and sometimes a perfectly 
 plain glass has become a menace to good morals and 
 borders on fraud. 
 
 For those, who have not learned that the extrinsic 
 muscles have as much to do with asthenopia as errors 
 of refraction, there is some excuse. There are some 
 patients, who think that any glass benefits them, and 
 when once put on, it is difficult to do away with them 
 until the muscles are made right, though they be only 
 .25 D. or even plain glasses, but the slight betterment 
 
156 HAZEN'S NEW FINDINGS 
 
 comes so far short of the actual benefit they might have, 
 that it seems to those, who know the situation, that it 
 is a farce. 
 
 By experience, I have come to the conclusion that 
 in young persons there is no need of a spherical of 1 D. 
 or under, or a cylindrical of .50 D. when that cylinder 
 stands at 90° or 180°. It has been said that there is much 
 doubt as to the propriety of putting low powers of con- 
 vex spherical glasses on children. Since learning that 
 eye strain is so often found in the muscular system, 
 this proposition is the better confirmed. The neutral- 
 izing of the hypermetropia is taking off the stimulus in 
 the act of convergence and insufficiency sooner becomes 
 manifest. If the cylinder that corrects, stands obliquely 
 even in low powers, it is often necessary to wear it, 
 because objects, letters and other things are made up 
 mostly of vertical and horizontal lines. Nearly all 
 cases which I have treated for asthenopia, when 1 D. or 
 under, voluntarily took off their glasses. I have had a 
 large number of cases, who had a refraction of +1.25 D. 
 or +1.50 D. who have gone without their glasses for 
 months and some for years, and some of them are very 
 close to the age of forty years. 
 
 The facts are that asthenopia is seated in the extrinsic 
 muscles as frequently as in the ciliary, but there are a 
 few who have pure accommodative asthenopia, and these 
 are relieved by correcting the refraction. Most accommo- 
 dative asthenopia is associated with muscular asthenopia. 
 The treatment of the external muscles innervates the 
 ciliary for it is supplied by the same nerve. The dif- 
 ferentiation of Accommodative and Muscular Astenopia, 
 by the symptoms, is very difficult. 
 
 A prominent symptom of muscular trouble is the vic- 
 tims' horror of motion; it is the bane of their existence, 
 and they soon assume a stoical manner and deny them- 
 selves amusements that involve motion before their 
 
HAZEN'S NEW FINDINGS 157 
 
 eyes, or riding which gives apparent motion to fixed 
 objects. These persons suffer most at sea, for sa'ling 
 is but the two relations acting together. 
 
 The story of asthenopia for fifty years, as told in these 
 pages, is a tale of general neglect, or of a long delayed 
 recognition of the participation of the muscular system 
 of the eye, in the wide spread affection of asthenopia; 
 that the inefficient methods of the few, who have found 
 that the muscles have such a bearing, that the work of 
 those few has been set aside and the treatment they 
 instituted, ignored, and that the teachings of many 
 authors has either been, that there is no such thing as 
 "muscular asthenopia" or that all asthenopia can be 
 cured by correcting the ametropia, and on the other hand, 
 that there has been much teaching of the doctrine, that 
 muscular troubles are an imbalance or want of equili- 
 brium, and do not lie in the pathological weakness of 
 these muscles — in view of all of this, I recommend a 
 new method and a new view of the condition. 
 
 In consideration of the fact, that the method instituted 
 under this view, has been tried and found entirely effica- 
 cious in relieving a large number of persons, who had 
 undergone treatment by the former methods, I ask for 
 it a faithful trial. 
 
158 HAZENS NEW FINDINGS 
 
 THE KRATOMETER. 
 See Figs. II and III 
 
 This instrument has been named from the Greek word 
 Kratos meaning strength, and the Latin word meter, to 
 measure. 
 
 It is intended to carry out in the best manner possible, 
 the principles found necessary in the examination and 
 treatment of the Muscular system of the eyes, on the 
 theory that eye strain, and the chief symptom asthenopia, 
 are situated in the muscles, intrinsic and extrinsic, and that 
 trouble of the extrinsic constitute at least half of the cases 
 of asthenopia; that this trouble is weakness, from some 
 condition of the tissue of the muscles, or a deficiency of 
 nerve innervation or both together, and that muscular 
 discipline is the chief method of correcting the anomalies. 
 To carry out this method to its best consummation, we 
 find it necessary and most convenient — 1st. To fur- 
 nish in the instrument, the requisite means of diagnosing 
 all the anomalies as well as treating all the abnormal 
 conditions. 2nd. To afford a restful situation for the 
 person while being examined and treated, so that the 
 nervousness so often found may be quieted; to protect 
 the region of the face and eyes, the eye brows and lashes 
 from being touched in manipulation of lenses, which 
 often occurs in the usual methods, causing nervousness, 
 sickness and headache. 3d. To manipulate the lenses 
 smoothly and with facility, at right axis and with uniform 
 intervals; to be able to pass the requisite number of lenses 
 at a sitting to effect the purpose, with comfort to the 
 patient and with as little labor as possible. 
 
Fig II. 
 HAZEN'S KRATOMETER 
 
 For Gymnastic Treatment of the Extrinsic Muscles 
 of the Eyes 
 
 E. H. HAZEN, M. D., Ophthalmologist 
 A. W. HAZEW Optician 
 
Figs. I and II — Stand. 
 
 Figs. Ill and IV — Head with Stem. 
 
 Fig. V — Phorometer Slide. 
 
 Figs. VI and VII — Batteries. 
 
 T 
 
 n 
 
 ,; 
 
 TLe^rr ~Fic^r r 
 
 A — Set Screw. 
 
 B — Clamp. 
 
 C — Fingers of Clamp. 
 
 D — Clamp Screw. 
 
 E — Battery Guide. 
 
 F — Set Screw. 
 
 G — Set Screw. 
 
 H — -Lens Rest. 
 
 I — Eye Cup. 
 
 J— Lens Disk. 
 
 K — Phorometer Slide. 
 
 L — Pulpilary Aperture. 
 
 M— Maddox Plate. 
 
 N — Red Glass. 
 
EXAMINATION OF THE PJIOKIA 161 
 
 ITS APPLICATION. 
 Diagnosis. 
 
 The instrument is made so that, when screwed to a 
 table, the vertical and horizontal lines are correct. The 
 very accurate adjustment necessitating a level to the in- 
 strument, is superfluous. A general attention to the 
 table used, with a plum line and square is all that is 
 necessary. The height of the instrument should be 
 adjusted by the height of the stool on which the patient 
 is to be seated, and the height of the head piece in the 
 instrument, which is fastened by a clamp screw. The 
 head should be in the primary position and the P. D. 
 arranged. The apertures in the cups through which the 
 patient looks, are about a half inch in diameter, this 
 size being found large enough to give sufficient field, and 
 small enough to prevent the patient from deflecting 
 the head to correct an hyperphoria, instead of by action 
 of the muscle. 
 
 The two batteries contain 15 lenses each, one (the 
 units) has an interval of one degree, rising from 1° to 
 15° bases on the side, so it can be used, base in or out. 
 The other battery (fractional) has intervals of 1-4° with 
 base up or down and rises to 3 3-4°. 
 
 The Phoria. 
 
 The phoria or balance is tested by use of the Maddox 
 Rod and Maddox double prism, which are in one plate 
 and are adjusted before the R. E. and a red glass is near 
 in the same slide to throw over the L. E. as occasion 
 requires. 
 
 Lateral Muscles. 
 
 To get the balance of the Lateral muscles, the hori- 
 zontal rod is placed over the R. aperture — if the streak 
 of light which it produces, is through the light, it is 
 
162 HAZEN'S NEW FINDINGS 
 
 orthophoria, if it is on the right, we have esophoria — 
 if on the left, it is exophoria. By carrying the units 
 battery up, entering the least degree first (base cul) 
 until the streak is through the light, the prism that brings 
 it into this position, gives the amount of esophoria; 
 if the battery is carried down (base in) the amount 
 required to bring the streak into the light, eives the 
 amount of exophoria. 
 
 Verticals. 
 
 The exrmination of the verticals is made with the 
 Maddox Rod placed, vertically over the R. E., which 
 gives the streak horizontally. If the streak is below 
 the light, we have R. hyperphoria; if above, it is L. 
 hyperphoria. This is measured by the 1-4° batter}', 
 passing it up or down as required. In examination 
 of the verticals, a small light should be used, or a light 
 behind a small aperture of a half inch in diameter. 
 
 Oblique. 
 
 To detect Cyclophoria, bring the Maddox double 
 prism over the R. E. and direct the attention to a hori- 
 zontal line 20 ft. distant. The patient is asked to put 
 his head in position so that the line between the two 
 prisms is midway over the pupil, when he will see the 
 line doubled; on opening the L. E. there will appear 
 a third line between the two; if the line is parallel to the 
 other two we have orthophoria in the L. E. 
 
 If the line dips down in the right end, the superior 
 oblique of the left eye is in a state of underaction; if it 
 dips to the left, the inferior oblique is weak. Reverse 
 the Phorometer slide so that we can examine the R. E. 
 with the Maddox prism over the L. E. When the right 
 end of the middle line runs upward the superior oblique 
 of the R. E. is weak; if the left end of the middle line 
 turns upward, the inferior oblique of the R. E. is weak. 
 
CONVERGENCE 163 
 
 Convergence Rod. 
 
 The Kratometer is provided with a Convergence rod 
 for testing accommodation and convergence. It is marked 
 with Centimeters, which conforms to the system of 
 Dioptries and Meter Angles. (Xagel) 
 
 The accommodation is measured by use of a small 
 card with print, the standard of Jaeger, which is placed 
 in the carrier of the rod. Xote should be made of the 
 centimeter, where the print begins to blur in reading 
 the card. To ascertain the convergence, turn the card 
 over and place it with the line found on it vertically; 
 note the point in centimeters where the line becomes 
 double. Dividing 100 by the number of centimeters 
 in either case, will give you the dioptries of accommoda- 
 tion in one case, and the meter angles of convergence 
 in the other. 
 
 Reading Distance. 
 
 A test at the reading distance, one-third of a meter 
 (33 1-3 cm) is the most practical. At this point, it is 
 well to test the power of convergence, both minus and 
 plus, by carrying the units battery down (base in) to 
 test the converging power in the act of accommodation. 
 If the line still stays single to the end of the battery 
 (15°) place the 10° or 15° lens on "H" with base in — then 
 proceed as before with the units battery. The conver- 
 gence should be 25° or 30°. I regard this test better 
 than that of \ on Graefe, but his should also be made. 
 With the card at one-third of a meter, with the dot line 
 in view, put the 10° square prism on "H" base down; 
 this doubles the card, with the card of the R. E. thrown 
 up above the other. If the line is continuous there is 
 no insufficiency, according to \ on Graefe. This, how- 
 ever, will often show up all right for the short time of 
 examination, under the stimulation of accommodation, 
 
164 HAZEN'S NEW FINDINGS 
 
 but on examination at 20 ft. wc often find that patients 
 cannot adduct 5°, showing want of endurance, and that 
 although the line test will show well, yet they may be 
 suffering from asthenopia. These tests unveil a large 
 number of insufficiences, that are easily cured by mus- 
 cular discipline. This test is very much neglected in 
 glass fitting. The placing of a convex glass removes, 
 in part, the accommodative stimulus. The internal 
 muscles, having had the habit of converging, commen- 
 surate with the accommodation used, now lag in the act 
 of convergence, which is now made independent, and of 
 which there is as much required as before glasses were 
 put on. (Fig. 1) 
 
 This is a common trouble in administering to Pres- 
 byopia. Although the lenses are right ,the muscles are 
 weak and the spectacles are thought to be wrong. 
 
166 
 
 HAZEN'S NEW FINDINGS 
 
 FIG. 1. 
 
 (See opposite page for explanation) 
 
CONVEX LENZES 167 
 
 Fig. 1. THE EFFECT OF CONVEX LENSES ON CONVER- 
 GENCE. 
 
 Lei R. R. be the parallel lines which the axis of the eyes take 
 on looking at a distance. When the eyes are directed, say to 
 P. (the reading distance) if the eyes are normal, that is, have accom- 
 modation and convergence in harmony, convergence accompanies 
 accommodation and both are upon the object, but if for any reason, 
 glasses are put on to aid accommodation to enable persons to see 
 at o M. A. the accommodation is aided and there is not the required 
 focal effort made to see at a near point as before; they may see 
 to read with one eye plainly, or for a short time with both eyes. 
 but, as the association between the two functions, accommodation 
 and convergence is broken, the convergence is not stimulated as 
 before, and the visual axes of the eye-balls stand out as represented 
 by the lines C. C. The object then is doubled or indistinct. 
 
 When glasses are first put on there is often this weakness and the 
 muscles have to be disciplined by gradual overcoming the new 
 relation or a system of gymnastics must be provided for meeting 
 the condition. 
 
 When Presbyopia is gradually met by frequent increase of the 
 convex lens as it developes, the convergence is disciplined by 
 effort of the will and the new relation is met and no great incon- 
 venience is felt, but it is not always thus. Asthenopia may be 
 felt and sometimes using the eyes at a near point, has to be aban- 
 doned. 
 
168 
 
 HAZBN'S NEW FINDINGS 
 
 FIG. 2. 
 
 (See opposite page for explanation" 
 
NAGEL'S SYSTEM ICO 
 
 Fig. 2. TO DEMONSTRATE NAGEL'S SYSTEM of me- 
 
 uring convergence and its relation to accommodation. 
 
 Nagle takes one metre as a unit, called Metre Angle, which cor- 
 responds to the Metre Lens in the Dioptric system, which we have 
 adopted in the trial case of which Xagel is the author. 
 
 The Metre Angle is the angle formed at one meter distance by 
 the intersection of the visual line with the median line. 
 
 In Fig. 2 let the pupillary distance P. P. be the base line; H. 
 the center and _M. H. the median line. Inf. will be the direction 
 of the optic axis (visual line) when looking at a distance or "In- 
 finity." The visual lines arc then parallel to the medium line 
 M. H. Xow let the eyes lix upon an object at 1 Cone metre). 
 Then the deflection of the axis of each eye to 1 with P. H. forms 
 the angle 1 P.H. and it is the metre angle of deflection or conver- 
 gence of each eye. 
 
 At 2 or 50 C. M. it is 2 M. A.; at 3 it is 1-3 of a metre angle or 
 3 M. A.; at 5 it is 5. M. A. This system applies to the measure- 
 ment of accommodation in dioptres and at those points it is repre- 
 sented by the same figures but designed as dioptres. When the 
 measurement is taken on the centermeter scale it is easily reduced 
 to Xagel's notation. 
 
 The lines D. D. represent divergence and are measured by the 
 system of Stevens on a distant object and are negative and the 
 angle is formed by carrying it to a point which would be behinf 
 the eyes at O. 
 
 The condition of the visual axes of main' eyes before the glasses 
 are prescribed is represented by the lines D. D. 
 
170 HAZEN'S NEW FINDINGS 
 
 Examination. 
 The Test for Muscular Strength. 
 
 Heretofore, the process for testing the capacity of the 
 muscles, has been to put such prism before the eye as 
 will cause diplopia, and ask the patient to fuse the divided 
 light. This process is contrary to the principles of mus- 
 cular discipline. The modern method of using dumb 
 bells is to first use light weights, and gradually increase 
 their heft. We would not direct the jumping of a canal 
 to discipline the leg muscles. \\ ith this method, so 
 long used, no adequate information of the strength of 
 the recti is obtained. 
 
 The appeal to the muscles, by this system, is so radi- 
 cally different, that it changes the whole aspect of the 
 subject of muscular discipline. This fact, with the dif- 
 ference we make in the adaptation of the denomination 
 of the lenses to the particular pair we wish to discipline, 
 leads us to affirm that muscular discipline of the eye 
 muscles has not been adequately tried. The quick 
 response to the improved method shows this to be true. 
 
 The particular change in method, which we use, is 
 to pass, in succession, the prisms from a low denomination 
 to as high an one as the eyes are able to keep fused, and, 
 when the eyes cannot hold the light singly, we stop, 
 for that last prism designates the strength of that pair 
 of muscles. 
 
 The Internal Recti. 
 
 \\ ith the light at 20 ft., commence by turning a 5° 
 prism in the disk over the L. E.; if this is fuses, turn on 
 the 10°; if this is also fused, go on until one is turned 
 on that will cause diplopia. When on-e causes double 
 vision, turn back to the one that can be fused, and then 
 proceed over the R. E. with battery thrusting before 
 it, in the guide (E) the 1°, and carrying it up until the 
 
TESTING STRENGTH 171 
 
 light parts. This measures the strength of that pair. 
 Care is to be taken that the battery is run smoothly 
 for a hitch or accident, that jars, will cause the eyes 
 to let go. It is better, at the first sitting, to perform 
 this twice. 
 
 Another precaution must be kept in mind. These 
 cases have so schooled themselves as not to take notice 
 of objects, moving before them, and they will allow the 
 light to part and one object to pass out of the field with- 
 out noticing it. On coming to the end of the battery, 
 ask them to take notice, as you quickly jerk up the bat- 
 tery. The eyes are in position to cause two lights to 
 be seen for an instant, if they have fused every one. 
 This will catch their dereliction. 
 
 \\ ith those whose muscles are sore, the parted light 
 will fly off quickly, and there will be no movement 
 toward fusing again, while with others, the light will 
 sail off slowly, and still others will suddenly see twc 
 lights and not see them part. From this behavior, 
 under this test, much can be learned to discipline these 
 muscles. 
 
 It is found that very often a patient cannot fuse more 
 than a 5° jump, but will make 12° to 15° in adduction by 
 adding small units, showing the utility of at least a 15° 
 battery for the end of the left, and demonstrating that 
 this process measures, more accurately, the strength 
 of the muscles, than was done by the former method. 
 Then, it may be noted that the muscles will act more 
 uniformly and do better, when the}' are appealed to by 
 regular intervals, with a slight jump between. 
 
 The standard for the strength of the internal recti should 
 be, at least 25° to 35°. It takes 23° to converge to reading 
 distance, but I have seen several cases, who adducted 
 35° and yet suffered from use of eyes. In these case-. 
 it takes several seconds before the eyes are adjusted, 
 so that quickness and facility of adjustment of the 
 
172 HAZKN'S MOW FINDINGS 
 
 c\ cs is a necessity as well as strength. Some of these 
 cases have a history of great discomfort, and have been 
 slower to gel well. Other muscles are often involved. 
 \\ here there is much exophoria, it is necessary to use 
 the slide lenses accompanying the instrument, putting 
 in a 3° or 5° over left eye with base in, and sometimes 
 the 1° over the R. E. in addition, in the phorometer 
 slide to make the patient see through the eye cups and 
 get within the compass of the instrument. Of course, 
 the denomination of these must be included in the problem . 
 
 The External Recti. 
 
 The strength of these muscles is found by the use of 
 the units' battery over the R. E., carrying it down with 
 the guide (E) with base in — abduction. At the end, 
 the quarter degree battery is carried in horizontally 
 on the lens rest "H," a lens at a time. The lenses being 
 placed, base up, in this battery, adds at the end of the 
 left, a 1-4° at a time to the unit battery carried in the 
 guide, base in. The standard for these muscles should 
 be at least 5° on the first examination. 
 
 The Vertical Muscles. 
 
 These muscles are examined with the quarter degree 
 battery over the R. E. Infraduction is done by carrying 
 the battery up, and sursumduction by carrying it down. 
 
 This is the first instrument provided with a quarter 
 degree battery. In treatment, we give deflection of bat- 
 ter}' to increase duction. 
 
 The Obltque Muscles. 
 
 The measurement of the strength of these muscles 
 alone has not been accomplished, except by Steven's 
 Clinoscope, but the strength of those associated with 
 
TREATMENT 17:'> 
 
 the Superior and Inferior Recti, I am led to believe can 
 be done with the 1-4° battery, carrying it up or down 
 as required and deflecting it, right or left, to the angle 
 necessary to get into the line of action of the two muscles. 
 The degree of the last fused lens will give the power, 
 that can keep the light fused in this direction. 
 
 I have not had sufficient experience with this condi- 
 tion since I conceived the thought to fully elucidate this 
 point. 
 
 TREATMENT. 
 
 The treatment consists almost entirely of gymnastic 
 exercise. Medicine has been used in its connection 
 for costiveness, and in one or two instances, a nerve 
 tonic. 
 
 The refraction is looked after, but, in most cases, they 
 have been in the hands of others and refracted, and as 
 a rule, the glasses are not changed until after the gym- 
 nastic treatment has been finished. 
 
 In some cases, the lenses worn, are so infinitesimal, 
 that it is recommended to lay them off; as a general rule, 
 we let the former examination stand, and allow the patient 
 to use his own discretion, whether to continue wearing 
 them or not. In the majority of cases, where they are 
 wearing under +1.50s D, with .50 D. cylinder, axis 
 90° or 180°, they have taken off their glasses volun- 
 tarily. In some cases, on first examination, the glasses 
 seemed to be wrong, but exercise of the muscles was 
 instituted, and correction of refraction was put off until 
 the end of treatment, when, after such muscular exercise 
 and discipline, the glasses proved to be all that were 
 needed. 
 
 We have never put prisms on in spectacles over any of 
 these muscles since instituting this gymnastic treatment, 
 nor have we seen a case that we would tenotomize, except 
 once, and in that case the vision could not be developed. 
 
174 HAZEN'S NEW FINDINGS 
 
 Before the discovery of this treatment, I performed 
 tenotomy and, for many years, frequently performed 
 the operation of advancement. 
 
 As we have already said, the treatment of the extrinsic 
 muscles is not founded on the phoria, or the position, 
 that the eyes are related to each other, (balance) or that 
 the object in the treatment of them is to correct the de- 
 partures we set up as standards of position, yet the phoria 
 is one of the concomitants of the disease, and should 
 be watched, and if possible, brought to that position, 
 where there is the least expenditure of force in projection, 
 to do the work of functioning. It is also an index of 
 some indications in the treatment. It leaves the eyes 
 nearer to that ideal which we believe Nature would seek 
 to maintain. \\ e therefore measure the phoria at the 
 beginning of every sitting. 
 
 We always discipline the muscles with the object 
 (light) at 20 ft. away, free from the element of accommo- 
 dation. This we regard as important, as Dr. Stevens'' 
 conclusion that equilibrium should be preserved at all 
 points. Von Graefe, he says, was wrong in operating 
 to fit the eye for near work, and throwing it out of balance 
 for distant adjustment. If the eyes are disciplined on 
 the distant point, they are more likely to come into 
 balance, in the end, for all points. Experience shows 
 that in cases, fully disciplined in the infinite distant 
 point, the eyes are fitted for all points. Then, the time 
 in which the eyes are brought to a healthy condition, 
 in this method, is at least 1-5 of the time, given in any 
 report, made by those, who use methods, that combine 
 accommodation and convergence. 
 
 We treat the muscles in pairs, and do not know of any 
 use to be made of the knowledge of one muscle of the 
 pair being stronger or weaker than its fellow. 
 
ADDUCTION 175 
 
 Adduction. 
 
 The pair of muscles that do the work of adduction are 
 the muscles that modern civilization yokes to accomplish 
 her ambition and to pile up the fruits of industry. No 
 wonder that the pace man has set for these muscles, 
 should tire, produce aches and at last a break-down. 
 
 They are, then, the principal object of our treatment 
 in muscular affections. The standard is 50° and it is 
 often advisable to go to 60° or "0°. This gives a reserve 
 of ability that lasts for years. 
 
 \\ ith judicious treatment by the Kratometer, 10° 
 to 20° of exophoria have been made orthophoric within 
 a month and amblyopia has been relieved and useful 
 vision restored. 
 
 The use of the "slide lenses," as directed in the Exami- 
 nation or Test, is very serviceable and indispensable 
 in high degrees. 
 
 The exercise of these muscles should be guided by a 
 good deal of judgment. There are some patients, who 
 have to be urged and taught to throw the will into the 
 converging act; some are very slow and will allow the 
 light to go apart without a bit of evidence of using the 
 will. Others of the nervous, quick ambitious type, will 
 overdo, and if care is not taken, they will undo all the good 
 that the first few treatments almost invariably show. 
 From five to seven lifts are general!}' all, that should be 
 given at a sitting once a day. If they progress very 
 fast, three lifts are all they should be allowed on this 
 pair. 
 
 The progress of exercise is much the same as described 
 in examination, adding 5° at a time, turning the prism, 
 in the disk, onto the L. E. and adding the square lenses 
 over the R. H., which I generally hold between my 
 thumb and finger on the rest "H." I allow a rest of 
 
176 HAZEN'S NEW FINDINGS 
 
 a few seconds after each lift. The slide lenses can be 
 used if it is desirable to go above 60°. 
 
 \t the beginning of the treatment, as soon as the light 
 parts, I take away the lenses, but as progress is made, 
 I allow the patient to bring back the parted light, and 
 further on, 1 urge them to fuse. There is but one degree 
 to correct on the extrinsic of the left in this case. 
 
 A valuable use of the square lenses is found to be in 
 climbing to higher degrees of adduction. \\ hen a second 
 or third lens in the disk is turned on, the full denomina- 
 tion of the lens has to be corrected on fusing it, and not 
 the difference only between the last two. W hen not 
 able to correct the last one, instead of turning back to 
 that one which he has fused, by thrusting the 5° square 
 lens over the R. E. on "H" with base in, the patient is 
 enabled to fuse — then withdrawing this, it adds 5° more 
 — then putting it back with base out, that may be fused — 
 then go on with the battery for the extreme of the lift. 
 
 Abduction. 
 
 In the discipline of the external recti the units' battery 
 is used over the R. E. and the fractional at the end of 
 the lift. Carry the unit battery down, base in, until 
 diplopia is produced, then go back to the lens that is 
 fused, and thrust in, horizontally, the quarter degree 
 battery, which adds 1-4°; if that is fused, add 1-2° and 
 so on to 1°. If the pupillary space is made sufficient, 
 there is room for the four lenses. When that is accom- 
 plished, we can generally drop the units battery another 
 degree and then proceed as before. 
 
 Of all the eye muscles, those of the external recti are 
 the most stubborn, but they will generally yield. More 
 lifts can be made in these muscles, at a sitting, than in 
 any other pair. The standard of Dr. Stevens of 8° 
 
VERTICAL MUSCLES 177 
 
 for abduction is to be sought, but 6° is often sufficient, 
 and even 5° will prove to be all that is necessary, if the 
 other muscles are doing their part. 
 
 Verticals. 
 Infraduction and Sursumduction. 
 
 The carrying of the quarter degree (fractional) with 
 the bases of the lenses up over the R. E. or down over 
 the L. E., we term Infraduction, and vice versa Sursum- 
 duction. 
 
 In many of these cases, the slide lenses are serviceable 
 in assisting the eye to see the light through the apertures 
 in the cups. \\ hen the L. E. turns up, the base of the 
 prism should be down over that eye or up over the R. E. 
 
 Following the rule, that in putting a prism before 
 the eye as a crutch, the base should be toward the point 
 to which the eye ought to turn, and in putting it over 
 the fellow eye to help the same eye, it should be reversed, 
 To discipline the eye to action, it is observed the apex 
 is in the direction toward which the eye ought to turn. 
 
 With an appeal to the vertical muscles of a quarter 
 degree interval of prism, the muscles respond to gym- 
 nastic treatment as well as do the internal recti to that 
 of one degree interval. A very serviceable way to make 
 these muscles respond is, when — for instance Infraduction 
 is the exercise, on going up, when the light parts and the 
 patient cannot fuse, deflect the battery tovard the median 
 line at the lower end, to or near to 45 D until the lights 
 are fused and ask the patient to hold them, while the 
 battery is returned to 90° . Often another quarter can 
 be added and sometimes a full degree can be climbed 
 at one sitting, and a high degree of hyperphoria can 
 be corrected in one month or less. 
 
l78 hazen's new findings 
 
 Cycloduction. 
 
 The treatment for this has been found to be Infraduc- 
 tion and Sursumduction. The cylinder treatment of Dr. 
 Savage, has not proved to be as good, in my hands. 
 
 The line of action of the oblique is nearly like that 
 of the verticals. To bring into action the oblique, the 
 treatment under Infraduction and Sursumduction has 
 been found to be effective, and Cyclophoria has dis- 
 appeared. 
 
 Red Glass. 
 
 The Red glass is kept in the slide, as a rule, and is 
 in situation to quickly throw it before the L. E. as occa- 
 sion requires. In the cases, who have learned to sup- 
 press the image, the red glass is often very serviceable. 
 It is sometimes better that the red glass be put over the 
 best visioned eye. 
 
 Fusing Faculty. 
 
 I have not met a case that has not the "fusing faculty" 
 unless it was a blind eye. It is sometimes dull but I 
 have attributed the inaction to the presence of Am- 
 blyopia, or to the indisposition to call into action the 
 muscles, the patient having acquired the habit of allowing 
 things to happen before his eyes without fixing his gaze 
 upon them. Certain cases, who have had several treat- 
 ments with about the same indifferent results, when 
 they have been urged to exert their will power and hold 
 the fusing of the lights, have seemed to awaken to a new 
 idea and have brought this fusion faculty into action. 
 
 The successful treatment of these cases is not so simple 
 a matter as one might suppose from reading this de- 
 scription of the process. 
 
 The important difference in these cases is not in the 
 imbalance, neither is it in the lifting power of the muscle, 
 
UNNECESSARY GLASS FITTING 179 
 
 but in the classification of the weakness of the apparatus 
 of this function. It is found in the nervous temperament 
 and constitutional make-up of the individual. Some 
 have nerves like wire, that do not feel anything, when 
 you know that the same amount of irritation would 
 put others to bed. Oculists know this to be true. One 
 man, with ulceration of the cornea, will not acknowledge 
 pain, even when there are ulcerative abrasions, the size 
 of a half pea; another, with a much less dangerous con- 
 dition, will not leave his bed. So it is in the ocular 
 muscles. A man may have a high degree of hyper- 
 phoria, and although he uses both eyes in reading and 
 expends a vast amount of nervous force in adjustment, 
 there is no complaint of pain, and he only drops to sleep 
 in a few minutes. 
 
 Another has sufficient nervous vitality to correct an 
 exophoria but irritation is not reflected on systemic 
 nerves. The power of resistance is so effective that 
 the only inconvenience is weariness on near work. 
 
 GLASS FITTING CRAZE 
 
 The author of this system is well aware of the antag- 
 onism he produces, in some quarters, to the extensive 
 craze of fitting lenses for every symptom of discomfort 
 from use of the eyes. He believes that the majority 
 of young people, who are wearing lenses (spherical, 
 cylinders and prisms) have merely had a splint or crutch 
 adjusted, which supports or props up and puts at rest a 
 condition, that should be met by a different method of 
 treatment, and this conviction comes, not from theory 
 but from practical experience and observation. In this 
 category he would make exception in high degrees of 
 Ametropia, which are deformities, and need braces, 
 and of course, also that condition of Presbyopia, which 
 necessitates glasses for all, when the time comes. 
 
1*" HA/K.VS XKW FINDINGS 
 
 After fifteen years' practice of this system, and having 
 practiced the old method twice this length of time, and 
 after making a faithful study of the progress in the man- 
 agement of the Function of Vision, in the hands of his 
 predecessors for half a century; and knowing the claims 
 of the disciples of Donders, regarding refraction; and 
 fully appreciating the great improvement Donders has 
 made, toward the solution in the immense field of dis- 
 orders of the function of vision — it must be acknowledged 
 that "New Findings" has a narrow margin of nezv prin- 
 ciples, but the application of the principles already 
 known, and the findings of new applications, with some 
 variation in appliances, are achievements which are 
 gratifying — especially, when these new applications are 
 responded to quickly and satisfactorily in a large number 
 of cases formerly passed by. They also open new avenues, 
 which the Ophthalmologist has not supposed belonged 
 to his branch; symptoms that are pronounced strange 
 and which go unlabeled and unexplained. While the 
 difference in and additions to the mechanism seem small, 
 the success of the adaption to the end is marvelously 
 great. 
 
 Thus we see that "New Findings" is but the adapta- 
 tion and application of the old and well known principles 
 in physical development; that exercise, discipline and 
 work are the right means for bringing into health and 
 use, any and all functions of the physical organism; 
 that to attain a high degree of perfection in the physical, 
 mental and even the moral system, or attain to the best 
 possibilities of the human functions, zvork and incessant 
 toil are necessary, and not rest; that to keep these functions 
 in repair, and give them long life, and enable them to 
 reach tow r ard a still higher point of conception, can be 
 done only by continued effort and strenuous activity. 
 
 This system of gymnastic treatment of the eye, which 
 I have found practical for fifteen years, and have attemp- 
 
FIELD OF APPLICATION 18 
 
 ted to describe in these papers, opens up a successful 
 and effective treatment of certain forms of eyestrain, 
 which have been so easy of management in my own hands 
 and those of others who have tried it, that the success 
 has been a continual surprise and wonder. 
 
 We are constantly meeting with cases in whom there 
 has been no suspicion of asthenopic symptoms, and who 
 have made quick recovery with this exercise. Many 
 cases, classified under the head of nervous and non- 
 organic, have been permanently relieved or greatly 
 benefitted. Not only has it been applied with much 
 quicker and surer results, in those cases of the lateral 
 muscles, already recognized as muscular forms of eye 
 strain, but it has effectively taken hold of those most 
 puzzling cases of the verticals, and, with equal facility, 
 conquered these in which there was formerly no success, 
 and has shown that these muscles belong to the general 
 lrws governing orthoptic treatment of eye muscles and 
 are equally susceptible to it. 
 
 Again, there is a high percentage of cases, which 
 have been lost to Ophthalmologists, by being relegated 
 to other specialists for constitutional treatment and pro- 
 longed rest, and were cut out of the industrial world 
 for a time, or permanently, who have been restored 
 to active usefulness, within a month, by this treatment. 
 
 Indeed, I predict that, when due attention is paid to 
 "Muscular Eye Strain," according to the idea of "New 
 Findings," it will be found to occupy as conspicuous 
 a place in Ophthalmology as does that of its twin sister 
 "Refraction." 
 
EXAMINATION OF EYE MUSCLES 
 OF 502 CHILDREN 
 
 IN THE 
 
 DES MOINES SCHOOLS 
 
 From Fifth to Eighth Grade, Age 10 to 12 years. 
 
The pupils were designated by number. The age 
 and whether or nor they were troubled with their eyes 
 was ascertained by questioning; and if any discomfort 
 their symptoms were noted briefly. The vision was 
 taken of each eye singly, and then the balance. The 
 common method of using a prism (square) was used, 
 free from the instrument to see what prism could be 
 corrected in adduction. The test was then made by the 
 Maddox rod for lateral and then vertical deviation. 
 The number of inches was noticed on the cross-bar 
 as suggested by Maddox, and the deviation was measured, 
 also by the prism. Care was taken to have the aperture 
 through which the candle shone, at twenty feet distant, 
 but half an inch in diameter to get the hyperphoria, 
 and a 1-4° was noted. There was no consonance between 
 the number of inches on the cross-bar, either lateral 
 or vertical, to what was found by the prism. It sometimes 
 differed widely. Fifty-six of the cases had hyperphoria 
 of this amount but in my tables I do not use this amount 
 in casting up the percentage of hyperphoria, so that I 
 might conform to the reports of other observers. These 
 tests were also made by the Maddox double prism for 
 heterophoria, at 16 inches distance; the double prism 
 also for cyclophoria; then Yon Graefe's test at 16 inches 
 with base down looking at a dot with line drawn verti- 
 cally through it. In high degrees of heterophoria, the 
 red glass is used over one eye. The duction power: 
 adduction, abduction and sursumduction — carrying the 
 battery over the right eye was then taken, one right after 
 the other. 
 
 Of the 502 examined, there were those with one blind 
 eye, strabismus, and dummies, making 12 cases deducted 
 
1S»; HAZEN'S NEW FINDINGS 
 
 from 502, which leaves 490 from which I compute my 
 statistics. Of these, half were boys and half girls. Two 
 hundred and forty one, 49 per cent of the number claimed 
 they had no trouble with their eyes, and 249 had more 
 or less "hurt"-— 51 per cent. Twenty-seven more said 
 at first they had no trouble, but on questioning them 
 further admitted that they had had headache, but did 
 not attribute the symptoms to any connection with their 
 eyes. Of the two hundred and forty nine cases, 50 per 
 cent had symptoms of headache — forehead, temples and 
 back of head — eye ache, dizziness, watering, blurring, 
 double vision, smarting and hurting on use of eyes. Of 
 the four hundred and ninety, sixty had vision below 
 standard. A few of these had vision in one eye 20 /xx. 
 There were 28 wearing glasses; 25 had worn glasses but 
 had discarded them. 
 
 The refraction was not corrected before the examination 
 of the muscles was made. The balance and strength of 
 the muscles was the object, aside from the cause. The 
 tables herewith will give further results of this examination. 
 
TABLE-SCHOOL EX A MI NATION 187 
 
 TABLE NO. 1 SHOWING THE— PHORIA. 
 
 ESOPHORIA 
 
 EXOPHORIA 
 
 HYPERPHORIA 
 
 RECAPITULATION 
 
 DEC 
 
 NO. 
 
 DEC 
 
 NO. 
 
 DEC 
 
 NO. 
 
 LATERAL 
 
 
 X A 67 
 
 K 
 
 37 
 
 X 
 
 41 
 
 Orthophoria 96 
 
 19% 
 
 1 
 
 68 
 
 l 
 
 42 
 
 X 
 
 21 
 
 Esophoria 288 
 
 59% 
 
 2 
 
 42 
 
 2 
 
 12 
 
 1 
 
 12 
 
 Exophoria 106 
 
 22% 
 
 3 
 
 37 
 
 3 
 
 6 
 
 IK 
 
 5 
 
 
 
 
 
 
 •1 
 
 30 
 
 4 
 
 5 
 
 l# 
 
 5 
 
 490 
 
 100% 
 
 5 
 
 11 
 
 5 
 
 1 
 
 1M 
 
 2 
 
 VERTICAL 
 
 
 6 
 
 9 
 
 6 
 
 1 
 
 2 
 
 1 
 
 Orthophoria 343 
 
 70% 
 
 
 3 
 6 
 
 8 
 9 
 
 1 
 
 1 
 
 2K 
 3 
 
 2 
 
 1 
 
 l /i Hyper'a 56 
 
 11% 
 
 8 
 
 399 
 
 
 9 
 
 10 
 11 
 
 3 
 
 1 
 o 
 
 12 
 
 1 
 
 3^ 
 
 1 
 
 K Hyp & ovr 91 
 
 19% 
 
 
 106 
 
 
 91 
 
 490 
 
 100% 
 
 12 
 
 4 
 
 22% 
 
 
 20% 
 
 
 
 
 13 
 
 1 
 
 
 
 
 
 
 
 15 
 
 1 
 
 
 
 
 
 
 
 19 
 
 1 
 
 Orthophoria 
 
 96 
 
 
 
 
 20 
 
 1 
 
 
 19% 
 
 
 
 
 
 25 
 
 1 
 
 288 
 59% 
 
 
 
 
 
 
 
iss HAZEN'S NEW FINDINGS 
 
 At the risk of repetition of thought, I must, in closing 
 this dissertation on Eye strain, again call special attention 
 to this subject and endeavor to impress its importance 
 and universality, and show up the findings that have 
 been made, which have hitherto been entirely missed, 
 passed over, ignored or repudiated by the profession. 
 
 Alan's insight into the ailments of humanity is very 
 limited and his knowledge is hampered by his precon- 
 ceptions, his training, his prejudices and his self interest. 
 He is puffed up with learning and position; he is schooled 
 into doctrines and modes of thought; he casts aside 
 propositions that are not dressed in the fashions of the 
 day; he weighs the movement of confreres in the light 
 of self interest and avariciousness. A new theory, how- 
 ever brilliant and genuine, has to undergo the innuendoes 
 of men, who should be the first to interest themselves 
 in its investigation and promotion. 
 
 The history of Asthenopia has its moral and social 
 aspects, which have not been pictured in this book. 
 Men, who have contributed largely to its development, 
 have "suffered the slings and arrows of outrageous for- 
 tune," and have been ostracized by their brethren in 
 consequence. But the penalty of radical ideas in this 
 limited field of medicine, is the same as in the other walks 
 of life — martyrdom, in different degrees of severity, 
 is always meted out in proportion to the angle in which 
 it deflects the needle of the staid thought of the times, 
 and hurts in proportion to the size of the angle of current 
 opinion. 
 
 The system of the Kratometer, which administers to 
 the muscular cause of eye strain, is new in many respects 
 and differs from that heretofore practiced. It has for 
 its principle basis much that has been previously worked 
 out by others, and the modifications, which it institutes 
 seem to be not very radical, but its adaption to the con- 
 
EYE STRAIN 180 
 
 ditions of this particular form of Asthenopia is astonishing 
 to those who learn to apply it. 
 
 There is a certain percentage of weak convergence 
 and hyperemic conditions that responds quickly to the 
 treatment ;xu'i the result is satisfactory and delightful, 
 but there are in every community those, suffering from 
 the reflex symptoms of eye strain, which produce the 
 secondary symptoms, which are finally taken up as the 
 primary disease, and treated as a distinct disease, and the 
 first cause, the eye strain, is forgotten. These patients 
 first try the oculists or other men who adjust glasses, 
 and most of them have some inkling of the association 
 of the lextrinsic muscular system (adjustment) of the 
 eye with the refractive part of the function of vision, 
 but as a general thing it is entirely neglected or sup- 
 posed to be but little involved. The parties, getting 
 but little or no relief, try again and search for the one 
 of highest reputation as a dernier resort, and from him 
 they get their ultimatum in his specialty. Unless the 
 Asthenopia is accommodative entirely, they get no sat- 
 isfaction and gradually come to the conclusion that they 
 are invalids and have some constitutional disease and 
 proceed to the mummyfication of themselves. They may 
 have been advised by their Dernier, to quit work for six 
 months to recuperate their health. 
 
 This, to many, is too much of a doxology to their hopes 
 and aspirations, and they resolve to consult some Nervous 
 Disease man, for their symptoms are so distressing and 
 unbearable that they are willing to do anything to rid 
 themselves of this incubus. If the tangent, which the 
 reflex has taken, be neuralgic, analgesic remedies are 
 administered; if mental, rest at some Sanitarium with a 
 watchful nurse is recommended; if the pneumogastric 
 nerve plays havoc with the digestive apparatus, a course 
 of diet, baths, electricity and massage are prescribed. 
 
190 MAZKX'S N'KW FINDINGS 
 
 There is a high percentage of these cases that are 
 asthenopic, and have their first cause in Eye strain, and 
 a majority of them are ocular motor, which get different 
 classifications, such as, neurasthenia, nervous pros- 
 tration, psychosis, brain-fag, nervousness, hysteria, chorea, 
 insomnia, epilepsy. These are classifications of symptoms 
 merely; they are not organic and when the first cause is 
 removed the patient is well. 
 
 The professional gap between the Oculist and the Ner- 
 vous Disease man is a wide one. They have as little 
 interchange of thought or consultation as two denom- 
 inations in the ecclesiastical world. The human system 
 has a number of tabulated symptoms that arise from the 
 anomalies of the extrinsic muscles, which probably both 
 the Oculist and the Nervous Disease man had oppor- 
 tunity to handle, but neither has put his finger on the 
 cause and does not effect a cure because of this fact. 
 Occasionally some relief has been effected by withdrawing 
 the use of the eyes from labor, and the general health 
 has improved and maybe by such process they have been 
 relieved for a short time, but a return to the same labor 
 will bring about like results, for the cause is not removed. 
 
 Patients have been under my treatment, who have been 
 glassed by different men from four to fifteen times, and 
 who have also consulted Nervous Disease men, and in 
 some cases both specialists, failing to find a cause for 
 the symptoms described, have attempted to convince 
 the patients that there was no cause for their nervousness 
 and morbid fears, and that there was no occasion for their 
 anxiety that if they would summon their will power, 
 they could throw off their nervousness; or that if they 
 would take their minds off themselves and forget their 
 ailments they would overcome or master the imaginary 
 ills. 
 
 These people are real sufferers. It is sometimes psychi- 
 cal; in others abdominal; in others neuralgic; sometimes 
 
CASES L9J 
 
 attributed to billiousness, dyspepsia, or some consti- 
 tutional breaking down or want of rest. Whereas all 
 these are the effects of reflex symptoms of eye strain. 
 These patients get no sympathy from their friends. It 
 is often that the manifestation is such that the patient 
 is the only one to whom the phenomena are a reality, 
 and he learns to endure his ills with as much equanimity 
 as he can command. 
 
 In the meantime, much suffering abounds in every 
 community, and those who are expected to treat these 
 afflictions, are failing to discover that eye strain is very 
 closely related to many forms of Nervous disorder. When 
 it is once recognized that the reflex effect of Eye strain 
 upon the general nervous system is very severe and wide 
 reaching; when those, who make a specialty of ministering 
 to nervous debility, accept this as the real situation, 
 then they will join hands with the Oculist in investigating 
 this new field, and much good will be accomplished- — 
 through their united efforts. 
 
 CASES. 
 
 Case 1. August, 1896, Miss M. B., Indianola. Student. Age 
 about 20 years. Deficient in constitutional tone. I had corrected 
 refraction but on returning to study had trouble again; pain of a 
 smarting lancinating character. Orthophoric. Adduction 19°; 
 abduction 8. Having exhausted my knowledge on this case, I 
 sent her to Chicago to Dr. Holmes, who found nothing to do but 
 to give gymnastic exercise on the internal recti. The endeavor 
 to carry out this instruction resulted in the first steps of this treat- 
 ment. In fifteen treatments I brought the recti to the standard, 
 50°, and discharged her. She remained free from the trouble and 
 was able to prosecute her studies moderately. 
 
 Case 2. November 1896, High school student. Had trouble 
 with eyes since going to kindergarten; remains for hours at a time 
 in a dark room; intolerance of light, especially artificial light; 
 headache about the eyes, could get relief with hot applications. 
 She wore weak cylinders. Vision good, but found it difficult to get 
 clear vision because of blurring or double vision. Esophoria. 
 
1!»: HAZEN'S NEW FINDINGS 
 
 2 1-2* .Adduction 20°. Removed glasses. Treatment. Adduc- 
 tion, 23 treatments, when the esophoria was 1 1-2°. Remained in 
 school while treating, and improved from the start. January, 
 L901, lias been free from pain, and only on intemperate use exper- 
 ience- inconvenience. Has not worn glasses since, and has no 
 trouble whatever. 
 
 Case 3. January, 1897. W. G. R. Connected with a news- 
 paper and member of the Legislature. I had fitted him with glasses 
 under a cycloplegia, but he was not relieved For seven years 
 he had not been able to use his eyes in the evening. In the daytime 
 could use them but two hours, thirty minutes at a time at the most. 
 Eyes smarting and itching and headache. Esophoria, 2°, adduc- 
 tion 5°. In 32 treatments adduction 50°. He used his eyes that 
 winter night and day as any other member of the Legislature. 
 In the winter of 1898, he continued well. He is now the proof- 
 reader in a large establishment. 
 
 Case 4. February, 1897. Mrs. J. B. D., age about 30. Had 
 an attack of i ritis in right eye three years before, which left eyes 
 weak. Had been under good physicians and two oculists. Vision 
 good. Severe lancinating pains and feelings of eye-balls being 
 drawn back, especially at night. On waking in the morning was 
 obliged to rub eyes. Unable to use eyes with any comfort. Es- 
 ophoria, 10°, adduction 35°. Treatment, adduction. In 22 treat- 
 ments was relieved entirely. The winter of 1898 had Lagrippe 
 which seemed to affect eyes somewhat, but did not relapse and re- 
 mains well. The 10° of esophoria remains in this case. 
 
 Case 5. May, 1899. W. H. W. Age about 42. Travelling 
 man. Good constitution and physique; had had neuralgia in and 
 about the eyes for 15 years. Unable to use eyes at near work. 
 Deprived entirely of reading on the cars. Consulted an eminenz 
 oculist in Boston, and was wearing a prism prescribed by him, 
 which availed nothing. Examination showed he was emmetropic. 
 Orthophoric. Adduction only 5°. I gave him the Kratometric 
 treatment on adduction daily when in the city, which was broken 
 into sometimes for long intervals and it extended to September, 
 30 treatments in all. After the fifth treatment he had no more 
 neuralgia, and it never returned. Heterophoria was developed — 
 first exophoria, and then esophoria. 
 
 He died from Bright's diseaes, August 2, 1904, but had no return 
 of eye trouble. 
 
 Case 6. May 25th., 1897. Dr. S., age about 35. Addicted to 
 much reading; for three or four years had been troubled with 
 
CASKS 193 
 
 ness of eyes on reading; eyes hot and dry, feeling of sand under the 
 lids, which would grow worse if reading was continued, artd the 
 letters would dance and become blurred, when in a short time, 
 he would be unable to open his eyes. The swollen condition 
 showed itself under the eyes, like the condition often attributed to 
 disease of kidneys. Emmetropic esophoria, 2°; adduction 5°; 
 Kratometric treatment of the adductors resulted in attaining 50° 
 in 25 treatments, when all disagreeable symptoms were removed, 
 and he has had no return of the trouble since. In this case, as in 
 many, the heterophoria increased. 
 
 Case 7. Miss S. M., Brooklyn, Iowa. Age 23. Graduated 
 from high school with difficulty, having trouble for about eight 
 years. Tried college work and teaching, but had to give them 
 up, and for two years had hardly been able to read a newspaper 
 the length of a finger. Had been fitted and refitted by different 
 oculists; the last one put on plain glasses. She was in fairly good 
 health. She had nearly all the symptoms of asthenopia given 
 under this head. She was unable to look up, or at any moving 
 object without immediately closing her eyes. Her manner had 
 become stiff and eyes red, dull and without animation. Emme- 
 tropic. Orthophoric. Adduction 34°; abduction 9°; sursumduc- 
 tion 1-4° Treatment consisted in the duction of every muscle in 
 the orbit. Adduction attained 65°; abduction 15°; sursumduction 
 3 3-4°. 
 
 By Christmas she was free from pain, attended the theatre with- 
 out i neon venience and in the next three months read several books 
 without return of symptoms to any great extent. This case puzzled 
 me under my own theories and I could get no satisfaction in the 
 theories of the books. The development of a high standard of 
 strength of the muscles seemed the only treatment indicated. Ex- 
 amined eyes for error of refraction under a cycloplegia (atropia) 
 and found -4- :50 hypermetropia. Glasses not recommended. 
 
 Case 8. October 9th., 1902. J. C. Lohrville, Iowa. Age 14 
 years. Had been fitted with glasses four years before. The pre- 
 sent trouble commenced in January 1902. Pain in the eye-balls. 
 Relief on pressure of the eyes. Exophoria 3°; adduction 6°; ab- 
 duction 8 . In twenty treatments taken in ten days, attained 
 adduction of 60°. Esophoria 10° on conclusion of treatment. 
 She returned home and at once resumed her studies and remains 
 well. 
 
 Case 9. December 20th., 1902. Miss X. L. H., teacher. Been 
 troubled five or six years. Constitution good. Been fitted plain 
 
194 HAZEN'S NEW FINDINGS 
 
 and bold to persist in wearing them. Inability to fix eye 
 on object; sensation of drawing eyes backward; nervous, sleepless; 
 eyes watering on use; pain in balls of eyes, shooting through; pain 
 on top of head, back and in shoulders. Relief on pressure of eye 
 balls. Esophoria, 1°; adduction, 17°; abduction, 6°. Twenty 
 three treatments. Adducted, 70°. Took set of four prisms to 
 practice at home. Has been free from pain ever since, and is in 
 much better health and spirits. 
 
 Case 10. March 24th. ,1903. F. W. — Electric lineman, inside 
 work; age about 25 years. Had been under treatment of general 
 practitioner for several months for headache, back and front. For 
 eight weeks it became so severe he had to stop work although it 
 was the busy season. Could not stand on a ladder and ,when stoop- 
 ing, black objects came before his eyes. His eyes had that dull 
 look, as if moving the ball was painful. He had no suspicion 
 that his eyes were defective. He was sent to me by his physician 
 to see if there was not some eye affection. Vision /xx. Emme- 
 tropic. Exophoria, °1. No hyperophoria. Adduction, 12°; ab- 
 duction, 7°; sursumduction, 2 3-4°. Treatment, adduction. After 
 fifth treatment, there was no more pain in the back of the head. 
 When he reached adduction 30°, he went to work and lost no more 
 time. In fifteen treatments, he reached 50° and, after twenty two 
 treatments, was pronounced cured. He still remains well. He 
 showed esophoria after a few treatments, and quit at 1-2° of esophoria 
 
 Case 11. Dr. H., Dentist. Age about thirty years. Wore 
 glasses when a boy but not in late years. Had attacks of sudden 
 blindness. Once while playing in an orchestra fell off his chair; 
 was carried home, put to bed and treated for billiousness; there were 
 but few untoward symptoms; some blurring, and a hot feeling of 
 the eyes and pain in temple, but he was generally able to attend to 
 his practice. His physique was extra good. 
 
 Emmetropic (manifest) vision 20/xx — Orthophoria of all the 
 muscles — adduction 12° to 15°; abduction 6°. He attained 50° 
 adduction in 6 treatments. In twenty-two treatments he was pro- 
 nounced cured. The sysmptoms did not return, and the two sub- 
 sequent months, he was found to maintain 50° adduction. 
 
 Case 12. July 22. 1904. Age 50 years. Architect. Had 
 been fitted by four or five oculists, in this city and Philadelphia. 
 The results of these examinations were about the same, -J- 1.50. 
 Very nervous on using eyes; watering of eyes; swelling about eyes; 
 dull drowsy look; dizziness; stomach affected; sickness at and before 
 meals; costiveness; pain in eyeballs, especially in the morning, 
 
CASKS 195 
 
 also in temples. Fingered and pressed on eyeballs a good deal. 
 About to give up profession. Could not go up onto buildings, 
 and drafting became almost impossible. 
 
 My examination of the refraction showed about the same results 
 as found by others. There was a spasm of muscles and examination 
 was not satisfactory. 
 
 Orthophoria of both laterals and verticals. Could jump 15° 
 but was slow to adjust when taken away. The exercise caused 
 sickness of the stomach, whenever the highest number he could 
 attain was reached. The light would grow dim but after five or six 
 treatments, the light became clearer and vision on the street im- 
 proved. In 20 treatments he found that his digestion had greatly 
 improved, and costiveness, for which he had been treated by several 
 physicians, was relieved without medicine. Appetite so much im- 
 proved that he was apt to overeat. 
 
 The esophoria increased under treatment which was mostly 
 adduction, to 14°, but the adduction was uniform in its progress. 
 
 At the end of the treatment, there still remained a difficulty in 
 his drafting; the side of the sheet would seem to turn up and form 
 a hollow curve of the sheet. O. D. Astigmatism of -j~ .50 was found 
 at an axis of 10° out of the vertical. These glasses, with pres- 
 byopic addition, were ample to make him efficient in his severe 
 labors in this very arduous occupation, and the standard has been 
 maintained to the present time without difficulty. 
 
 Case 13. August 4th., 1904. Miss J. J. M., age 34. House- 
 work and china painting. Had been fitted under atropia, R. and 
 L. -f- 1.00. + -50 at 180°V 20 /xx. Sleeplessness on using eyes. 
 Car sickness. Pain lancinating in balls. Relief on pressure. 
 Had been troubled for two years, and for one and a half years had 
 given up painting. Esophoria 4° verticals orthophoric. Adduction 
 23°, abduction 7°. Improved fast in adduction. All the extrinsic 
 muscles were treated and responded quickly. So much improved 
 that she ventured to take in the St. Louis fair and did it without 
 detriment. This case increased in esophoria to 14° but the abduc- 
 tion was 9° notwithstanding, and, in two months, she showed 
 esophoria 8°. She took off her glasses; has painted; kept books, 
 and remains well and, to this time, does not wear glasses. 
 
 Case 14. July 24th., 1905. Miss C, age 27. Teacher of draw- 
 ing. Broke down during study, five years before. Spent I 
 years in Colorado for health and gained 25 pounds. On returning 
 to work lost 20 pounds. A neighboring oculist, on examination 
 under "drops" pronounced, "no glasses needed." She was a slim 
 
196 HAZEN'S NEW FINDINGS 
 
 nervous organization full of ambition. No car sickness but going 
 to church always gave headache. Pain back, of head, running 
 down into spine. Relief very quick. No more headache after 
 five treatments. Although attaining to 50° of adduction soon, 
 exercise continued because slow and want of facility of adjstment. 
 Finished in 27 treatments. She gained in weight before end of 
 treatment, and afterwards engaged in active pursuits without 
 relapse. 
 
 Case lo. February 6th., 1906. Mr. B. A. C, neighboring city. 
 Age 29. Pharmacist. Has been fitted with glasses by five oculists, 
 one in Chicago, the others in other cities. Tenotomy, three times. 
 Eyes red and angry. Riding or attending theater used him up. 
 Pain, smarting, sticking of eyelids; back of head, temples and 
 shoulders, on pressure of hand , would get temporary relief. Had 
 taken strychnia, and had some prism exercise. Esophoria and some 
 hyperphoria. Adduction 32°, abduction 3 1-2°. The adjustments 
 were very slow. 
 
 Gave general discipline of all the muscles. With 28 treatments 
 was entirely relieved. Have no report after two months, but up 
 to that time was all that could be desired. 
 
 Case 16. March 29th., 1905. Miss B. H., miniature painter. 
 Had spent several years in France and Holland under the best 
 teachers for her art, and opened a studio in New York City. Be- 
 came nervous and unable to work — had not thought of the cause 
 being in the eyes at first. But eyeballs became swollen; blurring; 
 pain in the eyeballs, head, temples, extending down spine. Con- 
 sulted three oculists i n New York City. The duction in all pairs 
 of muscles was unusually good. Adduction 40° abduction 5°. 
 Infra- and sursumduction, 2 1-2°. In two weeks, duction of all 
 muscles was up to standard. Able to read without headache. 
 In one month discharged. Returned to her profession, opened a 
 studio in Chicago, and took the prize for miniature painting at an 
 exhibition in Philadelphia. 
 
 Case 17. March 11th., 1906. Canadian. Age about 40 years, 
 Exophoria, 18°. Hyperphoria 18°, L. E. Emmetropia. This 
 case was remarkable for lack of pain. She was wearing 4 , base in 
 over one eye and 4°, base up over the other eye. She could not 
 get along without these on the street, and required +1..25 D. for 
 near work in addition. 
 
 With these prisms, she could adduct 13 and infraduct, 2 1-4° • 
 
 In two weeks the lateral prism was taken off and the vertical 
 changed to 2°. In less than two weeks more she became ortho- 
 
CASES 19? 
 
 phoric in the lateral and adducted 50° and the verticals 1 1-2° 
 with a 2° prism. In one month was enabled to go without prisms 
 indoors. At the end of six weeks, she wore a prism of 2° for hyper- 
 phoria and a blank for the laterals. 
 
 She was unable to continue the office treatment longer. This 
 case was treated by gymnastic exercise alone, no medicine or oper- 
 ation. During the whole treatment, she read and wrote many 
 hours a day. I have not the least doubt but the vertical muscles 
 could have been brought to Orthophoria in another two weeks' 
 treatment and then an occasional attention over a period of three 
 months to keep them balanced, but she came from a distance and 
 was unable to remain longer. 
 
 Case 18. May 31st., 1907. Miss J. D., age 28. Had trouble 
 since 10 years of age. Confined to housework, because she could 
 not keep books for her father, who was a grocer. Was treated for 
 two years, and refracted several times by one of the best oculists 
 in the west. Wearing R. E. +1-50 +.25 at 180°, L. E . + 1.25 
 + 25, 170° V. 20/ xx 20+ xxx. Carried head to left to avoid 
 diplopia; intense pain if turned to right. Pain in temples, forehead 
 and back of balls and occipit. 
 
 Exophoria 10°; adduction 9°; verticals normal. Did not change 
 glasses. In ten days, she adducted 50° Headache gone. In one 
 month became orthophoric, and remained so while under observation 
 two months subsequently. 
 
 She at once commenced studying, and has been able to fulfil her 
 duties since. 
 
 Case 19. June, 1908. J. M. M.. age 25. R. R. Mail agente 
 Suddenly broke down on duty and was about to resign. Unable 
 to read on train. 
 
 Esophoria, 1°. Verticals normal. Adduction, 15°. For tem- 
 porary use, gave R. and L. +1.25 D. and treated him when at 
 home. In 24 treatments adducted 50°. He has kept at his duty 
 since that time, and does not use glasses, and is entirely free from 
 apprehension about the eyes. 
 
 Case 20. June 16th., 1908. E. M. S., age 37. From a neigh- 
 boring city. Editor and Postmaster. Troubled with eyes for 
 15 years. Fitted by occulists with R. and L. — 50 at 180° and changed 
 frequently on both sides of the emmetropic line. Exophoria of 
 laterals, verticals normal. He showed no insufficiency at readine 
 point but could not jump 5° adduction for distance, but by pre- 
 senting 1° increase at a time could go to 17°, slow fusing. Was 
 
l'.is HAZEN'S NEW FINDINGS 
 
 told by former oculist that he must give up his work for six months 
 and take a rest. 
 
 This man is of good physique, but very nervous and full of fore- 
 bodings. Whenever he went home, he would tax his eyes severely 
 in an effort to catch up with his work, which had necessarily been 
 neglected. Notwithstanding, he progressed and attained 60° 
 adduction in 26 treatments, and has not only returned to regular 
 duty, but preformed extra duty to catch up back work, and for a 
 short time did not only his own work, but that of his stenographer 
 who went on a vacation. The nervousness has not wholly subsided. 
 unless his inordinate ambition for work is checked, it is to be feared 
 he will break down, but he is going it at full pace at the present 
 time. 
 
 Case 21. August 7th., 1908. Wm. McE. Age 44. Traveling 
 salesman. Been troublrd 25 years. Broke down suddenly at 
 school. Has been fitted fifteen times by eminent oculists all over 
 the country, east and west. The variation in formula is remark- 
 ably slight. Some added prisms. Has worn glasses for twenty 
 years. Wearing R. and L. +.75 at 180°. Lids droop a little 
 blush of conjunctiva. Had twitching of lids; learned to keep out 
 of crowds; pain at occipit extending down spine. Has had three 
 attacks of sudden blindness. 
 
 Exophoria 2° R, hyperphoria, 1-2°. Adduction, 25°. Infra- 
 duction 1 1-2°. In twenty treatments became orthophoric and 
 duction standard, both lateral and vertical. Reads as much as 
 he wants to — even on cars — no pain and sometimes does away 
 with glasses. 
 
 Case 22. September 8th., 1910. Mrs. S., physician's wife, 
 and a musician. Age 32. Been troubled since a girl going 'o 
 school; s ck headache once or twice a week; never went to eh b, 
 amusements or rode on cars, or went into a crowd, without ving 
 to pay the penalty of hours in bed with hot cloths on hea Pain 
 
 in top and forehead; tender spot occipit and a little to one side. 
 
 Fitted 12 years ago in office of one of the best known oculists in 
 the U. S., after going to his office twenty times. Glasses were 
 fitted and changed about a dozen times. She had worn these for 
 12 years. 
 
 There was no particular change in her condition before or since 
 the fitting. Could use her eye for 15 to 20 minutes, but soon ha 
 symptoms of headache and sickness. Glasses R. E., — |— 1.25 + 25. 
 30°. L. E. +1.25 V +20/xxx. Es 3° Verticals orthophoria. 
 Adduction, 7°; abduction 5°; Infraduction, 2°; sursumduction, 
 1 1-4 . 
 
CASES 199 
 
 For a month, the duction stood almost without improvement. 
 Either there was no fusion faculty, or the patient did not, from 
 habit, make any effort to use the muscles. 1 think it was the latter, 
 for, in less than a week she adducted 40°, improving steadily and 
 in two weeks attained 50° and was discharged with 5° of esophoria. 
 Having broken her glasses about this time, she was compelled to 
 go without them, and finding that she got along as well without 
 them as with them, she has not worn them for two months and 
 thinks she does not need them. Is able to do anything she chooses 
 and no return of pain or discomfort. 
 
 I have had three cases of pronounced chorea, two of them resulting 
 satisfactorily, but the third relapsed after two years. One, a boy 
 of 12 years was perfectly cured and has used his eyes uncommonly 
 for one so young. Another, a musician has been free from trouble 
 for four years, although he uses his eyes as a musician, playing 
 in an orchestra in a theater. Xo medicine used. 
 
200 HAZEN'S NEW FINDINGS 
 
 OCULAR TRAPEZE. 
 
 And Modification of Landolt's Ophthalmo-dyanomometer. 
 
 To further facilitate the management of these cases, 
 in diagnoses and treatment, I have devised the "Ocular 
 Trapeze," and a Modification of Landolt's Ophthalmo- 
 dyanomometer. 
 
 In the former edition of "New Findings," it was recom- 
 mended that the light (the best is a small frosted electric 
 bulb) be placed on the left side and a little behind the 
 patient, with the patient behind the Kratometer, at a 
 distance of ten or twelve feet from a looking glass, at 
 least the size of 21 by 27 inches, placed on the wall in 
 front. This method of using the light has proved satis- 
 factory. The light is at hand to turn on and off, and 
 saves considerable expense in appliances, for 20 feet 
 distance, and makes it possible to use a short room and 
 get the proper length. 
 
 Then, for examining convergence, the light is in right 
 position, as well as being convenient for making notes in 
 the somewhat darkened room which is the best for this 
 kind of work. 
 
 It is necessary to have a black background, and the 
 patient should be free from such surroundings as glass, 
 pictures, or anything that will reflect light and cause 
 confusion with the object light in the looking glass, on 
 which he is to concentrate his gaze. 
 
 In order to make the method a still more serviceable 
 one, I have devised this Trapeze, made of 3-8 iron rod 
 in the form of the staple 21 inches inside measurement 
 and long enough to reach from the ceiling to within 
 5 feet, 7 inches of the floor, and hung by hooks in the 
 end of the rod, into eye hooks, screwed into the ceiling. 
 The rod between the legs of this staple is horizontal and 
 at right angles to the vertical rod. 
 
OCULAR TRAPEZE 
 
 201 
 
 — 
 
 o 
 
 — 
 
 - 
 
302 HAZEN'S NEW FINDINGS 
 
 Fifteen inches above this horizontal bar is another 
 bar running across from leg to leg and parallel to the 
 lower one. Into this space between the bars, a piece of 
 tin. painted black, is hung, so as to easily swing in the 
 space described. Two loops of tin are riveted to the 
 sheet, and form hinges around the lower bar and serve 
 to hold in position, when thrown up between the bars, 
 or let down below the lower one. On this trapeze are 
 rings, one at each of the four corners, and one between 
 the two hinges of the lower bar. The two upper rings 
 enable one to thread a string through to give the vertical 
 movement to the light, for testing the vertical muscles; 
 the ring between the hinges on the lower bar to give the 
 horizontal movement for testing the lateral muscles in 
 cases of paralysis of these muscles. 
 
 The patient is seated just in front of the trapeze, before 
 a stand, onto which the Kratometer is fastened. The 
 electric light is hung upon the Trapeze, at the left side, 
 behind the patient, and the operator is at his right hand. 
 
 In this simple and inexpensive apparatus, the operator 
 has, together with the Kratometer, a complete contri- 
 vance by which he can go through all the tests and exer- 
 cises of the muscles, as well as test vision and detect 
 presence of astigmatism of the muscles, without getting 
 off his stool at the patient's side. 
 
 The tests by movement of the light horizontally or 
 vertically placed, which the books describe, to ascertain 
 the muscle paralyzed, are very conveniently performed 
 with this device. The operator has at hand, the other 
 and more modern tests with the Maddox rod, double 
 prism and red glass; he has the light in position for testing 
 convergence and accommodation, and the Von Graefe 
 test for insufficiency; he can hang on this trapeze, the 
 looking glass test type, the lines of astigmatism or the 
 single line to use with the double Maddox prism for test 
 
<HTI,\i; TKAriCXE 
 
 203 
 
 of Cyclophoria at a distance, or these may be pasted on 
 one side of the tin — better on the side that faces the glass, 
 when it is put up between the two horizontal bars. He 
 also has the test for cyclophoria at the reading distance. 
 
 To obtain a small aperture for testing the muscles, 
 particularly the verticals — a half inch hole may be made 
 in the tin pkte, in the left lower corner when let down. 
 A smaller one can also be made in this region if thought 
 best. The electric bulb is hung behind this hole. 
 
 The electric light may be held in one hand of the oper- 
 ator to illuminate the letters, and the right hand index 
 finger can point out the letter he wishes named, or by 
 reflectors fastened to the trapeze, the whole surface can 
 be properly illuminated. 
 
 Glasses may be fitted with this device, and nearly all 
 the tests, regarding the function of vision, may be per- 
 formed. 
 
 Fig. 4. 
 
 Convergence Rod— with Modification of Landolt's Ophthalmo-dyan)mometer. 
 
OTOLOGY 
 
NEW FINDINGS IN OTOLOGY. 
 
 OTITIS MEDIA. 
 A Plea for the More Frequent Use of the Eustachian Catheter. 
 
 It is gratifying to one who spans a generation in his 
 profession to see the advances that have been made in 
 the art of surgery, in solving the difficulties that used to 
 be impenetrable to the skill of the surgeons of earlier 
 times. At the time of the Civil War ,a person shot in 
 the abdomen was portentious of an early demise, and 
 the surgeon but shook his head when appealed to. In- 
 flammations that started in the right illiac fossa spread 
 to the perotinitis, in which fatality was great. In these 
 days the calvarium is opened with impunity, and the 
 surgeon seeks abscesses in this cavity, as former men 
 sought them in hand or foot. The surgery of Otology 
 is especially brilliant now, and exemplifies the boldness 
 and consummate skill of the surgeon of the day. Lives 
 are today saved by the knowledge of the aurist that 
 would, if the case had occurred in former days, perhaps 
 have been regarded as a mystery, or knowing its patho- 
 logical condition, the surgeon might yet have been un- 
 able to cope with its presentation. 
 
 There are yet many who die with purulent inflam- 
 mations of the ear that produce abscesses of the brain, the 
 sequel of scarlet fever, measles, diphtheria, variola, eri- 
 sypelas, typhoid fever, pneumonia, diabetes, Bright's 
 disease, bronchial catarrh, tuberculosis, puerperal fever, 
 influenza and lagrippe, unrecognized, or they are al- 
 lowed to succumb to the secondary condition, without 
 proper attempts to relieve, and this sequel, which we 
 call the real cause of death, is covered up in the diagnosis 
 of the original affection. 
 
 The cavity of the tympanum, situated so near to 
 the brain, has its mucous lining extending to the throat 
 through the Eustachian tube, through which so many 
 
208 HAZ E N 'S NEW FIND1 NGS 
 
 diseases incite to its inflammation. This complication 
 becomes the most serious part of the sickness which 
 brought it on. It is said that 99 per cent of cases of in- 
 fection of the middle ear, are through the /Eustachian 
 tube. (Andrews.) These are too often considered 
 lightly by the attending physician, and if the case re- 
 covers from the fever, a running ear is thought too slight 
 to be considered, and it is left to be "outgrown." 
 
 But while fault may justly be found with general 
 practitioners for regarding too lightly the complications 
 that arise and involve the ear, we think we see the oppo- 
 site extreme in the hands of the specialist. It is not the 
 desire of the writer to inveigh against the judgment of 
 the specialists who have so cautiously proceeded to so 
 important an operation, and who have saved a few on 
 the extreme limits of dissolution, but rather he would 
 commend the skill and daring that probes the cavities so 
 near to vital parts. The more simple operation of open- 
 ing the mastoid antrum has become familiar, but he 
 now seeks the accumulated pus that has burrowed to the 
 meninges through the tegmen tympanum and around 
 into the sinuses and sometimes buried beneath the Gas- 
 serion gangleon and in the region of the torcular Hero- 
 phili, or in the jugular veins. Nothing daunted, the 
 hand of the surgeon follows it and snatches from Death 
 the victim that has been dragged to the door. The 
 study of brain abscesses caused by middle ear diseases 
 took fresh impetus after the work of Macewen of 1893, 
 and has progressed steadily since. Nevertheless it seems 
 to the writer that there is no necessity for the frequency 
 of these operations at the present day. 
 
 Surgical sanction is being asked by some of them to 
 open the antrum mastoides in cases of chronic otitis 
 media, where there is no indication of acute inflamma- 
 tory exacerbations, and also its performance more fre- 
 quently in the acute forms. 
 
 Twenty years ago there were but few operations on 
 the Mastoid Cells. There are now as many Antrectomy 
 performed in one hospital in New York City in one 
 year, as were performed in all of them in ten years be- 
 fore. A surgeon at a meeting of the Otological Section 
 of the Academy of Medicine, in New York City, Feb- 
 
OTITIS MEDIA 209 
 
 ruary 13, 1903, asserted that he had examined the reports 
 of three institutions of New York, for ten years, and 
 there were as many operations performed in three weeks, 
 in one of these institutions, as during the ten years men- 
 tioned, in the three. 
 
 The following tables will give some idea of the in- 
 creased percentage of operations on the same class of 
 diseases. The operations on the mastoid in the first 
 table, include the mere incisions of abcesses behind the 
 ear (Wilde's), which was a very common operation, 
 whereas the opening of the cells was a very uncommon 
 one. 
 
 The first table is taken from Dr. Roosa's book on 
 "The Diseases of the Ear," fourth edition (1891). 
 
 The following table is compiled from late reports: 
 
 Mat'd 
 
 CASES YRS. AFF. WILDS INCISIOK 
 
 Manhattan Eye and Ear Hospital 14,720 17 110 105 and Mastoid 
 
 Brooklyn Eye and Ear Hospital 18,366 18 91 126 
 
 N. Y. Opth. and Aural Institute 14,634 17 112 108 
 
 Mass. Charitable Eye and Ear 9,533 3 62 30 (estimated) 
 
 Newark Chart'Eye and Ear Inf. 3,021 3 22 15 
 
 Illinois Eye and Ear Inf. 2,464 4 8 16 
 
 N. Y. Charity Hospital 20 1 1 11 
 
 Dr. Roosa's practice 5,797 22 59 42 
 
 Total 68,555 443 
 
 The following is compiled from late reports: 
 
 HOSP TAL CASES VR MASd' AFF. MAs'd OP'n 
 
 Royal Ear Clinic, Halle 2,425 1 
 
 Royal Polv Clinic, Munich 2,831 
 
 N. Y. Eye and Ear Inf. 10,235 1902 
 
 Manhattan Eye and Ear Hospital 4,526 1901 
 Ditto 5,314 1902 
 
 Total 25,331 746 
 
 The greater frequency of these operations, it cannot 
 be doubted, is to a great extent, on account of the skill 
 attained and the confidence acquired in their perform- 
 ance. But to the author it seems there is another reason, 
 which will be made maifest in due time. 
 
 The minds of men run in grooves, ruts and surveyed 
 channels. Fashion guides, customs prevail, and creeds 
 
 
 129 
 
 
 44 
 
 410 
 
 334 
 
 143 
 
 128 
 
 136 
 
 111 
 
•210 HAZEN'S NEW FINDINGS 
 
 bind the thoughts of each time and period. The bell- 
 wether leaps over an imaginary or real obstruction and 
 the flock goes with him into green pastures or into the 
 turbulent sea. Now and then the non-conformist stands 
 beside the road and dares to question and cry Halt! 
 but the world goes on, and often the objector dissenter 
 or the doubter is trampled out of sight, his warning un- 
 heeded until a second or third may dare to demur, and if 
 he have influence becomes a bell-wether on his own tan- 
 gent. It is as true in medicine as in other walks of life, 
 and its history is full of blind, headlong precipitation as 
 any other field that is not built on fact and reason. 
 
 The profession in Otology seems now to be faced all 
 one way, and that toward the development of the path 
 of curing Otitis Media Purulenta by the mastoid route, 
 while the labors of the former generation on the treat- 
 ment of the Eustachian tube, is ignored. The author 
 believes that this is one of the reasons for the readi- 
 ness with which the "radical operation" is so often per- 
 formed. 
 
 The writer hopes to make good his remarks, that may 
 seem to the reader pretentious, in showing his methods, 
 followed in treatment of middle ear inflammations. 
 
 The operation of treflning the mastoid process itself 
 fell into disrepute because a Danish surgeon by the name 
 of Berger in 1792 caused it to be performed upon himself 
 for "deafness w r hich was accompanied by vertigo, head- 
 ache and noise in both ears." Meningitis resulted and 
 the patient died in a few days. 
 
 The diseases of the ear and their treatment were a 
 jumble of contradictions and inconsistances down to the 
 generation which has just about passed off the stage. 
 
 Dr. D. B. St. .John Roosa, in his work on "Diseases 
 of the Ear," gives due credit to foreign authors and espec- 
 ially to Wilde (1843) of St. Mark's Hospital, whom he says 
 "probably did more to place our science upon a sound 
 basis, than anything that has been done in Otology 
 since the days of Valsalvia." He recognizes the works 
 of Toynbee, Von Troltsch, Politzer, Gruber, Weber, 
 Rudinger ,Hinton and others and many in this country — 
 Knapp, Turnbull, Blake, Burnett and Pomoroy, but 
 there are none to whom America is so indebted as to 
 
OTITIS MEDIA 211 
 
 Dr. Roosa himself. For clearness of classification and 
 common sense, he is excelled by none other in his writings. 
 On treatment he is most satistactoiy. 
 
 The drift of all the discussions on the middle ear dis- 
 eases and in their more severe forms involving the mas- 
 toid cells particularly is toward giving vent to the pus 
 collection, in the first case, by paracentesis of the mem- 
 brane, and in the second, by Antrectomy. 
 
 This latter operation is now performed in acute sup- 
 purations, and also in the chronic form, for purposes 
 of thorough cleaning, where in neither case, there is 
 immediate fear of involvement of the brain. In ihe 
 many discussions for several years, and the giving of the 
 history of many cases, there is no mention of getting 
 vent or drainage through the Eustachian tube by use of 
 the Catheter. The manipulation of the Catheter seems 
 to be one of the lost arts. 
 
 Some mention occasionally is made of the cautious use 
 of the Politzer bag and some authors advocate use of 
 the Eustachian bogie, while others mention repeated 
 incisions of the drum membrane and cleaning the tym- 
 panum by a thorough wet or dry method. 
 
 The experience of one who has labored in a different 
 direction to relieve these most difficult and trying group 
 of diseases, may be of interest to those who come in con- 
 tact with them. 
 
 When the method hereinafter described, was insti- 
 tuted, the operation on the mastoid was considered a 
 capital operation, and the wish was to avoid it if possible. 
 This may be the reason of its inception, and promotion 
 and the writer finds it sufficient in a very large percent- 
 age of cases. This is the use of the Eustachian catheter 
 and injections of a bactericide through it to the seat of 
 the disease. 
 
 The Eustachian tube is the natural drainage tube 
 for the cavity of the Tympanum, and when this tube 
 becomes clogged, the writer deems it the first, and al- 
 ways, the duty of the surgeon to restore it to its function, 
 by the best possible method. Until the natural drainage 
 is established, by some means, the case cannot get well. 
 
 The writer, when a boy, moved to Ohio, and was sent 
 with a laborer, to drain a piece of wet land. When his 
 
2 12 1 1 A Z E N s X B W FINDINGS 
 
 uncle came out to see the progress of the work, he found 
 us commencing our ditch on the highland end. He has 
 never quite gotten over the chagrin caused by this proof 
 of his lack of common sense thus exhibited. 
 
 This tube is a little over an inch in length, divided 
 into two portions, the osseous upper portion, called the 
 isthmus, 1^2 to 2mm. in height and l / 2 to ^4 mm. in width, 
 widening out rapidly as it proceeds to the throat in the 
 cartilagenous portion, at an angle, in the adult, of about 
 40 degrees in direction, measuring at its orifice 9mm. 
 high, and 5mm. broad. (Roosa.) The length, direction 
 and size, varying in age and in individuals of adult age. 
 It is as large in the tympanic orifice, in the child, as in 
 the adult. Besides being more horizontal in the child, 
 it is shorter and wider and consequently fluid passes 
 more readily from the tympanic cavity, through it into 
 the throat. (Macewen.) The ciliated epithelium which 
 lines the Eustachian tube, and partly the tympanic 
 cavity, has the movement of the cilia toward the pharynx. 
 (Macewen.) 
 
 The tegmen tympani is a wide plate of thin bone, lying 
 between the conuous ear cavity and the dura mater 
 under the brain. It is continuous from the escaping 
 Eustachian tube, anteriorly, over the tympanum (the 
 attic) and continued over the Antrum in the mastoid 
 cells (the latter portion sometimes called the tegmen 
 antre.) In adults the antrum is somewhat dropped 
 down, and has not quite the straight relation as in child- 
 hood, but this only forms a more secure cup for the pus 
 that may be received from the tympanum. The bone is 
 very thin and often very defective. The petro-squamous 
 suture is sometimes large enough to constitute a perfect 
 "dehiscence" of the roof. (Broca.) A straight probe 
 thrust into the opened antrum, in the case of the child, 
 can be passed through the tympanum, over the audits 
 (touching the ossicles) when it will engage in the Eu- 
 stachian tube on the other side of the tympanum. 
 (Broca.) This continuous roof is covered over with 
 periostium and lined with mucous membrane, forming 
 a direct guide for a column of air projected through the 
 Eustachian tube, through the tympanum and into the 
 antrum of the mastoid cells. 
 
OTITIS MEDIA 213 
 
 EUSTACHIAN CATHETER. 
 
 Why, in late years, the disuse of the Eustachian 
 catheter, with injections into the middle ear, has come 
 about, is difficult to explain. But that attention is led 
 off to the more brilliant and difficult course of procedure, 
 is quite evident. 
 
 The catheter requires skillful manipulation, with 
 a good "muscular sense," and the time put in in acquir- 
 ing the skill is well repaid. In the time of Wilde, Toyn- 
 bee, Yon Trolsch and Hinton, the catheter was used 
 much more than at this time. More was done to get 
 drainage by the Eustachian tube, and injections of the 
 tube were frequently advocated. The history of the in- 
 strument does not show there has been mischief done 
 with it. Xo cases of death have been reported In the 
 hands of reputable physicians. 
 
 In regard to the manipulation of this instrument, 
 the directions given by the books are almost all alike in 
 directing, that on passing the catheter, it should be car- 
 ried on to the posterior wall of the pharynx, and then 
 drawn forward, and while turning the beak toward the 
 tube, to let it ride over the posterior lip of the trumpet- 
 shaped orifice of the tube, which is generally aided by 
 the patient lifting the palate. The carrying of the 
 catheter to the posterior zvall is not necessary, and when 
 done, the patient will invariably draw up the palate and 
 catch the catheter, and this incident is the most disagree- 
 able part of the procedure, and very often the patient 
 demands that it be taken out. The second hurt comes 
 on in riding over the lip of the tube. The catheter 
 should be carried in only so far as the posterior nares 
 and turned about the corner and into the tube without 
 passing so far back that when the patient swallows, he 
 can joggle the catheter. If the catheter can be touched 
 by the palate on swallowing, it is too far in. When the 
 entrance of the Eustachian catheter is thus gained, of 
 course the fossa of Rosenmuller is not reached. Some- 
 times this posterior lip is quite prominent and there is 
 much pain in riding over it. 
 
•Jit HAZEN'S NEW FINDINGS 
 
 DIAGNOSTIC OR AUSCULTATING TUBE. 
 
 The diagonistic or auscultating tube should always be 
 used. I would as soon dispense with the receiver in tele- 
 phoning as I would with it, in examining the ear. One 
 who uses it constantly can learn much of the condition 
 of the tube, and I am in accord with Kramer in his dec- 
 larations that much can be learned thereby. He goes 
 no farther in this than the declarations made in regard 
 to the auscultations of the chest. I prefer a silver cathe- 
 ter, although I sometimes use a vulcanized one but am 
 chary with these in refactory patients, for fear they 
 will be broken. Putting one end of the diagnostic tube 
 in the hand of the patient and directing him to put it 
 in the ear when the proper time comes, holding the cathe- 
 ter in the hand best suited for the side to catheterize 
 (left hand for the left nostril of the patient, amd right 
 hand for the right nostril) and placing the other arm 
 across the shoulder, with the fingers on the occiput of the 
 patient I seldom have difficulty, when the nostril has 
 room enough, and the patient is over ten years of age. 
 Children in this country are not sufficiently disciplined 
 by parents, to be handled by a surgeon, and sometimes it 
 is necessary to wrap them up in a sheet or blanket to 
 accomplish a very trivial operation. 
 
 It is often advisable to use a swab with cocaine. To 
 cocanize the orifice of the Eustachian tube, wTap a 
 "cable temple" of a spectacle frame, with cotton satu- 
 rated with a solution of cocaine and carry it into the 
 nares in such a way that it will hug the floor and outer 
 wall of the nares, and when arriving at the posterior 
 nares, it will turn toward the end of the tube; this will 
 not only anaesthetize but swab this locality. 
 
 In the beginning of my practice, I used to occasion- 
 ally have a faint with some susceptible patients, but I 
 learned that this was much my own want of confidence 
 or assuring manner. If I see any tendency this way, I 
 wrap them on the knuckles with the end of the diagnos- 
 tic tube: with some have dipped my finger in water, 
 and snapped in the face of the patient, when they will 
 generally come to time. Giving them something to do 
 in placing the diagnostic tube in their ear is generally 
 
CATHETER VS. POLITIZER BAG 215 
 
 sufficient to direct their attention from the catheter. Then 
 again much explanation of the process to the patient 
 previous to its performance, is only magnifying the act 
 in the mind of the patient. 
 
 CATHETER VS. POLITIZER BAG. 
 
 The superiority of the catheter over Politzer's-bag 
 method of inflating the Eustachian tube when there is 
 fluid or pus in the middle ear, is very great. The Eus- 
 tachian catheter occupies only a portion of the caliber 
 of the tube, and the propulsion of the air into it, allows 
 a return current past the beak into the pharynx, carry- 
 ing the accumulated contents with it. Whereas in the case 
 of the Politzer the pressure of the body of air, acting 
 upon the contents of the tube, drives it forward, and 
 probably over the audit us ad antrum into the mastoid 
 antrum. The air penetrates the middle ear and breaks 
 up the secretions, but inevitably, the contents of the 
 tympanum must be more or less driven directly that 
 way, as it is in direct line, and has the ossicles only as 
 an obstacle to its course, which must be swept by the 
 projected fluid. The result of Politzeration, is that a 
 portion of the secretion is gotten rid of over the auditus, 
 and it breaks up the bulbous mass, and the good effect 
 arises from the penetration of the air into the cavity of the 
 tympanum and the disturbance of the contents which 
 afterwards drains more or less down the tube. I am as 
 reluctant in using the Politzer, in elderly people with 
 fluid in the Eustachian tube, as I am of incising the 
 drum. I don't know of a better method of infecting the 
 mastoid cells with the fluids of the tympanum, than this 
 very process that so many surgeons use, and which, not 
 knowing or suspecting this consequence, is considered as 
 a brilliant and effective performance. The catheter has 
 no such effect, but cleans out the tube by the counter- 
 action of the stream of air forced in by the bag from 
 without. Another point in the use of the bag for inflation 
 through the catheter. I have the nib which fits the end 
 of the catheter, on a rubber tubing about two inches in 
 length, and then joined to the air bag. The hand that 
 presses the bag need not then be in line with the cath- 
 eter, but be below it. The nib thus placed in the cath- 
 
216 HAZEN'S NEW FINDINGS 
 
 eter will bounce out if there is too much resistance to 
 the passage of the air into the catheter, which is an indica- 
 tion that it is out of place or some other cause that needs 
 correction. It acts as a saftey valve. 
 
 INJECTION OF FLUIDS. 
 
 In the time of Wilde, Von Troltsch and Hinton, in- 
 jections were advocated, especially in the treatment 
 of the chronic non-supurative inflammation of the Eu- 
 stachian tube and middle ear; with some in large quan- 
 tities, and others by drops, but the latter of greater 
 trength; sometimes carrying these drops into the mid- 
 dle ear by a middle ear catheter, which was a flexible 
 tube of small caliber pushed in through the ordinary 
 catheter. Hinton advocated the injection of the middle 
 ear through the open drum down the Eustachian tube, 
 the fluid being caught in a cup under the nose. These 
 medications have not been more successful in the treat- 
 ment of these nonsuppurative cases, than other methods, 
 and probably brought about the disuse of injections al- 
 together. 
 
 CHRONIC NON-SUPPURATIVE CATARRH. 
 
 The more common diseases of the ear, and those in 
 which so much has been attempted, are those of the non- 
 suppurative form which comes on insidiously, and 
 causes the deafness of old age. They are the bane of 
 the aurist, and tend more to the disparagement of his 
 reputation than any class of diseases of the ear. They 
 are generally the result of a neglected catarrh which 
 fastened on the patient in childhood, and which caused 
 deafness at the time, but which broke away, and the 
 hearing restored to a degree, but which left a chronic 
 condition w r hich gradually produces changes, that when 
 fixed are very difficult to remedy. This chronic condi- 
 tion can be carried hidden in the cavity of thejiead, and 
 will not, like the chronic inflammations of the eye, be 
 
MODERN BACTERICIDAL METHOD 217 
 
 attended to because of appearances. When the hearing 
 is reduced in the second ear, to losing common conver- 
 sation, then they are driven to the aurist and expect 
 quick relief. 
 
 MODERN BACTERICIDAL METHOD. 
 
 Since the bactericidal method of treatment of the 
 purulent affections, it seems that the revivement of Eu- 
 stachian injections should be made in the treatment of 
 those diseases which give muco-purulent secretions. The 
 writer has for more than twenty years injected the Eu- 
 stachian tube through the catheter, in these forms of in- 
 flammation of the middle ear. He regards it the first 
 and most rational proceedure to get drainage into the 
 pharnyx ,and that, too, before the paracentesis of the 
 drum, and this is most effectually done by inflating with 
 the catheter, and the injections of fluid. The operation 
 is not nearly so severe as paracentesis, and goes directly 
 toward relieving the cause of the severe symptoms, which 
 in the opening of the drum only relieves the pressure at 
 one end of the tract, and does nothing for the other 
 where the disease is most active and from which the 
 trouble arose. 
 
 Since the recommendation of Bezold, of the use of 
 boracic acid in the treatment of purulent diseases of the 
 middle ear, we have a safe and effectual remedy. He 
 however recommended weak solutions of 1 per cent in 
 sterilized water, whereas I have used it in saturated so- 
 lutions, and indeed am not particular that all of it is 
 dissolved in the hot water, but try to carry it in by sus- 
 pension. In chronic suppuration where the drum is per- 
 forated, I can sometimes inject the Eustachian tube 
 clear into the tympanum, and the patient often turns a 
 few drops out of the meatus. My method is to place the 
 catheter, and make sure it is so, by the diagnostic tube, 
 
218 HAZEN'S HEW FINDINGS 
 
 then ask the patient to swell the cheeks and incline the 
 head back slightly, then push the fluid through the cath- 
 eter (two or three drams) with a Arm but steady push. 
 The most of the fluid, at once flows back into the phar- 
 n\ x, and with it some of the secretion. It does not go 
 into the throat, if the cheeks are kept, inflated. The cath- 
 eter is then removed and the patient turns to a spittoon, 
 or empties the contents of the nose into a napkin held 
 under the nose. The inflation of the cheeks is impor- 
 tant, for if the fluid goes into the lower pharnyx it may 
 strangle and cause coughing, or it will go into the stom- 
 ach, which it is better to avoid. 
 
 BACTERIOLOGY. 
 
 Parallel with the investigations for the kind of micro- 
 organisms found in the pus taken from the tympanum, 
 should be discovered the germicide that would be most 
 effectual in their destructions. Then the knowledge 
 that is said to be already ours, the micro-coccus lance- 
 alatus the pneumo-bacillus of Friedlander, the strep- 
 tococcus pyogenes, the staphylo-coccus pyogenes aureus, 
 albus and citreus; the klebs Loeffler bacillus, the bacillus 
 of influenza, and the Diplococcus introcellulares min- 
 ingitude, will be of some utility in this connection. 
 
 The new chemical substance to which the profes- 
 sion is directed by Professors Frier and Novy of Michi- 
 gan University called Acetozone, might be of great serv- 
 ice here. I have not tried it, but here make the sugges- 
 tion. 
 
 This douching through the catheter, both in acute 
 and chronic otitis media purulenta, has been very satis- 
 factory, in cases before and after the drum has been per- 
 forated. The medication has been salutary on the in- 
 flamed mucous membrane at the entrance of the tube, 
 and the second injection is better endured than the first, 
 
CLEANING THE TYMPANUM 219 
 
 Indeed the patient is so much relieved, that in the ma- 
 jority of cases, he is anxious to have it repeated. I con- 
 tinue the injections of the Eustachian tube, so long as 1 
 get the sound of fluid on its inflation through the cath- 
 eter. There can be no more satisfactory result in re- 
 lieving the head symptoms and restoring the function 
 of the Eustachian tube. 1 have relieved many who had 
 the more severe symptoms: swelling behind the ear, 
 debilitated, high temperature, and severe pain, with 
 symptoms of mastoid complication, with these injections. 
 
 CLEANING THE TYMPANUM. 
 
 To facilitate the cleaning of the cavity of the tym 
 panum when there is perforation of the membrane, I 
 direct that the patient take a dropper instead of a syr- 
 inge (which latter is well said by the books, cannot be 
 used by the patient, and very few learn to use it on an- 
 other). The patient, himself, can use the dropper and 
 make it more effectual in removing the secretions, be 
 they cholesteatomatous in character or less hardened 
 secretion. The dropper should be a double shoulder 
 (French) air tight and smooth at the end. They are 
 directed to three-fourths fill the dropper with the fluid 
 used, always warm, incline the head to bring the ear 
 treated upward, pass the small end within the drum per- 
 foration, press it all out into the tympanum, then draw 
 it back again press, so back and forward two to five 
 times, when the dropper is filled with the saturated so- 
 lution of pus, and emptied, then more solution; proceed 
 in this way until the fluid returns into the dropper 
 clear, when the cavity is dried and a powder of boracic 
 acid is blown in the meatus. It is often that strings of 
 muco-purulent matter are engaged in the tube or drop- 
 per, and by atmospheric pressure are held there until 
 they are drawn out. To facilitate the opening and 
 
220 HAZEN'S NEW FINDINGS 
 
 drainage of the Eustachian tube, I direct that after 
 cleaning, the ear be filled with the injection and then the 
 tragus be pushed down to stop the ear and give a pres- 
 sure while the patient swallows, when the fluid is often 
 tasted in the pharnvx. This indicates patulency of the 
 tube. 
 
 It is not my intention to dissertate on the compli- 
 cations found in otitis media purulenta. Polypi, etc., 
 must be attended to as they arise; but in all cases first, 
 last and always, there is the duty of maintaining good 
 drainage through the Eustachian tube. 
 
 DOUCHING THE NOSE. 
 
 There is a second requisite, fully as necessary, and 
 which promotes the accomplishment of the first, viz: the 
 treatment of the pharnvx. Since the report of Dr. 
 Roosa of the dangers of the Thudicum or Webster douche 
 this instrument has gradually become less common in 
 the hands of reputable physicians. There is no doubt, 
 that in the hands of those best instructed in its use, the 
 fluid used, will be flooded into the Eustachian tubes and 
 sometimes into the tympanum. In consequence, when 
 used at all, the medication must be so weak that it is 
 inocuous in the tympanum, and this would render it 
 ineffective in the pharnvx. The spray-apparatuses that 
 are so common to-day are difficult to use, and in the 
 hands of the patient, are very inefficient. A fluid 
 sprayed is always cold, which is another objection. 
 
 DOUCHE AND INHALER. 
 
 Our climate, in modern times, seems to be adapted 
 to the development of diseases of the mucous membrane 
 of the air passages. The dust of the cities, the sporules 
 of the flora and grasses of the country, acute colds, the 
 
DOUCHE AND INHALER 221 
 
 employments of baking, milling, factor} operations, 
 threshing, traveling on the railroad, and ,not least, bad 
 ventilation, all tend to the development of local disea 
 In the majority of cases it is but a local disease; in a feu- 
 it arises from a low vitality of the system, or an actual 
 constitutional disease; but the nasal cavity, subject to 
 such noxious influences as above enumerated, followed 
 bv inattention to the acute stage on catching cold, is left 
 in a semi-inflamed condition, and this is the chronic ca- 
 tarrh; and each successive cold and exposure to irritat- 
 ing influences but adds to the inflammation, and leaves 
 an additional chronic condition. A small percentage of 
 people catching colds have vitality to throw off the local 
 effects with the restoration of the constitutional disturb- 
 ance; but the majority, after such attacks, experience 
 insidious effects, and a continuance of these conditions 
 break down the health. 
 
 It is not strange that the nasal organ should suffer 
 in the new order of things in a forced civilization — suf- 
 fer in its office of purifying the atmosphere under such 
 modes of living. The too common opinion that catarrh 
 is a disease of the blood, and that it can be cured by con- 
 stitutional remedies, must be given up. The tone of the 
 system, it is true, will make some difference in the power 
 of resistance of the effects, and this, even, can be heieht- 
 ened by some internal medicines, and people will recover 
 from colds without the chronic effects, but nasal and 
 throat catarrh affect the most robust, as every physician 
 knows who has treated this disease to any extent. The 
 specialty of the diseases of the throat and nose has im- 
 proved the means of treating these parts, both in instru- 
 ments for examination and treatment as well as in the 
 remedies for medication. The paraphernalia oi the 
 physician in a well equipped office is very satisfactory 
 or' office treatment, but the instruments are expensive 
 
EAZEN'S NEW FINDINGS 
 
 and must be handled by experts. The expectation of 
 having patients attend long enough and often enough to 
 be cured, is not realized in the majority of cases, and 
 the consequence is, these troubles have the reputation of 
 being incurable. 
 
 The greatest necessity in the case is to secure an 
 apparatus sufficiently simple, agreeable and effective; 
 one that can be easily handled and daily applied by the 
 patient at home. Frequent washings and medication are 
 necessary, and when this is done under proper direction 
 with the remedies, of which we have abundance, disease 
 can be averted ,and disease already established can, in a 
 
 Fig. i. 
 
 An Apparatus for the Treatment of the Mucous Membrane 
 oi the Air Chambers. * 
 
 majority of cases be effectually cured. Neglect of the 
 principles which cause disease in any part of the system, 
 viz: allowing foreign accumulations to remain in the 
 parts and neglecting the proper cure of the acute stages, 
 will inevitably develop the chronic forms, which will 
 result in future suffering or will open the avenues upon 
 
 This Instrument can be had of A. W. Hazen, Des Moines, Iowa. 
 
DnrcilK AND ixiiai.kr 
 
 
 which the patient makes his exit out of the world. Why 
 catarrhal troubles should be so neglected, and why inat- 
 tention to them should be so universal, with the idea 
 it is "only a cold", or that "they will outgrow it," seems 
 strange, unless it be because of the generally disagreeable 
 methods practiced. 
 
 Fig. 2. 
 Douche and Inhaler. 
 
 In 1S80 the writer devised a douche and inhaler and 
 an account of it was published in the transactions of the 
 Iowa State Society, 1881. The process of douching 
 by this instrument, is founded upon the fact that by 
 blowing upon a body of fluid in an air-tight chamber, it 
 can be made to rise in a tube thrust in it, and flow out 
 through it into the nose when directed there, and in this 
 act of blowing, the palate presses upon the posterior 
 pharnyx, and forms a floor, and will sustain this body 
 of fluid as it rises to the roof of the nasal cavity. It the 
 head is thrown well back, the cavity will hold about an 
 ounce. The fluid thus acted upon, floods the posterior 
 and superior parts of the cavity and on removing the in- 
 
•.'•21 KAZEN'S NEW FINDINGS 
 
 strumenl from the nose and mouth, it is in the best pos- 
 sible position to be thrown into the anterior parts, by 
 bringing the head forward, and at the same time exhal- 
 ing forcibly. 
 
 The safety in this douche is in the fact there is no 
 pressure to carry the fluid into the Eustachian tube, 
 and as the tube remains closed only as the act of swal- 
 lowing is performed, and that while performing the act 
 of douching, they cannot swallow, it renders it per- 
 fectly safe. From this fact it allows, also, medication 
 of such strength, that it will be of more effect than the 
 solutions that must be used in the ether forms of douche. 
 The Sphenoid sinus is also medicated quite effectually 
 by this douche and the interstices about this cavity are 
 cleaned by it. The instrument is made of glass and is 
 easily cleaned. This instrument has now been in use 
 for over twenty years in the writer's practice, and no 
 inflammation of the Eustachian tube produced by its 
 use has come to his knowledge. 
 
 DIRECTIONS FOR USE. 
 
 Showing position of head in act of douching by this method, 
 and the internal parts involved, i b, turbinated bones: d, sphenoid 
 cavity; e, eustachian orifice; c, palate closing upper pharnyx from 
 lower, upon the act of blowing upon the mouth-piece of instrument; 
 a, level of fluild obtained by the use of douche. 
 
 FIRST. USE AS A DOUCHE (FIG. 3.) 
 
 Directions. — Remove cork (c, Fig. 2), and pour the flluid to 
 be douched into leg, A; the replace cork; place forefinger on opening 
 at E, other fingers aroynd B, and thumb around A; the introduce 
 end of flexible tube., F, into nostril, straight back, allowing it to 
 rest on the floor of the nose; then put the mouth-piece G, into the 
 mouth (having taken a long breath); blow steadily, inclining the 
 head backward, whereupon the fluid will ascend through the head 
 backward, whereupon the fluid will ascend through the inner tube 
 in B, and flow into the nasal cavity. Before a full breath can be 
 
DOUCHE AND [NHALER 
 
 
 exhausted, the fluid will overflow out of the nose, or a lignal will 
 be given by the air entering the tube at the bottom of B, when the 
 
 instrument may be removed; and if the checks arc swelled out bj 
 
 inflation of air, the palate will continue to form a floor and hold 
 the fluid in the nasal capacity. After retaining the fluid for a 
 few seconds, and turning the head from side to side, on bringing 
 the head forward the fluid will run out of the nostrils over the 
 floor of the the nose. 
 
 Fig. '3. 
 ANATOMICAL. 
 
 When it is desirable to medicate the turbinated bones (t b). 
 anteriorly, this can be effected by coming forward quickly and 
 exhaling from the lungs suddenly, thus blowing the medicine well 
 into the front. 
 
 N. B. — A full breath must be taken at the start, and if a pre 
 is not kept up by a gentle blowing, the palate will not maintain 
 its place. If taking a breath is attempted during the pr 
 fluid will fall upon the larnyx. which will cause cough 
 
226 
 
 HA ZEN'S NEW FINDINGS 
 
 SECOND. STEAM INHALATION FIG. 4). 
 
 Directions. — Put into leg A, the 
 medicine to be inhaled. 
 
 (a) For treatment of the Nasal 
 Cavity Only.. — Take out the inner 
 P tube in B, and put the end of the 
 flexible tube, F, into cork, D. with 
 the flexible tube outside, and place 
 the other end into the nostril, with 
 the forefinger on E, and blow into 
 the mouth-piece. By this method 
 the nasal cavity can be treated 
 without medicating the throat or 
 lungs. 
 Fig. 4 
 
 (b) For Medicating the Whole Mucous Membrane of the Brionchal 
 Tubes, Throat, and Nose (Fig. 4). — Take off the flexible tube; 
 put medicine into leg, A; put the forefinger over vent, E; draw 
 steadily at the mouthpiece, G (a piece of cotton wadding or sponge 
 can be put under cork, C, but generally it is not needed). The 
 vapor is inhaled directly into the lungs and exhaled through the 
 nose. The fluid in the bottom of the U tube can be kept hot by 
 immersing the U tube midway into a cup of hot water or sand. 
 
 THIRD. DRY VAPOR INHALATION (FIG. 5). 
 
 Directions. — Put medicine for 
 vaporing on cotton as at H, Fig. 5 
 
 (a) For treatment of the Nasal 
 Cavity Only. — Put end of flexible 
 tube, F, into the nostril, forefinger 
 on E, and blow. 
 
 (b) For Medicating the Whole 
 Mucous Membrane of the Bronch- 
 ial Tubes, Throat, and Nose. — 
 Take off the flexible tube, and 
 draw into the lungs through the 
 mouth-piece; and exhale through 
 the nose. 
 
 X. B. — The temperature of the 
 air brought to the mucous mem- 
 
 Fig. 5. 
 
DOUCHE AND INHALER 
 
 brane can be raised and the medicine mure readily vaporized by 
 putting the U tube into hot water or sand, as in Fig. 1. 
 
 FOURTH. AMMONIA INHALATION (FIG. 6 . 
 
 Directions. — To leg, B, (Fig. 2), a small bulb. I . firmly 
 attached — a rcceptable for the Muriatic Acid. In this, first put 
 
 a small amount of absorbent cot- 
 ton, loosely packed, on which 
 drop three drops of the acid. Put 
 the Ammonia (about 20 drops) and 
 two teaspoonfuls of water in b< 
 of U tube. Then add mcdicim 
 required. Then place forefinger on 
 end of tube at D. Upon inhaling 
 at the mouth-piece, G, nascent Mur- 
 iate of Ammonia will be generously 
 produced. To prevent the Ammonia 
 from being inhaled before the acid 
 comes in combination with it, place 
 a piece of moist sponge under cork, 
 
 FIFTH. TO USE IN THE EXTERNAL EAR FIG. 7 . 
 
 Direction a --To 
 
 douche the externa! car, 
 fill the instrument; put 
 the tube, F. into the 
 meatus, and blow the 
 fluid into ear by blow- 
 ing on the mouth-piece, 
 :id holds a small \ es- 
 sel under the 
 
 hi case "! earache 
 
 7 : \ ■■ ke oul 
 
 cork. D . I with 
 
 ilisidc tube and the I 
 ible tube; take 
 
 ible tube, and take oul 
 
 ■HRB11 the long glass tube: re- 
 
 Fig. 7 
 
2 I i 
 
 HAZEN'3 NEW FINDINGS 
 
 place the cork. Now put the glass end of flexible tube, F, into 
 cork, and then put the straight end of the long glass tube on the 
 other end of flexible tube, and it is arranged as in Fig. 7. 
 Put two teaspoonfuls of hot water in U tube, then put U tube into 
 hot water or sand; place the bent edge of glass tube into the ear, 
 with forefinger on E, and blow gently at the mouth-piece; the 
 warm vapor should be blown directly onto the drum, and it will 
 almost invariably relieve the pain. 
 
 SIXTH. POWDER BLOWER— INHALATION (FIG. 9). 
 
 Directions. — Take 
 out cork ,D, with glass 
 tube and flexible tube. 
 Put powder on paper, 
 and push it with a 
 knife, as shown in 
 Fig. 8, into end of 
 tube, I; then by plac- 
 ing the end of the tube 
 Fi §- 8 - thus loaded into ear 
 
 or nose, as required, and the end, F, into the mouth, the powder 
 can be blown into the part. A second person or an airbulb is re- 
 quired when the nasal cavity is medicated from behind the palate. 
 The bent end is introduced into the mouth and the medicine is 
 thrown into the nose from behind the palate. 
 
 Caution. — The temperature of fluids for douching should be 
 above blood heat. In all these methods, in order to make the 
 instrument work satisfactorily, it is necessary that the corks be 
 air-tight. Patients using the instrument in the winter should 
 not go into the open air for half an hour. 
 
 DIRECTIONS FOR CLEANING. 
 
 Empty the instrument of cotton, etc.; replace corks; place the 
 end, F, into water, a,nd draw at the mouth-piece until the instru- 
 ment is nearly full; then shake, and blow out the fluid, reversing its 
 course. 
 
DOUCHING OF CHILDKKN 
 
 DOUCHING OF CHILDREN. 
 
 It cannot be expected that children under ten years 
 of age will be able to douche the nose. For those of 
 over four years of age, I fill the common vulcanized 
 syringe with the fluid to be injected, and put the child 
 in front of me, with his back against me and holding 
 the face steadily by placing my hand under the chin, and 
 stretching his neck a little, cause him to swell the cheeks, 
 when I place the nozzle in one nostril, directing the 
 stream back over the floor of the nose with some consid- 
 erable force, when it will return out at the opposite side 
 in a stream into the spittoon placed in front. If the 
 child will keep his cheeks swelled out, no fluid will pass 
 into the throat, and the cavity is fairly medicated. To 
 medicate the region of the Eustachian tube on the oppo- 
 site side as well, the injections should be given in a simi- 
 lar manner on the opposite side. 
 
 The writer regards douching of the nose with warm 
 solutions, much more favorably than sprays. The lat- 
 ter in the hands of the skilled operator may be effectual 
 in cleaning the interstices of the cavity of the nose, but 
 the spraying is a cold process and all the erectile tissues 
 of the cavity are excited and catheterization is more diffi- 
 cult and painful afterward. The douching by the in- 
 strument above described is directed by the author, to 
 be done before visiting the office, or before his visit at 
 the home, and the locality is generally clean, and all ex- 
 citement will have subsided. More thorough cleaning 
 is sometimes necessary, but not often. 
 
 The writer has repeatedly cured acute cases of otitis 
 media purulenta by this method when, in the light of 
 the present day, many surgeons would decide on an- 
 trectomy, and in many cases this had already been ad- 
 vised. He believes that when the tympanum is relieved 
 
280 IIAZEXS NEW FINDINGS 
 
 of the pressure of fluids, by giving vent through the Eu- 
 stachian tube, the contents of the mastoid antrum can 
 be, and are drained from this cavity; that in many 
 natural positions of the head, when in this condition, 
 fluid escapes into the tympanum and out by the Eusta- 
 chian tube. At least the products of inflammation es- 
 cape or are absorbed, for mastoiditis gets well without 
 opening the cells. 
 
 A few cases are herewith appended: 
 
 Case 1. Miss E. A., young lady of 18 years, was brought to 
 my office by her attending physician, November 19, 1S9 — . She 
 was pale and aeneanemic, having lost fifteen pounds since becoming 
 sick. She had to be supported in walking, becoming dizzy when 
 on her feet. She held her head to one side. Behind the right ear, 
 over the mastoid, there was a swelling that was red and fluctuating, 
 and caused the ear to stand out at nearly right angles to the bone. 
 She had the following history. On the 27th of October, after riding 
 about two miles she had a sore throat, and in three weeks had 
 earache. The drum broke the next day, since whick time she had 
 been treated with tonics, narcotics, Politzerization, fomentations 
 and syringing the auditory meatus. The ear remained closed, 
 however, and the heavy dragging feeling was not relieved. 
 
 I at once introduced the catheter and injected the Eustachian 
 tube with solution of Boracic acid ;afterwards blew out with air 
 bag and catheter which opened up the ear. After blowing in the 
 powder of the acid in the tympanum, she went to her boarding 
 place. The next morning at 8:30 I found that she had had the best 
 night's rest since she became sick. Swelling behind ear had gone 
 down two-thirds. She was eating her breakfast and feeling in 
 good spirits. Injected as before, the solution penetrated well up 
 into the tube and opened the cavity. Left douche to be used 
 twice a day with solution of Potass cholras and Borax each four 
 and a half grains to the ounce of water. To syringe ear with 
 pippette, as described in these pages, and then blow in the meatus 
 powder of Boric acid. This case was thus treated daily for seven- 
 teen days at which time the discharge was stopped, hearing good, 
 and improved in general health. No tonics, or narcotics were 
 given. 
 
 Case 2. E. R., December 6, 1894, a girl of 13 years found 
 lying in bed and very weak. For ten days had had pain in right 
 
DOrCIUNd OF CHILDREN 281 
 
 ear, but was relieved after three day's suffering, to a consider., 
 extent, by breaking of the drum and a discharge from the ear. 
 The former physician had given her internal medicines but made 
 no application to the ear. She was SO reduced in strength that 
 she had to be propped up with pillows, while introducing the catheter. 
 I treated her as in the former case six days in n when 
 
 seemed perfectly well, and though she remained in bed two w< 
 thereafter under the care of another physician for malaria or la 
 grippe, her ear troubled her no more. 
 
 Case 3. E. R. T., a young man of twenty years, a ph 
 rapher came to my office December 17, 1894. Two days before 
 his ear commenced to pain from a severe cold he had caught. He- 
 was reduced in strength and was suffering intensely. Found drum 
 bulging which I incised and injected as in other cases, blow 
 air in afterwards through the catheter, which opened up the 
 and made it lighter. Up to Christmas (eight days) ear continued 
 to discharge from the meatus, but then ceased, but the sound 
 on blowing through the catheter, was persistent, and I treated him 
 after this time although he returned to his work. The treatments 
 were now at longer intervals, and I discharged him cured with 
 good ear on the 6th of March. 
 
 Case 4. Mrs. W., a middle aged lady. Called to her 
 at 9 o'clock in the evening of April 19, 1893. She had had an 
 attack of gastritis and was under one of our best physicians. She 
 claimed that she had no nasal catarrh, but acknowledged that there 
 was some dropping down the posterior pharynx and some cough. 
 She was having earache in right ear and was applying hot fomenta- 
 tions and douching the ear. The external ear was so swollen that 
 I could not get a view of the drum, but there was no discharge. 
 I treated this case with the air bath with the catheter, which g 
 immediate relief, and in the morning injected the boracic acid so- 
 lution. Ten treatments in this case gave permanent cure and a 
 good ear. 
 
 Case 5. R. B. S., May, 1S99. Farmer, age 31. Called in 
 consultation with one of the first surgeons at Mercy Hospital. 
 Had had severe inflammation and earache for four weeks in left 
 ear. Pain mostly behind ear, far back; tender on W I 
 
 so much debilitated that the surgeon deemed it unsafe to und 
 an operation. While sitting up in bed I introduced the call; 
 and injected the Eustachian tube with Boracic acid Boluti 
 Douching of the nose was then directed to be given with the I 
 tube twice a day, two doses at a sitting. The next morning found 
 that the patient had had the best night's rest than for many night 
 
282 IIAZEXS NEW FINDINGS 
 
 Repeated the treatment daily, and washed out the external meatus 
 as well, dried with swab and blew powdered Boracic acid. In a 
 few days the Eustachian tube became pervious and on injections 
 there would be a few drops of fluid in the external meatus. The 
 discharge which was ropy at first, lost this quality and in fifteen 
 davs he was sufficiently recovered to be able to attend at the office, 
 lie. however, had a relapse by catching cold and his surgeon per- 
 formed the Mastoid operation. 
 
INDEX 
 
 Page 
 
 Accommodation 100, 
 
 Abduction _ r,7 
 
 Adduction 1 7 5 
 
 Adjustment — Stevens. Neuropathic tendency 89 
 
 American Ophthalmological Society Meeting 
 
 Amplitude of convergence »; j 
 
 Ametropia, etiology 7 7 
 
 Ammonia Inhaler 227 
 
 Asthenopia 13, 1!'. 1-7 
 
 Accommodative, Anamolies of 17 
 
 Accommodative, Bader :: 1 
 
 Apparent 19, 32 
 
 Associated with muscular 17 
 
 Congenital predisposition explained 19 
 
 Bonders 17. 
 
 Noyes _ ) ■'• . 17 
 
 Oliver, Philology 7 > 
 
 Early history of . 1 9 
 
 Philology of 
 
 Philology of -- 1:7 
 
 Proceeds from Fatigue 21 
 
 Roosa 
 
 Rueta, theory of 
 
 Se-hmidt-Rumplcr 71 
 
 Stellwag - 
 
 True and false H 
 
 V< 'ii Graefe I s 
 
 Wells J. Soelberg 
 
 Treatment 
 
 Althoff, Dr 
 
 Author 1 » :; - 1 •"• 4 
 
 Bader, Charles '• - 
 
 Delafield, Dr 
 
 Derby, Dr 
 
 Donders, Prof ' '■' 
 
 Dyer, Dr 
 
 Electricity in 
 
 Landolt, Dr 
 
 Noyes, Dr 
 
 
284 [NDEX 
 
 Page 
 Asthenopia— Treatment— Continued. 
 
 < Hiver, l >r 78, 84 
 
 Roosa, I >r, 75 
 
 Sands, I >r. 73, 27 
 
 Schmidt-Rumpler ~- 
 
 Steven.s, Dr. . l 37, 96 
 
 wells, j. Soelberg ...... 41 
 
 Williams, 1 >r 30 
 
 Causes of — 
 
 i [eterophoria 79 
 
 Donders, Prof -- 20 
 
 Noyes, l »r 15, I ~ 
 
 Oliver 7 s 
 
 Roosa 71 
 
 Stellwag 36 
 
 Muscular — 
 
 Landolt, Dr 55, 66 
 
 Noyes, Dr 27, 46. 48, IT 
 
 Oliver, Dr s l 
 
 Roosa, Di\ "4 
 
 Stellwag, Prof 36 
 
 Vt .n Graef e 21 
 
 Wells, J. Soelberg ~ 39 
 
 Retina r hyperemia — 
 
 Stellwag- 36 
 
 Wells 39 
 
 Bader, Charles 31 
 
 Balance and Equilibrium, Author 131 
 
 Balance simple, Howe 112 
 
 Balance compound, Howe 11-1 
 
 Cases, Ophthalmological 191 
 
 Cases, Otological 230 
 
 Convergence, Author 163, 203 
 
 Diagnosis, Landolt 66 
 
 Effect of glasses 53 
 
 Treatment, Landolt 68 
 
 Not in other animals 57 
 
 Relation to accommodation 108 
 
 Non-paralytic. Landolt 58 
 
 Insufficiency of — Landolt 63 
 
 Catheter-Eustachian 213 
 
 Vs. Poleitzer-bag 215 
 
 Convergence — 
 
 Author 163, 203 
 
 Classification — 
 
 Author 148 
 
 Cycloduction — 
 
 Author 178 
 
INDEX 
 
 Cyclophoria 
 
 Author 117 
 
 Clinoscope :• 1 
 
 Decentering of Lenses 
 
 Declination, treatment 
 
 Declination, measurement :• i 
 
 Delafield, I »r. E 23, 24 
 
 Derby, Dr. :\ 
 
 Deviation 119 
 
 Diagnosing, Author 161 
 
 Divergence, non-paralytic. Landolt 58, ( '-i 
 
 Donders, Prof 17 
 
 Douching, Otological 220 
 
 Douching children 229 
 
 1 >ry Vapor — Inhalation 
 
 Duction 
 
 I >yer, Dr 
 
 Ear-ache 227 
 
 Esophoria, Author — — l 96 
 
 Equilibrium 81, 131, 133, L39 
 
 Eukenises 1 09, L35 
 
 Examination — Methods — Howe 106 
 
 Extra Ocular Muscles 11". 11-' 
 
 pupils school 1 y ■"■ 
 
 Exophoria Author __ .. L96 
 
 Eye strain 13, 78, 11". 117. 127 
 
 Find/ngs, Author Ill 
 
 Fusing faculty 178 
 
 Fusing power, Howe 
 
 Glass-fitting craze 179 
 
 Maddox Rod, Landolt — 
 
 Mental, Author 153 
 
 Meter angle, Nagel . — 
 
 Migraine. Oliver s 7 
 
 Moore, Wm. D., Translator 17 
 
 Muscle Examination, Howe L06 
 
 Muscle Balance, Howe L09 
 
 Muscular Imbalance — 
 
 Weakness ' ' 
 
 Trouble 16 
 
 Habitudeo vises 19 
 
 l [ackley, « Jharles E., M. I » 
 
 Heterophoria "'•'• s ' • 
 
 Heterophoria latenl 82, L37 
 
 Howe, Lucien, M. D 
 
 Heterocykinesis, Howe 1,n 
 
 Heterophoria, Author ••* 
 
 compound, Howe '- 1 
 
 simple, i [owe ' -'" 
 
 Hypermetropia, discovery of ' s 
 
 Hyperphoria, Author ' ,,: 
 
236 INDEX 
 
 Page 
 
 [ntroductlon 
 
 Enquiries 14 
 
 Insufficiencies 21, 50 
 
 Bodrr 32 
 
 Donders, Prof 2 1 
 
 1 1 < >\ve 13 
 
 Latent 37 
 
 Landolt .",, 63, 65 
 
 Schmidt- Rumpler 71 
 
 Roosa 74 
 
 Imbalance, result of Eye-strain 110 
 
 Imbalance, ocular muscle 109 
 
 Imbalance, simple, Howe Ill 
 
 [mbalance, compound, Howe 114 
 
 Intra-ocular muscles __ Ill 
 
 Kinothalmoscope. Landolt 68 
 
 Kratometer 158, 188 
 
 Landolt, E. M. D. __ 53 
 
 Lenses, effect of 163, 166 
 
 Maddox Rod, Landolt 67 
 
 Mental, Author _. __ 153 
 
 Meter angle, Nagel 169 
 
 Migraine, Oliver 87 
 
 Moore, Wm. D., Translator .- — 17 
 
 Muscle Examination, Howe — 106 
 
 Muscle Balance, Howe -- . . 109 
 
 Muscular Imbalance 109 
 
 Muscular Weakness 44 
 
 Muscular Troubles 4 6 
 
 Nagel' s M. a 169 
 
 Nature aids __ „ 143 
 
 Nerve storms 79 
 
 Neurasthenia 79 
 
 Xeuhasthenia, Author __. . . 149 
 
 Neuralgia __ __ 149 
 
 Nomenclature of Stevens --. 91 
 
 Noyes, Dr. H. D 23, 27, 43, 136 
 
 Ocular Trapeze 209 
 
 Oliver, Dr. Chas. A 7 7 
 
 Ophthalmo dynamometer 66 
 
 Ophthalmo dynamameter, Modification __ 203 
 
 Operation, Bader 33 
 
 Orthoptic treatment 138 
 
 Otology 207 
 
 Otitis Media 207 
 
 Paretic Heterophoria 80 
 
 Philology of Asthenopia 127,128 
 
 Phoria, Stevens _. 91 
 
 Phorometer, Stevens . .__ 93 
 
 Power balance of — Howe _. 107 
 
 Powder blower 228 
 
[NDEX 
 
 Page 
 
 Preface 
 
 Prism — Crutch v ( 
 
 Prisms — Howe l l ::, i i 1 
 
 Prism, effect of lenses ;, I , 
 
 Pism efficiency of — not realized 
 
 Principles of Author j \ _• 
 
 Ranney 1 :: 7 
 
 Reading distance test, Author 1 r,:: 
 
 Red glass, Landolt 1,7 
 
 Reflex go, 1 1 8 
 
 Reflexes 1 ;, 1 
 
 Regional Exclusion :, s 
 
 Roosa, D. B. St. John, Dr :;:,. 
 
 Roosa, Dr., Ear _. 210 
 
 Ruete & Bohm Is 
 
 Sands, Dr 26 
 
 Screen test :; j 
 
 Schmidt-Rumpler, Dr 71 
 
 Stevens, Dr. Geo. T 89, 137 
 
 Stellwag, Carl, M. D :::, 
 
 Strabismus, Wells (0 
 
 Strabismus, Landolt ."7 
 
 Strabismus, Non-paralytic divergent 58, »'• 1 
 
 Strabismus, Causes, Landolt 
 
 Treatment, Landolt _. 60 
 
 Stereoscopes, Howe 1 "7 
 
 Strength of muscles 135 
 
 Strength of Muscles, Author . 163 
 
 Steam Inhalation 
 
 Spasms of Accommodation 17. 19 
 
 Spastic heterophoria 80 
 
 Suppression of false images 95, 
 
 Tests — 
 
 Classification, Howe 103 
 
 Convergence. Author 163, 203, 166 
 
 Reading distance 
 
 Muscular strength IT" 
 
 Noyes I •'• . 50 
 
 Tendon Insertions '.'1 
 
 Torson 90, 108, LIS 
 
 Tropometer 90 
 
 Torticollis 115 
 
 Stevens 
 
 Tenotomy — 
 
 Landolt 
 
 Stevens 1 ■". 7 
 
 Trapeze Ocular 
 
 Tympanum, cleaning 
 
 Verticals, Author 17 7 
 
 Von Corion, Carl Stellwag 
 
INI) 1 X 
 
 Page 
 
 Von Graefe 18 
 
 Wells J. Soelberg 39 
 
 Weakness of muscles, Stevens 94, 136 
 
 Williams, I>r., of Boston 25 
 
 Williams. Dr., of Cincinnati 25 
 
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