THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES LOGIN BROS. MEDICAL BOOKS 1114 W HARRISON ST. CHICAGO NORMAL FUNDUS, grange Gofer.) MANUAL CLINICAL OPHTHALMOLOGY BY HOWARD F. HANSELL, M.D., LECTURER ON OPHTHALMOLOGY IN THE JEFFERSON MEDICAL COLLEGE; CHIEF CLINICAL ASSISTANT IN EYE DEPARTMENT, JEFFERSON MEDICAL COLLEGE HOSPITAL; MEMBER OF AMERICAN OPHTHALMOLOGICAL SOCIETY; FELLOW OF THE COLLEGE OF PHYSICIANS, PHILADELPHIA, ETC., AND JAMES H. BELL, M.D., LATELY DEMONSTRATOR OF ANATOMY IN JEFFERSON MEDICAL COLLEGE ; MEMBER OP OPHTHALMOLOGICAL STAFF, JEFFERSON MEDICAL COLLEGE HOSPITAL; OPHTHALMIC SURGEON TO SOUTHWESTERN HOSPITAL AND DISPENSARY, ETC. WITH 120 ILLUSTRATIONS. PHILADELPHIA: P. BLAKISTON, SON & CO., 1012 WALNUT STREET. 1892. COPYRIGHT, 1892, BY P. BLAKISTON, SON & Co. PTCM or WM. F. Fru. * Co. 1220-24 SANSOM ST. TO WILLIAM THOMSON, M. D., PROFESSOR OF OPHTHALMOLOGY, JEFFERSON MEDICAL COLLEGE, AS A DISTINGUISHED REPRESENTATIVE OF THE SCIENCE, IN RECOGNITION OF HIS FRIENDSHIP, THIS VOLUME IS INSCRIBED WITH THE SINCERE RESPECT AND ESTEEM OF THE AUTHORS. PREFACE, It has been our purpose in the following pages to place before the undergraduate and general practitioner of medi- cine, a brief review of the anatomy, physiology, refraction, and common diseases of the eye. No attempt has been made to treat the subjects exhaustively. Simplicity and brevity of statement have not been sacrificed to the mere attractiveness of literary finish. We have, in a word, endeavored in good faith, to make the volume conform to the purpose for which it was written, by giving it the character, directness, and practicability of clinical teaching and practice. We have been equally and jointly engaged in the com- position and arrangement of each and every chapter, and for all portions of the book we are, therefore, equally and jointly responsible. TABLE OF CONTENTS. PART I. PAGE GENERAL CONSIDERATIONS, STRUCTURAL AND PHYSIOLOGICAL. Sclera. Cornea. Choroid. Ciliary Body. Ciliary Processes. Iris Retina. Anterior Chamber. Posterior Chamber. , Vitreous Chamber. Hyaloid Membrane. Ligament of the Lens. Crystalline Lens. Anterior Capsule. Optic Nerve. Optic Tracts. Chiasm. Nerves. Arteries and Veins. Lym- phatics. Muscles. Optic Axis. Conjunctiva. Lacrymal Ap- paratus. Accommodation. Relative Accommodation. The Metre Angle. Test Cards and Lenses. Field of Vision. The Perimeter. Colors. Color-Sense. Color-Blindness, .... 9-41 PART II. PHYSIOLOGICAL OPTICS. Reflection. Refraction by Plane, Prismatic, Spherical, and Cylin- drical Lenses. The Dioptric System. The Ophthalmoscope. Formation of Images by Direct and Indirect Methods, 42-52 PART III. REFRACTION. Normal Refraction. Emmetropia. Hypermetropia. Myopia. Astigmatism. The Refraction Ophthalmoscope. Direct Examination. Indirect Examination. Determination of Refrac- tion by the Ophthalmoscope. Retinosocpy by the Plane Mirror. Presbyopia. Mydriatics, 53"77 vii VI11 TABLE OF CONTENTS. PART IV. PACK THE OCULAR MUSCLES. Paralysis of. Ophthalmoplegia Externa and Interna. Nystagmus. Orthophoria. Hetcrophoria. Orthotropia. Heterotropia. The Tests for Muscular Strength Symptoms of Heterophoria. Diagnosis of Heterophoria. Treatment of Heterophoria. Strabismus, 78-9,' PART V. DISEASES OF THE CONJUNCTIVA. Hyperaemia. Conjunctivitis: Acute Catarrhal, Chronic Catarrbal, Vernal, Follicular, Granular, Blennorrhoeal, Phlyctenular, Croupous, Diphtheritic. Xerosis. Pterygium. Tumors, . . . 92-105 PART VI. DISEASES OF THE LIDS. Coloboma. Epicanthus. Congenital Ptosis. Traumatism. Phleg- mon. Hordeolum. -Blepharitis. Marginal Blepharitis. Erythema. CEdema. Emphysema. Rodent Ulcer. Epithe- lioma. Lupus. Xanthelasma. Chancre. Chalazion. Ecchy- mosis. Milium. Trichiasis. Alopecia. Pediculus Pubis. Entropion. Ectropion. Blepharospasm. Blepharophimosis. Acquired Ptosis. Symblepharon. Ankyloblepbaron. DISEASES OF THE LACRYMAL APPARATUS. Hypertrophy of Lacrymal Gland. Abscess of Lacrymal Gland. Fistula of Lacrymal Gland. Malposition of Puncta Lacry- malia. Stricture of the Nasal Duct. -Blennorrhcea of Lacrymal Sac. Dacryocystitis. Abscess of Lacrymal Sac. Fistule of Lacrymal Sac, Io6-I2l PART VII. DISEASES OF THE CORNEA. Phlyctenular Keratitis. Herpes. Pannus. Ophthalmic I lerpes Zoster. Resorption Ulcer. Serpiginous Ulcer Interstitial or Parenchymatous Keratitis. Abscess. Neuro- Paralytic Kera- titis. Necrosis. Arcus Senilis. Opacities. Conical Cor- nea. Staphyloma. Tumors. DISEASES OF THE SCLERA. Scleritis. Anterior Staphyloma. Posterior Staphyloma 122-135 TABLE OF CONTENTS. IX PART VIII. PAGE DISEASES OF THE CRYSTALLINE KENS AND LENS CAPSULE. Cataract: Central, Anterior Polar, Posterior Polar, Zonular, Total, Senile, Traumatic. Dislocation of the Lens. Apliakia. Depo- sition on Anterior and Posterior Surfaces of Capsule. Wounds. Secondary Cataract, 136-146 PART IX. DISEASES OF THE UVEAL TRACT. The Iris. Congenital Anomalies. Aniridia. Coloboma. Persis- tent Pupillary Membrane. Polycoria. Albinism. Hyper- semia. Plastic Iritis. Serous Iritis. Parenchymatous or Sup- purative Iritis. Mydriasis. Myosis. Argyll - Robertson Pupil. Hyphsemia. Detachment. Tumors. The Ciliary Body. Cyclitis. Sympathetic Inflammation. Chronic Cyclitis. DISEASES OF THE CHOROID. Choroiditis. Disseminated. Areolar. Central. Central Senile Atrophy. Central Guttate, 147-162 PART X. DISEASES OF THE VITREOUS. Hyalitis. Muscae Volitantes. Synchisis. Synchisis Scintillans. Hyaloid Artery. Foreign Bodies, 163-165 PART XL GLAUCOMA. Simple, Chronic Inflammatory, Acute Inflammatory, Fulminating, Secondary. Glaucomatous Degeneration 166-171 PART XII. DISEASES OF THE RETINA. Hyperremia. Anaemia. Embolism Central Retinal Artery. Hemorrhage. Opaque Nerve Fibres. Hemorrhagic Reti- niti?. Albuminuric Retinitis. Diffused Chronic Retinitis. Retinitis Pigmentosa. Detachment. Acute Central Reti- nitis. Hyperaesthesia. Anaesthesia. Glioma 172-184 X TABLE OF CONTENTS. PART XIII. PAD! DISEASES OK THE Optic NERVK. Acute Neuritis. Papillitis. Retro- Bulbar Neuritis. Atrophy. Tobacco and Alcohol Amblyopia. Hemianopsia, i<\=; !')_ PART XIV. * DISEASES OF THE ORBITAL CAVITY. Periostitis. Phlegmon. Tumors. Exophthalmus. Enophthalmus. 193-194 PART XV. OPERATIONS. Cataract Extraction with Iridectomy. Cataract Extraction without Iridectomy. Discission. Iridectomy. Iritomy. Paracentesis Cornea. Sc-emisch Incision. Conical Cornea. Staphyloma Cornea and Sclera. Tattooing. Foreign Bodies in Conjunctiva, in Cornea, in Anterior Chamber, in Lens, in Vitreous Cham- ber. Tenotomy. Graded or Partial Tenotomy. Advancement of Tendon. Enucleation. Symblepharon. Ankyloblepharon. Canthotomy. Canthoplasty. Tarsorraphy. Excision of Cilize. Entropion. Ectropion. Chalazion. Ptosis. Stricture of Lacrymal Duct. Epithelioma. Ulcer. Naevi. Warty Kx- crescences, 195-223 LIST OF ILLUSTRATIONS.* KIG. PAGE 1. Vertical Section of the Cornea, II 2. Vertical Section of the Choroid, 12 3. Antero- Posterior Section of the Cornea and Sclerotic, 13 4. Anterior Quadrant of a Horizontal Section of the Eyeball, Cornea, and Lens, 15 5. Vertical Section of Human Retina, . . 16 6. Section of the Fovea Centralis, 17 7. Fibres of the Lens, 19 8. Diagram of the Decussation of the Optic Tracts, 19 9. Horizontal Section of the Entrance of the Optic Nerve and the Coats of the Eye, 20 10. Diagram of the Blood-vessels of the Eye, 23 n. Lateral View of the Muscles of the Eyeball, . . . . 26 12. Vertical Section through the Upper Eyelid, 28 13. Lacrymal Apparatus 30 14. Scheme of the Accommodation for Near and Distant Objects, ... 32 15. Test Case 35 16. McHardy's Perimeter, 38 17. Spectrum Obtained by Means of a Prism, 40 1 8. Refraction by Medium with Parallel Sides, 43 19. Refraction by a Prism, 44 20. Juxtaposed Prisms, 45 21. Different Forms of Spherical Lenses, 45 22. Refraction of Parallel, Diverging and Converging Rays by Convex Lens, 46 23. Refraction of Parallel Rays by Concave Lens, 48 24. Cylinders, 48 25. Direct Examination by Ophthalmoscope, 51 * None of the illustrations are original ; they have been taken from the works of Meyer, Netileship, Landois and Stirling, Littell, Harlan, and Jaeger. E. A. Yarnall & Co. have furnished the cuts for the instruments, and J. L. Borsch & Co. for lenses and for an astig- matic chart. xi Xll LIST OF ILLUSTRATIONS. FIG. PAGE 26. Indirect Examination by Ophthalmoscope, 52 27. Condition of Refraction in the Normal Passive Eye and During Accommodation, 53 28. Condition of Refraction in the Normal Eye During Accommodation, 54 29. Hypermetropic Eye 55 30. Myopic Eye, 57 31. Action of an Astigmatic Surface on a Cone of Light, 60 32. Astigmatic Clock for Testing Astigmatism 62 33. Morton's Ophthalmoscope, 64 34. The Entrance of the Optic Nerve with the Adjacent Parts of the Fundus of the Normal Eye, 65 35. Illustration of Retinoscopy by the Plane Mirror, 69 36. Diagrams of Range of Accommodation in E., H., and M., .... 74 37. Scheme of the Action of the Ocular Muscles, 79 38. Pathological Convergence : Homonymous Diplopia, 80 39. Pathological Divergence : Heteronymous Diplopia, 8l 40. Conjunctival and Subconjunctival Injection, 93 41. Granular Conjunctivitis, 96 42. Pannus Affecting Upper Half of Cornea, 98 43. Phlyctenular Ophthalmia, Conjunctival Form, 102 44. Pterygium, . 105 45. Epicanthus, 106 46. Ptosis, 107 47. Meibomian Cyst. Lid Forceps, 1 1 1 48. Trichiasis, 1 1 3 49. Distichiasis, 113 50. Entropion of Lower Lids, 114 51. Ectropion of Lower Lid 115 52. Symblepharon, 117 53. Ankyloblepharon, 117 54. Lacrymal Gland 118 55. Fistule of Lacrymal Sac, 120 56. Phlyctenular Ulcer 123 57. Perforating Ulcer of the Cornea ; Adhesion of Iris, 126 58. Onxy and Hypopyon, 126 59. Acute Serpiginous Ulcer of the Cornea 127 60. Interstitial Keratitis, 128 61. Partial Staphyloma of the Cornea, 130 62. Partial Staphyloma of the Cornea and Iris, 130 63. Total Staphyloma of the Cornea and Iris, 131 LIST OF ILLUSTRATIONS. xiii FIG. PAGE 64. Staphyloma of Sclera 133 65. Post-Staphyloma, 134 66. Posterior Polar Cataract, 136 Illustrations of Cataract, 139 and 140 67. Posterior Synechia, 148 68. Serous Iritis, 151 69. Atrophy after Syphilitic Choroiditis, 159 70. Central Choroiditis, 159 71. Central Guttate Senile Choroiditis, 160 72. Glaucomatous Excavation of the Optic Nerve (Vertical Section), . 168 73. Glaucomatous Excavation (Ophthalmoscopic View), 168 74. Embolism of the Central Artery of the Retina, 173 75. Retinitis x Albuminurica, 177 76. Retinitis Pigmentosa, 180 77. Ophthalmoscopic Appearance of Detached Retina, 181 78. Optic Neuritis, 186 79. Atrophic Excavation, 189 80. Lid Speculum, 196 81. Fixation Forceps, 196 82. Graefe Cataract Knife, 196 83. Iris Forceps, 197 84. Iridectomy Scissors, 197 85. Cystotome 198 86. Expulsion of the Cataract, 198 87. Graefe Cataract Spoon and Cystotome, 198 88. Wire Loop, 200 89. Lens Extractor, 200 90. Discission, 201 91. Soft Cataract Needle, 202 92. Escape of Lens Masses from Anterior Chamber, 202 93. Linear Incision at the Superior Margin of the Cornea, 203 94. Iridectomy Knife, 203 95. Artificial Pupil as seen in Anterior Chamber after Iridectomy, . . . 204 96. Iridotomy Knife, 204 97. De Wecker's Iritomy Scissors, 205 98. Paracentesis Knife, 205 99. Needles in Position (Ant. Staphyloma), 206 100. Excision of the Staphyloma, 207 101. Appearance of the Stump after Excision of the Staphyloma, . . . 207 102. Tattooing Needle 208 XIV LIST OF ILLUSTRATIONS. FIG. PACK 103. Spud 209 104. Incision of the Conjunctiva 210 105. Section of the Tendinous Insertion, 210 106. Strabismus Hook 210 107. Conjunctival Scissors, 211 108. Enucleation Scissors, 214 109. Operation for Symblepharon, 215 no. Aril's Method 215 111. Canthoplasty, 216 112. Tarsorrhaphia, 217 113. Horn Plate, 217 114. Lid Forceps, 217 115. Operation for Distichiasis, .'.... 218 1 1 6. Operation for Ectropion, 220 117. Operation for Ectropion, 220 118. Canaliculus Knife, 221 119. Probing the Nasal Duct, 222 1 20. Bowman's Probes, 222 ERRATUM. Page 77, line 9. Hydrobromate should read Hydrochlorate. A MANUAL CLINICAL OPHTHALMOLOGY, PART I. GENERAL CONSIDERATIONS STRUCTURAL AND PHYSIOLOGICAL. The human eyeball is spheroidal in shape ; 24 mm. in its antero-posterior, 23 mm. in its transverse, and 23 mm. in its vertical axis. Three tunics are commonly described, namely, an inner percipient coat, the retina, a middle vas- cular coat, the choroid, and an outer and protecting coat, the sclera, with its transparent continuation in front, the cornea. The sclera is a bluish-white, opaque, dense, resisting membrane, composed of closely interlacing connective tis- sue fibres with a sparse intermingling of fine elastic tissue. Among the fibres are numerous lymph channels communi- cating with the lymph system of the cornea, the underlying peri-choroid, and with the overlying capsule of Tenon. A few small blood-vessels and nerves are distributed through- out its substance. Slightly below and four mm. to the nasal side of the posterior extremity of the horizontal axis of the 9 IO A MANUAL OF CLINICAL OPHTHALMOLOGY. ball is an incomplete opening, \y* mm. in diameter, the sclerotic foramen, over which is stretched a white fibrous veil, the lamina cribrosa, pierced by the optic nerve, central artery and vein of the retina. At the margin of this fora- men the sclera is one mm. thick, being reinforced by a deflection of the outer sheath of the optic nerve, and gradu- ally thins off anteriorly, to be again reinforced six to eight mm. back of the limbus cornea, corneo-sclcral margin , by the expanding tendons of the recti muscles. It is marked just at its corneal border by a slight depression, the su/cus schra. The sclera is pierced ten to twelve mm. from the foramen sclera by the posterior ciliary vessels and nerves ; again midway between the optic nerve entrance and cornea, by four or five large veins, venae vorticosae, which empty into the ophthalmic vein. It is again perforated two mm. from the limbus cornea by the anterior ciliary vessels, four or five in number. The cornea is the anterior, smaller and transparent por- tion of the external tunic, measuring eleven mm. vertically, twelve mm. horizontally, and one mm. in thickness at its apex. The layers may be multiplied indefinitely by resort- ing to useless and confusing subdivision ; three are here given. The anterior layer consists of columnar epithelium continuous with the epithelium of the conjunctiva, and a homogeneous elastic, basement membrane (Bowman's). The second or middle layer composes the tissue proper of the cornea, and is formed by sixty or more laminae of fibrous tissue, containing, in great number, irregularly placed lymph spaces, in which lie the corneal cells, connected with each other in all directions by canaliculi. The poste- rior layer consists of a homogeneous basement membrane (Descemet's), on which is a single layer of hexagonal cells continuous with that on the anterior surface of the iris. GENERAL CONSIDERATIONS. II In health the cornea is devoid of blood-vessels, except at its periphery, and contains under Bowman's membrane a few terminal branches of the ciliary nerves. There is ana- tomically no distinct line of union between the sclera and cornea, but the former slightly overlaps the latter on its anterior aspect, and beneath this shelving border of sclera, in clear cornea, lies the canal of Schlemm, which is con- FIG. i. : . ..'. : ->-^ --'>> ti:"-x--v /-.:/ ..:- VERTICAL SECTION OF THE CORNEA, STAINED WITH GOLD CHLORIDE. n. Nerve-fibrils, a. Perforating branch, r. Nucleus. /, b. Inter-epithelial termination of fibrils, s. Anterior elastic laminae. nected with the angle of the anterior chamber by the spaces of Fontana. The choroid is the vascular and pigmentary coat, extend- ing posteriorly from fo& foramen opticus choroidea, through which the optic nerve passes, and anteriorly to the ciliary region. Its outer surface lines the sclera from which it is separated by a double layer of serous membrane, supra- ckoroidal lymph space, and its inner surface is attached to the basal membrane of the pigment coat of the retina as far for- ward as the ora serrata. The choroid may be divided into 12 A MANUAL OF CLINICAL OPHTHALMOLOGY. two layers : an outer, containing relatively larger vessels and more pigment, and an inner, containing capillary vessels and less pigment. The most conspicuous vessels of the external layer are the veins, which, converging, form the vena vorti- cosce. The capillary vessels of the inner layer are derived FIG. 2. VERTICAL SECTION OF THE CHOROID AND A PART OF THE SCLEROTIC. i. Sclerotic. 2. Lamina suprachoroidea. 3. Layer of large vessels. 4. Limiting layer. 5. Chorio-capillaris. 6. Hyaline membrane. 7. Pigment epithelium, g. Large blood- vessels. /. Pigment cells, c. Sections of capillaries. mainly from the short ciliary arteries. The pigment, con- sisting of hexagonal cells filled with dark-brown granules, is scattered throughout both layers, occupying the meshes between the vessels in quantity and density sufficient to absorb light. The ciliary body comprises the ciliary muscle and pro- FIG. 3. ANTERO-POSTERIOR SECTION OF THE CORNEA WITH THE SCLEROTIC. a. Anterior corneal epithelium, b. Bowman's lamina, c. Corneal corpuscles. /. Corneal lamellae (the whole thickness lying between b and d is the substantia propria cornea). d. Descemet's membrane, e. Its epithelium, f. Junction of cornea with the sclerotic. ^. Limbus conjunctivae. //. Conjunctiva ; canal of Schlemm. k Leber's venous plexus (is regarded by Leber as belonging to i). m, m. Meshes in the tissue of the ligamentum iridis pectinatum. n. Attachment of the iris. o. Longitudinal, /, circular (divided transversely) bundles of fibres of the ciliary muscle, u. Transverse section of a ciliary artery, v. Epithelium of the iris (a continuation of that on the posterior surface of the cornea), iv. Substance of the iris. x. Pigment of the iris. z. A ciliary process. 13 14 A MANUAL OF CLINICAL OPHTHALMOLOGY. cesses, and the space they occupy, together with the cor- responding circular strip of sclera, is the ciliary region. The ciliary muscle, attached anteriorly to the ligaincntuni pectinatum iridis and lost posteriorly in the choroid oppo- site to the ora serrata, consists of radiating and circular bundles of unstriped muscular fibre, containing the arterial circle, the circulus ciliaris. The ciliary processes consist of an anterior prolongation of the pigment stroma and blood-vessels of the choroid, with a reduplication into sixty or seventy folds, resting on the anterior periphery of the vitreous. The Zone of Zinn is the pigmented indentations made by the ciliary processes in the hyaloid membrane. The Iris is a circular framework of elastic and non-striped muscular fibres, lined anteriorly by flat epithelium, con- tinuous with the membrane of Descemet, and posteriorly by the uvea, or pigment coat, continued forward from the ciliary processes. It is suspended in the aqueous humor 2 l /t mm. behind the cornea, and in front of the lens and ciliary processes. By the ciliary ligament (ligamentum pectinatum iridis) its circumference is attached to the limbus cornea;. It is perforated by a nearly circular hole, the pupil, the margin of which, the pupillary border, lies in contact with the anterior capsule of the lens. The sphincter pupillce is a circular band of muscular fibres surrounding the pupil. The dilator iridis is, according to late authorities, not a muscle, but a fibre-elastic tissue. The iris has two circles of anastomosing vessels, the larger surrounding the ciliary and the smaller the pupillary border, branches of the anterior and long ciliary. Filaments from the lenticular (ophthalmic) ganglion, containing motor fibres from 3rd, sensitive from ist division of 5th, and sympathetic filaments from the carotid plexus, furnish its nerve supply. GENERAL CONSIDERATIONS. The Retina, or nervous, tunic, is composed of three main layers : the inner, fibre and nerve-cell, the middle, granular, and the internal, or layer of rods, cones and pigment. The FIG. 4. ANTERIOR QUADRANT OF A HORIZONTAL SECTION OF THE EYEBALL, CORNEA, AND LENS. Substantia propria of the cornea, b. Bowman's elastic membrane, c. Anterior corneal epithelium, d. Descemet's membrane, e. Its epithelium, f. Conjunctiva. g. Sclerotic, h. Iris. i. Sphincter iridis. j, Ligamentum pectinatum iridis, with the adjoining vacuolated tissue, k. Canal of Schlemm. /. Longitudinal, m, circular mus- cular fibres of the ciliary muscle, n. Ciliary process, o. Ciliary part of the retina. q. Canal of Petit, with Z, Zonule of Zinn, in front of it, and /, the posterior layer of the hyaloid membrane, r. Anterior, v, posterior part of the capsule of the lens. t. Cho- roid. 4 u. Perichoroidal space. T. Pigment epithelium of the iris. x. Margin of the lens. first or inner layer consists of the expanded intra-ocular ex- tremity of the optic nerve fibres, stripped of their medullary sheaths, with numerous multipolar cells ; the second, of i6 A MANUAL OF CLINICAL OPHTHALMOLOGY. granular and granulated cells, arranged in four strata, con- necting the inner and outer ; the third is the sentient layer proper, and is composed of elongated nerve-cells, the rods FIG. 5. VERTICAL SECTION OF HUMAN RETINA. a. Rods and cones. l>. Ext. and, /, int. limit, memb. c. Ext. and,/, int. nucl. layers, e. Ext. and, g, int. gran, layers, h. Blood-vessels and nerve cells. /. Nerve-fibres. and somewhat shorter cones, inserted into the pigment layer. Each layer is transparent, with the exception of the pigment coat. The retina is about .25 mm. in thick- ness, covers the under surface of the choroid from the GENERAL CONSIDERATIONS. \"J foramen choroidea to the ora serrata, or notched and den- tated anterior margin of the retina, allowing the lining mem- brane of vitreous to come into immediate contact with the choroid for the space of a few mm. behind the ciliary body. The macula lutea is a yellowish spot, as seen by the ophthal- moscope, irregular in shape, but usually circular, 0.5 mm. in diameter, and lies slightly to the temporal side of the posterior end of the optic axis. In the centre of the macula FIG. 6. SECTION OF THE FOVEA CENTRALIS. a. Cones, b and g. Int. and ext. limit, memb. c. Ext. and e, nuclear layer, d. Fibres. f. Nerve-cells. is the fovea centralis (Fig. 6), .2 mm. in diameter, charac- terized by an absence of all the layers of the retina, except- ing modified rods and cones. The central artery and vein of the retina pass through the poms opticus, a comparatively large aperture in the lamina cribrosa, and, dividing, ver- tically, into large and, horizontally, small vessels, are distributed in the fibre layer of the retina, anastomosing at .the ora serrata with the choroidal and, at the optic nerve entrance, with the short ciliary vessels. l8 A MANUAL OF CLINICAL OPHTHALMOLOGY. The anterior chamber is an angular space, bounded in front by the posterior surface of the cornea, at its angle by the ligamentum pectinatum iridis, and behind by the anterior surface of the iris. It secretes and contains the aqueous humor, a feebly saline, transparent fluid. The smaller posterior chamber is bounded in front by the posterior surface of the iris, and behind by the ciliary pro- cesses, suspensory ligament of the lens and lens, and con- tains aqueous humor. The anterior and posterior chambers are in free communication through the pupil. The vitreous chamber is bounded by the retina, ciliary processes and lens, and contains the vitreous humor, a transparent, jelly-like substance, supported by numerous septa. The Hyaloid membrane is a fine, transparent layer of con- nective tissue, enclosing the vitreous, and forms, by division anteriorly at the ciliary processes, the suspensory ligament of the lens. The canal of Petit is the name given to the space between the layers of the suspensory ligament at the periphery of the lens. Anteriorly the vitreous presents a well-marked depression, the hyaloid fossa, in which rests the posterior convexity of the lens. The vitreous is tra- versed in its antero-posterior axis in the foetus by the canal of Cloquet, containing the hyaloid artery. The crystalline lens is a biconvex and transparent body, varying in consistence at different ages, from 8-10 mm. in diameter and 34 mm. in depth at its axis. It is enveloped in front by the capsule, at its periphery by the suspensory ligament, and behind by the hyaloid. Its substance is arranged in concentric lamellae, composed of minute fibril- lae, hexagonal in horizontal section (Fig. 7, 2). Between the lamellae and among the fibres is an oil-like material, Liquor Morgagni, which permits of change of form without GENERAL CONSIDERATIONS. 19 friction. The concentric lamellae are approximated by sutures, thus dividing the lens into sections along radiat- ing planes. Considered as a whole, the lens consists of a nucleus, the almost structureless centre, and cortex, the outer fibrillary and softer portion. Fie. 7. FIG. 8. FIG. 7. FIBRES OF THE LENS. 2. Transverse sections of the lens fibres. FIG. 8. DIAGRAM OF THE DECUSSATION OF THE OPTIC TRACTS. T. Semi-decussation in the chiasma. T, Q. Decussation of fibres behind the ext.geniculate bodies (C, G). a',b. Fibres which do not decussate in the chiasma. 6',a'. Fibres pro- ceeding from the right eye and coming together in the left hemisphere (L, O, G). L,O,G,K. Lesion of the left optic tract, producing right lateral hemianopsia. a. Lesion in the left hemisphere, producing crossed amblyopia (right eye). T. Lesion producing temporal hemianopsia. n, n. Lesion producing nasal hemianopsia. The anterior capsule is tough and elastic, and is lined on its posterior surface by a layer of hexagonal cells, whose function it is to nourish the fibres. The fibres of the optic nerves (Fig. 8) arise in two bands, the optic tracts, from the corpora geniculata, corpora quad- 20 A MANUAL OF CLINICAL OPHTHALMOLOGY. FIG. 9. HORIZONTAL SECTION OF THE ENTRANCE OF THE OPTIC NERVE AND THE COATS OF THE EYE. , Inner, i>. Outer, layers of the retina, c. Choroid. d. Sclerotic, t. Physiological cup. f. Central artery of retina in axial canal, g. Its point of bifurcation, h. Lamina cri- brosa. /. Outer (dural) sheath, m. Outer (subdural} space. . Inner (subarachnoid) space, r. Middle (arachnoid) sheath. /. Inner (pial) sheath. i. Bundles of nerve- fibres, k. Longitudinal septa of connective-tissue. NERVES. 2 1 rigemina and ophthalmic ganglion, which are connected by radiating fibres with the cortical centre in the occipito- angular region of the cortex. Each optic tract winds obliquely across the corresponding crus cerebri, converges forward to meet its fellow on the opposite side, forming at their intersection the optic commissure, or chiasm. In the chiasm is a partial crossing of the fibres from each tract. The nerves arise from the chiasm, diverge, and each passes through the optic foramen in the corresponding lesser wing of the sphenoid bone. Each nerve is covered by pro- longations of the membranes of the brain, which form its sheaths and between which are the intervaginal and sub- dural lymph-spaces. Just before the nerve reaches the lamina cribrosa, the network of connective tissue extending across the foramen sclera, the dura mater passes over into the sclera, the arachnoid and pia mater are discontinued, the medullary covering of the nerve fibres is dropped, and only the axes-cylinders pass through the foramen sclera and choroidea to form the nerve-fibre layer of the retina. Eighteen mm. posterior to this point, the ophthalmic artery and vein pierce the nerve obliquely, and having reached its centre, continue forward, and, passing through the porus opticus, are distributed to the retina. NERVES. The eyeball and its appendages are supplied by sensory branches from the first and second divisions of the fifth pair, motor branches from the third, fourth, sixth, and seventh pairs of cranial nerves, and sympathetic filaments from the carotid and cervical plexuses. The ciliary ganglion, lodged in the orbit below the superior and to the median side of the ex- ternal rectus behind the ball, receives sympathetic fibres from the carotid plexus, sensory from the first or ophthalmic divi- 22 A MANUAL OF CLINICAL OPHTHALMOLOGY. sion of fifth, and motor fibres from the third. From it a small twig joins the branch of the third, supplying the inferior oblique, and from three to six branches, subdividing into twenty, the short ciliary, enter the sclera around the optic nerve. The ophthalmic division of the fifth gives off three purely sensitive branches just before passing through the sphenoidal fissure; the lacrymal, accompanying the lacrymal artery, runs along the external rectus muscle to the lacrymal gland, supplying it, conjunctiva, and integu- ment of the upper lid ; the frontal, running forward above the levator palpebra? muscle, supplies by its two terminal branches the corrugator supercilii, occipito-frontalis, orbicu- laris palpebrarum, and the integument of the lids, forehead, and scalp ; the nasal, passing through the orbit and giving off a twig to the ophthalmic ganglion, as well as two or more branches the long ciliary nerves, which perforate the sclera with the short ciliary, and run forward between the sclera and choroid to be distributed to the ciliary body, iris, and cornea; and the infra-troclilear to the conjunctive and appendages of the eye. The third nerve, motor oculi, supplies the internal, supe- rior and inferior recti, inferior oblique, levator palpebnr, ciliary muscle, and iris, and furnishes a motor root to the ophthalmic ganglion. The fourth nerve, trochlear, supplies the superior oblique. The sixth nerve, abducens, supplies the external rectus. The seventh nerve, facial, supplies the orbicularis palpe- brarum. ARTERIES. The ball and its appendages (Fig. 10) are supplied with blood directly from the ophthalmic branches of the internal carotid, and indirectly by anastomoses between ARTERIES. its terminal branches and similar branches of the ex- ternal carotid. The lacrymal artery supplies the lacrymal gland, upper FIG. 10. DIAGRAM OF THE BLOOD-VESSELS OF THE EYE. {Horizontal view ; veins black, arteries light, with a double contour.') aa. Short posterior ciliary, t. Long posterior ciliary, cc'. Anterior ciliary artery and vein. dd 1 ' . Artery and vein of the conjunctiva. ee f . Central artery and vein of retina. f. Blood-vessels of the inner, and, g, of the outer optic sheath, h. Vorticose vein. i. Posterior short ciliary vein confined to the sclerotic, k. Branch of the posterior short ciliary artery to the optic nerve. /. Anastomosis of the choroidal vessels with those of the optic nerve, m. Chorio-capillaris. n. Episcleral branches, o. Recurrent choroidal artery. /. Great circular artery of iris (transverse section), q. Blood-vessels of the iris. r. Ciliary process. .?. Branch of a vorticose vein from the ciliary muscle, u. Cir- cular vein. v. Marginal loops of vessels on the cornea, -cu. Anterior artery and vein of the conjunctiva. 24 A MANUAL OF CLINICAL OPHTHALMOLOGY. lid, and conjunctiva; the supraorbital,\\\z superior rectus and levator palpebne muscles, inner canthus, skin and mus- cles of the forehead ; the two palpebral, the lids ; the nasal, a branch to the lacrymal sac ; the short ciliary, pierce the sclera around the optic nerve and are the main supply to the choroid ; the long ciliary, supply the ciliary body and iris ; the anterior ciliary, given off from the muscular, perforate the sclera near the limbus, and supply the ciliary body and iris; the hvo muscular, supply the external ocular muscles. LYMPH SYSTEM. Lymph vessels, with their own walls, are found in the lids and conjunctiva, and empty into the parotid and sub- maxillary glands, accompanying the venae facialis and tem- poralis. In the conjunctiva is a superficial and deep net- work of canals communicating freely with one another, and in close connection with the lymph systems of the cornea and sclera. The spaces in the cornea communicate prob- ably with the great lymph space of the anterior chamber by means of Schlemm's canal and the spaces of Fontana. On the sclera lies another lymph space, Tenon s capsule, composed of two layers of delicate connective tissue, an inner, episcleral, and an outer, muscular layer. The inner lies immediately on the sclera as far forward as the insertion of the tendons, where it is reflected into the outer. Between the tendons it is carried forward nearer the cornea, and is there reflected. Both layers are lined with epithelium and extend backward to the foramen sclera, communicating with the intervaginal lymph space. Between the sclera and choroid is a third space, the pcricJioroidca, communicating with Tenon's capsule by fine canals through the sclera. The vitreous body and lens are nourished by the surrounding MUSCLES. 25 blood-vessels of the uveal tract, and do not certainly possess lymph vessels proper, as does the cornea. In the foetus, the lens is nourished by the hyaloid artery, which is given off from one of the branches of the arteria centralis retinae, and pursues a straight course through the vitreous, termi- nating in fine branches on its posterior lenticular surface. It is said that from the ciliary body a stream of lymph flows downward and backward through the vitreous, then forward and through the canal of Petit to the posterior chamber ; downward and forward through the pupil into the anterior chamber, and outward to the angle, whence it escapes through the membrane of Descemet and ligamentum pectinatum to the canal of Schlemm. Tributary streams of lymph flow into the posterior chamber from the posterior surface of the iris and from the ciliary body, and into the anterior chamber from the anterior surface of the iris and meshes of Fontana's space. The corneal, scleral, con- junctival, perichoroidal, and Tenon's lymph spaces also communicate with the anterior chamber. The lymph canals of the retina accompany the retinal vessels and discharge through the poms opticus. MUSCLES. The position of the eyeba.ll in the orbit is maintained and its movements governed by the action of six muscles, namely, four straight and two oblique. The recti, superior, inferior, external, and internal, and the superior oblique have a nearly common origin from the margin of the optic foramen in the lesser wing of the sphenoid bone. The recti, diverg- ing in the directions indicated by their names, run forward parallel to the orbital wall, perforate the capsule of Tenon, and are inserted into the sclera at distances varying from six 3 26 A MANUAL OF CLINICAL OPHTHALMOLOGY. to eight mm. from the cornea. The superior oblique passes forward and upward to the upper and inner angle of the orbit, thence through a bony and cartilaginous pulley out- ward and backward under the superior rectus, to be inserted into the sclera on its posterior and superior surface. The inferior oblique arises from a depression in the superior FIG. ii. LATERAL VIEW OF THE MUSCLES OF THE EYEUAI.I.. 5. Trochlea or pulley of the superior oblique muscle. /, z, 6. Optic nerve. 8. Superior, 9, inferior, and 12, external rectus. 13. Inferior oblique. maxillary bone at the inferior and anterior angle of the median wall of the orbit, passes outward and backward under the globe, and is attached to the sclera on its external and posterior surface. The Uvator palpebra arises from the upper portion of the bony wall of the optic foramen, passes forward and upward THE APPENDAGES OF THE EYE. 2/ to be inserted into the cartilage of the upper lid. Its func- tion is to elevate the lid. The orbicularis palpebrarum is a broad, circular muscle, arising from the inner canthus and from the soft tissues im- mediately adjacent to the nose, passes under the skin of the lids and between them and the orbital ridges, and is inserted close to its origin. By its contraction the lids are closed. The optic axis is a line drawn from the centre of the cornea to the centre of the retina. The ends are called respectively anterior and posterior poles. The visual axis is a line drawn from the fovea centralis to the object in view. The angle a is formed at the intersection of the visual with the optic axis. In H.* it is usually larger and may cause an apparent divergence. In M. it is small, or may be absent (negative), i. e., the optic and visual axes coincide. This may give rise to the appearance of convergence. The angle Y is at the centre of rotation of the ball, and is the angle formed at the junction of a line drawn from the cen- tre of rotation to the object in view with the optic axis. THE APPENDAGES OF THE EYE. The lids (Fig. 12) are composed of skin, muscle, dense, fibrous tissue or cartilage, the tarsus, and mucous mem- brane. The cutaneous layer of the upper lid, containing partly-developed papillae and numerous fine hairs and some sweat glands, is loose and distensible ; at the margin it becomes modified, and is continued on the under sur- face, where it becomes mucous membrane. Connective tissue in wide meshes, highly vascular, separates the in- * Abbreviations : E. Emmetropia. II. Hypermetropia. M. Myopia. As. Astigmatism. 28 A MANUAL OF CLINICAL OPHTHALMOI .< >< .V. FIG. 12. to- YIKIICAL SKCTION THROUGH THK UITER KYKI.II>. .1. ('mis; i. Epidermis; 2. Corium ; t>. and 3. Subcutaneous connective-tissue; C. and 7. Orbicularis muscle ; D. Loose submuscular connective tissue; E. Insertion of H. Miil- ler's muscle; F. Tarsus; G. Conjunctiva;/. Inner, A". Outer edge of the lid ; 4. Pig- ment cells ; 5. Sweat-gland ; 6. Hair follicles ; 8 and 23, Sections of nerves ; 9. Arter- ies ; 10. Veins; n. Cilia; 12. Modified sweat-glands : 13. Circular muscle of Riolan ; 14. Meibomian gland; 15. Section of an acinus of the same; 16. Posterior tarsal glands, submuscular connective tissue ; ai and 22. Conjunctiva, with its epithelium ; 24. Fat; 25. Loosely-woven posterior end of the tarsus; 26. Section of a palpebral artery. THE CONJUNCTIVA. 29 tegument from the second or muscular layer, the lid por- tion of the orbicularis palpebrarum. The tarsus of the upper lid consists of dense, closely-interwoven fibrous tissue, connected rather loosely with the muscle above and closely with the mucous membrane below. It is 9 mm. in height, 20 mm. in length, and .8 mm. in thickness. Into its upper margin is inserted the tendon of the levator palpebrae. The lower border is free and in its substance are found tarsal or meibomian glands and hair follicles, the ciliae. In the lower lid the cartilage is almost undeveloped, and the glands are fewer and relatively insignificant. CONJUNCTIVA. The conjunctiva, continuous with the Schneiderian mu- cous membrane of the nose and the integument of the lids at their free margins, is a mucous membrane com- posed of columnar epithelium with its basement mem- brane, and is richly supplied with vessels and nerves. It is divided into palpebral, the portion lying in juxtaposi- tion to the lid ; fornix, the upper and lower cul-de-sac, where the conjunctiva leaves the lid and is reflected over into the sclera, and ocular, the portion lying on the ball. The epithelium is continued over the cornea, forming its first layer, while the loose, connective tissue ends at the corneo-scleral margin. The palpebral portion is thick, contains numerous papillae and glands, and is highly vas- cular. The ocular conjunctiva is less dense, loosely con- nected with adjacent parts, and transparent. The conjunc- tiva forms a small fold at the inner angle, \\\& plica scniilnnaris, adjoining which on the nasal side is a small conical body, caruncula laaymalis, composed of muscular fibre, fat, and mucous membrane, and supporting a few fine hairs. A MANUAL OF CLINICAL OPHTHALMOLOGY. LACRYMAL APPARATUS. The lacrymal gland, which secretes the tears, is held by a few fibrous bands in a depression in the frontal bone at the upper and outer angle of the orbit. Its under surface rests upon the ball and adjacent portions of the superior and ex- ternal recti muscles. It is about the size and shape of an almond, and opens into the outer and upper fornix by a FIG. 13. LACRYMAL APPARATUS. i. Upper lid. 2. Lower lid. 3. Canaliculi. 4. Lacrymal sac. 5. Puncta. 6. Plica semilunaris. 7. Caruncula. 8. Nasal duct. 9. Lacrymal gland. 10. Tubules. number of tubules, through which the tears are conveyed into the conjunctival sac. From this point, tears flow over the conjunctiva and cornea, cleansing and lubricating these parts, and are forced by winking into the f>nncta lacryinalia, two small openings opposite one another near the nasal extremity of the ciliary borders of upper and lower lids; thence into the caiialiculi, two small canals 1 2 mm. long, by ACCOMMODATION. 3! which they are conveyed into the lacrymal sac, the expanded upper extremity of the nasal duct. The sac is lodged in a depression formed by the lacrymal and nasal process of the superior maxillary bone, and is covered and compressed by the tendo-tarsi muscle and by the fibrous expansion of the tendo-oculi. From the sac the tears pass into the nasal duct, a membranous and bony canal, 20 mm. long, emptying into the inferior meatus of the nose. ACCOMMODATION. By accommodation is meant the power that resides in the ciliary muscle of so altering the length of the antero- posterior diameter of the lens, that the eye becomes adapted in its focal length to any distance within infinity. By contraction of the radiating fibres of the ciliary muscle toward their fixed points in the choroid, the angle of the anterior chamber is drawn inward and backward, while the diameters of the lens are simultaneously shortened by the contraction of the circular fibres of the same muscle. The effect of this double contraction is to relax the suspensory ligament of the lens. Thus in the act of accommodating the lens is increased in convexity, the iris is contracted, and the anterior chamber becomes shallower. (Fig. 14.) Accommodation is said to be positive or negative. It is positive when the ciliary muscle contracts in the manner just described, and negative when the refracting power of the lens is difriinished instead of increased, and this is accomplished, theoretically, by supposing the angle of the anterior chamber to be the fixed and the choroid the mov- able points, inducing a flattening of the lens or a positive diminution in the antero-posterior diameter of the vitreous by a dragging forward of the choroid and retina. 32 A MANUAL OF CLINICAL OPHTHALMOLOGY. The range of accommodation is the distance from the far point, r, to the near point, p. The amplitude of accom- modation is the accommodative effort of which an eye is capable, and is equal to the difference between the refrac- tion when the eye is at rest, or adapted for its far point (/), and when the accommodation is exercised to its fullest extent (/>). Hence a p r. Example : in emmetropia, FIG. 14. SCHEME OF ACCOMMODATION FOR NEAR AND DISTANT ' The right side of the figure represents the condition of the lens during accommodation for a near object, and the left side when the eye is at rest. The letters indicate the S.IIM-- parts on both sides ; those on the right side are marked with a dash. A. Left, /' right half of the lens; C. Cornea; S. Sclerotic; CS. Canal of Schlemm ; /"A". Anterior chamber ; J. Iris; P. Margin of the pupil ; V, Anterior surface ; //. Posterior surface of the lens; R. Margin of the lens ; /'. Margin of the ciliary processes ; a and b. Space between the two former; the line ZX indicates the thickness of the lens during accom- modation for a near object ; /.Y. The thickness of the lens when the eye is p.. p = 6 cm., r = oo (infinity) ; a = 6 cm. oo ; a = 6 cm., or its range extends from infinity to a point 6 cm. from the eye. Its amplitude or power expressed in diopters is obtained thus: 6 cm. divided into 100 = 16.6 diopters. In other words, a convex glass, 16.6" placed before the eye makes parallel the rays which diverge from the near point and substitutes the greatest contraction of the ciliary muscle. ACCOMMODATION. 33 RELATIVE ACCOMMODATION. Accommodation and convergence bear a constant relation to one another, within the limits of the amplitude of ac- commodation on the one hand and the amplitude of con- vergence on the other. Thus with the visual lines parallel, accommodation may be determined by placing before the eyes minus glasses of constantly increasing strength. The highest number that can be overcome, vision always f , is the measure of the accommodation exercised independently of convergence. Convergence, when accommodation re- mains unchanged, may be estimated by prisms. The strongest prism, angle in, through which binocular vision is maintained at 6 m., is the measure of the limit of the converging power, independent of accommodation. The strongest prism, angle out, through which single vision is maintained under the same conditions, is the measure of the limit of minus convergence. Tlie Metre Angle. For every distance nearer than 6 m., convergence bears a fixed relation to accommodation. Thus, by the exercise of I D. of accommodation in emme- tropia, the internal recti so direct the visual axes that they cross at I m. from the basal line uniting the two eyes, and form with the perpendicular to that line at its centre, an angle, called the metre angle. By the exercise of 2 D. of accommodation, the convergence will equal two metre angles, with 3 D. of accommodation it will equal three metre angles, and so on. Again, if the object is situated at i m., convergence will equal one metre angle, if at 50 cm., it will equal two metre angles, etc. 4 34 A MANUAL OF CLINICAL OPHTHALMOLOGY. TEST CARDS, TEST LENSES, ETC. The test letters commonly in use are so constructed that their vertical diameter shall be the sine of the angle of 5'. Suppose two lines are drawn, one from the top and the other from the bottom of such a letter, so that they meet in the lens of an eye. They are not mathematically parallel, but they are so nearly parallel that the angle of 5' which they form with each other, at their crossing point in the posterior part of the lens, is disregarded, and they are considered parallel. This angle is chosen, because it is the smallest which includes recognizable objects. But mathemati- cally parallel rays can come only from an object at an infinite distance. Hence we say that all objects included in the lines forming this angle are at an infinite distance. The farther removed from the eye the greater the size of such objects must be, although their images on the retina are of the same size. Thus, the card 50 BN = A 40 ER = 1 30 N C D = 20 P R F H i 15 LCBDT & 10 EPGBU a 5 TCNDEOF 1 The extremities of the vertical lines of B N measure the sine of the angle of 5' at 50 m. The normal eye sees B N at 50 m., but at no greater distance ; E R at 40 m., but at no greater distance ; TCNDEOF at 5 m., but at no greater distance. The acuity of vision is expressed by a fraction, the numerator of which is the distance of the TEST CARDS, TEST LENSES, ETC. 35 patient from the test-card, and the denominator the line he reads at that distance. Hence, normal acuity equals f, f , or i. A diminished acuity would be, for example, ^5-, -/$. If the acuity should be so low that B N cannot be seen at 5 m., we must bring the card closer to the patient or use larger letters. FIG. 15. TEST CASE. The metric system of numbering lenses according to their refracting power and not according to their focal length, as in the obsolete inch system, is now universally employed by properly equipped ophthalmic surgeons and opticians. A lens which will bend parallel rays of light to a focus at the distance of I m. is called " I Diopter," 36 A MANUAL OF CLINICAL OPHTHALMOLOGY. expressed I D. The word diopter, literally signifying the refractive media of the eye, is transferred to the glass. One-half diopter (.50 D.) will focus parallel rays at the dis- tance of 2 m., 2 D. at y 2 m., 3 D. at % m., 4 D. at ^ m., etc. The weakest lens ordinarily used is .25 D., 4 m. in focal length, and the strongest 20 D., 5 cm. in focal length. The refracting power of a minus lens, negative focal length, is the same as that of a plus lens of the same number. The cylinders are plus and minus, and are marked like sphericals, in strengths from .25 D. to 6 D. Higher strengths, which are seldom required, may be obtained by superimposed cylinders, whose sum is the refracting power desired. The frame for holding lenses before the patient's eyes, consists essentially of two circular lens-holders, marked in degrees from o to 180, held together by a nose-piece and a horizontal bar, along which they can be moved. FIELD OF VISION. When refraction and accommodation are normal and the media clear, subnormal vision is attributable to some lesion of the retina, choroid, optic nerve or cerebro-spinal system, and when this is the case, it becomes necessary to accurately measure the field of vision, the area over which objects can be seen while the eye remains fixed on a given point. The objects thus bounded by the ultimate range of peripheric vision without changing the direction of the visual line, mark the limits of the visual field, which may be contracted in various ways under pathological influences. The field may be concentrically smaller, it may be diminished or altogether lost on the nasal or temporal side horizontal hemianopsia ; FIELD OF VISION. 37 the superior or inferior fields may be similarly affected, vertical hemianopsia, or irregularly shaped defects may be found in its centre or elsewhere, scotomata. The sensibility of the retina rapidly diminishes from the fovea to the periphery, and it should be remembered that the bridge of the nose considerably limits the visual field in its inner half, and that the optic disc projects a blind spot of proportionate size to the temporal side of the fixa- tion point, but when the normal field is diminished in any particular section, there is lessened sensibility of the retina. The visual field may be approximately measured by direct- ing the patient to sit facing and about twelve inches away from a blackboard in the centre of which a small white cross is marked with a piece of chalk, and to look steadily at this cross with the eye under examination, the other eye being closed, while the examiner with a piece of chalk attached to a dark handle marks on the blackboard the points, in all meridians, at which it fades from peripheric vision. The point at which the patient first sees the chalk as it is moved toward the centre, or at which it disappears from view when moved from the centre, is marked on the blackboard, and is a measure of the visual field. The quantitative field of vision thus determined is not to be confounded with the central smaller area, or qualita- tive field, in which small objects, such as letters, are dis- cernible. The perimeter, a simple and comparatively inexpensive instrument, exactly defines the field of vision, and its employment has very generally superseded measurements by the earlier and clumsier methods. It consists essentially of an arc comprising a quadrant, or semicircle, marked in degrees, and adjustable at any angle, and an upright bar to 3 A MANUAL OF CLINICAL OPHTHALMOLOGY. which is attached a movable chin rest. On the arc, in the axis of the instrument, is a white mark or cross, thirty cm. from patient's eye, and a sliding clip containing white or colored test. The white test should be eleven mm., and the blue, red and green five mm. in diameter. The patient's ga/c is directed toward the cross while the clip is moved from MCHARDY'S PERIMETER. the centre toward the periphery. The point at which it disappears from the patient's vision is the limit of the perception of the retina in that direction. A chart is thus made and the visual field for white and colors measured in degrees. The limit of the normal field, subject to variations according to the conformation of the COLORS. 39 face, for white, blue, red and green, is illustrated in the following table : White. Blue. Red. Green. Externally, 7o-9o 65 60 40 Internally, 5O-6o 60 50 40 Upwards', 45-55 45 4O 3o-35 Downwards, 65-7o 60 50 35 (Landois and Stirling.) COLORS. Solar light, which is uniform and colorless, is transmitted through what we vaguely term the luminiferous ether in transverse waves of varying length, which, separated, give rise to certain visual impressions that are the source of all color sensations. The dispersion of a beam of light into its separate wave-lengths is effected by means of a prism, which disposes them, refracting each ray in proportion to the shortness of its wave, in a colored spectrum, or band, from which they can by reversion through a similar prism be reformed into a beam of colorless light. Without going into a discussion of the Young-Helmholtz, or Hering the- ories of color vision, which are elaborated in the larger text-books on Physiology, it may be stated that the so- called spectrum colors so shade off, one into the other, that their division by name is largely a matter of arbitrary ar- rangement. Red, blue, and yellow are regarded as primary colors, and form, by combination, secondary colors, that is to say, combinations of blue and red will give purple and violet ; yellow and red combined give orange; and blue and red combined make green. Our color sensations admit of certain other relations and combinations of colors, giving by association in one case, and disassociation in the other, respectively complementary, and contrast or confusion colors. COLOR SENSE is quickly and most accurately determined 4O A MANUAL OF CLINICAL OPHTHALMOLOGY. by the distinction and separation of various colors without designating them by name. For this purpose it is usual to employ Holmgren's worsteds, a set of skeins of wool made up of the primary, secondary, and confusion or mixed colors. Among them are three large skeins, a light green, a light purple, and a scarlet red. The patient is first asked to match the green, which the examiner does not desig- nate by name. If blind for green, he will confuse with it grays, browns, yellows and drabs. Or if blind for red, he will choose purple, blue and light shades of violet, FIG. 17. SPECTRUM OBTAINED BY MEANS OF A PRISM. red, gray and green. If the patient's color sense is nor- mal, there will be no confusion of the colors in separating the skeins. COLOR-BLINDNESS. The question of congenital achro- matopsia, or color-blindness, has acquired considerable im- portance of late years, or since the discovery of the fact that about i in 25 of the entire male population is partially affected by it. The proportion of color-blind is signifi- cantly small in women, being about I in 400. The defect usually is not suspected until its presence is revealed by COLORS. 41 examination. Railway men, sailors and soldiers are almost universally compelled to undergo an examination for color- blindness previous to employment Acquired achromatopsia is an occasional symptom of disease of the optic nerve, or of hysterical amblyopia, and is treated under these heads. PART II. PHYSIOLOGICAL OPTICS. Light proceeds from all luminous bodies through "the ether," a medium independent of the atmosphere, by un- dulations of inappreciable height. The principal source of light is the sun. We conceive that all visible objects con- sist on their surface of innumerable luminous points from which rays of light travel in all directions. It follows that some of the diverging rays from each luminous point must enter the pupil of the eye in straight parallel lines. Rays are assumed to be parallel, in physiological optics, that proceed from a small object removed 6 m. or more from the eye, and an object thus far removed, is said to be at an in- finite distance. Refection is the bending or turning back of a ray of light from a surface that neither absorbs, transmits, nor scatters it. Refraction is the deviation of light from a straight line in passing obliquely through transparent media of different densities. The index of refraction of a substance expresses in num- bers the relative power that medium possesses of bending oblique rays of light which pass through it, away from the direction pursued by them before entering it, or the ratio of the sine of the angle of incidence to the sine of the angle of refraction. The index of refraction of air is taken as I, that of water, as 1.336 (sin. : i. : sin. : r. : : 4 : 3); that of glass, as 1.535 (sin. : i. : sin. : r. : : 3:2). 42 PHYSIOLOGICAL OPTICS. 43 In passing from one medium to another of different density air to glass a ray of light, a a, entering the second medium perpendicular to its surface continues its course unchanged. (Fig. 18.) On the other hand, an oblique ray, b, passing from a lighter to a denser medium, ;//, is bent toward the perpendicular, and from a denser to a lighter medium away from the perpendicular, and if the two sides of the refracting medium are parallel, the emerging ray, b, pursues its course parallel to the incident ray, simply under- going parallel displacement. FIG. 1 8. REFRACTION BY MEDIUM WITH PARALLEL SIDES. The angle of incidence, x, equals the angle of emer- gence, y. The incident and emergent rays are not parallel, how- ever, when a ray of light traverses a medium with non- parallel surfaces, but are angularly displaced. In physio- logical optics we simply apply the law of angular deviation experienced by a ray of light in its course through a medium of non-parallel surfaces. This law is best studied in the action of a prism upon rays of light. Thus (Fig. 19), in the prism ;//, b is the incident, and b' 44 A MANUAL OF CLINICAL OPHTHALMOLOGY. the emergent, ray. It is thus shown that the rays of light are always bent toward the base of the prism, while the source of the rays is apparently displaced toward the apex, a. The angle formed by the meeting of the prolongation of the incident and emergent ray is the angle of deviation, and is about one-half the size of the apex angle. Prisms are numbered according to the number of degrees included in the apex. A new nomenclature by which they shall be numbered according to their refractive power, or size of angle of refraction, is under discussion. FIG. 19. REFRACTION BY A PRISM. The lenses used for the correction of spherical errors of refraction are of two kinds (Fig. 20), and may be practically considered as formed by two juxtaposed prisms which, joined by their bases, form convex, and, by their apices, concave lenses. Bearing in mind that in the case of a lens, as in a prism, the rays are always refracted toward its base (thickest portion), the subject is greatly simplified. It is obvious that rays of light are made to converge by the action of a convex, and to diverge by the action of a concave, lens. PHYSIOLOGICAL OPTICS. 45 The lenses commonly used in ophthalmic practice are made of flint glass or pebble rock crystal, and form either the segment of a sphere, spherical glasses, or the segment FIG. 20. of a cylinder, cylindrical glasses. Both influence alike the course of rays, but spherical glasses having a centre of cur- vature form images, while cylindrical glasses, having no FIG. 21. DIFFERENT FORMS OF SPHERICAL LENSES. curve parallel to their axes, focus all incident rays into a line parallel to the axis of the cylinder. Six modifications of spherical lenses are employed double convex, plano-convex, converging concavo-convex, 46 A MANUAL OF CLINICAL OPHTHALMOLOGY. Kir. 22. I I REFRACTION OF PARALLEL, DIVERGING AND CONVERGING RAYS HY CONVEX LENS. PHYSIOLOGICAL OPTICS. 47 or parabolic, double concave, plano-concave, and diverging concavo-concave. In Fig. 21 these lenses are shown in the order named, from left to right. The centre of the lens is called the optical centre, o, (Fig. 22, I). The principal axis, m m, is a line passing through the optical centre perpendicular to the surface, and is not refracted. All other rays are refracted, but those passing through the optical centre undergo but slight refraction, emerge in the same direction as they entered, and are called secondary axes, n n. Rays of light in passing through a convex lens parallel to its axis, a, II, converge to a point on its distal side, the principal focns, f. The distance from the centre of the lens to the principal focus is the focal distance of the lens, o f, and the degree of bending, or the refraction of the rays, as controlled by the index of refraction and the curve of the surfaces, is the refracting power. Converging incident rays also come to a focus, b, III, on the distal side at a point nearer to the lens than its principal focus, f, and diverg- ing incident rays focus to a point, 1, IV, which is farther removed than the principal focus, f. It follows that incident rays diverging from the principal focus emerge in parallel lines ; that incident rays diverging from a point nearer to the lens than its principal focus, diverge on emerging; and, lastly, that incident rays diverging from a point farther from the lens than its principal focus, converge on emerging. The nearer the principal focus the greater the refracting power of the lens. CONCAVE LENSES AND THEIR ACTION ON RAYS OF LIGHT. In passing through a concave lens, parallel rays a b, a' b' (Fig. 23), are rendered divergent, c d, c' d', as if proceed- ing from a point F on the line of the principal axis between and on the same side of the lens with the parallel incident 4 8 A MANUAL OF CLINICAL OPHTHALMOLOGY. rays (negative form). This point is the virtual focus, and its distance from the lens is the measure of its negative foe it I length. Rays diverging from the principal focus are ren- FIG. 23. dered still more divergent, and converging rays are ren- dered less converging. A cylinder (Fig. 24) having its curve in one direc- FIG. 24. tion only, must refract rays of light in one direction, namely, in its axis, or in the line passing through the summit of the curve in a convex, and the depth of the depression in a con- PHYSIOLOGICAL OPTICS. 49 cave, cylinder, at right angles to the curve. Let us imagine the cylinder is composed of an infinite number of curved lines in juxtaposition, each one being just wide enough to admit of a single beam of light. Each line will then focus each beam to a point, but the lines are in juxtaposition, hence the points of focus must also be in juxtaposition. Since a line is made up of points, the focus of a cylinder must be a line. The refracting power, focal distance, and other qualities of a cylinder, are spoken of in the same meaning as of a spherical lens, always bearing in mind the fact that it focuses in a line and not in a point. The minus cylinders have negative qualities, as the minus sphericals. Around the lens-holders in the test frame is a semicircle marked in degrees, and one end of the axis of the cylinder may be turned to any desirable degree. Hence we say, cyl. ax. 90, or ax. 180, or ax. zjj, etc. When adjusted to the patient's face, the left extreme end is arbitrarily chosen as o, the right or opposite end as 180, and between these extremes, the semicircular bar is marked at intervals of 5. The dioptric system, or the refracting media of the eye, which influences the course pursued by rays of light, is composed of structures which differ in density and in the curvature of their surfaces, but it suffices, practically, to average the refracting indices of the several factors, and to consider them as forming, in combination, a double convex lens. A double convex lens of this description is found by intersecting the cornea by an imaginary line continuous with the posterior surface of the lens. The focal length of the combined surfaces thus formed is 22.23 mni -, and the media have a common index of refraction of 1.33. Parallel rays impinging upon the cornea of a normal (emmetropic) eye, are brought to a focus upon the retina in the absence of accommodation. Under the same condi- 5n. The diagnosis may be partially made by the ophthalmo- scope, but it can only be completely and satisfactorily determined by retinoscopy, or by test lenses after the accommodation has been paralyzed by a mydriatic. Let us illustrate this by a case : A young man, clerk, age twenty, has suffered for several years from a nearly con- stant headache, which is aggravated by his long hours of office work. General treatment and hygiene have afforded no relief, and he has given up reading at night on account of consequent pain. V. = , made worse by plus, perhaps im- proved by weak minus lenses. Ophthalmoscope shows normal fundus. Headache relieved in three quarters of an hour after instillation of Duboisine, gr. ij-Sj, but V. de- clined to -j 6 ^. Ophthalmoscope gives + 2 D , Retinoscopy -|- 2, and -f 2 D =. Latent Hypermetropia = 2 D . By means of constant over-action of the ciliary muscle, the patient was enabled to increase the antero-posterior diameter of the lens two diopters. The symptoms of combined manifest and latent hyper- metropia, are defective vision, blurring of letters in reading, headache, and pain in eyes, aggravated by their use in near work. Case : V. fy, -f I s = $ . During paralysis of accom- modation, V. = ^, -f 3 8 = f . Order, -f 2.50" for constant use. In this case the manifest hypermetropia equals i", latent equals 2 D , and the sum of the two, or total hyper- metropia, = 3. It will be noticed that the full correction (total H.), after the paralysis of accommodation has passed away, will not give perfect vision, or -|, in a patient under forty years of age. The reason is obvious. The hypermetropia is concealed both from patient and physician by contraction MYOPIA. 57 of the ciliary muscle before instillation of the mydriatic, as well as after its effect has passed away. Hence addition of the glass correcting latent H, unless relaxation of the muscle takes place, must decrease acuity of vision by rendering the eye artificially myopic. Persistent wearing of the correct- ing glasses will eventually cause the latent H. to become manifest, and visual acuity in the distance will thus become normal. The range of accommodation in hypermetropia is ex- pressed by the equation a = p -j- r, a representing accom- modation, / the near point, and r the far point. To the FIG. 30. MYOPIC EYE. lens which equals in focal distance the near point must be added the lens which adapts the eye to parallel instead of converging rays. Thus, if / = 20 cm. (5), and + 2 is needed to correct total H., Ace. = 5 + 2 D = 7. MYOPIA. In emmetropia, it will be remembered, the antero-posterior diameter of the globe is of such length that parallel rays of light come to a focus upon the retina, and that in hyper- metropia this axis of the ball is shorter, and parallel rays tend to a focus behind the retina. In myopia, the antero- 6 58 A MANUAL OF CLINICAL OPHTHALMOLOGY. posterior diameter of the globe is longer than it is in emmetropia, and parallel rays are focused in front of the retina. In the myopic eye, therefore, as in the hyperme- tropic eye, the retina receives only circles of diffusion, vary- ing in extent with the degree of the myopia. The imme- diate cause of the longer axis of the myopic eye is found in the too great convexity of the cornea or lens, or both, or in the stretching of the sclerotic coat. Myopia is con- genital or acquired, and is usually progressive, that is to say, it has a tendency to increase. It is said to be low when the myopia is 3 or less ; moderate in the degrees between 3 and 6 D , and high in the degrees above 6 D . The far point of a myopic eye is the distal limit at which vision equals that of an emmetropic eye, and the near point \s, the approx- imate limit at which the retina is enabled to distinguish small objects (fine print). The former depends on the degree of the myopia, the latter on the power of accommodation. The distance between the far and near points, is the range of accommodation, and is expressed a = p r, because the lens which gives full acuity of V for distance must be subtracted from the lens whose focal length equals the dis- tance of the near point, since the exercise of accommodation can only begin at the far point, which necessarily lies within infinity. Thus,^ = 20 cm. (5), r = 50 cm. (2), a = 5 - 2 = 3. An example of each form of myopia may serve to fix the differences between them more firmly in the student's mind. Low myopia. Patient, age twenty, complains of inability to see distant objects clearly. No asthenopia. Has never worn glasses. V. in each eye = ^, 2 D in trial frame, gives . The far point is 50 cm. ; near point, 8 cm. Order full correction for distance. No glass for near is required ASTIGMATISM. 59 in the absence of astigmatism, or of heterophoria at the near point, for the patient reads at 33 cm. by the exercise of I D of accommodation and 3 meter angles of convergence, and no symptoms will arise from the use of the unaided eyes in near work, unless the relative accommodation is too much dis- turbed. Moderate Myopia. Patient, age twenty, complains of bad vision for distance, headache, pain in eyes, and blurred vision in near work, caused by the necessity of holding the work close to the eyes, which strains the convergence, and this strain quickly induces a divergence through failure of con- vergence. V., in each eye, ^ ; 6. D in trial frame gives ^. Far point, 16 cm.; near point, practically the same. The patient does not require, and, therefore, has never developed, accommodation. The correction ordered is, for far, 5-5O D ; for near, 3. This correction gives far point at 33 cm., at which distance the patient can comfortably read. For dis- tance, less than the full correction is given, to avoid dizzi- ness and other discomfort from apparent diminution in size of objects. High Myopia. Patient, age twenty, vision very bad for distance, and binocular vision for reading impossible. The myopia = 15. V., in each eye, = -^ ; 15 = ^-. Full acuity of vision cannot be obtained on account of organic changes in the interior of the eye and the apparent reduc- tion in the size of all objects seen through minus glasses. Order, 12 for far, and IO D for near. Accommodation is entirely absent. ASTIGMATISM. ASTIGMATISM is that condition of refraction in which the curve of the cornea or lens or both, is non-spherical, and parallel rays of light entering the pupil are not focused to 6o A MANUAL OF CLINICAL OPHTHALMOLOGY. a point, but in a line. Astigmatism of the cornea is either regular or irregular ; regular when the two principal meri- dians are at right angles to each other and have radii of different length, and irregular when the corneal curve, as a result of disease, is broken by a number of irregularly defined facets, each one of which has its own radius. Regular astigmatism is hypermetropic, myopic, compound hypermetropic, compound myopic, or mixed. In hypermetropic astigmatism one principal meridian is em- metropic and the other principal meridian at right angles to FIG. 31. ACTION OF AN ASTIGMATIC SURFACE ON A CONE OF LIGHT. (Frost.} a, t, c, rfis the astigmatic surface: diverging rays proceed from point_/^ and, passing through c ft, come to a focus at ./>, while those passing through a, b come to a focus at/2. 'I he outline of the cone of rays a f>, c d, and/I? varies, as shown in the figure. it is hypermetropic; in myopic astigmatism one meridian is emmetropic, and the meridian at right angles to it, myopic. Compound hypermetropic astigmatism is that condition in which both principal meridians are hypermetropic, one more than the other ; and in compound myopic astigmatism the two principal meridians are myopic, one more than the other. In mixed astigmatism one meridian is hyperme- tropic, and the other meridian at right angles to it, myopic. The symptoms of astigmatism are defective vision, in- ASTIGMATISM. 6 1 ability to use the eyes in prolonged near work, pain in the eyeballs, headache, and other reflex neuroses, more or less obscure and ill-defined, which distract the patient until the ametropia is relieved by the correcting lens. Diagnosis and Treatment. An astigmatic test-card,* con- sisting of exactly similar radiating stripes or lines (Fig. 32), is placed 6 m. from the patient, who is directed to look at them and tell which are the clearest and best seen. One or two of these radiating lines will appear to be brighter and more distinct than the rest. The patient is hypermetropic or myopic for the dull lines. The plus or minus cylinder required in astigmatism to supplement the defective refrac- tion of the hypermetropic meridian, or to diminish the myopic meridian, is placed before the eye with its axis parallel to the faintest lines. When the lines are by this method ren- dered equally clear, the astigmatism is corrected. In com- pound hypermetropic or compound myopic astigmatism, the apparent inequality of the lines may be first overcome by a cylinder, and the remaining hypermetropia or myopia cor- rected by a plus or minus spherical lens, or if the spherical defect is so marked as to prevent recognition of the differ- ences in the lines on the astigmatic test-card, a part or all of such defect may be corrected by a spherical lens, and a cylindrical lens used to correct the remaining astigmatism. In mixed astigmatism the lines will appear to be equally indistinct at 6 m., when the hypermetropic and the myopic meridians are defective to the same degree, but if the astig- matic card is brought nearer the patient, the lines in the myopic meridian will become more clear, and those in the hypermetropic meridian fainter. A minus cylinder will * The astigmatic card depicted in Fig. 32 was recently made, at our request, by Joseph A. Mullen, and may be obtained from J. L. Borsch & Co., 1324 Walnut Street, Philadelphia. 62 A MANUAL OF CLINICAL OPHTHALMOLOGY. correct the myopic, and a plus cylinder the hypermetropic, meridian. The two cylinders at right angles to each other FIG. 32. ASTIGMATIC CLOCK FOR TESTING ASTIGMATISM. are converted into a sphero-cylinder, which the patient is instructed to wear. For example, a patient sees horizontal ASTIGMATISM. 63 lines best at I m. i c ax. 180 gives normal vision for such lines, and -|- i c ax. 90 corrects vertical lines at 6 m. The formula is: i c ax. 180 O + i c ax. 90, or, and this is the better formula, I s o -f 2 C ax. 90. Following are illustrations of the other forms of astig- matism : Hypermetropic Astigmatism : V. = -f , accommodation paralyzed; horizontal lines seen best; -j- I s gives vertical lines best without increasing acuity of vision, and I s makes vision worse; -f i ax. 90 renders lines equally clear and distinct in all meridians and gives -f. Myopic Astigmatism : V. = f , vertical lines are seen best, -f- I s increases dimness of lines in all meridians. I s im- proves horizontal and dims vertical lines, i c ax. 180, brings out clearly the lines in defective meridians, and gives normal vision, . Compound Hypermetropic Astigmatism : V. = -fy, hori- zontal lines seen best but imperfectly, -f- I s improves lines in all meridians, + 2 s over-corrects lines on the horizontal axis + I s O -j- i ax. 90, gives the appearance of equal- ity to all lines, and vision is increased to -|. Compound Myopic Astigmatism : V. = -f% ; all lines in- distinct and acuity of vision too low to discriminate differ- ences in them ; 2 s improves all lines, and renders the vertical lines normal in outline and color; I 8 added brings out the horizontal, and dims the vertical lines. Hence a stronger minus glass is required for the horizontal than for the vertical meridian. The formula, 2 s o i c ax. 1 80 makes all lines appear equal, and gives |-. Irregular Astigmatism cannot be corrected, but an exam- ination of the refraction will not infrequently reveal an underlying spherical or astigmatic defect, the correction of which will greatly improve vision. 6 4 A MANUAL OF CLINICAL OPHTHALMOLOGY. EXAMINATION BY THE OPHTHALMOSCOPE. The refraction ophthalmoscope (Fig. 33) consists of a rect- angular or round concave mirror perforated in its centre by a circular opening 4 mm. in diameter. Immediately back of the mirror is one or more metal discs in which is placed a number of lenses, plus I D to 20 and minus I D to 2O D , somewhat larger than the opening in the mirror, FIG. 33. MORTON'S OPHTHALMOSCOPE. any one of which is made by a simple mechanical device to rotate in position behind the opening. In the direct examination by the ophthalmoscope, the patient is placed about 50 cm. from, and with his back to, the light, which should be drawn to the side of, and on a level with, the eye under observation. To examine the right eye, the observer holds the ophthalmoscope in his EXAMINATION BY THE OPHTHALMOSCOPE. 65 right hand and in front of his right eye. Looking through the opening in the mirror at some little distance from the patient, whose eye is illuminated by reflection of light from the mirror, the observer sees a red reflex through the pupil, the reflection from the choroid of the light thrown by the mirror into the patient's eye. The outlines THE ENTRANCE OF THE OPTIC NERVE WITH THE ADJACENT PARTS OF THE FUNDUS OF THE NORMAL EYE. A. Physiological excavation, b, Choroidal ring. c. Arteries, d. Veins, g. Division of the central artery. A. Division of the central vein. L. Lamina cribrosa. t. Tem- poral (outer) side. . Nasal (inner) side. of the majority of the choroidal vessels are concealed by the pigment coat of the retina, and only a glare is seen. Approaching the eye as closely as possible, without chang- ing the refraction of the ophthalmoscope, the vessels of the retina are displayed, leading to and from the optic disc or 66 A MANUAL OF CLINICAL OPHTHALMOLOGY. papilla (Fig. 34), which appears as a pinkish-white round or oval disc, slightly excavated in its centre. Only a small portion of the fundus can be seen at once, but to the ob- server, standing in close proximity to the patient, the field covered is apparently large, the details being magnified about fourfold. The principal points to be observed and noted, are the condition of the media, shape of disc, the distinctness of its marginal outlines, character and de- gree of excavation, pulsation of veins or arteries, presence or absence of pigment spots, calibre of vessels, and dis- turbances in their coats. The fovea is removed about four times the apparent diameter of the disc to the temporal side of the nerve, and appears as a rounded red spot with a bright, glistening centre, round or oval, and inclined to modify its shape according to the amount, intensity, and direction of the light thrown upon it. The fovea is free from visible blood-vessels. Each part of the fundus should be observed in turn : first, the nerve and adjacent parts, then the fovea, and finally the different quadrants or sections of the fundus. This is readily accomplished by having the patient rotate the eye in different directions. It is good practice in all ophthalmoscopic observations, to examine first the cornea, using + 6 D in ophth. for this purpose, secondly, the pupil and lens with -f- 5 and the anterior and pos- terior portions of the vitreous with -f- 3 s , before proceed- ing to the details of the fundus. By the indirect method the light is thrown by the mirror through a lens of 13 into the patient's eye. The light, returning through the lens, is focused at approximately its focal distance. Before the opening in the mirror is -|- 4 D , to enlarge the aerial image and to replace the observer's strain of accommodation. This method is EXAMINATION BY THE OPHTHALMOSCOPE. 67 especially useful in determining the condition of the choroid and retina in high myopia and in opacities of the media. To determine refraction by the ophthalmoscope by the direct method, theoretically, the observer's eye should be emmetropic and at rest, and the accommodation of the eye examined in abeyance. The mirror with the observing eye immediately back of it, is held within half an inch of the eye observed. The media are clear. If observed and observing eyes are emmetropic, rays passing from each point of the fundus of the former become parallel as they emerge out of the cornea, and, entering the cornea of the latter parallel, are focused upon the observer's retina. If the patient is hypermetropic, ob- server emmetropic, the rays emerging from his cornea are divergent, details indistinct, and a plus glass will be re- quired to so bend the rays that they enter observer's eye parallel, and this is done by rotating the metal disc in the ophthalmoscope until the glass required to clear the picture comes in position behind the mirror. If the patient is myopic, observer emmetropic, the rays emerging out of his cornea are convergent, and a minus glass will be required to render them parallel as they enter the observer's eye. In both instances the observer is aware, by the dim images of the small vessels near the fovea, where only an accurate determination may be made, that the rays from this region are not entering his eye parallel, but from this knowledge alone he cannot tell whether they are converging or diverging. He revolves the disc until he finds a glass which defines the image, and that glass is the measure of the ametropia of the observed eye. In simple astigmatism the vessels in one meridian will be seen more clearly defined than those of the opposite 68 A MANUAL OF CLINICAL OPHTHALMOLOGY. meridian, and the spherical lens, plus or minus, which makes those vessels clear and blurs the opposite ones, will designate the degree, kind and axis of the astigmatism. In compound astigmatism, vessels in all meridians arc indis- tinct, some more than others. The glass, plus or minus, which makes each set of vessels in turn clear and distinct, will be the kind and degree of ametropia for these meri- dians. The disc is usually oblong, its long diameter corresponding with the axis of the astigmatism. Diagnosis of Hypermetropia by the Ophthalmoscope. The retinal vessels are seen at several inches from the observed eye, and apparently move in the same direction as the mirror. More details are evident on closer approximation of the oph- thalmoscope. The nerve and vessels are distinctly seen without a lens, but they can also be seen tJirough a conrc.v glass.. The first, by overcoming the divergence of rays emerging from observed eye by contraction of the ciliary muscle in observing eye, and the latter, by relaxation of the contraction, and substitution of a convex glass for it. The disc is apparently smaller than in emmetropia or myopia. The Diagnosis of Myopia by the Ophthalmoscope. The disc is large, but ill defined, and can be distinctly seen only through a minus glass and on close approximation. In high de- grees of myopia, 8 D or more, an aerial inverted image of a small part of the fundus may be seen at a distance of five inches or less. The image is inverted, and vessels, there- fore, move in an opposite direction to that of the mirror. An accurate estimation of the degree of the ametropia is rarely attained, but an approximate estimate is always made by the experienced ophthalmoscopist. FIG. 35. ILLUSTRATION OF RETINOSCOPY BY THE PLANE MIRROR. 1. L. Source of illumination. M. Mirror. /. Inverted image of L on retina. /. Apparent source of illumination. If the mirror be rotated to M': I' New position of L on retina. /'. New apparent position of L. Hence the shadow has moved with mirror. 2. Myopic eye, producing an inverted aerial image, since the rays coming out from the eye cross between the cornea and mirror. 69 7O A MANUAL OF CLINICAL OPHTHALMOLOGY. RETINOSCOPY BY THE PLANE MIRROR. The observer stands I m. in front of the patient, behind and slightly above whose head a small, bright light is placed. The mirror reflects parallel rays of light into patient's eye, and the rays return out of it parallel (emmetropia), diverging (hypermetropia), or converging (myopia). In an cmmctropic eye, the image of the flame on patient's retina moves with the movement of the mirror in all meridians. If -f 3" is placed in spectacle frame before the patient's eye, the rays emerging out of which are parallel, they will be brought to a point at the focal distance of the lens, 33 cm., the /#/>// of reversal, as it is called. The point of reversal is determined by the ob- server, who gradually approaches the patient, rotating the mirror until he notices that the light or shadow in the patient's eye ceases to move against it. No movement of the light is noticed exactly at the point of reversal, but nearer the patient's face, or within the focal distance of the lens, the light will move in the same direction as the move- ment of the mirron All meridians of the cornea must be examined, and in each axis the point of reversal will be found at 33 cm. from the patient's eye. In hypermetropia t the shadow moves with the mirror. Use -f 3 lens as in the previous case. If the point of reversal is I m. from the patient's eye, there must be 2 D of hyperme- tropia. The -j- 3" corrects all the hypermetropia and pro- duces i of artificial myopia, the far point of which is I m. (The rays enter the lens diverging from the patient's eye, are brought to a focus at I m., hence the -f 3" over-corrects the defect by i n .) If no point of reversal can be determined by -f 3" at I m., the hypermetropia exceeds 2", and a stronger lens will be required. Suppose we place -f 5 in spectacle RETINOSCOPY BY THE PLANE MIRROR. /I frame, and find that the point of reversal is at 50 cm., which is the far point of 2 D of myopia, the hypermetropia will, in this case, equal 3", the + 5" having over-corrected the defect by 2 D . In myopia, the shadow moves in the opposite direction to the movements of the mirror. No lens is necessary unless the defect is less than I D . The point of reversal will be found at the far point of the eye, and the distance between this point and the eye equals the refracting power of the excess of curvature in the eye. Thus, if the far point is 40 cm., the myopia equals 2.50; if at 33 cm., the myopia equals 3", or, if at 25 cm., the myopia equals 4". If the far point cannot be found at 25 cm., or farther, and if the shadows continue to move opposite to the mirror at 25 cm., myopia of more than 4 is assured. Closer than this, an inaccurate estimate of the point of reversal, when the shadows cease to move against, and begin to move with the mirror, causes a considerable error in the result, and to avoid error it is best, under these conditions, to disperse the rays by placing a minus glass in spectacle frame. The lens used for this purpose must be added to the myopia determined by its use. For example, if, with 3 held in trial frames the point of reversal is found to be at 50 cm., the myopia = 5. HYPERMETROPIC AND MYOPIC ASTIGMATISM are de- termined by the method employed in spherical defects, and are not more difficult. The point of reversal is found to be at different distances for the two principal meridians. For example, with -f- 3 point of reversal for horizonal meridian is at I m., and for vertical meridian 33 cm., the hypermetropic astigmatism is equal to 2 D ax. 90. Or suppose with -f- 5 D the point of reversal for horizontal meridian is at 50 cm., H = 3" ax. 90, and at 33 cm., for vertical meridian H = 2 D ax. 180, it must be evident that 72 A MANUAL OF CLINICAL OPHTHALMOLOGY. there is compound hypermetropic astigmatism, equal to + 2* o -f- i c ax. 90. If without a lens, the point of reversal for vertical meridian is at 33 cm., the myopia will equal 3" for that meridian. With -f I the point of reversal for horizontal meridian is at I m. ; that meridian is emmetropic. Glasses for this case should be, 3 ax. 180. Again, suppose that without a glass point of reversal for axis 45 (meridian opposite) = 50 cm. (myopia = 2 D ax. 45), with -\- 4 D in spectacle frames for axis 135 (meridian opposite) = 50 cm. (hypermetropia 2" ax. 135), the cor- rection will be, -- 2 s O -f- 4 C ax. 135. In conducting examinations by retinoscopy the patient's pupil should be dilated. This method of determining the refraction is accurate, rapid, scientific, and especially valuable in children and illiterate persons, and in the diagnosis of irregular cornea without opacities. PRESBYOPIA. PRESBYOPIA (P) is a failure of accommodation due to senile changes, and is manifested by a recedence of the near point. It is not a disease, it is not an error of refraction, but a loss of elasticity of the crystalline lens, or of power in the ciliary muscle, or the two combined. Greater stress should be laid on the former. Presbyopia in emmctropia, begins to manifest itself at or about the age of 45 years, the subject noticing that small objects, print, cannot be comfortably or distinctly seen for any length of time at the usual reading distance, 35 cm., and is obliged to hold the book, paper, or sewing farther from the eye than formerly. Continuous reading induces blurring, pain, headache, lacrymation, etc. A glass which will bring the near point closer to the eye, and thus diminish PRESBYOPIA. 73 the effort to focus small objects at 35 cm., in which there is an obligation to call too much on the reserve accommoda- tion, is required. About the age of 45 years, the near point = 20 cm., the reading distance 33 cm., and the reserve accommodation = 2 D . At this age, therefore, an emme- tropic person must exercise in near work all but 2 D of accommodation. With -f- I D , the near point is brought back to 16 cm., and he thus has for 33 cm., 3 of accommo- dation in reserve. At 50 years the near point has receded to 25 cm., and the total accommodation equals 4, and -f 2 D brings near point to 16 cm. and patient reads comfortably at 33 cm. with 3 of accommodation in reserve. At a more advanced age, accommodation has entirely failed and must be substituted by a plus glass which has a focus at a con- venient distance for close work. Patients differ in showing signs of advancing age, and no law governing increase of glass can be laid down as unalterable, but the above changes represent the average of cases, and must be modi- fied to meet individual necessities. Presbyopia in hypcrmetropia and in compound Jiypcrme- tropic astigmatism. The convex lens necessary to restore the receded near point, must be determined exactly as in emmetropia, and added to the correction of existing hyper- metropia or compound hypermetropic astigmatism. For example, -f- 2 D = -| in a patient, age 50, near point (with + 2" ) = 25 cm. By adding -f i.5O D , the near point = 1 8 cm.; -f 2 D is ordered for distance, and -f 3-5 for near. Another case : Patient, age 45, -f- 1 s o + 2 ax. 90 = f-, which is ordered for distance, and -f- 2 o + 2 C ax. 90 for near. Presbyopia in Myopia, and Compound Myopic Astigmatism. The presbyopic correction in higher grades of myopia must be made at a much earlier age than in emmetropia or 7 74 A MANUAL OF CLINICAL OPHTHALMOLOGY. hypermetropia, on account of the natural feebleness from non-development of the ciliary muscle. Example: 2 D = . No glass will be required for near work until patient has reached forty-five to fifty years, because he has used but I D of accommodation for reading at 33 cm. After that age plus glasses must be added, accommodation having FIG. 36. A. 15 14 13 12 11 10 9 87654 3 2 IDoolD !i 3 * E. .M5 Acc=i2o. ; _l I I I I ! i M.'iD. 1 r Acc?120. H.3Q.aetJ5. Acc=12D. rr - H- E.aeUO AccT4-5D. E. eet.50. Acc=2-5D. M.3D.at.50. .Acc=2-5D. H.3D.ath.4Q Acc?4-5D. H.3D.aet50 Acc?2-5D. DIAGRAMS OF RANGE OF ACCOMMODATION IN E., H. AND M. A. Patient aged 15. B. From 40 to 50 years. commenced to fail. At sixty, 2 for far, and + 1-50" for near vision. Patient, age forty-five, requiring 8 O 2 C ax. 1 80 for distance, will wear 5 o 2 r ax. 180 for near. Take, as an example, next, simple myopic astig- matism : 2 C ax. 135 = f, in a patient forty-five years old, MYDRIATICS. 75 the presbyopia correction is -J- I o 2 C ax. 135. At the age of fifty, the correction would be -f 2 O 2. c ax. 135 (= + 2 c ax. 45 ). Presbyopia in mixed astigmatism : age forty-five, I o -f- 3 ax. 90 = f. Add -\- I- f r near, which would give as the presbyopic correction + 3 ax. 90 (+ I added to i = o) ; at fifty, add + 2 D for near, which would equal -f i o -\~ 3 ax. 90. In all cases of presbyopia the weakest glass which will serve all the purposes demanded should be ordered, for it must be remembered that the ciliary muscle and internal rectus are supplied by the same nerve, and that a strong glass enforces excessive convergence. MYDRIATICS. In estimating total hypermetropia or hypermetropic astigmatism, and especially those of minor degree, it will be necessary to paralyze the accommodation in most persons under forty years of age. After that age the accom- modation is so limited that it may be dispensed with as an important factor in the correction of ametropia. Contra- indication to the use of a mydriatic in a patient more than forty years of age, is based on the fact that its employment may precipitate an attack of acute glaucoma in an eye pre- disposed to that disease. In persons less than forty years old, this disease is rarely encountered. Moreover, after that time of life the accommodation has become relaxed to such an extent that paralysis is not only unnecessary but a positive hindrance, since it is desirable in most cases of this nature to estimate the range of accommodation and pre- scribe glasses for near work, and this cannot be accurately done during paralysis. 76 A MANUAL OF CLINICAL OPHTHALMOLOGY. In low degrees of myopia and myopic astigmatism in young persons, abolition of the accommodation is necessary, because contraction of the ciliary muscle increases the defect, and a glass ordered without mydriasis would over- correct the error. Spasm of Accommodation, which is frequently present in low degrees of hypermetropia or hypermetropic astig- matism, simulating myopia, cannot be corrected without mydriasis. The patient should be informed that vision will be temporarily disturbed by the mydriatic, and that near work will not be possible during the continuance of its action. The patient should also be told of the possible constitutional effects, such as flushing of the face, dry throat, dizziness, drowsiness, and, in rare instances, active delirium. Mydriatics are sometimes very useful in discriminating nervous symptoms due to eye strain, headache, chorea, and other reflex disturbances of function, from those due to other causes. During paralysis of accommodation, should they be due to overaction of the ciliary, or extrinsic ocular muscles, they will be modified or entirely subdued, to re- turn when the mydriasis has passed away. When the symptoms are due to organic lesions, or disease of other organs, they are not affected by paralysis of accommoda- tion. Atropine sulphate (gr. iv-5j), duboisine sulphate (gr. ij 5j), hyoscyamine sulphate (gr. ij-Sj), and hydrobro- mate of homatropine (gr. viij-5j), are the mydriatics employed for the purposes thus indicated, as well as in certain inflammatory conditions of the eye to secure rest of the organ, and to prevent adhesions between the iris and lens capsule, or between the iris and cornea. For determining refraction, duboisine is to be preferred to MYDRIATICS. 77 other members of the group. It acts more rapidly, and the effects pass away sooner, than atropine ; and as compared with hyoscyamine and homatropine, the mydriasis is more complete, when induced by one or two instillations of the drug. Atropine is indicated in disease. To dilate the pupil for the purpose of examining the eye ground homatropine is probably the best agent, its action being rapid and transient. The hydrobromate of cocaine (4 per cent, sol.) dilates the pupil and partly paralyzes the accommodation, and should, therefore, be classed among the mydriatics. It is, however, useless as a mydriatic, because it destroys the epithelium of the cornea and clouds its transparency. In ophthalmic practice it is only used to induce local anaes- thesia, or as an adjunct to other mydriatics to secure the widest possible dilatation of the pupil. PART IV. THE OCULAR MUSCLES. The action of the muscles upon the eyeball should be considered, first, in respect of the change of position of the cornea ; and, secondly, of the change of position of the vertical meridian of the cornea. The external rectus rolls the cornea outward, the inter- nal rectus inward, the superior rectus upward and inward, the upper end of the meridian turning inward, and the inferior rectus rolls the cornea downward and in- ward, turning the upper end of the meridian outward. The superior oblique muscle rolls the cornea downward and outward, turning the upper end of the meridian inward, and the inferior oblique rolls it upward and outward, rota- ting the upper end of the meridian outward. The globe is rolled outward by the combined action of the external rectus and the two oblique muscles ; inward by the internal, superior, and inferior recti ; ufnvard by the superior rectus and inferior oblique, and dim' meant by the inferior rectus and superior oblique. (Fig. 37). The muscular apparatus of the two eyes are in intimate asso- ciation, have a concerted action, and are stimulated by a common nervous impulse. PARALYSIS. In paralysis of an ocular muscle, the symptoms are marked and significant. There is double vision (diplopia) with limited movement of affected eye on the side and in the 78 PARALYSIS. 79 direction of the paralyzed muscle, and secondary squint, or corresponding deviation of the sound eye, when fixing with the affected eye. The head is disposed toward the paralyzed side, and the eye has a tendency to close. Dizziness, con- fusion, and incorrect estimation of position and of space, FIG. 37. SCHEME OF THE ACTION OF THE OCULAR MUSCLES. Q E. Direction of traction of ext. rect. Qi, I. Of int. reel. Si. Of sup. and inf. recti. ab. Of inf. oblique, c d. Of sup. oblique. O. Point of rotation. Q Qj. Transverse axis. are occasional symptoms. The two images of a single object seen in the median line are more widely separated when the object is moved in the direction of the action of the paralyzed muscle. The true image is seen by the sound, 8o A MANUAL OF CLINICAL OPHTHALMOLOGY. and the false image by the affected, eye. To determine the eye and muscle affected, the position of the images and the changing relation between them, induced by the move- ment of head and object looked at, must be studied. It may be stated in general terms that, first, the image is false, and belongs to the affected eye, which, in the region of FIG. 38. diplopia, moves faster than the moving object; second, that in pathological convergence homonymous (image on same side as the eye), and in pathological divergence, hctcr- onymous (image on side opposite to eye), diplopia is found ; and, third, the false image stands in such relation to the affected eye as the paralyzed muscle normally functionates. PARALYSIS. 8l In paralysis of the external reclu s (Fig. 38) the diplopia is homonymous (not crossed), and the images are not tilted at either end. In paralysis of the internal rectus (Fig. 39) the diplopia is, conversely, heteronymous (crossed), and the false image is not tilted at either extremity. The diplopia is crossed opposite the affected muscle in paralysis of the FIG. 39. ob. Object. Fob. Apparent position of object seen by right eye. superior rectus, and the upper end of the false image is tilted slightly inward. The diplopia is also crossed in paralysis of the inferior rectus, the upper end of the false image tilting slightly outward. There is homonymous diplopia in paralysis of the superior and inferior oblique ; 82 A MANUAL OF CLINICAL OPHTHALMOLOGY. in the former case the upper end of the false image is* tilted inward, and in the latter outward. The position of the images is modified when more than one muscle is paralyzed, and the diagnosis is, under these conditions, not infrequently obscure. OPHTHALMOPLEGIA is the name given to designate paraly- sis of all the muscles of the eye. Ophthalmoplegia externa is an occasional symptom of locomotor ataxia. Ophthal- moplegia interna is very rare, but paralysis of accommo- dation, or partial Ophthalmoplegia interna, is a common sequence of diphtheria. The affection may be caused by syphilis, rheumatism, traumatism, tumors, hydrocephalus, diphtheria, meningitis, spinal affections, and by basal, cortical, or nuclear disease. Prognosis is good in syphilis, rheumatism, and diph- theria, and grave in organic disease of the brain, nerve, or spinal cord. Treatment is medical or electrical, and is primarily ad- dressed to the cause of paralysis. Operative interference is not warranted. NYSTAGMUS is an involuntary oscillation of the eyeball, due to the instantaneous contraction and relaxation of one or more muscles from defective co-ordination. It is con- genital in microphthalmus, coloboma, certain forms of congenital cataract, albinos, and in Friederich's disease. It is present, sometimes, in lesions of transparency due to ophthalmia neonatorum, and in retinitis pigmentosa. Miners who are compelled to work for long periods of time in strained positions, and in darkness, frequently develop the disease. Internal squint is a frequent compli- cation of nystagmus. The prognosis is never encouraging under the most favorable circumstances, but the vision, which is usually FUNCTIONAL MUSCULAR AFFECTIONS. 83 defective, may be improved by glasses, the squint cured by operation, and some relief from the more distressing symp- toms obtained by these means in cases of recent duration. No further relief has been hitherto accomplished. FUNCTIONAL MUSCULAR AFFECTIONS. In muscular anomalies of a functional character, there is a deviation, or a tendency to deviation, of the eyes from equilibrium. Accepting Stephens' nomenclature, which is accurately descriptive and scientific, the different muscular anomalies are defined as follows : Ortliophoria, perfect binocular equi- librium ; Heterophoria, imperfect binocular equilibrium ; Hyperplioria, a tendency of one eye to deviate upward ; Esophoria, a tendency to deviate inward ; Exophoria, a tendency to deviate outward ; Hyperesophoria, a tendency to deviate upward and inward of one eye, or downward and inward of the other ; Hyperexophoria, a tendency to deviate upward and outward of one, or downward and outward of the other, eye. It must be borne in mind that functional deviations in- volve both eyes. One eye alone cannot be at fault in con- vergence. In hyperphoria, one eye may have a tendency upward, or the other eye downward, and these relations may be interchangeable. The term, therefore, does not indicate where the fault lies. For instance, right hyper- phoria means that the superior rectus of the right eye is too strong for the inferior rectus of the same eye, or that the inferior rectus of the left eye is too strong for its superior rectus. Right hyperphoria means, then, that the right eye has a tendency to turn higher than the left. Orthotropia is a term used to express perfect binocular 84 A MANUAL OF CLINICAL OPHTHALMOLOGY. fixation ; lleterotropia, a turning from parallelism ; Esotropiin, a turning inward, convergent squint; Exotropia t a turn- ing outward, divergent squint; Hypertropia, a turning upward ; Hyperesotropia, a turning of one eye upward and inward, and Hyperexotropia, a turning of one eye upward and outward. The strength of an ocular muscle is measured by its ability to overcome prisms, while both eyes are fixed on a small light at 6 m. The external recti, abduction, overcome in the average 8, and the internal recti, adduction, 30. The superior rectus of one and the inferior rectus of the other eye (sursumduction) overcome, on the average, 3. This power to overcome prisms may be greatly increased by exercise. The procedure is not difficult. Place a small light 6 m. away and instruct the patient to look steadily at the flame with both eyes. To measure the strength of the internal recti, adduction, place a prism of 10 with the angle /;/ before the right eye. The image of the flame is thrown to the right of the fovea, and double images are momentarily seen until the internal rectus contracts, and thus rotates the eye inward till the fovea reaches the site of the image and there is fusion of the images. Another prism of 10 introduced before the left eye, angle in, throws the image to the left of the fovea; the internal rectus contracts to the same extent, and again single images are seen. This pro- cedure is carried on until the internal recti can no longer fuse the images. The highest prism through which single images can be seen is the measure of adduction. While overcoming prisms of increasing strength, the eyes are seen to become more and more turned inward. To measure the strength of the external recti, abduction, prisms of increasing strength with their angles outward, are placed FUNCTIONAL MUSCULAR AFFECTIONS. 85 before the eyes, until about 7 are used. In order to over- come the double images one eye is deflected strongly ont- iunrd, that is to say, the external rectus of that eye is contracted. The angle of the prism is placed in the direction of the action of the muscle to be tested. In low degrees of heterophoria, the diagnosis depends on the induction of artificial diplopia, and on establishing the relation to each other of the two images thus induced at infinity, and at the reading distance. In testing for hy- perphoria, lateral diplopia must be produced by a prism strong enough to overcome either the external or internal rectus. As the external recti at 6 m. are the weaker mus- cles, a prism of 4, held horizontally a few inches in front of each eye, with its angle outward, may be used. In orthophoria, the images of the candle flame at 6 m. will be side by side in the horizontal plane. In hyperphoria the images will be lateral, but one higher than the other. For example, in left hyperphoria, the left eye is released by the prism of 8, which the external recti cannot over- come, from the necessity of maintaining binocular vision, and, yielding to its abnormal disposition to deflect from parallelism, turns upward. Hence its image will be lower than the image of the right eye. The prism required to restore it to the plane of the image of the right eye, with its angle upward, will be the angular measurement of its displacement, and the left hyperphoria will equal that num- ber in prismatic degrees. In testing equilibrium of the lateral muscles a prism, strong enough to overcome the action of the superior or inferior rectus, will give vertical diplopia. If the lateral muscles are in equilibrium, the images will be in a vertical plane. In esophoria, the candle flame at 6 m., seen by the 86 A MANUAL OF CLINICAL OPHTHALMOLOGY. right eye, will be to the right of the vertical plane passing through the image seen by the left eye, homonymous diplopia ; and in exophoria the image seen by the right eye will be to the left, crossed diplopia, and the prism, base out in esophoria and base in in exophoria, which restores the image seen by the right, into the vertical plane of the left, will be the angular measurement of the deviation. For the reading distance, 35 cm., the tests are conducted in precisely the same way, but the object for fixation should be the size of letters ordinarily read at that distance. Esophoria is usually greatest in the distance, and exo- phoria at the near point.* Hyperphoria is the same at all distances. In many cases of heterophoria it cannot be de- termined which eye is at fault. We are sometimes aided in diagnosis by information supplied by the patient as to which image, during artificial diplopia, wanders from equilibrium, which seems to the patient to be the true and which the false, and by the condition of the refraction. If a refraction error exists, and is greater in one eye than in the other, or if the acuity of vision differs in the two eyes, the affected muscle may be ascribed to the weaker eye. As has just been intimated, heterophoria is influenced by refraction. Hypermetropia and hypermetropic astig- matism cause esophoria in a very considerable proportion of cases, and are found associated with it. Although exo- phoria cannot be said to depend on refraction error, it is frequently associated with myopia and myopic astigmatism. Hyperphoria seems to be largely independent of ametropia. The local symptoms are those of accommodative strain, and are of little value in the diagnosis. The reflex symp- toms are at times severe headache, nausea and vomiting, * In testing muscles, ametropic and presbyopic corrections should be worn. FUNCTIONAL MUSCULAR AFFECTIONS. 8/ indigestion, choreic movements, and the various vague and misleading phenomena of nervous prostration. On the other hand, they may be slight or altogether wanting. The diagnosis of heterophoria is not difficult, although its detection may require patient and skillful manipula- tion. Double vision may never have been noticed by the patient, but can be often produced by covering one eye with a red glass while the patient looks at a small flame at 6 m. With a little perseverance, the patient will acknowledge seeing the two lights, one natural in color the other red, and by the relations they bear to one another, the kind and degree of heterophoria may be determined. And this is true whether the squint is high -or low. Even in cases of long-continued internal or external strabismus, where the patient has ceased to have double images by the unconscious suppression of one, its existence may be thus recognized ; and when the patient is convinced that he really sees two lights, the diagnosis is simple. In treat- ment it is important that the patient shall acknowledge the two lights, for the surgeon is guided during his operation by the new position of the images. Maddox has suggested the use of a glass rod, instead of prisms, in the determination of heterophoria. A glass rod is a strong cylinder which distorts the natural flame into a long streak of light. The difference between the image seen by the eye before which the glass rod .is placed and that seen by the other eye, is so marked that binocular fixation is not possible in the absence of muscular equilibrium. If, for instance, the rod is placed before the right eye in an exactly vertical position, the streak of light will be horizontal, and in orthophoria the light will be seen directly in the centre of the streak. In hyperphoria the light will be above or below the streak. In esophoria it will be to the left, and in exophoria to the right of the 88 A MANUAL OF CLINICAL OPHTHALMOLOGY. streak. The light will be restored to its proper position in heterophoria by a prism of necessary degree with its angle in the direction indicated by the existing conditions ; or in testing for esophoria or exophoria, the rod may be held horizontally, and the streak of light thus rendered vertical. It will then be necessary for the patient to determine whether the streak is to the right or left of the light.* Treatment. In every instance, the refraction should be examined, and ametropia corrected. This procedure alone will in some cases, and particularly in esophoria, be found sufficient to modify the defect or even restore the muscles to a condition of equilibrium. No arbitrary rules can be laid down for the treatment of the muscular anomaly itself. It is a functional affection, subject to variations in the degree of the defect, as well as in the severity of its symp- toms. In general, experience teaches that (i) prisms should be tried ; (2) that the degree to be worn shall approach as nearly as practicable the total degree of insuf- ficiency ; (3) that they should be constantly worn, excepting in exophoria for near, where there is orthophoria for dis- tance ; (4) that prisms should be worn long enough to allow the muscles time to spontaneously regain their equi- librium ; (5) that prisms may develop latent heterophoria. If the correction of the ametropia and the wearing of prisms prove ineffectual, tenotomy must be performed. HETEROTROPIA. STRABISMUS or SQUINT. Heterotropia is a deviation of the visual axis of one eye from that of the other in the act of vision, the result of muscular overaction, or of muscular * It is essential in the diagnosis of muscular anomalies, that the patient's head shall be held erect, inclining to neither side. HETEROTROPIA. 89 weakness. Ordinarily, the squint is of such degree that simple inspection is sufficient to designate the eye affected. When the patient fixes an object indifferently with either eye, the squint is alternating. If the same eye always deviates, the strabismus is mono-lateral, or constant. To determine the character of the deviation more accurately, the patient is directed to look at a small flame at 6 m. with each eye alternately, the other being covered with a card, and if no deviation of the eye behind the card is present there is binocular vision for that distance. The light is now brought within 50 cm. of the eye and the preceding test repeated. If again there is no deviation, the squint is only apparent, and due to a large angle a in hypermetropia, or to a small angle a in myopia. If one eye suddenly deviates, the condition is termed concom- itant strabismus. If the sound eye turns from fixation, when covered, the movement is termed secondary deviation. In differentiating paralysis of an ocular muscle from func- tional squint, the action of the muscle in the former is inter- mittent and limited, and the secondary is always greater than the primary squint. The image of the squinting eye is after a time unconsciously suppressed, and the most scientific method of determining the character and degree of the de- viation, is to compel recognition of the double images which are invariably present. To accomplish this end, repeated examinations with colored glasses adjusted before the eyes, and the exercise of a considerable amount of patient manipu- lation, are necessary. A deep-blue or red glass, held before the fixing eye, so subdues its image that the patient will more readily recognize the false and brighter image seen by the deflected eye. It is not infrequently found by this method that ihefa/seis not on a horizontal plane with the true image, but lies above or below the plane in this meridian, 90 A MANUAL OF CLINICAL OPHTHALMOLOGY. demonstrating the involvement of other as well as the lateral muscles. INTERNAL STRABISMUS, ESOTROPIA, is the deviation in- ward of one eye, and is in four-fifths of all cases, caused by, and associated with, hypermetropia. It will be remem- bered, in explanation of this statement, that the hyper- metrope attains visual acuity only by the exercise of an abnormal amount of accommodation, involving a corres- ponding stimulation of the internal recti muscles (conver- gence). If convergence equal accommodation, the visual axes would cross in close proximity to the eyes, and all objects beyond this point of crossing would appear double. In order to maintain single and moderately clear vision, the patient learns to unconsciously throw all stimulation into the internal rectus muscle belonging to the eye which, by reason of its higher optical defect, or impaired vision from other causes, is more or less strongly converged. Images are on the same side (homonymous diplopia). Strabismus due to hypermetropia is likely to manifest itself at an age when small objects, letters of the alphabet, etc., are first noticed. Moderate degrees of hypermetropia, two to four diopters, may be overcome, and good acuity of vision obtained, by accommodation at the expense of conver- gence, but in higher degrees, the accommodation is not strong enough to overcome the error of refraction for any length of time and, in consequence, the internal recti mus- cles do not receive abnormal impulse. Hence internal squint is rare in high hypermetropia. Amblyopia of the squinting eye is common, but whether the imperfect vision is due to the squint, or the squint to the imperfect vision, is a question yet undecided. In all cases, the error of refraction (hypermetropia) should be corrected, and in a certain proportion, where the strabis- HETEROTROPIA. 9! mus is of moderate degree and not of long standing, the eyes may be brought into equilibrium by lenses which remove the strain on the accommodation ; when, however, binocular vision is not obtained by this means, the internal recti should be divided. The performance of this operation is followed by relief of the deformity, but does not mate- rially improve the vision of the squinting eye. EXTERNAL STRABISMUS, EXOTROPIA, is an outward devi- ation of the visual axis of one eye from fixation, frequently dependent on and associated with myopia. It is caused, not by over-action of the external recti muscles, but from a weakness of convergence, consequent upon the abolition of the necessity for accommodation, due to the increased con- vexity of the ball in myopia. It is occasionally found in eyes not myopic, and is then due to insufficient action of the internal recti muscles, or to acquired monocular blindness. The images in divergent strabismus are crossed (heterony- mous diplopia). Before the eye becomes permanently deflected, correction of the myopia which necessitates the use of a normal amount of accommodation for near objects, and hence for convergence, will be sufficient to effect a cure, aided by the exercise of the internal recti in overcoming prisms with their bases out, the patient gazing at a bright object 6 m. removed. Tenotomy of the external recti alone, or in conjunction with advancement of the tendons of one or both internal recti muscles will, in most cases, be neces- sary. Functional squint upward, or downward, is seldom mani- fested otherwise than as complications of internal and external strabismus. PART V. DISEASES OF THE CONJUNCTIVA. CONJUNCTIVITIS. The terminal branches of the transverse facial, facial, middle temporal, lacrymal, infraorbital, supraorbital, pal- pebral, frontal, nasal and muscular arteries, ramify loosely over the sclera through the subconjunctival mucous mem- brane, and are injected in the different forms of conjunc- tivitis. They are not normally visible, but when the tissues supplied by them are irritated or inflamed, they are visibly congested, tortuous and movable, their calibre gradually diminishing as they approach the corneal border. In the palpebral conjunctiva, the individual vessels are not always seen, but a diffuse and deep-seated redness is imparted to the entire surface during the continuance of an inflamma- tory process. In all forms of conjunctival inflammation, the discharge, an invariable symptom, is contagious. HVPERJEMIA. Hyperaemia of the conjunctiva maybe acute or chronic. In either case, it is characterized by in- jection of the ocular and palpebral vessels, and by a local- ized or diffused swelling, chemosis, cedema, or hyper- trophy of the mucous follicles or papillae. The cause of the hyperaemia will usually be found to be due to the lodg- ment in the conjunctiva of a small foreign body, to lacry- mal obstruction, ametropia, or to inverted ciline. The patient will complain of dryness, burning and itching of the affected lids, and of lacrymation. These symptoms are relieved, 92 CONJUNCTIVITIS. 93 and the patient cured in a few days, by bathing the affected eye with cold water, followed by mild astringent washes. A solution of cocaine hydrochlorate (2 per cent), dropped into the conjunctival sac every two or three hours, will give temporary and welcome relief. ACUTE CATARRHAL CONJUNCTIVITIS. In acute catarrhal conjunctivitis, the redness and other symptoms noticed in hyperaemia are more aggravated and pronounced, and, in FIG. 40. CONJUNCTIVAL AND SUBCONJUNCTIVAL INJECTION. i. Pericorneal zone. 2. Conjunctival injection. 3, 3. Sclerotic injection. addition to them, there is a discharge of mucus or muco- pus from the inflamed surface. During closure of the lids in sleep, the discharge collects and dries on their free margins, gluing them together. There is also pain, photophobia, and inability to use the eyes in prolonged, close work. It is a universally common affection, occurs idiopathically and in epidemic form, " pink-eye," and may arise from the causes which induce hyperaemia, from inflammation of contiguous 94 A MANUAL OF CLINICAL OPHTHALMOLOGY. membranes, or from contagion. Treatment consists in removal of the cause, in the local application of astringent lotions, and in marginal inunctions to prevent gluing. The patient is directed to bathe the eyes frequently through the day with the following effective lotion : R . Sodii biboratis, gr xx Aquae camphonv, Aquae destillat aa 31], and to rub Pagenstecher's ointment, K . Hydr. oxidi flavi, gr j Ungt. petrolei, 3J, along the margin of the lids on going to bed at night. Hydrochlorate of cocaine (gr. ij 5j) may be added to the lotion if there are special indications for its employment. CHRONIC CATARRHAL CONJUNCTIVITIS is due to the long continuance of one or more of the causes noticed in the etiology of the acute form, to which might be added smoky or dusty atmosphere, and poor hygienic surroundings. In the chronic form of the disease it may be necessary, in addition to the treatment already given, to frequently apply to the everted conjunctiva of the lids, the nitrate of silver in solution (grs. ij-5j), copper sulphate (gr. j-5j), or a solution of tannic acid in glycerine.* A severe case is usually followed by blepharitis marginalis or angularis, dermatitis angularis, eversion of lower punctual with epi- phora, and by keratitis. The use of caustics is contraindicated in anaemia of the * H. Tannic Acid, Glycerine, M. S. Apply to everted lids every other day. CONJUNCTIVITIS. 95 conjunctiva, or while the exudation is thin and sanious, and indicated in high degrees of conjunctival injection when the discharge is excessive, thick and purulent. The strength of the solution, and the intervals between applications, depend on the amount and purulency of the discharge. Its strength should be lessened as the inflammation dimin- ishes. VERNAL CATARRH is characterized by hypertrophy of the conjunctival epithelium, deposition of inflammatory exudation at the corneo-scleral margin, vascular fullness, and by peripheral opacity of the cornea. The ocular conjunctiva is but slightly injected, while the palpebral conjunctiva is, on the other hand, thickened, smooth, and pallid. The affection is binocular, affecting children and young adults, appears in the spring of the year, attains a maximum of severity in a few weeks, and continues, practically uninfluenced by treatment, with slight exacerbations and remissions, until frost, when it slowly disappears. Its average duration is four years. The symptoms are those of chronic catarrhal conjunctivitis. FOLLICULAR CONJUNCTIVITIS is characterized by the de- velopment, immediately under the palpebral epithelium, of small, round and prominent, pale-red follicles, consisting of lymph deposits, arranged in parallel rows. These deposits are more marked and numerous near the fornix in the lower lid. When the inflammation has subsided, they disappear, leaving no cicatrix in the conjunctiva. The disease is acute or chronic. In the former case, the inflammation is severe, the hypersemia intense, and there is, in the region of the fornix, a marked infiltration of the tissues, with pericorneal injection. The secretion is thin and abundant. In four or five days after the onslaught of the disease, follicles appear in both lids. In the chronic 96 A MANUAL OF CLINICAL OPHTHALMOLOGY. form, the signs of inflammation are not marked, and the follicles are limited to the lower lids. Follicular conjunctivitis is induced by contagion, pro- longed local medication, such as applications of nitrate of silver, instillation of atropine, etc., and by unhygienic sur- roundings. The disease may last for weeks or months, but the prognosis is favorable. The cause should be ascer- tained and removed, and remedies employed to subdue the Fin. 41. GRANULAR CONJUNCTIVITIS. inflammation and indirectly remove the follicles. Treatment is not primarily directed toward the eradication of the follicles. GRANULAR CONJUNCTIVITIS, OR TRACHOMA, consists of deposition in the stroma of the conjunctiva of small masses of lymphoid cells (Fig. 41), most marked in the upper lid. These cells are nourished by newly formed blood-vessels, and gradually undergo transformation into connective tis- sue elements. The process is a true hyperplasia, always CONJUNCTIVITIS. 97 attended by severe inflammation, and eventuates in per- manent tissue changes in the conjunctiva and cartilage. The granulations, which first develop in the upper lid, are numerous, adjacent to one another, and, spreading over the surface until the entire lid is involved, present the charac- teristic appearance of minute bunches of grapes, of a deep red color. The granulations are smaller and less thickly spread over the surface of the lower lid. Through an exten- sion of the inflammatory process, the ocular conjunctiva and cornea are eventually involved. The inflammation is of a high grade in the acute form of the disease, develops rapidly, and, if checked before merging into the chronic form, is not attended by permanent con- sequences of a serious character. The chronic form, which is most frequently seen in hospital practice, is divided into three stages. In the first stage, the stage of development, the injection of the conjunctival vessels may be moderate or intense, and there is either a gradual or rapid infiltration of the conjunc- tiva of the upper lid. In the former case, the development of granulations is slow ; in the latter, numerous and large granulations quickly appear on the conjunctiva of the upper lid, accompanied by a constant and profuse discharge, the acute thus passing into the chronic form. In the second stage, or stage of acme, the conjunctiva of the upper lid is transformed, its proper epithelium destroyed, old blood vessels enlarged, new ones formed, and granulation cells deposited in its stroma Owing to these changes, the conjunctival surface is irregularly roughened by eleva- tions and depressions. The conjunctiva of the lower lid undergoes similar alterations in a less degree. The ocular conjunctiva, particularly the upper section, is hyperaemic and the seat of granulations. The scleral and episcleral 9 98 A MANUAL OF CLINICAL OPHTHALMOLOGY. veins are distended. Even the cornea is invaded, usually in its upper half. It becomes vascular, opaque, and denuded of epithelium, which is destroyed either by extension of the peculiar granular inflammation into its stroma by continuity, or by friction of the roughened upper lid. The keratitis thus produced is a superficial vascular inflam- mation, pannus (Fig. 42). In the third stage, or stage of cicatrization, the granulations have disappeared and the conjunctival surface has lost its roughness. The membrane is, however, shrunken and streaked with one or more hori- Fir.. 42. PANNUS AFFECTING UPPER HALF OK CORNEA. zontal white lines, marking its close anatomical connec- tion with the underlying cartilage, which is curved with its convexity outward (entropion). The lids droop, the cilia; are irregular (distichiasis), or turned inward against the cornea. The palpebral space is narrowed by atrophy of the conjunctiva in its entirety. The cornea is partly opaque, and is traversed by a few tortuous vessels. The lower lid undergoes changes and malformations of the same character, but in less degee. The symptoms are, in the first stage, pain, burning, and CONJUNCTIVITIS. 99 itching of the lids, discharge of pus or muco-pus, lacry- mation, photophobia, and inability to use the eyes. In the second stage, dimness of vision is added to the above symptoms, and, in the third stage, there is a partial loss of vision with the annoying symptoms caused by in- verted lashes, etc. Permanent deformity of the lids, partial ptosis, limited movement of the ball, opaque cornea, and staphyloma are the frequent and distressing sequelae of the dreaded disease. It is caused by unhygienic habits of life, contagion, and scrofula. The disease occurs most frequently among young persons between the ages of fifteen and thirty, and is usually binocu- lar. Germans, Poles, Hungarians, Egyptians, and Italians are peculiarly susceptible to granular conjunctivitis, whether as the result of inherent peculiarities of temperament, or from neglect of sanitary laws, has not been definitely deter- mined. The prognosis is unfavorable. Complete recovery is rare. The disease lasts for years. Treatment. The affection is greatly modified by treat- ment, which is largely local. For the first stage, antiphlo- gistics and antiseptic remedies are indicated, such as leech- ing, applications of bichloride of mercury, 1-500 or i-iooo, scarification of the everted lids, and frequent cold water baths to the eye. After the granulations have formed, the treatment which at present would seem to prom- ise the best results, is extrusion of the granules by expres- sion with the roller forceps, while the patient is under the influence of anaesthesia. The older treatment, such as cauterization, the application to the granules of crystals of copper, or alum, or of the mitigated stick of the nitrate of silver (thirty-three per cent.), atropine, and inunctions of IOO A MANUAL OF CLINICAL OPHTHALMOLOGY. yellow ointment of mercury is, at best, only palliative. It should be the surgeon's aim to abort or destroy the granula- tions. If pannus should form it must be combated by an incision of the blood-vessels from which those of the cornea are derived at the corneo-scleral border, and by instillation of atropine and frequent hot-water baths to the eye. In the third stage, or stage of cicatrization, diverted lashes should be removed, the entropion relieved by operation, and the contracted commissure widened, if any of these conditions are present as a result of the inflammation. The general system should be supported by tonics, pure air, good food and exercise. Confinement in a dark room should be avoided. BLENNORRHOZAL, PURULENT, or GONORRHOZAL CONJUNC- TIVITIS, or OPHTHALMIA NEONATORUM, is an intense inflam- mation of the ocular and palpebral conjunctiva with chemosis, hypertrophy of epithelium and papillae, char- acterized by an excessive discharge of pus or muco- pus. It is acute in its course unless a sequel of acute catarrhal conjunctivitis. Within a few hours of its incep- tion, the upper lid becomes greatly swollen, smooth, and shiny on its cutaneous surface. The lashes are grouped into bundles and covered with discharges. The lower lid is puffed out, pus and tears escape from the outer canthus, and the conjunctiva, infiltrated with serum, is elevated from the sclera, so that the cornea appears sunken. In a few days a section of the cornea loses its transparency, the epithelium is cast off, forming an ulcer, which, in the graver cases, advances to perforation with escape of aqueous, and, finally, to sphacelus of the entire cornea ; or the inflamma- tion moderates, swelling subsides, discharge lessens, and the products of inflammation are gradually absorbed without involvement of the cornea, or, if involved, it recovers with CONJUNCTIVITIS. IOI opacity and, probably, anterior synechia. The prolonged inflammation, rather than its intensity, decides the question of corneal infection. The keratitis is induced by interruption of the blood supply, the result of pressure on the pericorneal and episcleral vessels from exudation in that region. The serum may become partially absorbed, but the conjunctiva is still elevated and uneven from the presence of more or less exudation. During and for several weeks after the termination of the acute stage, the conjunctiva of both lids, the upper lid more especially, projects in horizontal ridges with deep furrows between them resembling granular con- junctivitis, caused by the excess of inflammatory exudation, which persists long after the other symptoms of inflamma- tion have subsided. The cause is infection. Ophthalmia neonatorum is caused by the absorption by the conjunctiva of other as well as gonorrhceal pus. The mother giving birth to an infant which becomes, in a day or two, affected with this disease, is not necessarily a subject of gonorrhoea. In other words, the vaginal secretion causing the disease, is not always gonorrhceal in character. The inflammation primarily attacks one eye, and is conveyed by the inter-communicat- ing nasal ducts, or by carelessness, to the other, or both eyes are affected simultaneously and from a single cause. Treatment in the acute stage consists in applications of ice, or ice water, renewed every few minutes day and night, thorough cleansing of the conjunctival sac with saturated solution of boric acid, which should be squirted into the commissure every half hour by means of an eye-dropper, or absorbent cotton may be used for the purpose. Nitrate of silver (grs. v to Sj r g rs - x to 5j, if the discharge of pus is abundant) should be applied to the everted lids once or twice daily. These remedies, with atropine (gr. iv-5j), IO2 A MANUAL OF CLINICAL OPHTHALMOLOGY. when the cornea is threatened or attacked, are the most effective. In the subacute stage, nitrate of silver in dimin- ishing strength, and at increasing intervals, until the palpe- bral regions are of normal smoothness, mild antiseptic washes, and vaseline applied to the lids at night to prevent the gluing together of their free margins, are indicated. PHLYCTENULAR, LYMPHATIC, SCROPHULOSIS OR HKKI-KTIC CONJUNCTIVITIS is a frequent affection among children. It is characterized by the formation in the conjunctiva of one or more blebs containing serum or pus. The vessels supply- FIG. 43. PHLYCTENULAR OPHTHALMIA, CONJUNCTIVAL FORM. ing the affected region, are injected and pursue a tortuous course from the fornix to their endings at the phlyctenulc. Other parts of the conjunctiva are but slightly, if at all, injected. The symptoms are not severe, except in the pur- ulent form, and cause the patient little inconvenience. At- tention to the diet, pure air, out-door exercise, the removal of the cause of reflex irritation, such as worms in the intes- tinal canal, and difficult dentition, the daily application to the margin of the lids of Pagenstecher's ointment, and thorough cleansing of the parts with a saturated solution of boric acid will, usually, cure the inflammation in a few days. Relapses CONJUNCTIVITIS. IO3 are likely to occur, involving the same or the other eye, or the two eyes simultaneously. CROUPOUS CONJUNCTIVITIS is an acute, highly contagious inflammation of the conjunctiva, characterized by the for- mation on a part or on the whole of the conjunctiva of a thin, yellowish-white membrane, composed of albuminoid and cellular substances, which is detached without difficulty, leaving a bleeding point or surface. The disease has a ten- dency to recur. It is an infrequent affection, confined prin- cipally to children, and while the symptoms swelling of the lids, chemosis, thin and abundant discharge, pain and heat are severe, the cornea is rarely involved. During the for- mation of the croupous membranes, caustics must be avoided, and, instead of their use, ice compresses, antiseptic lotions, and powdered quinine, dusted over the diseased surface, employed. After the acute stage, a blenorrhoeal conjunc- tivitis persists, and this is successfully combated by the application of the nitrate of silver (gr. v j). DIPHTHERITIC CONJUNCTIVITIS is an acute, intense, con- tagious inflammation, characterized by the deposition in the subconjunctival tissue of a yellowish-white membrane, so closely interwoven with the conjunctiva that its detach- ment is difficult. The local symptoms swollen lids, exten- sive chemosis, acute pain, heat, and sanious discharge are severe and very marked in character. There is superadded to them, in some cases, the constitutional symptoms of diphtheria. The cornea is often destroyed through ulcer- ation. In the course of a week, the false membrane and surrounding conjunctiva become necrosed and slough off, leaving a deep ulcer, which heals slowly. A more or less extensive cicatrix remains to permanently alter the con- tour of the lid. When the characteristic diphtheritic pro- IO4 A MANUAL OF CLINICAL OPHTHALMOLOGY. cess has subsided, a purulent or semi-purulent conjunc- tivitis remains. The disease attacks one or both eyes, is sporadic or epidemic, may precede or follow similar mem- branes in the throat or nose, or run its course as a purely local affection. The prognosis is not favorable. The treatment, during the formation and continuance of the membrane, is antiphlo- gistic and antiseptic. Atropine locally, and constitutional remedies, suited to the age and necessities of the patient, should be employed. Salivation is recommended in adult patients. XEROSIS is a dryness of the conjunctiva due to destruc- tion of the papillae and follicles through atrophy of the mucous membrane from severe and long-continued inflam- mation (diphtheritic or granular conjunctivitis), or to the improper and continued use of caustics. The functions of the eye are interfered with, and may be destroyed, through resulting opacities of the cornea. Treatment is of little avail. Constant instillations of glycerine is said to be palliative. PTERYGIUM is a vascular membrane, triangular in shape, closely resembling in appearance and structure the con- junctiva, on which it is superimposed. Its base corresponds with the curve of the sulcus at the inner canthus, and the growth extends horizontally until the apex has invaded the subepithelial layer of the cornea. Its apex may thus cover in part, or completely, the pupil. It may appear in both eyes simultaneously or be confined to one. In rare instances it is developed from the outer canthus. It is an affection of slow growth, and is most frequently found in elderly persons who have been exposed to wind and rain through many years of active, outdoor life. Sailors are CONJUNCTIVITIS. 105 peculiarly liable to the affection. It should be regarded as an hypertrophy of the conjunctiva, the result of constant exposure to the elements, rather than as an inflammation. FIG. 44. PTERYGIUM. TUMORS. Pinguecula is a small, yellowish-white, fatty- like growth, usually noticed between the cornea and inner canthus. It is harmless. Granuloma, or Polypi are not infrequently found attached to the conjunctival surface after an injury or operation; they should be excised. Dermoid cysts, lipoma, sarcoma, and melano-sarcoma are also found in the conjunctiva. They should be removed and the wound cauterized. PART VI. DISEASES OF THE LIDS AND LACRYMAL APPARATUS. CONGENITAL MALFORMATIONS. COLOBOMA is a fissure of one or both lids, and is often associated with similar deformities of the iris, choroid, and palate. EPICANTHUS (Fig. 45) is a widening at the base of the FIG. 45. ElMCANTHUS. nose, caused by a redundancy of the skin in this situation. The internal angle of each palpebral fissure is partly covered, and the fissures apparently shortened. When a fold of skin at the centre of the interpupillary space is elevated by forceps, the deformity temporarily disappears. PTOSIS (Fig. 46), is a drooping, partial or complete, of the upper lid, from paralysis of the levator palpebrae branch of 106 TRAUMATISM. lO/ the third nerve. This condition is most apparent when the patient's gaze is directed upward. The deformity may be relieved by operation. TRAUMATISM. Incised and punctured WOUNDS, involving only the lids, and not penetrating to the eye-ball, should be sutured and treated antiseptically with the double purpose of preventing deformity and promoting resolution. FIG. 46. PTOSIS. BURNS from acids, alkalies, molten lead, scalding water, etc., may lead to disastrous results from the formation of cicatricial contractions, which terminate in distortion of the lids, adhesions between their free margins, and consequent narrowing of the palpebral fissure, and lead, not infrequently, to destruction of the conjunctival sac. The aim of the treat- ment is to prevent marginal and surface adhesions, and the formation of cicatricial and distorting bands, by traction and the constant application of oil dressings to the wounded IO8 A MANUAL OF CLINICAL OPHTHALMOLOGY. surfaces. When the wound is superficial, involving a lar^e portion of the lid, skin grafting should be employed, and when the lid is destroyed, a plastic operation becomes necessary, the deficient or lost tissue being supplied from the adjoining parts. CONTUSION, "black eye," is usually the result of violence, such as a blow. The loose connective tissue of the lids becomes swollen, ecchymosed, and presents a bluish dis- coloration, which is a source of annoyance rather than of danger. The condition may be speedily relieved by the alternate application of hot and cold water, to which is added, in the proportion of one to eight, the tincture of arnica, or a wash of the chloride of ammonium, gr. v-5J, may be substituted. INFLAMMATIONS. PHLEGMON, ABSCESS, is an acute, purulent, circumscribed inflammation of the cellular tissue, attended with redness, swelling, pain, and localized elevation of the temperature. The abscess is at first hard, gradually increases in size, softens, and has a tendency to point through the skin. It may be the result of injury, of cold, or develop without assignable cause. When situated near the inner angle, the abscess should not be confounded with acute inflammation of the lacrymal sac. A threatened abscess, may be aborted by the local appli- cation of cold, and by the internal administration of calcium chloride, of which a two-grain pill should be given every two hours until four pills are taken. When the inflamed area presents a central induration, poultices, followed by an early incision, parallel with the margins of the lid, are indicated. After incision, the parts should be frequently cleansed with antiseptic lotions, and supported by a com- press. INFLAMMATIONS. IOO, HORDEOLUM, STYE, is a localized inflammation in or near the bulb of an eyelash. It rapidly advances to pustu- lation, and is accompanied by redness, pain and swelling, particularly when situated at the outer angle, and by local, and sometimes general, increase of temperature. There is usually a succession of styes, one following another at irregular intervals for several weeks or months. The cause is to be found in some refraction error, or in an impover- ished condition of the system. Treatment : cold com- presses in the early stage to abort, and hot poultices, later, to hasten suppuration. A small incision may be made through its apex, or the tumor left to open spon- taneously. BLEPHARITIS is an inflammation of the lids, acute or chronic, dependent upon disease of contiguous parts, such as the various forms of conjunctivitis, orbital disease, ery- sipelas, etc. MARGINAL BLEPHARITIS is a chronic inflammation of the free margin of the lids. In its early stage, it is character- ized by an induration around, and hypersecretion of, the sebaceous glands with the formation of minute pustules, which rupture, leaving small ulcers. The secretion, drying, forms crusts which become matted with the ciliae. When the crusts are removed, the edge of the lid presents a series of excoriated and bleeding points. The entire margin is finally involved in the inflammatory process, the ciliae fall out, and are replaced by a few fine and misdirected hairs, or they may be altogether absent. The symptoms are red- ness, swelling, itching, and a sensation of heat, aggravated by the use of eyes in near work, by smoke and other atmospheric impurities. It occurs in children and young adults, as a result of reflex irritation, ametropia, and scrofula. Treatment. The cause should be ascertained and re- I IO A MANUAL OF CLINICAL OPHTHALMOLOGY. moved ; the ametropia corrected by the proper lens ; the reflex irritation from painful dentition, or from intestinal worms, relieved by suitable remedies, and in scrofula, tonics and alteratives administered with good food, fresh air, and healthy surroundings. The crusts should be dissolved by mild alkaline washes, sodii bicarb., or biborate, gr. v-.^j, the ulcers stimulated by touching them with a pledget of cotton soaked in silver nitrate, gr. v-5j, and, once or twice daily, an ointment of the yellow or red oxide of mercury (gr. j, vaseline 5j) applied, or, in stubborn cases, aristol in the same strength can be substituted for the mercury. AFFECTIONS OF THE SKIN. ERYTHEMA, ECZEMA, and ERYSIPELAS appear occasionally on the lids, as elsewhere on the body, as a local manifestation of the general affection. They are to be treated on the prin- ciples laid down for these diseases. CEDEMA is a symptom of orbital disease, of purulent conjunctivitis, and of nephritis. In all cases of oedema without local cause, the urine should be examined for albumin. It requires no special treatment. EMPHYSEMA is an escape of air into the cellular tissue adjoining the lids, induced by violent sneezing, blowing the nose, and by asthma. Compression by a roller bandage is the only treatment necessary. RODENT ULCER begins at the margin of a lid, usually the lower, as a small excrescence which, in time, falls off, leaving an excoriated surface. This slowly increases in size until it has destroyed, after the lapse of many months or years, the lid and neighboring tissues. The pain is inconsiderable. The treatment consists in the early and complete excision of the diseased part. AFFECTIONS OF THE SKIN. Ill EPITHELIOMA presents in its initial stage similar appear- ances to the rodent ulcer, but is distinguished by the rapidity of its growth, lancinating pain, thin, offensive, ichorous discharge, and by its tendency to recur after exci- sion. It occurs, as does the rodent ulcer, in elderly per- sons. Early excision is the treatment. The application of glacial acetic acid, repeated tri-weekly until the ulcer is FIG. 47. B. MEIBOMIAN CYST. LID FORCEPS. A, Screw. B, Shank. cicatrized, has been advocated. It, together with other remedies of the same class that have been proposed from time to time, is not to be employed, however, when the patient is willing to submit to an operation. LUPUS is a tuberculous infiltration of the lid, and occurs usually as an extension of the disease from neighboring structures. All treatment heretofore devised has been simply palliative. No cure has yet been found for tubercle. 112 A MANUAL OF CLINICAL OPHTHALMOLOGY. XANTHELASMA is a fatty degeneration of the skin, of a bright yellow color, occurring in symmetrical patches on the lids of both eyes near their inner angle. They should be excised and the healthy skin drawn together by sutures. CHANCRE is a specific, indurated sore of the lid, due to direct contagion, having the same features and followed by the same constitutional infection, that characterize chancre in other situations of the body. The treatment is anti- syphilitic and constitutional. CHALAZION (Fig. 47, A) is a small cyst developed in the tarsal cartilage from obstruction of a meibomian duct, damming its secretion. It is a common but insignificant tumor, easily removed by excision. ECCHYMOSIS is an effusion of blood beneath the skin or conjunctiva from traumatism, or from idiopathic rupture of a small vein. No treatment is necessary. MILIUM is the name given to a minute, hard, pearly-like growth, situated on the margin of the lids, or in the skin. It requires no treatment, but may be readily removed iTthe patient so desires. AFFECTIONS OF THE EYELASHES TRICHIASIS (Fig. 48) is that condition in which the cili;u assume, as a result of chronic disease of the conjunctiva, independent directions, some normal and others distorted. Those turned against the cornea should be pulled out, or their bulbs excised. DiSTiCHiASis(Fig. 49) is the condition in which there is a second irregularly placed row of lashes, congenital or ac- quired, partially or wholly in contact with the cornea. This is a painful complication of chronic conjunctivitis. Friction of the distorted hairs against the cornea produces a super- AFFECTIONS OF THE EYELASHES. 113 ficial keratitis with permanent impairment of vision in some cases. The treatment is depilation. The hairs should be removed as often as they appear. FIG. 48. TRICHIASIS. ALOPECIA is a falling out of the lashes due to granular conjunctivitis, blepharitis marginalis, or to constitutional disease (syphilis). The predisposing cause should be ascer- tained and treated. FIG. 49. PEDICULUS PUBIS, crab-lice in the cilia% are sometimes found in those who are filthy in their persons and surround- ings. They cause intolerable itching, which is relieved, 114 A MANUAL OF CLINICAL OPHTHALMOLOGY. and the crabs destroyed, by the daily application to the free margin of the lids of the yellow oxide of mercury ointment. ACQUIRED DEFORMITIES. KNTROPION (Fig. 50) is a partial or complete inversion of the ciliary margin of the lid. It is sometimes noticed as the temporary result of spasm of the orbicularis muscle, induced by the long-continued application of a pressure- bandage after operations, but is more often found as a per- FIG. 50. ENTROPION OK LOWER LIDS. manent deformity, caused by atrophy of the conjunctiva and consequent abnormal convexity of the tarsal cartilage, from granular conjunctivitis, or traumatism. The affection is, in a large majority of cases, complicated by vascular inflammation of the cornea, and of the conjunctiva of the inverted lid. Temporary entropion is relieved by drawing, and holding, the edge of the lid outward by adhesive strips fastened to the neighboring skin. Many operations have been devised for the permanent cure of entropion, which is not easily remedied. Advancement of the tendon ACQUIRED DEFORMITIES. 115 of the palpebral muscle has, in our hands, given the best results. ECTROPION (Fig. 51) is a partial or complete eversion of the margin of the lid, and, like entropion, is sometimes found as a transient symptom of inflammatory swelling of the lid, or as a permanent deformity from paralysis .of the orbicularis muscle. It is, however, most frequently caused by cicatricial contraction of the palpebral or neigh- boring integument, the result of destructive injuries, such as burns, wounds, etc., involving these parts. When of long FIG. 51. ECTROPION OF LOWER LID. standing, the exposed conjunctiva becomes hypertrophied. From eversion of the puncta lacrymalia, tears collect in the conjunctival sac, and flow over the cheek, causing still more irritation. If the upper lid is affected, the cornea may suffer from adhesion of particles of dust. In the- transient form, recovery of the normal position of the lid ensues when the cause is removed. In the permanent form, a plastic opera- tion is the only measure by which relief can be obtained. BLEPHAROSPASM is an involuntary closure of the lids from tonic or clonic spasm of the orbicularis muscle. The Il6 A MANUAL OF CLINICAL OPHTHALMOLOGY. abnormal contraction of this muscle is reflex, excited by photophobia, foreign body in the cornea, neuralgia, and by accommodative or muscular strain. The condition may manifest itself by an occasional twitching of the lids, so slight as to be hardly noticeable, local chorea, or, by the forcible closure of the lids, lasting a considerable length of time. The cause should be. ascertained and relieved. In young persons, the defect will be found, in many cases, to be due to an error of refraction, or muscular anomaly, correction of which will result in a cure of the spasm. Division of the supraorbital nerve has been advised in otherwise in- tractable cases. If the affection is found to be clue to some constitutional dyscrasia, remedies addressed to the general system, rather than to the local manifestation, will, of course, be indicated. BLEPHAROPHIMOSIS is a narrowing of the palpebral fissure, consequent upon long continued inflammation of the con- junctiva. The proper length of the commissure should be restored by the operation of canthotomy or canthoplasty. PTOSIS is a drooping of the upper lid from paralysis of the levator palpebrai muscle, or from an increase in weight of the lid in chronic thickening and induration. The former, is a symptom of central or spinal disease, when not due to an affection of the orbit. Iodide of potassium, mer- cury, strychnia and electricity, are proper remedies to em- ploy when the initial lesion is in the cerebro-spinal system. Surgical interference is warranted under the same condi- tions that govern operations for paralytic strabismus. SYMBLEPHARON (Fig. 52) is a cicatricial adhesion, partial or total, of the lid to the eyeball, the sequel of destructive inflammation of the conjunctiva from burns or extensive ulceration. It is relieved by operation. ANYKLOBLEPHARON (Fig. 53) is a union of the free mar- DISEASES OF THE LACRYMAL APPARATUS. 1 1/ gins of the lids from traumatism or ulceration. Trauma- tism severe enough to cause complete adhesion between FIG. 52. FIG. 53. SYMBLPEHARON. ANKYLOBLKPHARON. the ciliary margin of the lids, will also destroy the cornea, and treatment, under these conditions, is unavailing. DISEASES OF THE LACRYMAL APPARATUS. HYPERTROPHY of the lacrymal gland, the position of which is shown by dotted line, Fig. 54, is occasionally met with in young persons as a small, movable tumor situated in the upper and outer angle of the conjunctival sac. It is not attended by pain, or other signs of inflam- mation, but the eyeball, against which it rests, is pressed downward and inward, causing double vision, the chief symptom of which the patient complains. The treatment consists in the free administration of tonics, such as the syrup of the iodide of iron, cod-liver oil, etc., and in a nourishing dietary. ABSCESS of the lacrymal gland is a rare affection, usually chronic, and is the result of injuries, and of chronic inflam- mations of the conjunctiva. Its presence is determined by Il8 A MANUAL OF CLINICAL OPHTHALMOLOGY. a fluctuating swelling at the site of the gland. It has a tendency to rupture through the skin, causing fistule, and should be incised as soon as fluctuation is determined. FISTULE of the lacrymal gland is the sequel of an abscess that has opened spontaneously. It remains patulous be- cause of the constant discharge through it of tears mingled with pus. The opening thus formed should be closed by cauterization, and a new one made into the con- junctival sac. Fie;. 54. LACRYMAL GLAND. MALPOSITION, or diversion of the puncta lacrymalia, which normally lie in contact with the conjunctiva of the ball, prevents the escape of tears which collect in the conjunc- tival sac, giving rise to epiphora, or watery eye. The con- dition is brought about by paralysis of the orbicularis muscle, chronic thickening and eversion of the lid from conjunctivitis, and by the other causes of ectropion. If the normal position of the lid cannot be re-established by massage, slitting up of one or both canaliculi, with their permanent transformation into gutters, will afford partial relief. DISEASES OF THE LACRYMAL APPARATUS. 119 STRICTURE of the nasal duct may form in any part of its course, but the junction of the bony and cartilaginous por- tions is usually the site. It is caused by chronic inflam- mation of the conjunctiva, or of the Schneiderian mucous membrane of the nostrils, lessening the lumen of the canal. Its constant and annoying symptom is epiphora. A small swelling is common on the site of the lacrymal sac, which by pressure exudes tears and mucus backward through the canaliculi. Blennorrhcea, Dacryocystitis, abscess, and fistule of the lacrymal sac, are common sequelae of stricture. (a) BlennorrlicEa. The mucous lining of the sac becomes inflamed from the presence and pressure of retained tears, forming a small tumor which exudes, when compressed, a glairy fluid (tears and mucus mingled) into the conjunctival sac, or downward through the stricture into the nostrils. This stage of the affection is termed mucocele. (ft) Dacryocystitis is a purulent inflammation of the lacrymal sac, following blennorrhcea as a later consequence of stricture, characterized by greater tumefaction, and by a discharge largely composed of pus, which the patient is compelled to express many times in the course of the day. Complaint is made of constant overflow of tears, pain and swelling at or near the inner angle of the lid, and of dis- turbed function. (c) Abscess is the culmination of an acute dacryocystitis, and is manifested as a rapidly developing inflammation of the lacrymal sac with extensive invasion of the surrounding parts, such as oedema, redness, and excessive swelling of the lids, so great in some instances as to produce closure of the commissure. The sac is exceedingly sensitive to pressure, and the abscess, if allowed to pursue its course I2O A MANUAL OF CLINICAL OPHTHALMOLOGY. uninterruptedly, will eventuate in necrosis of the bone, and in a fistulous opening through the skin. ((f) Fistnlc(Y\g. 55) is the establishment of a pathological channel from the lacrymal sac to the cutaneous surface, through which the products of inflammation are discharged. Treatment. In the earlier stages of stricture, massage and the local application to the conjunctiva of astringents, injected by lacrymal syringe into the canaliculi, or simply FIG. 55. FISTULE OK LACRYMAL SAC. dropped into the conjunctival sac, may be sufficient to abort the disease. The following is a useful lotion for the purpose : R . Boric acid, gr. v Zinc sulphate, gr. j Water *j. When it is clearly established that medication alone will not bring about a cure, the stricture must be either dilated or divided. This method of treatment is not in all cases satisfactory, and should be employed only when other and DISEASES OF THE LACRYMAL APPARATUS. 121 less radical measures have proved to be unavailing. When, however, the swelling at the site of the gland contains pus, as well as tears and mucus, the operation can no longer 'be delayed with safety to the patient, or with credit to the surgeon. The local application of lead water and laudanum, leeches, attention to the bowels, kidneys and skin, may abort an abscess during its formative stage. When the tumor shows a tendency to point it must be freely incised. No attempt to pass a probe is advisable until the swelling and tenderness have subsided ; it may then be treated as a stricture. The fistulous opening will usually close without direct medication when the normal passage for the escape of tears has been re-established ; if, however, the natural process of healing is too slow, union may be promoted by cauterization of the walls of the fistule. When it is not convenient for the patient to see the surgeon every day or two, a substitute for frequent probing is the leaden or silver style, which may be introduced and allowed to remain in the duct for several weeks or months, for the purpose of keeping the stricture dilated. PART VII. DISEASES OF THE CORNEA AND OF THE SCLERA. In corneal inflammations, the surrounding minute vessels, straight and parallel (terminals of larger conjunct! val and subconjunctival vessels, which in health are empty of blood and invisible), are, with few exceptions, injected. This zone of vascularity is known as the pcricorneal ring. Inflammations of the cornea (corneitis, keratitis) are divided into two classes, superficial and deep. SUPERFICIAL AND VASCULAR. In vascular inflammations of the cornea, newly formed arteries and veins, given off from the conjunctival vessels, ramify over the corneal epithelium. These vessels vary in size, length and number, involve a part or the entire surface of the cornea, appear early or late in the course of the disease, and may become entirely absorbed without leaving a trace. ' PHLYCTENULE (Fig. 56). Phlyctenular keratitis is charac- terized by the presence of one or more small cysts, which form on the limbus cornea, or in any other part of its surface, containing serum and lymph cells. The outer wall of the cyst is formed by the corneal epithelium. After the lapse of a few days, the bleb breaks through its epithelial wall and its contents escape, leaving an ulcer. In a few hours after the appearance of the phlyctenules, 122 PHLYCTENULAR KERATITIS. 123 vascular offshoots from the conjunctiva pursue a tortuous course to the diseased spot or spots. There is usually a leash of these vessels, four or five in number, with its base on the limbus and its apex in the phlyctenule. The disease manifests itself oftenest in children, especially those who have inherited a scrofulous diathesis, and is developed by improper nourishment, poor sanitation, and reflex disturb- ances (teething, worms, etc.). The main symptoms are photophobia, lacrymation, and acute pain. The blister, characteristic vascularity, and re- sulting ulcer sufficiently mark the disease. If the phlyc- FIG. 56. PHLYCTENULAR ULCER. tenule is single, it is usually found on the cornea in front of the pupil, or, if multiple, is manifested as a series of pin- point cysts or ulcers on limbus. The disease disappears without trace or sequelae in ten or fifteen days, under proper treatment, which consists in restricting the diet, regulating the bowels, and in the use, locally, of yellow ointment and atropine. HERPES is an accompaniment of catarrhal disease of the respiratory and intestinal tracts. One or more vesicles form on the cornea, in any situation, rupture and leave an ulcer with transparent floor, and clear cornea surrounding it, or, if infected by micro-organisms, the base of the ulcer 124 A MANUAL OF CLINICAL OPHTHALMOLOGY. is yellow, and a considerable portion of the surrounding cornea infiltrated and destroyed. It should be treated as an ulcer. PANNUS is a superficial vascular infiltration of the cornea with partial destruction of its epithelium, caused by granu- lar conjunctivitis. The epithelial layer of the cornea, usu- ally the superior half, in some instances the entire surface, is traversed by a leash of blood-vessels given off from the conjunctival arteries and veins. These newly-formed and tortuous vessels, largest at the periphery, are directed toward the centre of the cornea. There may be only a single vessel, or the entire corneal surface may be trans- formed into a velvety, beefy-looking mass with temporary destruction of vision. The cause is due either to friction of the roughened lids over the sensitive corneal epithelium, or to an extension into the cornea of the true granular pro- cess. The cornea between the vessels is infiltrated with lymph-cells, and on its surface are minute facets of ulcera- tion. These pathological changes are usually limited to the anterior layers of the cornea, do not often involve the structures underlying Bowman's membrane, and affect primarily the cornea underneath the upper lid. Pain, intolerance of light, lacrymation, swelling, and injec- tion of the conjunctival and ciliary vessels, are the usual symptoms. Prognosis is, as a rule, favorable, notwith- standing the long duration of the cause, but the recurrent and extensive destruction of the epithelium, and infiltration, lead to some permanent impairment of vision, and, in some- cases, to conical cornea, and to corneal staphyloma. Treat- ment is directed to the granular conjunctivitis, which is always the causes of pannus. Atropine and hot-water appli- cations, in conjunction with the treatment of the granular lids, are useful. SUPERFICIAL KERATIT1S. 125 NON- VASCULAR SUPERFICIAL KERATITIS. HERPES is the name given to the appearance, in groups on the cornea, of minute round vesicles in an eye already affected by catarrhal conjunctivitis. Calomel dusted into the conjunctival sac is the only treatment required. OPHTHALMIC HERPES ZOSTER is the formation, during an attack of frontal herpes, of a number of small vesicles on the cornea. These vesicles rupture, form ulcers, and leave opacities. There is incomplete anaesthesia- of the cornea. The treatment is by atropine, pressure bandage, and by the internal administration of quinine, arsenic, and bismuth. RESORPTION ULCER is a superficial, non-vascular loss ot corneal substance without severe symptoms. The pericor- neal injection is not marked. The ulcer forms in an eye previously healthy, or in one which is already the seat of corneal or conjunctival disease. The bottom of the ulcer nearly always remains clear, and the surrounding tissue is not infiltrated. The disease shows little tendency to in- volve the iris. Atropine and local irritants, are the reme- dies indicated. PROFOUND KERATITIS. DEEP ULCER (Fig. 57) is inflammatory, differing from the resorption ulcer in its involvement of the deeper layers of the cornea, and in its tendency to perforate. It is a localized loss of corneal substance attended by signs of active inflammation. The floor and margins of the ulcer exhibit a yellowish discoloration, the adjoining parts are infiltrated, and pus forms in the anterior chamber (Fig. 58), hypopyon, or there is a collection of pus in the most dependent portion of the cornea, onyx. The inflammation is acute, the pericorneal and conjunctival injection marked, and iritis may complicate the affection and aggravate the attending symptoms pain, photophobia, lacrymation, and 126 A MANUAL OF CLINICAL OPHTHALMOLOGY. loss of function. The prognosis will depend on the si/ the ulcer, its site, and on the severity of the inflammatory process. The more central the ulcer, the more damaging it will be to vision. All deep ulcers of the cornea leave a permanent cicatrix, dense and white when complicated by iritic adhesion (anterior synechia). Treatment. Atropine, hot water, leeches to the temple, saturated solution of boric acid, applied every two hours, repeated and persistent cauterization of the floor and sides of the ulcer with the thermo-cautery, or silver nitrate (gr. xx-rij), the instillation of eserine (gr. ss-5j) every two hours FIG. 57. FIG. 58. PERFORATING ULCER OK THE CORNEA, ADHESION OF IRIS (ANTERIOR SYNE- ONYX (6) AND HYI>OPYON (4, 5). CHIA). during the day, and atropine (gr. iv-5j) once or twice during the night, are indicated. Eserine is employed in threatened perforation to contract the pupil, thus diminishing intra- ocular pressure and supporting the tissues behind the diseased cornea, as well as for its beneficial local action on the cornea itself, while the atropine is given to prevent maximum contraction of the iris under myotic in- fluence, and closure of the pupil by exudation. The pressure bandage may be employed. When spontaneous perfora- tion is imminent, its worst features may be avoided by in- strumental perforation. The treatment after perforation is PROFOUND KERATITIS. I2/ by antiseptic washings of the wound with a saturated solution of boric acid, eserine, and by a pressure bandage which is allowed to remain undisturbed for 4.8 hours. The general system should be supported by tonics. SERPIGINOUS ULCER (Fig. 59) is a destructive purulent in- filtration of the cornea with a decided tendency to advance in extent and in depth. It may attack any portion of the cornea, is usually longer than it is broad, arc-shaped, and sur- rounded by streaks of opacity running into the clear cornea. The ulcer is yellowish in color, attended by moderate signs of inflammation, and not infrequently manifests itself in persons whose general health is at a low ebb. It is often FIG. 59. ACUTE SERPIGINOUS ULCER OF CORNEA WITH CRESCENTIC BORDER OF INFILTRATION. associated with disease of the conjunctiva and lacrymal ap- paratus. Onyx, hypopyon, and iritis, are frequently present. The treatment is the same as that given for other forms of deep ulcer. INTERSTITIAL or PARENCHYMATOUS KERATITIS (Fig. 60) is a disease involving, as its name suggests, the deeper tissues of the cornea, which become infiltrated by lymph cells. The appearance of the cornea is that of a piece of ground glass. The epithelium is partly destroyed, and the iris lies hidden behind the gray opacity thus formed. The pericorneal injection is very marked, while that of the conjunctiva 128 A MANUAL OF CLINICAL OPHTHALMOLOGY. is either slight or altogether absent. Vision is markedly reduced. Photophobia is intense, lacrymation profuse, but the pain slight; indeed, it is often altogether absent. The disease is slow and insidious, lasting from three weeks to many months. The opacity may entirely disappear, leaving, in the more favorable cases, irregularities in the corneal curve, or becomes dense and remains permanently. The iris may become adherent to the lens capsule, and occlusion of the pupil by inflammatory exudation occur. In the severer cases, blood-vessels are formed in the inter- stices of the cornea. The disease occurs among scrofulous, syphilitic, and anaemic young subjects, and is noted by some writers as a symptom of inherited syphilis. FIG. 60. INTERSTITIAL KERATITIS. Treatment is by atropine, heat, dry or moist, locally, and by mercury, iodide of potassium, syrup of the iodide of iron, and other tonic remedies, systemically. The patient's eye should be protected from light, but not from the atmosphere. ABSCESS begins as a single or multiple collection of grayish, inflammatory deposits in the corneal stroma, circum- scribed by healthy tissue which eventually breaks down, forming a single large cavity containing pus. The color now changes to a straw-yellow, the surrounding cornea is striated, opaque, and bereft of its epithelium. Ilypo- pyon and onyx are common. The abscess has a tendency PROFOUND KERATITIS. I 29 to increase in size until the enveloped pus and corneal debris are discharged through an anterior or posterior perforation. Iritis of severe type, is a usual complication of corneal abscess, which, in some cases, is even followed by capsular or lenticular cataract. Iritic adhesion to the corneal cicatrix, or the formation of anterior synechiae, is a common sequel to perforating abscess, just as it is to perforating ulcer not preceded by collections of pus. Abscess may occur as a result of traumatism, purulent conjunctivitis, the exanthematous fevers, paralysis of the fifth pair of cranial nerves, or from exposure, alcoholic ex- cesses, and from the debility of old age. The symptoms are lacrymation, pain, photophobia, and loss of function. Treatment. Alternate instillations of atropine (gr. viij-5j) and eserine (gr. j-5j), as directed under the treatment for ulcer, should be employed, and the eye bathed frequently with a solution of the bichloride of mercury (i to 3000). When the abscess threatens to perforate spontaneously, a free instrumental opening should be made by Saemisch's incision. After the escape of the aqueous and collapse of the anterior chamber following perforation, the cornea must be supported by a pressure bandage, which should be left undisturbed for seventy-two hours, except in blennorrhceal abscess, when the treatment is mainly directed to the dis- eased conjunctiva. NEURO-PARALYTIC KERATITIS is caused by pressure upon, or disease of, the ophthalmic division of the fifth nerve, which has become paralyzed, the tissues supplied by it losing their sensibility. The cornea is destroyed through loss of nourishment, disintegration of the trophic fibres, or from exposure to foreign bodies, air, etc. The surgeon should endeavor to remove the cause, and to keep the lids forcibly closed throughout the continuance of the disease. I3O A MANUAL OF CLINICAL OPHTHALMOLOGY. NECROTIC KERATITIS is a rapid destruction of the cornea without marked signs of inflammation, caused by maras- mus, and other exhaustive diseases of infancy and early childhood. ARCUS SENILIS, Annulus Senilis, is a partial or complete ring of fatty degeneration of the cornea about 1 mm. from the limbus. SEQUELS OF CORNEAL INFLAMMATIONS. OPACITIES OF CORNEA. A nebula is a faint, macula an easily seen but translucent, and lencoma a dense, white opa- city of the cornea. In young persons, or when the opacity is FIGS. 6 1 AND 62. PARTIAL STAPHYLOMA OF THE CORNEA AND IRIS. recent, absorption may be induced by mild irritants, e.g., finely powdered calomel dusted against the cornea, or yellow ointment applied to the margin of the lids once or twice daily. Eserine (gr. ss-5j) dropped into the conjunctival sac daily, may also prove beneficial. To improve vision, an iridectomy, opposite clear cornea, may be made, providing a new pupil for the transmission of light. CONICAL CORNEA (Fig. 61) is a thinning and cone-like projection forward of the cornea, without alteration in its transparency, or other sign of inflammation. It is a chronic PROFOUND KERATITIS. 13! and slowly progressive affection, the result of inherent weak- ness of the corneal stroma. It commonly occurs in persons between fifteen and thirty years of age, and is first sub- jectively noticed by a deterioration in vision, about which the patient will consult the surgeon. The condition is detected by the use of Placido's disc, or by the distorted image of a window frame on the patient's cornea, as well as by retinoscopy, in which the shadow is broken into a series of circular rings, and by the ophthalmoscope, which shows a varying degree of myopia as the gaze is directed through different parts of the cornea. The general refrac- FIG. 63. TOTAL STAPHYLOMA OF THE CORNEA AND IRIS. tion is myopic, but a minus spherical, or a combination of a minus spherical and a minus cylindrical glass, will be found to be of very little service, since the cornea has many radii of curvature. Treatment is of very little value, either by correcting the refraction, or by operation. STAPHYLOMA (Figs. 62 and 63) is a bulging forward of the opaque cornea, which has been so weakened by disease that it gives way to the normal pressure of the intraocular fluids. It involves a part, or all of the cornea, according to the intensity of the inflammation of which it is a sequel. 132 A MANUAL OF CLINICAL OPHTHALMOLOGY. Frequently the iris and lens are dislocated forward into the deepened anterior chamber, the former adhering to the posterior surface of the staphyloma, and the latter becom- ing opaque. Secondary glaucoma, with ciliary staphyloma, are not uncommon complications, and blindness more or less complete is the rule. Treatment is unavailing. Am- putation of the cornea or enucleation of the ball is indicated when the disfigurement is great, or the suffering severe. In children Critchett's operation is advisable, since the remain- ing stump includes two-thirds of the ball, and does not prevent development of the lines of the orbit, as does an enucleation performed in early life. TUMORS of the cornea usually occur as extensions of in- flammatory new formations from the conjunctiva, or from the deeper orbital tissues. Dermoid cysts, melanoma, pig- mented sarcoma, and melanotic cancer may grow directly from the cornea. The treatment is by excision or enuclea- tion of the ball. Recurrence of these growths is probable. DISEASES OF THE SCLERA. SCLERITIS is a localized inflammation of the scleral tissue, rheumatic in origin as a rule, characterized by slight swell- ing, pain on pressure, active injection of contiguous ciliary, deep pericorneal and conjunctival vessels, which impart to the diseased area a purplish hue. There are no signs of corneal or iritic involvement. The localized swelling and redness, and rheumatic history, render the diagnosis easy. The course of the disease is protracted, relapses frequent, and the pain severe. There may be temporary loss of function. Treatment. Dry heat locally, salicylates, phosphate of sodium by the stomach, and confinement of the patient DISEASES OF THE SCLERA. 133 to warm apartments, in which the light is subdued, are indicated. STAPHYLOMA (Fig. 64). Anterior staphyloma, or ciliary staphyloma, is a bulging outward of the sclera in the ciliary region, the result of long-continued increased intra- ocular pressure, as in secondary glaucoma, and involves in its distention, the underlying portion of the ciliary body or choroid. The sclera becomes gradually thinner, assumes a bluish discoloration, and the portion of the uveal tract FIG. 64. STAI'HYLOMA OF SCLERA. involved in the process atrophies, and its place is occupied by inflammatory exudations. There may be one or more pea- sized staphylomata, or the entire anterior half of the globe may form a single large, staphylomatous mass, involving ciliary body, lens, iris and cornea. The function of the eye is entirely and permanently destroyed. Amputation (Critchett's operation), or enucleation of the ball, is to be performed, when the tumor is large enough to warrant surgical interference. POSTERIOR STAPHYLOMA (Fig. 65). The pathogenesis of 134 A MANUAL OF CLINICAL OPHTHALMOLOGY. bulging of the sclera (non-traumatic) at the posterior pole of the globe, is dissimilar to the form just described. It is always present in high degrees of myopia, and its growth is dependent on the same causes that develop myopia. It is a true distention of the sclera, adjacent to the optic nerve, preceded by absorption of the choroid which so weakens it, that it cannot maintain its normal curve against the intra- ocular pressure. The true cause, and growth, of malig- nant myopia, whether inherited or acquired, are associated with weakness of the sclera, and its tendency to stretch, in this situation. The process is chronic and not attended by any evidences of inflammation in the sclera or adjoining coats. The staphyloma is at once seen by the ophthalmo- scope as a white placque, limited to one side (temporal), or surrounding the nerve with irregular small blotches of pigment distributed over its surface, traversed by retinal DISEASES OF THE SCLERA. 135 vessels. It is more or less distinctly bounded by choroidal tissue. Occasionally in advancing, or very high myopia, a second distention, joined to the first by a small ridge of normal sclera, and known as secondary staphyloma, is found. Patches of atrophied choroid in the foveal region, detached from the staphyloma, are not unusual. PART VIII. DISEASES OF THE CRYSTALLINE LENS AND LENS CAPSULE. LENTICULAR OPACITIES. CATARACT is an opacity of the lens, either congenital or acquired, and under these two heads the various forms of cataract are divided. CONGENITAL CATARACT is a development during intra- uterine life, as a consequence of anomalous structure or of embryonic disease, of certain distinctive opacities, which POSTERIOR POLAR CATARACT. have been classified and described under the following ap- propriate headings : (a] CENTRAL CATARACT is a small, round, dense white spot in the nucleus. (b) ANTERIOR POLAR CATARACT is an aggregation of numerous minute points of opacity grouped around the anterior extremity of the axis of the lens, sometimes associated with, and dependent on, pyramidal capsular cataract (exudation from the iris). 136 DISEASES OF THE LENS. 137 (c] POSTERIOR POLAR CATARACT is a similar opacity at the posterior pole of the lens, produced, probably, by the premature abolition of the hyaloid artery. Anterior and posterior polar cataract frequently co-exist in the same lens, and may be united by a line of opacity (fusiform cataract). (d) ZONULAR or LAMELLAR CATARACT, the form most fre- quently found, is an opacity involving one or more layers or strata of the lens about half-way between the periphery and nucleus, the portions within and without this ring re- maining transparent. The opaque lamella is seen by the ophthalmoscope to be of a dull gray color, sharply defined from the surrounding clear cortex, through which an indis- tinct view of the fundus can sometimes be had. The diagnosis is easily made when the pupil is dilated. TOTAL CONGENITAL CATARACT. The lens is either en- tirely opaque at birth, or opaque in its centre, the opacity rapidly advancing during the first few months of extra- uterine life, in the latter case, until the whole lens is opaque. The lens is at first soft and of normal size, but eventually shrinks and hardens from calcareous transformation. It is usually hereditary. It is of interest to know that while the varieties of cataract described above are in the majority of cases congenital, others, that resemble them in every way, are acquired through traumatism, local inflammations, and general disease, such as rachitis, convulsions, etc. Con- genital cataract may be monocular or binocular. The acuity of vision in any given case, will depend on the degree and extent of opacity in the pupillary area. Some subjects are enabled to pass through the school period, learning to read, write, etc., while others will be enabled to distinguish large objects only. Late in life, congenital cataracts are 138 A MANUAL OF CLINICAL OPHTHALMOLOGY. inclined to become wholly opaque. The "treatment is by discission, or iridectomy. ACQUIRED CATARACT. Traumatism, local inflammations, and debilitating constitutional affections, may produce catar- act at any age. The pathological process is primarily a dis- turbance of nutrition, and secondarily a disturbance of the anatomical relations of the strata of the lens absorption of the fluid, and sclerosis of its fibrous elements. In young individuals, twenty-five to thirty-five years old, the lens is soft, and lenticular opacities occurring in persons under the age of thirty years, are designated " soft " cataracts, while the term " hard " cataract is applied to opacities occurring in older persons. Traumatism, perforating corneal ulcer, chronic iritis and cyclitis, choroiditis, detachment of the retina, retinitis pig- mentosa, and diabetes, are among the ascertained causes of cataract in the young. Treatment : discission. SENILE CATARACT. The word senile is employed to de- scribe opacities occurring in persons of greater age than thirty years, and which can be ascribed only to senile change. Of course, the causes that are operative in the production of cataract in the young, are also operative in its production in older persons, and cataracts thus pro- duced are not, properly speaking, senile, but secondary secondary to traumatism, or to disease. Senile cataract is either " incipient" or " mature." The former is said to be nuclear when its starting point is in the centre, and cortical when the opacity begins in the pe- riphery of the lens. It may be observed, in connection with the natural his- tory of cataract, that a myopia of 3" or 4", due to swelling of the lens, usually precedes the loss of transparency. The CONGENITAL LAMELLAR CATARACT. (DILATED PUPIL). CONGENITAL LAMELLAR CATARACT ADVANC- ING TO TOTAL (DILATED Pui-n . INCIPIENT NUCLEAR CATARACT (DILATED PUPIL). INCIPIENT NUCLEAR AND CORTICAL CATARACT (DILATED PUPIL). CORTICAL CATARACT (DILATED PUPIL). CORTICAL CATARACT (UNDILATED PUPIL). CONGENITAL CAPSULAR CATARACT (DILATED PUPIL). IRREGULAR LENTICULAR AND CAPSULAR CATARACT (DILATED PUPIL). DISEASES OF THE LENS. 143 opacity commences as a few short streaks, seen as dark lines by the ophthalmoscope, in the cortex at the line of union of the different lens segments, or as a circular dark body limited to the nucleus, the process advancing by involvement of neighboring clear tissue until the entire lens is included. The period of growth from incipiency to maturity varies in different cases. It may be completed in a few months or in the longer lapse of years. Mature cataract becomes hypermature by a further tissue metamorphosis, the cortex becoming fluid, the fibres broken and irregular, and the lens shrunken, and infiltrated with myelin, cholesterin, and calcareous formations. Among the clinical features of cataract, it may be noted that one eye is, as a rule, first affected, its fellow following in the morbid process after a varying lapse of time. The patient suffers no pain, and consults the surgeon for the relief of gradually failing sight, which is very likely attributed to the lack of proper glasses. All objects are seen through a veil or mist which increases to blindness, or perception of light only, with increasing and .finally complete opacity of the lens. Such patients will very often not seek advice until the second eye is affected. By oblique illumination, the lens will show dark streaks, or areas, behind the pupil. By the ophthalmoscope, the opacity is clearly outlined against the red reflex of the fundus until the cataract is very nearly matured. The opacity is fixed, moving only with the movement of the ball (diagnosis between lenticular and vitreous opacity), and is seen immediately behind the pupil. A cataract is " ripe," and ready for operation, when, by oblique illumination, the opacity is seen on a plane, or nearly on a plane, with the pupillary margin, when vision is reduced to the perception of large moving objects, such 144 A MANUAL OF CLINICAL OPHTHALMOLOGY. as the hand, twelve inches away from the eye, and when light projection is possible in all parts of the visual field. (Patient is directed to look straight forward, and correctly give the position of the light as it is moved by the surgeon in the different situations. This the patient will only do when there is no serious defect of the eye ground.) K\- ceptionally, cataracts should be extracted before maturity. e.g., when both lenses are involved to the extent of pro- hibiting the necessary occupation of life. It is conservative surgery to operate on the eye first affected, when both are ripe. Treatment: extraction. Ninety per cent, regain useful vision. TRAUMATIC CATARACT. A contusion of the ball, ruptur- ing the lens capsule, disturbance of the anatomical arrange- ment of the layers or sectors of the lens, or laceration of its capsule by a foreign body, whether or not the lens is pierced, will lead to a partial or complete opacity of the crystalline body. As a rule, the entire lens participates in the morbid process. Immediately following the injury one or more stripes of opacity radiate through the lens, which swells and partly protrudes into the anterior chamber, where partial absorption takes place. Iritis is a frequent accom- paniment of traumatic cataract. Treatment : in young subjects the lens will probably undergo absorption without operation ; in elderly persons, it must be extracted. DISLOCATION OF THE LENS may exist congenitally, but it is more often acquired. A congenital anomaly of the vitreous or choroid is the underlying cause in the former, and the latter, may be ascribed to contusions, or to the direct and forcible contact of a foreign body. The lens substance DISEASES OF THE CAPSULE OF THE LENS. 145 usually becomes opaque, although it sometimes retains, in the congenital form, its transparency for many years. No treatment is advisable. In acquired dislocation of the lens, extraction should be performed when possible. APHAKIA, absence of the lens, is most frequently met with in persons upon whom discission or extraction has been performed. The diagnosis is made by the history, the appearance of the eye, deep anterior chamber, trembling of iris, absence of the small inverted image of a candle held a short distance from the eye (Purkinje's sign), high degree of hypermetropia, and by the loss of accommodation. Treatment : glasses for far and for near. DISEASES OF THE CAPSULE OF THE LENS. DEPOSITIONS ON THE ANTERIOR SURFACE are found, such as the remains of the embryonic pupillary membrane, the exudation from iritis, and cicatrices from temporary adhe- sions to the cornea, following perforating ulcer. On the posterior surface, the terminal remains of the hyaloid artery, and the deposition of irregularly shaped flocculi, precipi- tated from the vitreous, are occasionally found. WOUNDS. The capsule of the lens may be lacerated, and this injury is followed, in young persons, by retraction or gaping of the divided margins, produced by extrusion of lens matter, and by partial opacity of the anterior portion of the capsule. Slight wounds of the capsule in elderly persons are inclined to heal. Opacity of the capsule anteriorly, together with opacity of the adjoining lens, may entirely clear up. SECONDARY CATARACT is a loss of transparency of the capsule following, in a few weeks, extraction of the lens. 13 146 A MANUAL OF CLINICAL OPHTHALMOLOGY. Treatment. When the opaque capsule occupies the pupillary space, an opening should be made in its centre by means of two needles, or by division with a small sickle- shaped knife ; or, when possible, the opaque capsule should be extracted through an opening made in the cornea near its scleral margin. PART IX. DISEASES OF THE UVEAL TRACT. CONGENITAL ANOMALIES OF THE IRIS. ANIRIDIA is an absence of a part, usually the pupil- lary margin, or of the entire iris. It is an uncommon affection, and is found associated with other congenital defects, such as posterior polar cataract, or microphthalmus. COLOBOMA is a fissure of the iris, with its base at the pupillary margin, and its apex at or near the periphery. A similar defect in the ciliary body and choroid coat often co-exists. It is an indication of arrested development. PERSISTENT PUPILLARY MEMBRANE. The pupillary space is occupied in the fcetus by a thin, web-like membrane which occasionally remains after birth, as a few fine threads, running obliquely across the pupil, attached to the anterior surface of the iris. They might easily be mistaken for posterior synechiae, but their origin from the anterior surface, and not from the inner pupillary border, their fineness and uniformity of outline as contrasted with the irregularly shaped and dentated inflammatory adhe- sions, as well as their very slight influence on the mobility of the iris, will determine the diagnosis. POLYCORIA is a multiple pupil, formed by an imperfect coloboma, or by the remains of a persistent pupillary mem- brane, which divides the otherwise normal pupil into two or more spaces capable of contraction and expansion. ALBINISM is that congenital condition in which the uveal 147 148 A MANUAL OF CLINICAL OPHTHALMOLOGY. tract, the hair, eye-brows and lashes, contain no pigment cells. When the subject faces a bright light, the red reflex of the fundus shows through the pupil and inter- stices of the iris. Indistinct vision, from the imperfect absorption by the choroid of the rays of light and from myopia, congenital or acquired from the necessity of hold- ing objects close to the eye, and photophobia, are invari- ably present DISEASES OF THE IRIS. HYPER^EMIA OF THE IRIS is an abnormal fullness of its vessels preliminary to iritis, or accompanying inflamma- FIG. 67. POSTERIOR SYNECHIA. tion of the cornea, or of other and deeper-seated portions of the eye. It is recognized by the presence of enlarged vessels on the surface of the iris, its indolent response to variations of light, and by its lessened expansibility under the influence of mydriatics. The symptoms of hyperaemia are those of the disease it inaugurates or accompanies. PLASTIC IRITIS (Fig. 67). The conjunctiva in plastic iritis, DISEASES OF THE IRIS. 149 the most common inflammation involving the iris, is usually inflamed and chemosed, with a deep-seated partial or complete pericorneal zone of purplish vascularity. The iris, which also shows increased vascularity, is discolored and tumefied, and discharges on its surface, and in its par- enchyma, a tenacious lymphoid exudation, which quickly and permanently binds, if the disease is left uncontrolled, its pupillary border to the anterior surface of the lens cap- sule, thus forming posterior synechia. The synechiae, dis- colored by an intermixture of pigment from the uveal tract, visibly project in ragged edges from the pupillary margin. These adhesions may unite a part of the pupillary border to the anterior capsule of the lens, partial synechia, or the entire posterior surface of the lens may be adherent to the lens capsule (total or complete synechia), annihilating the posterior chamber. The pupillary space may be in part or altogether occluded by the membranous exudation, and, in such instances (they are not infrequent), the capsule imme- diately behind this space, is likely to become opaque, and the mobility of the iris lost. In this condition its response to mydriatics, is nearly or completely abolished, and the functions of the eye temporarily destroyed ; for vision is diminished in proportion to the extent and density of the exudation. Pain in the ball, radiating to parts supplied by the supra-orbital and infra-orbital branches of the fifth nerve, is felt. Increased lacrymation and intolerance of light, are also marked symptoms. Tension remains nor- mal. 'Sensitiveness over the ciliary region is excessive. The disease runs a course of from two to six weeks, or even longer. Chronic iritis as an independent affection rarely, if ever, exists. The word " chronic " as applied to plastic iritis, has refer- ence to the recurrent acute attacks, which are prone to occur I5O A MANUAL OF CLINICAL OPHTHALMOLOGY. from a disturbance of function caused by attachments be- tween iris and capsule, or from chronic inflammation of the neighboring parts. Iritis may under treatment recover without sequelae ; usually, however, synechia and minute patches on the lens capsule, mark the sites of adhesive exudation, and vision may be destroyed through pupillary occlusion. It is not infrequently found that a complete annular synechia re- mains, cutting off communication between the anterior and posterior chambers through the ordinary pupillary channel, and secondary glaucoma is the natural and inevitable con- sequence, unless the inter-pupillary communication is re- established by iridectomy. It is the duty of the surgeon, when the existence of this condition is definitely determined, to urge this operation, and to refuse to treat the case if the patient declines its immediate performance. It is not always easy to determine the cause of plastic iritis. It is consecutive to inflammation primarily in- volving any portion of the uveal tract, and to trauma- tism. The presence of a foreign body may set up a plastic iritis, or it may arise idiopathically. The common cause of the disease, are syphilis, gonorrhoea, rheumatism, and scrofula, or tuberculosis. Treatment is local and constitutional. The patient should be confined to a properly ventilated but darkened room- Atropine (gr. viij-5j), hot-water bathing, and leeches to the temple, are to be employed, and actively employed, locally. If the disease is due to traumatism, the appropriate local treatment should be instituted; if the outbreak is of rheu- matic origin, the salicylates are indicated ; if syphilis is the cause, the patient should be mercurialized to the point of mild sali vation,and mercury in lessening doses with the iodide of potassium, administered during the continuance of the DISEASES OF THE IRIS. 151 inflammation. The mercurials may be omitted if the affec- tion is due to gonorrhoea. In a word, the cause, whatever it may be, should be treated on general principles, inde- pendently of the local affection, the patient's strength nour- ished, and the general system built up by a generous dietary, tonics, and fresh air. SEROUS IRITIS, DESCEMITIS (Fig. 68), is recognized by the presence on the posterior surface of the cornea of a collection of minute points of exudation, and by a similar exudation, combined with larger and denser flakes, floating in the anterior portion of the vitreous chamber. The iris reacts sluggishly to the stimulus of light and accommo- FIG. 68. SEROUS IRITIS. dation, and may present one or more minute posterior synechiae. Light does not pass readily through the floccu- lated cornea and vitreous, and there is a resulting deterio- ration of vision. The details of the fundus are indistinctly seen by the ophthalmoscope. The nerve is ill-defined, and the retinal vessels veiled, as in neuro-retinitis. These appearances are due, as a rule, to the clouded media, but in some instances are the results of a co-existing optic neuritis. The pain and injection are inconsiderable ; they may, indeed, be altogether absent, and indistinct vision the symptom of which the patient most complains. The course of the disease is chronic, its etiology obscure, and the treat- 152 A MANUAL OF CLINICAL OPHTHALMOLOGY. ment unsatisfactory. Mydriatics, mercurials and the iodides are, however, employed. The nutrition of the lens is dis- turbed, streaks of opacity appearing in the cortex, followed by total opacity of the lens, in a small proportion of cases. PARENCHYMATOUS, OR SUPPURATIVE IRITIS. In simple plastic iritis, exudation from the inflamed membrane is largely deposited in the anterior chamber and pupillary space, but in parenchymatous iritis, the inflammatory exudates are mostly confined to the tissues of the iris, which become swollen and spongy in consequence, and its color changes to a yellow or greenish-yellow, as the lymphoid cells un- dergo transformation into pus. The pupillary border of the iris is hypertrophied and thickened by fibrinous exu- dations, which project into, and sometimes obliterate, the pupillary space. The characteristic sign of purulent iritis, is the deposition in the anterior chamber of pus, which, less consistent and more fluid than the hypopyon of keratitis, is absorbed and re-formed rapidly. Commonly there is a for- mation in one or more sections of the iris of small collec- tions of cells, tuberculous or gummatous according to the origin of the disease. Vision is generally permanently im- paired. The treatment is practically the same as that already given for the plastic form of iritis, and should be pushed energetically and persistently. MYDRIASIS, DILATATION OF PUPIL, is (i) Idiopathic when it persists for many years in one or both eyes, or alternates from one eye to the other, and is associated, in most cases, with paralysis of accommodation. It is likely to obtain in several members of a family, and exists without apparent cause other than heredity. (2) It is artificial, and transient, when the result of the instillation of a mydriatic; (3) symp- tomatic when it is the reflex of a lesion in the brain or spinal cord, or from intra-ocular, or extra-ocular pressure; (4) cmo- DISEASES OF THE IRIS. 153 tional when due to anger, fright, or nervous excitement. If the mydriasis is long continued, the local instillation of eser- ine may be beneficial. If, however, the mydriasis is due to a lesion of the cerebro-spinal system, treatment is unavailing. MYOSIS, CONTRACTION OF THE PUPIL, is (i) artificial and transient, when the result of the instillation of a myotic (eserine) ; (2) irritative when the 3d nerve, or its pupillary branch is excited to excessive action by central irritation, induced by the presence of a tumor, or by the continued, or strong contraction of other branches of the 3d nerve ; (3) reflex when due to neuralgia of the 5th nerve, or to in- testinal irritation ; (4) paralytic when the pupillary fibres in the cervical and dorsal plexus of the sympathetic are com- pressed or diseased from traumatism, aneurism, or other causes. Local treatment is useless when the myosis is the symptom of a central lesion. "ARGYLL-ROBERTSON PUPIL" is that condition in which the pupil contracts under the impulse supplied by the stimulus of the 3d nerve in the acts of convergence and accommodation, but not to the stimulus of light. HYPH.EMIA, or hemorrhage into the anterior chamber from the vessels of the iris, is spontaneous in sudden alteration in the tension of the ball, in glaucoma, and in menstrual irregu- larities ; and traumatic, in wounds, contusions and lacer- ations of the iris. In atrophied eye-balls, which are the seats of old hemorrhages, cholesterin crystals are sometimes found in the anterior chamber. Treatment is unnecessary. DETACHMENT OF THE IRIS from the ligamentum pec- tinatum, may occur as the result of a severe blow, and is always attended by hyphaemia, and by partial and tem- porary loss of vision. After the blood has been absorbed, the eye may regain normal vision. No treatment will restore the iris to its former position. 14 154 A MANUAL OF CLINICAL OPHTHALMOLOGY. TUMORS OF THE IRIS. CYSTS. One or more cysts, ranging in size from a pin- head to a pea, with solid or fluid contents, the result usu- ally of traumatism, may form on any part of the surface of the iris, and are attended with moderate inflammatory symptoms. They, together with the underlying iris, should be excised at the earliest possible moment. TUBERCLE is a collection of small, whitish elevations con- taining tuberculous matter, scattered over the surface, and coexist with similar growths in the choroid. They precede, or are developed, in a small proportion of cases, during general tuberculosis. GRANULOMA is a small benign tumor, resembling in appearance a granulation of the conjunctiva. The treat- ment is by excision with iridectomy. GUMMA is a syphilitic tumor, springing from the stroma at the pupillary border, or near the periphery of the iris, and consists of a mass of spindle-shaped cells, gummous exuda- tion, and newly-formed connective tissue, brownish-yellow in color, round in outline, vascular at its base, and projecting as far forward, in some instances, as the posterior surface of the cornea. It makes its appearance at the end of the second or the commencement of the third stage of constitu- tional syphilis, and, like gumma in other parts of the body, is amenable to mercury and potassium iodide administered in large doses. DISEASES OF THE CILIARY BODY. CYCLITIS, or inflammation of the ciliary body, is rarely an independent affection, but usually associated with disease of the iris or choroid, and should be considered as a com- plication, or concurrent symptom, in connection with inflam- DISEASES OF THE CILIARY BODY. 155 matory disease of these tissues. It is, therefore, an extension of inflammation of the iris, or choroid to the ciliary body, characterized by an increased sensibility to touch in the cil- iary region, and by the presence of opacities in the anterior portion of the vitreous humor. Treatment. Locally, atropine, hot water applications, and leeches to the temple. Internally, mercury and the iodides, or jaborandi. SYMPATHETIC OPHTHALMIA. The course of sympa- thetic inflammation is marked by two distinct and separate degrees of advancement, the stage of irritation and the stage of inflammation, which must be unmistakably recognized. The first stage, always the precursor of the second unless promptly discovered and checked by operation, is declared by a decrease in the range of accommodation in the eye not primarily affected, by photophobia, lacry- mation, slight pericorneal injection, sluggishness of the iris under the stimulus of light and of accommodation, and perhaps, by tenderness upon pressure over the ciliary region. Following, these symptoms, is the inauguration of the second stage with exudation into the anterior chamber and pupillary space, vitreous opacities, pain, moderate swell- ing of the optic nerve, and oedema of the retina. The flame is now well lighted up in the eye, and, with the super- vention of hypopyon, iritis, occlusion of the pupil, opacity of the lens, shrinking of the vitreous, and retino-choroiditis, goes on to panophthalmitis, atrophy, and destruction of the ball. The disease is transmitted along the ciliary nerves, or the lymphatic sheath of the optic nerve, or both. It may be caused by a foreign body, hernia of the iris, anterior synechia, dislocated lens, a cysticercus, trauma- 156 A MANUAL OF CLINICAL OPHTHALMOLOGY. tism, bony formation in the vitreous chamber, or by the irritation of an artificial eye. Treatment. Enucleation of the eye inducing irritation, in first stage ; local remedies, and mercurialization for the irido-choroiditis, in second stage, with enucleation of infect- ing eye, if it is hopelessly blind. CHRONIC CVCLITIS is the term given to a chronic inflam- mation involving nearly all the tissues of the eye, eventu- ating in the abolition of function, and in atrophy of the ball, f>/ithisis bnlbi. As a result of traumatism, an unsuccessful cataract extraction, for example, the uveal tract becomes inflamed, the iris totally adherent to the lens capsule, pupil occluded, lens capsule and lens opaque (if not previously extracted), ciliary body destroyed (atrophied), vitreous opaque and shrunken, retina detached, and the choroid dis- organized. The cornea, which may or may not be opaque, is lessened in its diameters. If inflammation should sub- sequently attack the eye thus destroyed, as not infrequently happens, the occurrence of a sympathetic inflammation in the sound eye is to be apprehended, and guarded against. After the lapse of years, the vitreous body of an eye de- stroyed through chronic cyclitis, is replaced by a button of bone, deposited very gradually from the choroid, which, acting as a foreign body, irritates the ciliary nerves by con- stant friction, and leads to sympathetic involvement of the sound eye. An atrophied eyeball is, therefore, a constant menace to the integrity of its fellow, and the only conser- vative treatment is enucleation. DISEASES OF THE CHOROID. 157 DISEASES OF THE CHOROID. CHOKOIDITIS. In inflammation of the choroid, its stroma is infiltrated with amorphous masses of exudation and col- lections of densely packed cellular elements at the periphery, pole, or in the neighborhood of the optic nerve, varying in size from a minute point to the patches of the diameter of the disc, or even larger. The pigment layer of the retina is always disturbed. The pigment cells are either absorbed or undergo proliferation, collecting in masses at the circum- ference of the patch. The exudate becomes absorbed in the later stages of the disease, its site being marked by an absence of pigment as well as of vessels, and the overlying retina is partly destroyed through cicatricial contraction. The patches vary in shape, but are either round or oval as a rule. The vitreous contains opacities, and is generally fluid. In purulent choroiditis, pus cells are dispersed every- where through the meshes of the choroid and retina, and may completely fill the vitreous chamber. The retina and choroid are so intimately associated in structure and function, that chronic disease of the one must involve the other. The names given to the various clinical manifestations of choroidal and retinal disease de- pend on the membrane in which it originates, but in every case it is a retino-cJwroiditis. The effect on vision of retino- choroiditis will depend on the site of the exudation, whether central (at or near the fovea) or peripheral, and on the amount of retinal tissue destroyed. It is much less, as a rule, than the ophthalmoscopic appearance would indicate. DISSEMINATED CHOROIDITIS (Fig. 69) is a collection of small, roundish aggregations of yellowish, subsequently white, exudation, surrounded by deposits of pigment, 158 A MANUAJL OF CLINICAL OPHTHALMOLOGY. scattered at first irregularly throughout the periphery, and, finally, in the neighborhood of the disc and macula. They rarely increase in size. AREOLAR CHOROIDITIS (Fig. 70). In this form of cho- roiditis the patches, fewer in number and larger in size than in disseminated choroiditis, are deposited here and there throughout the fundus. CENTRAL CHOROIDITIS is a limitation of the inflamma- tory and atrophic changes to the macular region. CENTRAL SENILE ATROPHY is characterized by absorp- tion of the choroidal tissue and destruction of the retina at and around the fovea, preceded, possibly, by apoplexy of the choroid. CENTRAL GUTTATE CHOROIDITIS (Fig. 71) is the term employed to designate the deposition, immediately behind the retina, of from six to twelve minute chalk-like aggrega- tions involving the fovea, or adjacent to it, and associated with partial destruction of the retina. It is commonly found in old persons. OPHTHALMOSCOPIC APPEARANCES. By the aid of the oph- thalmoscope, the observer is enabled to determine variations from the normal in color, together with the size, site, shape, approximate number arid character, of the discolorations de- scribed above. In the earlier stages of choroidal disease, the patches present a yellowish hue, which gradually assume, as the ghoroid is absorbed, the bluish-white color ofithe sclera, and are distinctly outlined by a black border of pigment. They vary in size and number, and are irregu- lar in shape. Occasionally a choroidal vessel is found run- ning across the patch. Among the patches, too, are often seen sm?ll black pigment spots, irregular in outline, which appear to be situated in the retina, as determined by their relation to the retinal vessels. The difference of level be- DISEASES OF THE CHOROID. FIG. 69. ATROPHY AFTER SYPHILITIC CHOROIDITIS, SHOWING VARIOUS DEGREES OF WASTING. a. Atrophy of pigment epithelium, b. Atrophy of epithelium and chorio-capillaris ; the large vessels exposed, c. Spots of complete atrophy, many with pigment accumula- tion. FIG. 70. CENTRAL CHOROIDITIS ( Wecker and Jaeger]. l6o A MANUAL OF CLINICAL OPHTHALMOLOGY. tween the centre of the patch and the adjoining fundus is always difficult, and sometimes impossible, to estimate ; if, however, the choroidal vessels have disappeared, and the retinal vessels pass over the affected spot, it is safe to assume that the choroid is the main and original seat of the disease. In disseminated choroiditis the spots are nqmerous, and average about half the size of the disc. They are found, FIG. 71. CENTRAL GUTTATE SENILE CHOROIDITIS. in the earlier stages of the disease, scattered over the equa- torial zone. In areolar choroiditis the patches are larger, several times the diameter of the disc, but fewer in num- ber, and usually involve the posterior pole. Round masses of pigment are spread, in its earliest stages, through the fundus, but these undergo gradual absorption, beginning in the centre and advancing to the circumference, leaving a white spot traversed by retinal vessels and outlined by DISEASES OF THE CHOROID. l6l pigment. The pigment line, in turn, is often girdled by a zone of opaque retina. The earliest change discernible by the ophthalmoscope in central choroiditis, is a collection of pigment spots in a mass of exudation, elevating the retina at and in the immediate neighborhood of the fovea. As the disease advances the spots become confluent, the exudation shallower, and the branches of the small retinal vessels turning toward the fovea are seen to bend at the margin of the plaque. Eventually the chorqid atrophies, and the overlying retina is destroyed, presenting the general appearances noticed in other forms of choroiditis. The whitish patch involving the foveal region in central senile atrophy, is preceded by no ophthalmoscopic evidence of inflammation. In choroiditis guttata, the ophthalmoscope reveals a collection, surrounding the fovea or between the fovea and disc, of pale yellow and glistening white dots, which have no clinical significance. In all forms of acute choroiditis, vitreous opacities are discernible by the ophthalmoscope. SYMPTOMS IN GENERAL. The main symptom is an im- pairment of vision, the character and degree of which will depend on the site of lesion, the extent of retinal implica- tion, and vitreous opacities. The visual declination is, it may be remarked here, not so great as the ophthalmo- scopic appearances would lead one to suppose. The patient will complain of a grayish or blackish defect in the centre of the object in view (positive scotoma), or, later on, of an utter effacement of the object in its centre (negative scotoma), or of a distortion of the object (metamorphopsia), and of sparks or flashes of light or color when the lids are opened or closed, owing to an irritation of the retinal elements (photopsia). The patient will complain, too, of spots or 1 62 A MANUAL OF CLINICAL OPHTHALMOLOGY. clouds which float before the sight, especially marked in a bright light In purulent choroiditis, the pseudo-glionia of some writers, vision is lost in a few hours because of the quick destruc- tion of the choroid and retina. Pus can easily be seen, by oblique illumination, collected in the vitreous chamber. The anterior chamber is shallow, iris and lens adherent, and both pushed forward by the purulent mass. The causes of choroidal disease are numerous. Con- genital and acquired syphilis, traumatism, metastatic infarction due to epidemic and sporadic cerebro-spinal meningitis, and other contagious fevers, pyaemia, endocar- ditis, and high myopia, may be mentioned. Treatment. In its early stages or manifestations, the dis- ease may be cured, or at least checked, by the energetic employment of the mercurials and iodides. The cause must be ascertained and treated on general principles. PART X. DISEASES OF THE VITREOUS. HYALITIS. : Inflammation of the vitreous is not an inde- pendent affection, but a development of cyclitis or choroid- itis. It is characterized by a change of consistency, opacities, and by partial disorganization of its own tissue. The opacities are of three varieties, namely, clouds of fine dust, significant of syphilitic disease of the choroid ; membranes, following hemorrhage, retinal detachment, and syphilitic chorio-retinitis ; and threads, or irregularly- shaped, dense, separate flocculi, seen in high grades of myopia, and in the various forms of chronic choroiditis. Purulent infiltration and degeneration of the vitreous fre- quently follow the entrance into the chamber of foreign bodies, choroiditis metastica, entozoon, etc., and eventuate in phthisis bulbi. MUSCLE VOLITANTES are minute physiological vitreous elements, causing a subjective sensation of shadows floating before the eye, not revealed by the ophthalmoscope, and while their existence is annoying, they are of little patho- logical importance. The causative agency is supposed to be ametropia, since they are dissipated by its correction. SYNCHISIS is the name given to a fluid condition of the vitreous. SYNCHISIS SCINTILLANS is the designation given to an accumulation of cholesterine and other crystals in the 163 164 A MANUAL OF CLINICAL OPHTHALMOLOGY. vitreous, revealed by the ophthalmoscope as glittering or silver-like reflections which move in all directions. The prognosis of vitreous opacities should always be in- fluenced by the reflection that they are, in fact, the floating wrecks of a preceding destructive inflammation of the choroid and retina, the visible marks of an inflammatory storm in these parts. Treatment is not encouraging. In opacities due to syphilitic disease, some improvement may be expected from mercury and the iodides. In a word, the underlying cause must be discovered and combated. The syphilis may yield to treatment, the hemorrhage be absorbed, and the foreign body removed by the proper treatment. PERSISTENT HYALOID ARTERY. In intra-uterine life the lens is supplied with blood from the hyaloid artery, a straight vessel given off to the posterior surface of the lens from one of the branches of the central retinal artery. It persists, as a fibrous cord, with its anterior end either attached to the posterior surface of the lens or floating unattached in the vitreous, in a small proportion of cases, and can easily be seen with the ophthalmoscope. FOREIGN BODIES, such as metallic chips, splinters of wood, shot, etc., are sometimes driven with great force through the external coats of the eye, and find lodgment in the vitreous chamber. It is a serious accident, termi- nating in the partial or complete destruction of the ball from supervening purulent inflammation, and is, moreover, a pro- lific source of sympathetic ophthalmia. The diagnosis is determined by the presence of a" superficial wound, sudden loss of vision, reduced tension, blood in the anterior and vitreous chambers, and, in some instances, by the ophthal- moscope and magnetic needle. A foreign body in the vitreous sometimes becomes en- DISEASES OF THE VITREOUS. 165 cysted, and remains for years without giving rise to serious symptoms. Its removal, by means of a magnet, is advis- able when practicable. If vision is completely and perma- nently lost, leaving a painful ball, enucleation should be promptly performed. PART XI. GLAUCOMA. Glaucoma is a disease characterized by abnormally in- creased intra-ocular pressure, usually and arbitrarily described under two main divisions, primary and secondary. The primary is subdivided into non-inflammatory or simple, and inflammatory. SIMPLE GLAUCOMA is a gradually advancing blindness with attendant, probably consequential, excavation of the optic nerve " amaurosis with excavation." Its pathology is not understood. The symptoms are not readily suggest- ive of the disease. The patient complains of gradually diminishing vision, and nothing more, as a rule. Even the pressure symptoms are negatively conspicuous. In truth, the symptoms of simple glaucoma are so little characteristic, that a diagnosis between cataract, atrophy of the nerve from other causes, and simple glaucoma can be determined only by the ophthalmoscope ; and even with this instru- ment as an aid to diagnosis, it is not always possible to definitely determine whether the cupping of the nerve is a precedent and independent, or a subsequent and dependent, condition. The cup, usually involving the entire disc, is shallow, surrounded by a narrow zone of atrophied choroid, and the arteries on the disc pulsate spontaneously, or can be made to pulsate by pressure of the fingers on the globe. The field of vision is limited concentrically, or the nasal field contracted, while the extreme temporal field, with 166 GLAUCOMA. 167 possibly one or more scotomata, is preserved to the last. Both eyes are, in the majority of cases, affected, although the disease is further advanced in one than in the other, when the patient comes under observation. If the patient seeks advice at a certain stage of the affection, it may be found that one disc is totally and the other only partially cupped. The disease runs a very chronic course, several years intervening before blindness is complete. Com- plete restoration of vision is rarely attained. The progress of the disease may be controlled, under favorable condi- tions, by operation. Treatment. Eserine ; iridectomy ; sclerotomy. CHRONIC INFLAMMATORY GLAUCOMA. In reference to the pathology of chronic inflammatory glaucoma (Figs. 72 and 73), it may be stated that changes in the periphery of the iris, which lead to partial closure or obliteration of the spaces of Fontana, thus preventing the outflow of intra- ocular fluids, are common. But whether these changes in the iris are primary and causative, or secondary and inci- dental to the glaucomatous process, is a question that has never been definitely determined. The immediate effect of such occlusion or obliteration of the spaces of Fontana is to add to the amount of intra-ocular fluid, and hence to increase intra-ocular tension. Other pathological pro- cesses, namely, peripheral adhesion of the iris to the cornea through inflammatory exudation, vascular engorgement of the iris and ciliary body, atrophy of the ciliary muscle, oblit- eration of the choroidal vessels and atrophy of its tissue, closure of the lymph spaces, sclerosis and degeneration of the retina and optic nerve, are directly due and traceable to increased tension. This form of glaucoma is characterized by the occurrence, following a premonitory stage of vary- 1 68 A MANUAL OF CLINICAL OPHTHALMOLOGY. ing duration, of attacks of true glaucoma, lasting from twelve to twenty-four hours. The symptoms of the premonitory stage are: (l) early presbyopia, or a recedence of the near point, due to pres- sure on the ciliary muscle, the patient requiring a stronger FIG. 73. GLAUCOMATOUS EXCAVATION. {Ophtkalmoscopic view.} GLAUCOMATOUS EXCAVATION OF THE OPTIC NERVE. (Vertical section.} plus glass for reading than the age would indicate, and there may be also a real diminution of refraction (acquired Hy- permetropia) ; (2) a colored ring is seen around a gas flame, caused by slight opacities in the media and by the dilated pupil ; (3) periodic obscuration of vision and ciliary neural- GLAUCOMA. 169 gia due to temporarily increased pressure. The objec- . tive signs present are increased tension, as determined by palpation over the closed lid, or directly on the sclera (normal tension is expressed by the letters Tn.; slightly increased tension by Tn. -{- I ; undoubtedly hard by Tn. -f- 2 ; stony hard by Tn. -f- 3 ; when slightly less than normal, by Tn. I ; undoubtedly soft by Tn. 2, very soft by Tn. 3) ; pulsation of the arteries on the disc, either spontaneous or easily induced by pressure on the globe. The intra-ocular pressure is so high that the blood enters the ball only with the systole of the heart, interrupting the con- tinuous flow through the artery, thus producing a systolic pulsation. This sign is not infrequently found in aortic dis- ease, and in exophthalmic goitre, and is occasionally found in persons apparently free from cardiac disease. Venous pul- sation has no pathological significance. The retinal veins are hyperaemic, tortuous, and expanded in calibre. The pupil is dilated and sluggish, a direct consequence of pressure on the ciliary nerves. There is, lastly, some opacity of the aqueous humor from the exudations of venous stasis. The prodromic stage may be said to be at an end, and true glaucoma begun, when, following one of these periodic attacks, the symptoms just described are unusually pro- nounced, with marked deterioration of vision. Each succes- sive attack is progressively severe, and occurs at lessening intervals, until the eye presents the distressingly character- istic appearances of glaucoma with vision entirely destroyed. The ciliary vessels are injected, the anterior chamber shal- low, the pupil widely dilated and immobile, the iris atro- phied, the lens partly opaque and slightly dislocated forward, the disc surrounded by a ring of atrophied choroid, and the eye, now blind, is the seat of periodic attacks of pain of the most excruciating character. 15 I/O A MANUAL OF CLINICAL OPHTHALMOLOGY. Treatment. During the premonitory stage, an attack may be warded off by the instillation of a solution of eser- ine sulphate (gr. ij-5j), repeated every two hours until the symptoms are relieved. When the disease is unmistakably developed, iridectomy should be at once performed. ACUTE INFLAMMATORY GLAUCOMA. A sudden outbreak of this disease, preceded in some cases by prodromic symp- toms, is announced by unmistakable signs. The conjunc- tiva is chemotic, the anterior ciliary and pericorneal vessels intensly injected, the cornea presents a steamy appearance and is denuded of its epithelium, the anterior chamber is shallow and the aqueous humor turbid, the iris widely dilated, oval and unresponsive to light, and but feebly, if at all, contracted by eserine, and the color of the pupillary space is grayish-green from opacity of the cornea and aqueous humor, and from reflection of light from the lens. The fundus is invisible. The patient complains of intense ciliary neural- gia, the pain radiating over the forehead and down the side of the nose, and of rapid and complete loss of vision, which is due to paralysis of the retina and optic nerve from exces- sive pressure. The attack lasts several days. The signs of pressure slowly subside, pain is diminished and finally disap- pears and vision is, in part, restored, although the eye never entirely regains its lost functions. Or, the acute may gradu- ally pass into the chronic form of the disease. An eye once attacked by acute glaucoma is predisposed to subsequent attacks. The optic nerve becomes excavated several days or weeks after the acute onset has subsided. The perform- ance of iridectomy should immediately follow the diagnosis. FULMINATING GLAUCOMA is the term applied to those cases in which the above conditions are most pronounced, and vision is lost in a few hours. Treatment. Iridectomy. GLAUCOMA. I/I SECONDARY GLAUCOMA is a result of certain local, chronic inflammatory diseases in which the intra-ocular pressure becomes permanently increased with excavation of the optic papilla. Among the causes thus operative, may be men- tioned anterior and annular synechiae, traumatic cataract, dislocation of the lens, and intra-ocular tumors. The prodromal stage is wanting. The symptoms are identical with those of chronic inflammatory glaucoma. Prognosis is unfavorable. Treatment. Iridectomy or sclerotomy. Glaucoma may be complicated with other diseases, such as cataract, detachment of the retina, atrophy of the optic nerve, etc. Its etiology is obscure. It affects persons who have passed the middle of adult life,* and preeminently those of a gouty diathesis. GLAUCOMATOUS DEGENERATION. After an eye has been in the condition of absolute glaucoma for a varying period of time, which cannot be accurately stated, it under- goes secondary changes of a degenerative character. Its volume may be decreased from ulcerative processes in the cornea, through which the cataractous lens and part of the fluid vitreous are expelled by hemorrhages from the dis- eased vessels of the retina and choroid, phthisis bulbi, or the weakened sclera, unable to resist the abnormal intra- ocular pressure, becomes staphylomatous, and the diame- ters of the ball enlarged. During the period of glau- comatous degeneration, the globe is, ordinarily, the seat of intense pain. The ball should be enucleated. * Mr. Priestly Smith has advanced the theory, based on numerous carefully conducted examinations, that idiopathic glaucoma is, in the main, dependent on an increase in size of the crystalline lens which, he claims, is common in advancing life. PART XII. NON-INFLAMMATORY DISEASES OF THE RETINA. HYPER/EMIA is an increase in length and width of the large retinal vessels, recognized by their lateral and vertical tortuosity, dark color, pronounced light reflex, which ex- tends far out toward the periphery of the fundus, by an increase in the apparent number and size of the smaller twigs, and by the color of the optic disc, which presents a deep red appearance so nearly the color of the surrounding fundus that the normal contrast in color between the two parts is almost lost. Pulsating veins on the disc are not infre- quently found in the absence of disease, and are not patho- logically significant, when moderate and confined to the superior and inferior veins, but pulsation of the smaller veins, and especially when it is noticeable some distance from the trunk, must be accepted as an evidence of disease. Hyperaemia of the retina and nerve, when it is not the initial stage of an acute inflammatory process, is an indica- tion of local irritation from ametropic strain, an associated symptom of disease of the uveal tract, or an evidence of central congestion or inflammation. The normal retinal variations are so great, that the diagnosis is difficult. The cause should be determined and treated on general principles. ANAEMIA of the retina is a symptom of constitutional dyscrasia. The calibre of the arteries is decreased, and 172 DISEASES OF THE RETINA. 173 they are less numerous, relatively, on the disc than in health. The veins are unaltered, or slightly tortuous, and the disc pale. EMBOLISM OF THE CENTRAL RETINAL ARTERY (Fig. 74) is a clot or embolus, which cuts off the retinal circulation, and is immediately followed by complete and incurable blindness. The distal branches assume a thread-like FIG. 74. EMHOLISM OF THE CENTRAL ARTERY OK THE RETINA. appearance, and have no light reflex. The veins are thin, the disc white, and pulsation in the arteries or veins can- not be induced by pressure on the ball. Degeneration of the retina rapidly follows. It becomes opaque; the opacity be- ing more pronounced in the region of the fovea, in which situation a well-marked, round, red spot (the choroid thus showing its normal color through the thinnest portion of the retina by contrast with the surrounding opacity) is dis- 174 A MANUAL OF CLINICAL OPHTHALMOLOGY. tinctly seen. Atrophy of the retina and nerve follow. Embolus of a branch of the central artery of the retina is occasionally found, and the part of the retina nourished by the affected vessel, becomes opaque, the veins dilated, and localized hemorrhages, which appear as dark red blotches, with flame-like marginal serrations, occur. Vision is lost in the section of the field governed by the diseased retina. Embolus is caused by hypertrophy and valvular disease of the heart, atheroma, pregnancy, and Bright's disease. Treatment is of no avail. The pathological changes of retinitis are modified by the cause, nature and tissue limitations of the process. The inflammation may be limited to the retina, or involve the optic nerve, papilla and choroid. In oedema, the fibre and nerve layer of the retina is infil- trated by serum, which separates its elements into spaces of varying size. The fibres are compressed, opaque, gran- ular, and swollen. The entire retina may be affected. In hemorrhagic retinitis, the blood primarily escapes into the nerve-fibre layer or immediately below it, and thence into the other layers, destroying the elements by compression. The interstitial coagula may extend forward into the vit- reous. The blood-cells break up finally, and the portion not absorbed is changed into lymph corpuscles, which form whitish or yellowish plaques. In extensive hemorrhage, the retinal pigment is disturbed and a pigmented cicatrix formed. Small hemorrhages may be, and frequently are, entirely absorbed. HEMORRHAGE OF THE RETINA is a single, or multiple effusion of blood. It occurs, without preceding inflamma- tion, as the result of a blow, high myopia, choroidal disc or as a symptom of some functional or organic disturbance DISEASES OF THE RETINA. 175 in other situations of the body. The exuded blood collects in one or more spaces, which are separated, one from the other, by compressed retinal tissue, and undergoes partial or complete absorption. The unabsorbed portion of the blood is formed into collections of lymph-cells, with alterations in the underlying pigment. Retinal hemorrhage is easily recognized by the ophthalmoscope as flame-shaped, or round, dark-red spots in the neighborhood of the disc or fovea. The presence of non-traumatic hemorrhage into the retina, is indicative of some grave disorder in other parts of the system diabetes, or atheroma of the vessels, for instance. OPAQUE NERVE FIBRES is a shiny, white and irregu- larly band-shaped opacity, a continuation forward into the fibre layer of the retina, of the white substance of Schwann, which normally stops at the scleral opening. It is phy- siological, and its only effect on vision is to increase the size of the blind spot. INFLAMMATORY DISEASES OF THE RETINA. HEMORRHAGIC RETINITIS. In this affection, the most prominent ophthalmoscopic symptom is extravasations of blood in the retina. The hemorrhagic areas are minute and numerous, scattered here and there throughout the fundus, and are, as a rule, in close proximity to the larger arteries. Spots of hemorrhage also appear on and in the immediate neighborhood of the swollen disc. The retina is opaque from oedema, the veins large, dark and tortuous, the arteries are conversely small, some of them appearing as white lines devoid of blood. The disc is hyperaemic, its outlines obscured by exudation, and small parallel fine stripes, hypertrophied nerve fibres, radiate from it into the retina. Yellow, or whitish round patches (old hemorrhages, 1/6 A MANUAL OF CLINICAL OPHTHALMOLOGY. fatty degeneration, or choroidal exudation) are seen in the retina. The vitreous is partly opaque from hemorrhages into its substance from the choroid or retina. The retinitis may be considered either as the cause of the extravasation, as in neuro-retinitis from cerebral tumor, or as a result of it. In the latter case, the hemorrhagic spots arc- not so numerous, and are limited, moreover, to the retinal section in which an infarction or embolus has occurred, or exclusively to the region of the macula. The effect on vision, depends largely on the extent and site of the hemorrhage, and on the proportion of nerve and retinal tissue destroyed. Examination will reveal one or more scotomata, central or peripheral, with diminution of central vision from oedema of the retina and vitreous opa- cities. The disease may involve one or both eyes. Treatment must be determined by the cause. Rest, leeching, and counter-irritation are indicated locally. ALBUMINURIC RETINITIS (Fig. 75). The retina in this disease, is the seat of pathological changes. The papilla is oedematous and swollen, the surrounding retina oedema- tous, and slightly detached. The rods and cones arc partly destroyed. The nerve- fib re layer is infiltrated with exudation. The fibres are hypertrophied, sclerosed, or transformed at intervals along their course into granules and fat cells, especially marked in the region of the macula. The vascular walls are thickened, and the lumen of the ves- sels contracted. Hemorrhages occur in the fibre and granular layers. Ophthalmoscopic examination reveals a hyperaemic and swollen disc, the outlines of which are lost, parallel white lines or stripes running into the retina, swollen veins, normal arteries, small hemorrhages in the neighborhood of the disc, round, white, small isolated patches of granular and fat cells, DISEASES OF THE RETINA. 177 and a stellate series of bright, glistening stripes of hypertro- phied and infiltrated fibres, which radiate from the macula. From these appearances, the diagnosis of kidney disease is easily made. The disturbance of vision is not so great as the appear- ances thus revealed might lead one to suppose. The acuity FIG. 75. RETINITIS ALBUMINURICA. of central vision is moderately reduced, but there is no limi- tation of the field, no scotoma, nor loss of color perception. The retinal changes occur, as a rule, late in the course of the disease, are chronic in character, and involve both eyes. They vary with the intensity of the kidney affection. If the nephritic inflammation is relieved, the eye lesions may 16 1/8 A MANUAL OF CLINICAL OPHTHALMOLOGY. entirely disappear. Ordinarily, however, the diagnosis is grave. Treatment is general and symptomatic. Retinal hemorrhages, hemorrhagic retinitis with plaques of white degeneration, paleness of the disc, distended and tor- tuous veins, and vitreous opacities, are frequently observed as localized expressions, in many of the severer blood affections, such as leucocythemia, pernicious anaemia, and in diabetes insipidus and mellitus. Treatment should be directed, as in albuminuric retinitis, to the primary dis- ease. To promote absorption of the hemorrhage, iodide of potassium in small doses is recommended. DIFFUSE CHRONIC RETINITIS is pathologically character- ized by an infiltration of the retina, the inner layers more especially, with lymph cells, numerous along the vascular areas, followed by the growth of interstitial connective tis- sue. The nerve fibre and molecular layers, thickened and permeated in spots by retinal pigment, finally atrophy, destroying in part the rods and cones. The choroid, in the majority of cases, participates in the morbid process as ;i disseminated choroiditis, and the optic nerve is swollen from infiltration of solid and fluid exudation. By the ophthalmoscope the papilla is seen to be hyper- aemic, the edge of the disc indistinct, the choroidal rin^ veiled by oedema, the retina around the disc opaque, the opacity fading peripherally to the normal reflex, the arteries reduced in calibre, the veins distended, and all vessels more or less veiled in the neighborhood of the disc by the retinal opacity, which is more marked in this situation. The fluid vitreous is filled with fine, dust-like opacities, which float in clouds, or appear as dense and large membranes. Circular patches of atrophied choroid, surrounded by pigment, are frequently found near the periphery. Corneal DISEASES OF THE RETINA. 179 opacities and the marks of an old iritis, are sometimes observed. Symptoms. Diminished central vision, particularly in dull light, floating clouds or spots, photopsia, metamorphop- sia, slight limitation of the field peripherally, deficient color sense in the late stages, and, frequently, scotomata. Diffuse chronic retinitis may be either monocular or binocular, is chronic in its course, liable to relapses, and ends, unless treated energetically, in atrophy of the optic nerve and retina. Tertiary and congenital syphilis, chronic choroiditis, and sympathetic inflammation, are among the common causes of the disease, which may, however, arise idio- pathically. Treatment consists in local blood-letting, counter-irrita- tion and mercurial inunctions, carried to the point of sali- vation, and in the liberal exhibition of the iodides. RETINITIS PIGMENTOSA (Fig. 76) is chronic in its mani- festations. Gradually the nervous elements of the optic nerve and retina atrophy. The layers of the retina, which is involved in its entire thickness, are infiltrated with pig- ment, which collects in great abundance in the fibre layer, and especially along the blood-vessels at their bifurca- tions. Cystic degeneration occurs in places with complete destruction of the rods and cones. The vascular walls, arterial and venous, are thickened and their lumen so dimin- ished that they appear peripherally as white lines or fibrous cords. The optic nerve is finally completely atrophied. Symptoms. Central and peripheric vision'slowly declines until the perception of light is lost, the field contracting concentrically, central vision being retained to the last. Night blindness (hemeralopia) is one of the earliest symp- toms of which the patient complains. Pigment spots of I SO A MANUAL OF CLINICAL OPHTHALMOLOGY. curious shape, not unlike bone corpuscles, more numerous peripherally than around the disc, are revealed by the oph- thalmoscope. These spots are greatest in number at the bifurcation of the larger vessels. The disc is white, the arteries and veins reduced in number, size and calibre. FIG. 76. RETINITIS PIGMENTOSA. and are accompanied by white lines. The light column is very fine, or altogether lost. The disease, usually developed in young persons, is hereditary, a frequent taint in the offsprings of consanguin- eous marriage, continues through a long course of years, and affects both eyes. DISEASES OF THE RETINA.. l8l Treatment is of very little value ; electricity and "strych- nine may, however, retard its course, and should be em- ployed. DETACHMENT OF THE RETINA (Fig. 77) is a separation from the choroid of all except its pigment layer. The detachment may be confined to a small area, or include the entire retina from the optic nerve to the ora serrata. It is caused by the sudden or gradual discharge of fluid from the choroidal vessels, the exudation of solid inflammatory new formations, the development of choroidal tumors, or FIG. 77. OPHTHALMOSCOPIC APPEARANCE OF DETACHED RETINA (ERECT IMAGE). <* After Wecker and Jaeger. by contraction of the connective tissue elements of the retina. The detached retina floating forward in the vitreous is not at first appreciably changed from the normal, but it eventually becomes degenerated, thickened and opaque, from a diffuse hyperplasia and consequent atrophy of its nervous elements. The subretinal fluid is thin, yellowish in color, and contains fat, lymph, blood-cells, and cholesterin. The fluid may be altogether sanguineous. The vitreous is opaque, partly fluid, and partly transformed into connective tissue. Tension is diminished. Symptoms. There is a sudden loss of a part of the visual 1 82 A MANUAL OF CLINICAL OPHTHALMOLOGY. field, the position and extent of which corresponds to the position and extent of the retinal detachment. CentraJ vision is deteriorated, objects distorted or only seen in part, and black opacities float in the visual field. As the fluid changes its position, gradually subsiding to the most dependent portion of the fundus, the blindness correspond- ingly alters. A portion of the field is usually retained for a long period of time, but is eventually, and gradually, lost through cataractous formation, or other degenerative changes. The ophthalmoscope shows a blue-white or gray reflex, much nearer the observer's eye than the bright red reflex of the healthy fundus surrounding it. The detached retina, which is seen most clearly with a strong convex glass (20 u ), floats in wavy undulations, and, adhering to its uneven sur- face dark lines, vessels from which the central bright line of reflex has disappeared, are seen. Floating vitreous opacities are invariably present. Detachment of the retina is caused by traumatism, high myopia with posterior staphyloma, tumors, hemorrhage, cysticercus, and, perhaps, by uncorrected presbyopia. The prognosis is unfavorable, although in a small proportion of cases, the retina returns to its normal position under treatment. Treatment. The patient should be kept in recumbent position, a pressure bandage applied over the eyes, and hypodermic injections of pilocarpine, gr. ^, repeated often enough to insure profuse perspiration, are administered. \Yhcn the detachment is not caused by tumor, high myopia, or other evident organic change, an operation by which the subretinal fluid is allowed to drain off", is advis- able. ACUTE CENTRAL RETINITIS, the result of exposure to DISEASES OF THE RETINA. 183 direct sunlight, or to the reflection of the sun on snow or water, is an active inflammation of the foveal region, char- acterized by metamorphopsia, and central scotoma for white and colors. The ophthalmoscope shows one or more white spots at the fovea, circumscribed by a zone of redness, which gradually shades off into the normal color of the fundus. The severity of the lesion will depend upon the length of time the eye has been exposed to the light. Complete recovery is unusual, but amelioration of the disease follows active treatment by strychnia, electricity, local bleeding during the congestive stage, and protection from light. HYPER/ESTHESIA of the retina is a condition sometimes found in anaemic, hysterical women, and in hypochondriacal men, and gives rise to concentric, or irregular limitation of the visual field, and to deterioration of central vision. Lacrymation, photophobia, and blepharospasm are accom- panying symptoms. The ophthalmoscope shows no evi- dence of disease. Remedies should be addressed to the cause, the eyes put at rest, protected from light, and the system built up by tonics. ANAESTHESIA of the retina is a rare, functional conse- quence of latent muscular insufficiency with co-existing ametropia. The acuity of vision, and the visual field, may be at first normal, but invariably deteriorate during exam- ination. The patient suffers from accommodative and muscu- lar asthenopia. The treatment is to correct the error of refraction by lenses, and the muscular anomaly by tenoto- mies. GLIOMA OF THE RETINA is a cancerous growth, composed of softened nerve tissue infiltrated with small round cells, which spring from the retina. It is of rapid development, 184 A MANUAL OF CLINICAL OPHTHALMOLOGY. invading the optic nerve, surrounding parts in the orbit and skull, and terminates fatally in a few months. Treatment. Extirpation of the eye-ball. The disease shows a singular tendency to reappear in the second eye, or in the brain. CONTINUED EXPOSURE to bright light, or to its reflection from water or snow, or to dazzling flashes of lightning, may lead to structural changes in the retina near the fovea. They are revealed by the ophthalmoscope as a closely united collection of pale-yellow and small round spots. Patients suffering from this affection, complain of metamor- phopsia, and of diminished central vision or of negative scotoma. It is in some cases modified by treatment, but usually leaves the vision permanently crippled, the result of destructive changes of the retina at the fovea. Treatment consists in rest, and in protection of the eyes from light, in small doses of potassium iodide and mercury, and, locally, in blood-letting and counter-irritation. PART XIII. DISEASES OF THE OPTIC NERVE. The physiological variations of the optic nerve as seen by the ophthalmoscope are numerous, and by this means alone one is often unable to differentiate between them and pathological conditions. The disc in health varies in color ; it may be white with few vessels, or so red, from the presence of fine vessels, that it differs very little from the normal choroidal reflex ; it may show black points of pig- ment, or be partly or wholly surrounded by a well-marked pigmented ring of considerable breadth ; its surface may be plane, or it may present a small excavation in its centre, or nearly the entire disc may be physiologically cupped, and clearly show, at its bottom, the mottled connective tissue web of the lamina cribrosa. Venous pulsation may be present or absent. The size and divisions of the arteries and veins in health are not invariable. In many cases, all areas of the visual field for white and colors, and for sco- tomata, must be determined by the perimeter, and the acuity of vision ascertained, to confirm the previous diag- nosis by the ophthalmoscope. OPTIC NEURITIS (Fig. 78). This affection is character- ized by hyperaemia of the disc, which is heightened in color from the presence of numerous small vessels, exception- ally seen in the normal eye, and by an obliterative exuda- tion of inflammatory products into its excavation. The clear outline of the disc, thus swollen by serous and solid exuda- 185 1 86 A MANUAL OF CLINICAL OPHTHALMOLOGY. tion is lost, and imperceptibly fades into the retina. The veins are distended and pulsate, the arteries either normal or reduced in size, while both arteries and veins are, in part, hidden by inflammatory exudates. The retina, in immediate proximity to the nerve, is streaked, thickened, and slightly opaque. In mild cases of optic neuritis, those usually classi- fied as hyperaemia, the changes just cited are so slight that Fin. 78. it is extremely difficult to arrive at a correct diagnosis ; on the other hand, they may be so considerable, as in choked disc, that even the site of the nerve can be only negatively determined by the blood-vessels. In the latter case, .small hemorrhages on or near the disc are common. PAPILLITIS is an inflammation limited to the intraocular end of the optic nerve. The signs manifest by the ophthal- DISEASES OF THE OPTIC NERVE. l8/ moscope, correspond to those described in optic neuritis, and affect the disc and retina immediately around it. NEURO-RETINITIS involves the retina, as well as the optic nerve, as in albuminuric retinitis, and is characterized by hemorrhages, patches of fatty degeneration, hypertrophy of its nervous elements, and deposition of pigment. Symptoms. Gradual failure of central vision. The vis- ual field is contracted peripherally, or in sectors for white and colors, and these may involve one- half the field (hemi- anopsia). Central color scotoma is an occasional symptom. There is an absence of pain. In optic neuritis there is an exudation of serous and plastic material in and about the papilla, perivasculitis, formation of new blood-vessels, swelling of the nerve fibres, and cedema of the optic sheath just behind the sclera. At a later stage of the morbid process, the inter- cellular infiltration is transformed into connective tissue which, by pressure, cuts off the supply of blood to the nerve fibres, causing them to atrophy, or to undergo fatty degen- eration. Among the numerous causes of optic neuritis may be mentioned brain and orbital tumors, injuries to the skull, simple and tubercular meningitis, erysipelas, periostitis, anaemia, diabetes, Bright's disease, diphtheria, scarlet and typhoid fever, measles, etc. Optic neuritis due to incurable constitutional or orbital disease, ends in total atrophy of the nerve fibres, in the course of a few months or years. When due to syphilitic tumors, or other curable affections, local or systemic, the optic neuritis slowly subsides under treatment, and vision may be completely restored. More frequently, however, the disease is only checked, the vision being permanently impaired. 1 88 A MANUAL OF CLINICAL OPHTHALMOLOGY. Treatment should be actively and persistently carried on. The underlying cause, whatever it may be, should be ascer- tained and the remedies best suited to its relief or cure, administered. Potassium iodide and mercury, local and general bloodletting, and, in acute cases, profuse diaphoresis should, as a rule, be employed independently of the cause. RETRO-BULBAR OPTIC NEURITIS is manifested in two forms, acute and chronic. Acute retro-bulbar optic neuritis is caused by exposure to cold, sudden cessation of the men- strual flux, and other causes which lead to a sudden serous exudation into the vaginal sheath of the optic nerve. Total blindness follows in a few days, the result of pressure on the blood-vessels and consequent functional inactivity of the nerve fibres. The ophthalmoscope reveals a papillitis of moderate severity. The disease, if seen in time, yields to energetic and well-directed medication, that is to say, to general blood-letting, salivation, and active diaphoresis. Chronic retro-bulbar optic neuritis, is an interstitial inflammation affecting, primarily, the axial fibres, and, secondarily, all fibres of the optic nerve. There is an hyper- trophy of the connective tissue fibres, followed by atrophy of the nerve. The ophthalmoscope shows a dull, slightly hyperaemic and foggy papilla, the outline of which is in places obscured. The veins are enlarged and the arteries diminished in size. The symptoms are slowly diminishing central vision ; cen- tral color perception and, later, perception for white, is lost. The patient's single complaint is loss of vision ; no pain or headache is experienced. Its most common cause, is the excessive use of tobacco and alcohol, one or both. Other toxic agents, such as quinine, lead, and syphilis, cause this form of the disease. Treatment. In tobacco and alcohol amblyopia the causa- DISEASES OF THE OPTIC NERVE. 189 tive agents must be abandoned in toto, and strychnine hypodermatically administered in increasing doses. This treatment will in most cases greatly relieve, or altogether cure, if the disease has not advanced to atrophy. Elec- tricity is also indicated in these cases. If syphilis is the cause, iodide of potassium and mercury are the most effect- ive remedies. ATROPHY OF THE OPTIC NERVE (Fig 79). Atrophy of FIG. 79. ATROPHIC EXCAVATION. the optic nerve fibres is the result of an increase in the in- terstitial connective tissue in the intra-ocular extremity alone, or in the nerve stem from the chiasm to the ball. It is primary when the result of a neuritis, and secondary when the deep origin of the nerve is destroyed, or when the retina is the site of the original lesion. Atrophy of the intra-ocular extremity of the nerve is the result of disease of the nerve, papilla, or of the retina. I9O A MANUAL OF CLINICAL OPHTHALMOLOGY. Causes. I. Mechanical pressure from tumors, orbital cellulitis, meningitis, inflammatory exudates, traumatism, and in hydrocephalus. 2. Embolus in the central retinal artery, which cuts off the blood supply, and in this way starves the nerve. 3. Traumatic or surgical section of the nerve. 4. Disease of nerve at its periphery, the retina, or at its origin in the optic thalami and neighboring basal ganglia. 5. Gray degeneration of the optic nerve, the final stage of neuritis medullaris, in which the fibres undergo softening and destruction in one or more bundles. 6. Sim- ple atrophy of the nerve trunk, and its intra-ocular end as a part of a similar process in the brain and spinal cord. This form is frequently associated with tabes dorsalis and cerebral sclerosis. OPHTHALMOSCOPIC APPEARANCES vary with the cause of the atrophy. The disc, in atrophy following papillitis, is in- creased in size, and the lamina cribrosa and its outline are more orl*ss obliterated by exudation in its tissue as well as in the surrounding retina. The arterial walls are thickened and their lumen lessened ; the veins may be distended and tortuous, normal, or reduced in size, and marks of old hem- orrhages, and of pigment changes, are discernible around the disc. The disc, following interstitial and medullary neuritis, is discolored, its edges and centre appear veiled, and the arteries and veins, particularly the former, are small. There are no evidences of gross lesions. The disc in simple or progressive atrophy of the optic nerve, is of a dead or bluish-white, sharply outlined against the red reflex from the choroid. The lamina cribrosa is distinctly visible, the nerve cupped, arteries reduced to white threads without any appearance of capillary dis- tribution, the veins more numerous and distinct than the arteries, but not so large or numerous as in health. DISEASES OF THE OPTIC NERVE. 19! The symptoms are gradual diminution in the acuity of vision, concentric limitation of the visual field for white and colors, loss of sectors of the field, central white and color scotoma, and hemianopsia. Both eyes are usually involved, the disease advancing equally in the two eyes, or more rap- idly in one than in the other. Treatment. Iodide of potassium, oxide of silver, bichlo- ride of mercury and electricity. TOBACCO AND ALCOHOL AMBLYOPIA. In this disease, which occurs so frequently and is so amenable to treatment that it would seem to demand separate mention, the con- nective tissue binding together the bundles of nerve fibres becomes hypertrophied, and the nerve fibres themselves un- dergo fatty degeneration late in the course of the disease, either from pressure, or from the direct action of the toxic agents. The structural changes in the optic nerve trunk in case of simple tobacco amblyopia are not easily determined, because persons addicted to the excessive use of tobacco are, in a very great majority of cases, also intemperate in the use of alcohol. The symptoms and ophthalmoscopic appear- ances are, however, identical, whether the cause be single or dual. These changes manifest themselves in a slow deteriora- tion of vision with central color scotoma, the peripheric field of vision for white and colors remaining unchanged until late in the progress of the disease, or until atrophic changes are well marked in the optic nerve. The disc is either normal or slightly hyperaemic, and its outline indistinct, at least in part. Later in the course of the disease, the disc presents the aspect of atrophy which follows a retro-bulbar neuritis, so that it is discolored and comparatively free from vascularity. Unless the disease has progressed to atrophy of the optic nerve when seen, the prognosis is good, provided the IQ2 A MANUAL OF CLINICAL OPHTHALMOLOGY. patient can abstain altogether from the use of tobacco and alcohol. Total abstinence from the use of alcohol and tobacco is a prerequisite to treatment, which consists, medicinally, in the use of strychnine. This agent should be gradually increased until maximum doses, the fifth of a grain three times daily, are reached. Local extraction of blood is valuable in patients who are not anaemic. Men are more frequently affected than women, and both eyes are usually, and equally, affected. HEMIANOPSIA is the condition in which one-half of the field of vision is lost. It is bilateral when the temporal half of one and the nasal half of the other eye is lost; bi- tcinporal when the temporal, binasal when the nasal halves of the field are lost, and vertical when the dividing line is horizontal and the upper or lower field is wanting. The dividing line, vertical or horizontal, rarely passes through the point of fixation, but makes a small curve around it, thus showing that the fovea is functionating. Other sec- tions, corresponding in each eye, may be obliterated. The ophthalmoscope reveals nothing abnormal, excepting atrophy of the optic nerve in the late stages of the disease. Hemian )psia is caused by pressure (tumor) upon half the chiasm, optic tract, or deep origin of the nerve, or destruc- tion of these parts from other organic changes. PART XIV. DISEASES OF THE ORBITAL CAVITY. PERIOSTITIS. The periosteal lining of the bony walls of the orbital cavity is sometimes the seat of inflammation of a chronic character, usually limited to a small area. The inflammatory process may, however, be so extensive as to involve the periosteum lining the frontal sinuses and the antrum of Highmore, and so protracted as to lead to ex- tensive necrosis of the underlying bones. It is usually found as a local indication of syphilitic, or tuberculous disease. The local, as well as the constitutional, treatment is the same as for periostitis in other situations. The affec- tion rarely involves the eyeball. PHLEGMON OR ABSCESS. From injury, thrombosis, ery- sipelas, etc., the supporting fat and loose connective tissue of the orbital cavity may become acutely inflamed. It is a purulent inflammation, characterized by marked oedema and increased tension of the conjunctiva and lids, which are distended forward, and by fixation of the eyeball in a straight or deviating position, and consequent double vision. It is an acutely painful affection, and should be relieved by free incisions, repeated if necessary, drainage, and by antiseptic dressings. TUMORS OF THE ORBIT. Cystic tumors, degeneration of the lacrymal gland, and various other forms of benign and malignant growths, are not uncommonly met with in this situation. They are easy of diagnosis. The treat- ment is by removal. i7 193 194 A MANUAL OF CLINICAL OPHTHALMOLOGY. EXOPHTHALMUS is a bulging forward of one or both eye- balls. The protrusion of one eye is likely to be the result of local cause (abscess, injury, aneurism, etc.), and should be treated accordingly. Protrusion of both eyeballs is, on the other hand, likely to be the result of a remote or sys- temic cause, such as hypertrophy of the thyroid gland, or of the heart, and, under these conditions, local treatment is of no avail. ENOPHTHALMUS is a sinking backward, or retraction in the orbital cavity, of one or both eyeballs. In senile enophthalmus, which is due to the gradual absorption of the orbital fat in old persons, both eyes are affected to the same degree. When one eye is retracted from trauma- tism, involving a fracture of the walls of the orbit, the result- ing inflammation is severe, an abscess forms, the eyeball becomes immovable, and atrophy! of the optic nerve is the ultimate consequence. PART XV. OPERATIONS. Such portions of the surgeon's person as are likely to come in contact with the patient, as well as the instruments and parts to be operated on, should be free from infection. To this end, the operator's hands should be thoroughly scrubbed with soap and hot water, and then bathed in a 1-5000 solution of the bichloride of mercury. Great care must be exercised, too, to render aseptic the conjunctival sac, the under surface of the lids, eyelashes and neigh- boring parts of the patient's face. The instruments should be disinfected by a 15000 solution of the bichloride of mercury, or, better still, by a saturated solution of boric acid. In the minor operations, as for squint, pterygium, etc., these prophylactic measures against micro-organisms, may be considered as complete when the operator's hands and instruments, and the patient's eye, have been suitably cleansed. Any coincident disease of the eye of an inflam- matory character should receive the necessary attention, and the general system put in the best possible condition, before the eye is invaded by the surgeon's knife in the graver operations. The eye is sufficiently anaesthetized by four or five instillations, at intervals of five minutes, of a four per cent, solution of the hydrochlorate of cocaine, to render all operations, except enucleation, painless. For plastic 195 196 A MANUAL OF CLINICAL OPHTHALMOLOGY. operations on the lids, and for enucleation, ether should be employed. CATARACT EXTRACTION WITH IRIDECTOMY. The patient FIG. 80. LID SPECULUM. is placed in a recumbent position, face up, and the eye to be operated on suitably illuminated. The speculum (Fig. 80) is then inserted or the upper lid elevated by an assistant, the FIG. 81. FIXATION FORCEPS. conjunctiva of the ball grasped a few mm. below the ex- tremity of the vertical meridian of the cornea, and gently but firmly held by fixation forceps (Fig. 81). I. A cut is FIG. 82. rafWAli Co. PH/LA. GRAEFE CATARACT KNIFE. made through the cornea with a Graefe knife (Fig. 82), which is entered at the corneal margin just above its horizontal diameter, and a counter-puncture made exactly opposite by passing the knife through the anterior chamber in front of the OPERATIONS. 197 pupil. By a sawing movement of the knife with its cutting edge upward, the corneo-scleral border is divided in its up- per two-fifths. When the cut is finished, the fixation forceps should be removed, at least temporarily. 2. A portion of the iris, is removed (iridectomy). When the patient is tractable, the iridectomy should be made without fixation. FIG. 8- A YARNALL CO. PHILA IRIS FORCEPS. The patient is directed to look downward and to keep the eye perfectly stiH. The iris forceps (Fig. 83) are intro- duced, closed, through the centre of the incision previously made, and then opened in order to grasp a portion of the iris, near its pupillary border, which is slowly withdrawn and cut off at its periphery. To excise a large piece, as in FIG. 84. IRIDECTOMY SCISSORS. the operation for glaucoma, the blades of the iris scissors should be held at right angles to the vertical meridian of the cornea and more than one clip made, but in the operation for cataract, they should be held in the plane of the vertical meridian, as only a small section of the iris is to be re- moved. 3. The anterior capsule of the lens is lacerated 198 A MANUAL OF CLINICAL OPHTHALMOLOGY. (capsulotomy). A cystotome (Fig. 85) is introduced through the incision as far as the lower pupillary margin with its cutting point directed upward ; one quarter revo- FIG. 85. FA. YARNALL CO. PHILA. CYSTOTOME. lution of the handle is then made, turning the point back- ward, and the capsule lacerated vertically and horizontally. Another quarter revolution of the handle is made, and the FIG. 86. EXPULSION OF THE CATARACT. instrument withdrawn with its point downward. The quar- ter revolutions prevent entanglement of the instrument in the iris and cornea on entering and withdrawing it. 4. The FIG. 87. GRAEFE CATARACT SPOON AND CYSTOTOME. lens (Fig. 86) is extruded through the lacerated capsule, artificial pupil and corneal cut, by gentle and sustained pressure with the Graefe spoon (Fig. 87), or with the OPERATIONS. 199 finger, on the inferior portion of the cornea and adjoining sclera, assisted by counter-pressure on the sclera above the cut. 5. The anterior chamber is freed from blood, and remaining cortical matter, by massage with the spoon, or by gentle injection of warm distilled water, or, better, by a solution of boric acid, gr. v-Sj. This may be done by means of an ordinary glass dropper, or by a syringe specially devised for the purpose. A small pad of absorbent cotton anointed with vaseline, is applied over the closed lids of both eyes, taking care that the lashes of the lower lids are not inverted, and held in position by a roll of flannel bandage, or, preferably, by a piece of loose worsted knitted for the purpose. This dressing should remain undisturbed for twenty-four hours. At the expiration of that time, it should be removed, the eye bathed with a 1-5000 solution of the bichloride of mercury, or with a saturated solution of boric acid, and the lower lid everted to permit the escape of tears which may have collected. The eyes are again dressed, as on the preceding day, and the dressing allowed to remain for another period of twenty-four hours, when the treatment is repeated. On the third day after the operation, the eye not operated on may be left unbandaged. On the fifth day, the cut may be inspected. Up to the fifth day, the patient should remain in bed, resting on the back as much as pos- sible. This plan of treatment should be closely followed in cases that run a normal course. If, however, severe pain in the eye, or in the adjoining parts, develops, indicat- ing iritis, or if a discharge of mucus or pus is noticed on the cotton when the dressing is changed, the eye must be ex- amined, and appropriate remedies applied, such as atropine instillations, the constant application of a saturated solution of boric acid by means of absorbent cotton, and leeches 2OO A MANUAL OF CLINICAL OPHTHALMOLOGY. applied to the temple, together with the internal adminis- tration of potassium iodide and mercury. In this operation, certain complications are likely to arise. First, the corneal cut may not be sufficiently large to admit of the easy escape of the lens ; second, if there is prolapse of the iris in the corners of the wound, it must be replaced by gentle manipulation ; third, if the view of the pupil is FIG. 88. WIRE LOOP. obstructed by a collection of blood in the anterior chamber, it should be expelled through the open wound by gentle and repeated upward pressure on the cornea with the spoon ; fourth, if the capsulotomy is too small to admit of the passage of the lens, the cystotome should be reintro- duced and a more complete division of the capsule made ; fifth, if a bead of vitreous presents at the corneal incision FIG. 89. LENS EXTRACTOR. before the extraction of the lens, the speculum must be withdrawn, and the lens removed by means of the loop or extractor (Figs. 88 and 89). CATARACT EXTRACTION WITHOUT IRIDECTOMY. A Graefe knife is used, and the incision includes five-twelfths of the corneo-scleral margin. The cut is made through the cornea at its junction with the sclera, and a conjunctival flap avoided. OPERATIONS. 2O I An extensive division of the lens capsule is next made with a Knapp knife, especially designed for that purpose, which is passed under the iris vertically and horizontally, and after division of the capsule slow, steady, and continuous pressure with the spoon on the lowest part of the cornea expels the lens. If the iris prolapses, it must be replaced. Eserine, gr. j 5J, is dropped into the eye, which is otherwise treated as in the preceding modified Graefe operation, before it is bandaged. FIG. 90. DlSCISSION. This operation is both difficult and dangerous. The advantages claimed for it are the avordance of iritis, which sometimes follows iridectomy, the round pupil, and better vision. The dangers to be considered are a prolapse of the iris, and a difficult technique, especially in the performance of the capsulotomy. SOFT CATARACT. Discission (Fig. 90) is the generally accepted operation for soft cataract. A stop needle (Fig. 18 202 A MANUAL OF CLINICAL OPHTHALMOLOGY. 91) is passed through the anaesthetized cornea into the dilated pupil, the capsule freely divided and the lens broken up by gentle movements of the needle point in its substance. The moderate reaction which follows this operation is controlled by frequent instillations of atropine, gr. viij-5J. If the reaction is severe, the lens greatly swollen and the iris FIG. 91. SOFT CATARACT NEEDLE. bellied forward with large sections of the lens floating in the anterior chamber, an incision with the Graefe or iri- dectomy knife should be made through the cornea, and the offending masses gently pressed out (Fig. 92). IRIDECTOMY is performed (Fig. 93) in glaucoma to lessen tension and to establish drainage from the eye, in cataract FIG. 92. extraction, lamellar cataract, in the removal of foreign bodies from the anterior chamber, in complete annular synechia::, and for optical purposes. The eye to be operated on, is held as in the operation for cataract extraction, and an incision made with the lance knife (Fig. 93) in the corneo-scleral border. The point of the knife is passed into the anterior OPERATIONS. 203 chamber, in front of and parallel with the plane of the iris, to the necessary depth. In withdrawing the knife, its handle is tilted backward to prevent too rapid escape of the aqueous FIG. 93. LINEAR INCISION AT THE SUPERIOR MARGIN OF THE CORNEA. FIG. 94. C.A. YARN ALL CO. PHILft. IRIDECTOMY KNIFE. humor and prolapse of the iris. The next step, without fixation when possible, is to introduce the forceps and grasp the iris, which is then withdrawn and excised in the manner 2O4 A MANUAL OF CLINICAL OPHTHALMOLOGY. already described in the operation for cataract. Finally, the angles of the pupil should be replaced, and the margins of the wound carefully approximated. The eye should be dressed as described in the operation for cataract extrac- tion. At the expiration of twenty-four hours the wound FIG. 95. ARTIFICIAL PUPIL AS SEEN IN ANTERIOR CHAMBER AFTER IRIDECTOMY. will have healed with re-establishment of the anterior cham- ber. The bandage may be discarded in three days and a shade substituted. IRIDOTOMY or IRITOMY is necessary when the pupil, as a result of traumatism or cataract extraction, is occluded by FIG. 96. IRIDOTOMY KNIFE. thickened and opaque capsule with inflammatory exuda- tions from the iris. A needle-knife (Fig. 96) with double cutting edge, so constructed that its shank completely fills the corneal wound, thus preventing the escape of the aque- ous, is thrust through the cornea midway between its centre OPERATIONS. 2O5 and periphery and into the occluding membrane, which is divided at right angles to the line of greatest tension. Scissors (Fig. 97) devised by De Wecker are sometimes suc- cessfully used in this operation. With the lance knife, a small wound is made between the centre and circumference of the cornea, the blade is then slowly withdrawn half way, allowing the aqueous, which carries the iris forward with it, to partly FIG. 97. DE WECKER'S IRITOMY SCISSORS. escape. The knife is then thrust through the iris and with- drawn. De Wecker's scissors are entered closed, opened in the anterior chamber, and one blade passed through the cut in the iris. Both blades are made to meet through the iris, thus elongating the incision made by the knife. PARACENTESIS CORNEA consists in perforating the cornea with a small, double-edge knife (Fig. 98). The object of FIG. 98. A.YARNflU CO. PH. PARACENTESIS KNIFE. the operation is to reduce intra-ocular pressure by empty- ing the anterior chamber. S.EMISCH INCISION is sometimes resorted to for the pur- pose of obviating the worst effects of corneal abscess. The clear cornea immediately surrounding the abscess is pene- trated by a Graefe knife, which is passed through the 206 A MANUAL OF CLINICAL OPHTHALMOLOGY. anterior chamber to a corresponding point in the clear cornea on the distal side of the abscess, dividing it in its long diameter. This procedure drains the abscess and union is promoted by the expulsion of the pus. CONICAL CORNEA. The operation for this condition, con- sists in excision of the cone, wholly or in part, by a Graefe knife, and bringing the divided edges together by sutures. Exceedingly fine needles armed by a single strand of silk are FIG. 99. NEEDLES IN POSITION. necessarily used in thus suturing the edges of the wound. The resulting cicatrix is, perhaps, less detrimental to vision than the previously existing cone. STAPHYLOMA OF CORNEA AND SCLERA (Figs. 99, 100, 101). Critchett's operation is to be preferred toenucleation in children, as the parts of the ball remaining in the orbit will prevent unsymmetrical development of the bones of the OPERATIONS. 207 FIG. 100. EXCISION OF THE STAPHYLOMA. FIG. 10 1. APPEARANCE OF THE STUMP AFTER EXCISION OF THE STAPHYLOMA. 2O8 A MANUAL OF CLINICAL OPHTHALMOLOGY. face, the invariable result of enucleation in children. The operation is simple and effective. Four threaded needles are inserted equi-distant and parallel with each other through the base of the staphyloma, the diseased tissues are then removed with a knife or scissors, the needles drawn through, and each thread tied. CORNEAL TATTOOING, which has for its object the substi- tution of a black and invisible for a white and disfiguring opacity of the cornea, is effected by several fine steel points or -needles firmly fastened in a handle (Fig. 102). The points are dipped in a solution of india ink, and the corneal FIG. 1 02. opacity gently punctured. If the opacity is large, several sittings are necessary in order to avoid the dangerous reac- tion of a prolonged, or too extensive operation. FOREIGN BODIES. A. In Conjunctiva. To inspect the lower cul-de-sac, the patient is directed to look upward while the lower lid is drawn down and away from the ball. The upper cul-de-sac is revealed by inverting the upper lid, and having the patient look downward. A foreign body when seen in either of these situations, is easily removed by a small spud, or by a pledget of cotton wound on the end of a match stick. B. /// Cornea. Before attempting to remove foreign bodies in this situation, anaesthesia of the part should be induced by a single instillation of a four per cent, solution OPERATIONS. 2O9 of cocaine. The body is then lifted or removed from its position by a spud (Fig. 103), or other suitable instrument. C. In Anterior Chamber. If the body is iron or steel, its removal may be accomplished, through a proper opening in the cornea, by means of a magnet. In the absence of a magnet, or when it is ineffective, that part of the iris on which the foreign body rests should be drawn out and cut off. It is a dangerous and often impracticable proceed- ing to attempt the extraction of a body thus placed, without simultaneously performing an iridectomy. D. In Lens. The presence of a foreign body in the lens, such as a fragment of metal may be early recog- nized with the ophthalmoscope or oblique illumination, by its lustre. If it has passed through the lens, its path FIG. 103. will be marked by a streak of gray opacity. In either case a cataract develops which must be, when sufficiently advanced, extracted. That procedure should be selected which, in case the lens contains the body, insures its extrac- tion, since enucleation will, in most cases, be necessary eventually, if the foreign body is dislodged into the vitreous chamber. E. In Vitreous Chamber. Extraction of the body by the magnet should be attempted. Enucleation of the ball, in order to prevent sympathetic involvement of the unaffected eye is, however, usually necessary. TENOTOMY (Figs. 104 and 105). The conjunctiva and capsule of Tenon are grasped by forceps over the insertion of the tendon, and divided at right angles to the line of its 2IO A MANUAL OF CLINICAL OPHTHALMOLOGY. FIG. 104. INCISION OF THE CONJUNCTIVA. FIG. 105. SECTION OF THE TENDINOUS INSERTION. FIG. 1 06. STRABISMUS HOOK. OPERATIONS. 211 attachment. A tenotomy hook (Fig. 106) is passed under the tendon, which is elevated from the surrounding parts, and drawn into view. The tendinous expansion of the muscle at its attachment to the sclera, thus brought into view, is divided by several clips with blunt-pointed scissors (Fig. 107). GRADED or PARTIAL TENOTOMY consists in making an incision, not exceeding 2 mm., through the conjunctiva and capsule of Tenon, as described in the foregoing opera- FIG. 107. CONJUNCTIVAL SCISSORS. tion for tenotomy, and passing a small hook (Stephen's) under the tendon, which is carefully separated from the sclera in its central attachment. The extent to which the tendinous division of the muscle is carried is proportionate to the effect desired. In practice, it will be found that no lessening of the muscular power, as determined by prisms, is obtained until the tendon is nearly, if not completely, divided. In this operation, therefore, the cut through the conjunctiva and capsule is smaller and the spreading, lateral fibres of the tendon are not divided. 212 A MANUAL OF CLINICAL OPHTHALMOLOGY. ADVANCEMENT OF A TENDON. The enveloping tissues, conjunctiva and capsule of Tenon, are dissected until the muscle and tendon to be operated on are brought clearly into view, and a needle armed with silk, not too fine, is passed through the muscle at right angles to its course, and carried first through the conjunctiva above and then below, the cornea. The muscle is next divided in front of the suture, and the thread drawn firmly and tied. The effect of the operation will be increased by excising a small portion of the conjunctiva and capsule, between the insertion of the tendon and the cornea. The surgeon should be careful to pass the needle through the capsule as well as conjunctiva, otherwise the thread will in a few hours cut its way out, and thus aggravate the symptoms the operation is designed to relieve. The sutures should be removed on the fourth or fifth day. Tenotomies and partial tenotomies are, of course, to be performed upon any of the recti muscles that may be at fault. PTERYGIUM. The old and unsatisfactory operation of abscission has been abandoned in favor of transplantation, a simple and more effective method of treatment. The edges of the pterygium are grasped, brought together and the whole mass elevated by fixation forceps. A strabismus hook is passed under the pterygium at the site of fixation by rupturing the two lateral folds of adherent conjunctiva, and its apex detached from the cornea by a sudden move- ment or jerk of the hook in the direction of the cornea. (No operation is advisable until the growth has invaded the cornea.) The detached apex is transfixed by a thread armed at both ends with a needle, and the two needles are carried a considerable distance under the conjunctiva to a point obliquely above or below the base of the growth, and passed out a few mm. from each other. The threads OPERATIONS. 213 are made taut, drawing the apex of the pterygium up- ward or downward under the conjunctiva, and tied. The pterygium is in this way transplanted and allowed to grow without subsequent disturbance to vision, or other annoyance to the patient. The traumatic ulcer of the cornea, made by tearing off the hypertrophied growth, heals rapidly, leaving as a rule a nearly invisible opacity, which may be disregarded. The thread is removed on the fifth day. ENUCLEATION. The patient is placed in recumbent posi- tion, anaesthetized and the parts thoroughly disinfected. The globe is exposed as much as possible by the introduction of a speculum, the arms of which are held widely sepa- rated. The surgeon grasps the conjunctiva adjacent to the inner extremity of the horizontal diameter of the cornea, and divides it circularly one or two mm. from the corneo- scleral border. This incision of the conjunctiva, which extends two-thirds around the circumference of the cornea, is made in two equally divided cuts, the first below and the second above, from the point of fixation. The separated conjunctiva and capsule of Tenon are pushed back with the fixation forceps or closed scissors, and the tendon of the internal rectus grasped, divided posterior to the forceps, and held until the operation is finished. One blade of the straight conjunctival scissors is passed beneath the inferior rectus and the two blades brought together, dividing the muscle. The superior rectus is divided in a similar manner. The enucleation scissors (Fig. 108) are now passed back- ward, with the points closed and hugging the sclera until the optic nerve is reached, which is then divided. The ball is now easily rotated outward and as it turns every tissue clinging to the sclera is divided and left in the orbit. Hemorrhage is checked by pads of absorbent cotton, con- 214 A MANUAL OF CLINICAL OPHTHALMOLOGY. fined by a roller bandage, which is drawn tight enough to exercise a moderate degree of pressure. This dressing is not changed for twenty-four hours. At the expiration of that time it is removed, the parts cleansed with a bichloride wash, and a new dressing of a similar kind applied. The bandage may be discarded on the third or fourth day, and a saturated solution of boric acid given the patient with instruction to bathe the orbit two or three times a day until the wound is entirely healed. As a rule, an artificial eye may be worn after the lapse of four weeks. SYMBLEPHARON. If the band holding the ball and the lid FIG. 108. EKUCLEATION SCISSORS. together is narrow, it may be separated by an enveloping lead ligature, tightly twisted, which is allowed to cut its way through. When this is accomplished the ocular extremity of the adhesion is removed and the part sutured (Fig. 109). When the adhesion is broad it is separated, under tension, from its ocular attachment by the knife or scissors. A thread armed with two needles is passed through the divided end of the cicatricial tissue. The needles are carried from the bottom of the cul-de-sac from within outward through the lid, the thread drawn tight over a small pad and tied, and the divided ocular conjunctiva sutured (Fig. 1 10). OPERATIONS. 215 ANKYLOBLEPHARON. The adhesions must be separated by knife or scissors, having first ascertained their extent FIG. 109. OPERATION FOR SYMBLEPHARON BY THE INTRODUCTION OF A LEADEN THREAD. FIG. no. ARLT'S METHOD. by passing a probe, and the lids kept apart by traction during the healing process. 2l6 A MANUAL OF CLINICAL OPHTHALMOLOGY. CANTHOTOMY. The temporary widening of the palpebral commissure, consists in introducing one blade of the enucle- ation scissors into the conjunctival sac at the outer angle of the commissure and carrying it toward the temporal side until it has reached the margin of the orbit, and then bringing the two blades of the scissors together, dividing skin, fat, orbicularis muscle, subconjunctival connective FIG. i ii. CANTHOPLASTY. tissue and the conjunctiva. This operation is of great benefit in chronic catarrhal conjunctivitis with corneal ulcer. CANTHOPLASTY (Fig. 1 1 1). The object of this operation is to permanently widen the palpebral commissure. The tissues are divided, as in the operation of canthotomy just described, by a single cut with the scissors, and the raw margins of the divided skin and conjunctiva brought together by three sutures, the first uniting the parts in the angle of OPERATIONS. 2I 7 the cut, the second and third sutures uniting them on the lower and upper lid in the order named. TARSORRAPHY (Fig. 112) is the operation for shortening, FIG. 112. FIG. 113. />. YARNALL CO.FHILA HORN PLATE. FIG. 114. LID FORCEPS. or altogether closing the palpebral aperture. It consists in stretching the upper lid over a horn plate (Fig. 1.13) or lid forceps (Fig. 1 14), and removing with a small iridectomy 19 2l8 A MANUAL OF CLINICAL OPHTHALMOLOGY. knife a flap, I mm. broad from its free margin, the desired distance toward the outer canthus, ab Fig. 112, including the hair bulbs. The excision is extended 2-3 mm. over the inner border, in order to insure close union of the parts in exact juxtaposition. The lower lid is similarly treated and the raw surfaces of the two lids are brought together by fine sutures. The eye is bandaged and kept shut until the wound unites ; the sutures are then removed. Fie. 115. OPERATION FOR DISTICH IASIS. EXCISION OF CILI;E (Fig. 115) is sometimes performed for the relief of distichiasis. The operation is simple, and usually effective. The lid is elevated by a horn or lid forceps, and an incision 2 mm. deep made between the tarsus and skin in the edge of the lid from one canthus to the other. A second incision of the same length is made through the skin 2 mm. from the border down to the tarsus. The portion of skin and fascia thus separated and OPERATIONS. 219 removed, should include the bulbs of the ciliae, but not the meibomian glands. Suturing is not necessary. ENTROPION. The skin overlying the centre of the upper border of the tarsus is nicked and lid forceps inserted. Commencing at the indentation thus made and passing horizontally right and left, the upper half of the cartilage is cleared its entire width by division of the skin, connective tissue and muscle which, after division, are pushed toward the ciliary border. A suture is passed from below upward through the pad of tissues thus formed, and carried through the upper border of the exposed cartilage. Fixa- tion forceps, held in the left hand, are now thrust backward and upward to grasp the relaxed levator palpebrae tendon, which is drawn forward. Finally, the needle is thrust through the tendon thus advanced, and the two ends of the thread tied. Two lateral sutures, one at either side of the first, are carried through the mass, in a similar manner, and tied. ECTROPION (Figs. 116 and 117). In eversion of the lid, some form of plastic operation is usually necessary. As a rule, a V-shaped excision of a part of the lid is made, and skin from below brought in its place and held by sutures. Occasionally it will be found sufficient to cauterize with a hot iron the everted conjunctiva, which will slough and leave a cicatrix extensive enough to maintain the lid in its proper position. Or, instead of the hot iron cautery, caustics may be employed to destroy the indurated and hypertophied conjunctiva, and to form the necessary cica- trix. CHALAZION. The removal of these bodies is the same as for cysts in other situations of the body. A chalazion can readily be dissected out from the conjunctival surface as a rule, and when practicable this surface should, for 220 A MANUAL OF CLINICAL OPHTHALMOLOGY. obvious reasons, be selected. The lid is secured by forceps, the cyst incised, emptied, and an obliterative inflammation FIG. 1 1 6. OPERATION FOR ECTROPION : THE INCISION. FIG. 117. OPERATION FOR ECTROPION: THE SUTURES IN POSITION. of its walls induced by the application of the solid stick of silver nitrate, or by crystals of copper sulphate. Under this OPERATIONS. 221 treatment, all signs of the tumor, and of the consequent inflammation, disappear. PTOSIS. The simplest and most effective operation, con- sists in passing a stout silk ligature vertically under the skin from the eyebrows to the margin of the lids, and firmly tying the ends. The noose thus formed is daily tightened until it has cut its way through the confined tissues. The resulting cicatrix restores and holds the lid in its normal position. STRICTURE OF THE LACRYMAL DUCT. The lower lid is made tense and the point of a Weber Knife (Fig. 118) introduced vertically into the punctum, its handle lowered until it is brought into a horizontal position, and the blade FIG. ii 8. CANALICULUS KNIFE. of the instrument with its cutting edge upward, thrust forward until it comes in contact with the lacrymal bone. The handle is again elevated to a point immediately in front of the supra-orbital notch, and a cut made along the inner and free margin of the lid, converting the canaliculus into a gutter. The point of the knife with its cutting edge forward, is now engaged in the lacrymal sac, whence it is carried downward, backward and slightly outward into the nasal duct, dividing the stricture. The canal thus re-established (Fig. 1 19) should be main- tained for a time by the daily introduction of a probe, No. 10, Bowman (Fig. 120). After the lapse of a week or ten days, No. 8 or 6 probe may be used, and the intervals 222 A MANUAL OF CLINICAL OPHTHALMOLOGY. FIG. 119. PROBING THE NASAL DUCT. E.A:fARNALL CO. PHI LA. OPERATIONS. 223 of its introduction gradually increased until all signs of ob- struction have subsided. Various operations for epithelioma, ulcer, naevi, warty excrescences, etc., have been suggested. They belong, how- ever, to the domain of general surgery. The ingenuity of the operator and his knowledge of the principles of general surgery, must be relied upon to devise proper measures for their relief. An operating case suitable for operations described in this volume would contain Graefe Knife, straight Keratome, bent Keratome, Graefe Cystotome, Small Strabismus Hook, Bowman's Stop Needle, Speculum, Double Scoop, Canaliculus Knife, Curved Iris Forceps, Fixation Forceps, Ciliae Forceps, McClure's Iris Scissors, Enucleation Scissors, Conjunctival Scissors, Lid Retractor, Set of Bowman's Probes, Lid Forceps, Horn Plate, Spud, Lens Extractor, Needle Holder, Needles and Silk. Cost, about $35.00. INDEX. A. Abduction, 84 Abscess of orbit, 193 Accommodation, 31 negative, 31 positive, 31 range of, 32, 57 relative, 33 spasm of, 76 Achromatopsia, acquired, 41 Adduction, 84 Advancement of tendon, 212 Albinism, 147 Alopecia, 113 Amblyopia, 90 tobacco and alcohol, 191 Ametropia, 54 Angle a, 27 7, 27 metre, 33 . of 5', 34 Aniridia, 147 Ankyloblepharon, 116, 215 Annulus senilis, 130 Aphakia, 145 Arcus senilis, 130 Artery, central retinal, 17, 24 anterior ciliary, 24 external carotid, 23 hyaloid, 18, 25, 137, 145, 164 internal carotid, 22 lacrymal, 23 long ciliary, 24 muscular, 24 nasal, 24 ophthalmic, 21 palpebral, 24 short ciliary, 24 supra-orbital, 24 Atropine sulphate, 76, 77 Astigmatism, 59 comp. hyper., 60, 63 myopic, 60, 63 diagnosis and treatment of, 60 by ophthalmoscope, 67 by retinoscopy, 71 hypermetropic, 60, 63 irregular, 60, 63 mixed, 60 myopic, 60, 63 regular, 60 symptoms of, 60 Axis, optic, 27 principal, 47 secondary, 47 visual, 27, 33 B. Blepharitis, 109 angularis, 94 marginalis, 94, 109 Blepharospasm, 115 Blepharophimosis, 116 Blind spot, 37 Burns, 107 C. Canal of Cloquet, 18 of Petit, 1 8 of Schlemm, II, 24 Canaliculi, 30 Cancer, melanotic, 132 Canthoplasty, 216 Canthotomy, 216 Capsule, anterior, 19 deposits on, 145 Tenon's, 24, 25 wounds of, 145 225 226 INDEX. Caruncula lacryraalis, 29 Caustics, contraindicated, 94 Cataract, 136 acquired, 138 anterior polar, 136 capsular, 129 secondary, 145 treatment of, 146 causes of, 138 central, 136 clinical features of, 142 congenital, 136 cortical, 136 extraction of, with iridectomy, 196 without iridectomy, 200 fusiform, 137 hard, 138 history of, 142 incipient, 138 lenticular, 129 mature, 138 nuclear, 138 posterior polar, 137, 147 pyramidal capsular, 136 senile, 138 secondary, 138 soft, 138, 201 spoon, 198 total congenital, 137 traumatic, 143 treatment of, 143 ripe, 142 zonular or lamellar, 137 Ciliae, excision of, 218 Ciliary body, 12 circle, 14 processes, 14 region, 14 Chalazion, 112, 219 Chamber, anterior, 18 posterior, 18 vitreous, 18 Chancre of conjunctiva, 1 12 Chi asm, optic, 21 Chorea, 1 1 6 Choroid, 1 1 central senile atrophy of, 158 ophthalmoscopic appearances in disease of, 158 Choroiditis, 157 rhoroiditis, areolar, 158 central, 158 guttate, 158 disseminated, 157 retino-, 157 symptoms of. in general, Ibl Cocaine hydrochlorate, 77 Coloboma of iris, 147 of lid, 1 06 Color-blindness, 40 sense, 39 Colors, 39 complementary, 39 confusion of, 39 primary, 39 secondary, 39 Commissure, optic, 21 Conjunctiva, 29 fornix of, 29 ocular, 29 palpebral, 29 hyperarmia of, 92 xerosis of, 104 Conjunctivitis, 92 blennorrhoeal, loo catarrhal, acute, 93 chronic, 94 croupous, 103 diphtheritic, 103 follicular, 95 gonorrhoeal, 100 granular, 96 herpetic, 102 lymphatic, 102 phlyctenular, 102 purulent, 100 scrophulosis, 102 vernal, 95 Contusion, 108 Convergence, 27, 33 Cornea, 10, 29 abscess of, 1 28 conical, 124, 130, 206 tattooing of, 208 tumors of, 132 Corneitis, 122 Comeo-scleral margin, 10 Corpora geniculata, 19 quadragemini, 19 Correction, full, of ametropia, 56 Cortex of lens, 19 INDEX. 227 Critchett's operation, 132, 133 Crus cerebri, 21 Cyclitis, 154 chronic, 155 Cylinders, 48, 49 Cystotome, 198 D. Dacryocystitis, 119 Depilation, 113 Dermoid cyst of conjunctiva, 105 of cornea, 132 Descemitis, 151 Deviation, angle of, 44 Dilator iridis, 14 Diopter, meaning of, 36 Dioptric system, 49 Diplopia, 80 Distichiasis, 98, 112 Double vision, 117 Duboisine sulphate, 76 Duct, nasal, 31 E. Ecchymosis, 112 Ectropion, 115, 219 Eczema of lids, 1 10 Embolism of retinal artery, 173 Emergence, angle of, 43 Emergent ray, 43 Emmetropia, 32, 53 diagnosis of, by retinoscopy, 70 Emphysema, no Enophthalmus, 194 Entropion, 98, 114, 219 Enucleation, 213 Epicanthus, 106 Epiphora, 118, 119 Epithelioma, III Erysipelas, no Erythema, 1 10 Esophoria, 83, 85 Esotropia, 84, 90 Exophoria, 83 Exophthalmus, 194 Exotropia, 84, 91 Eyeball, 9 F. Far point, 32, 57, 58 Focal distance, 47 length of eye, 49 Focus, principal, 47 virtual, 48 Foramen sclera, 10, 21 choroidea, 1 1 Forceps, fixation, 196 iris, 197 Foreign bodies in anterior chamber, 209 in conjunctiva, 208 in cornea, 208 in lens, 209 in vitreous chamber, 209 Fossa, hyaloid, 18 Fovea centralis, 17, 66 G. Ganglion, ophthalmic, 14, 21, 22 Gland, lacrymal, 30, 117 abscess of, 117 fistule of, 118 hypertrophy of, 117 Glands, Meibomian, 29 Glaucoma, acute inflammatory, 170 chronic inflammatory, 167 fulminating, 170 secondary, 132, 133, 150, 171 simple, 1 66 Glaucomatous degeneration, 171 Glioma, pseudo, 162 Granuloma, 105 H. Hemianopsia, 192 bilateral, 192 binasal, 192 bitemporal, 192 horizontal, 36 vertical, 37, 192 Herpes, 123, 125 zoster, ophthalmic, 125 Heteronymous images, 80 Heterophoria, 83, 85 diagnosis of, 87 Heterotropia, 84, 88 Homatropine hydrobromate, 76 228 INDEX. Homonymous images, 80 Hordeolum, 109 Humor, aqueous, 1 8 vitreous, 18 Hyalitis, 163 Hyoscyamine sulphate, 76 Hyperesophoria, 83 Hyperesotropia, 84 Hyperexophoria, 83 Hyperexotropia, 83 Hypermetropia (hyperopia), 27, 54, 84 accommodation in, 57 diagnosis by ophthalmoscope, 68 by retinoscopy, 70 manifest, 55 latent, 55, 57 total, 55, 57 Hyperphoria, 83, 85 Hyphsemia, spontaneous, 153 traumatic, 153 Hypopyon,i24, 128, 152 I. Image, false, 80, tt seq. true, 79, 89 Incidence, angle of, 43 Incident ray, 43 Iris, 14 absence of, 147 colobomaof, 147 cysts of, 154 detachment of, 153 granuloma of, 154 gumma of, 154 hyperamia of, 147 tubercle of, 1 54 Iridectomy, 202 Iridotomy (iritomy), 204 Iritis, 129 cause of, 150 chronic, 149 parenchymatous, 152 plastic, 148 serous, 151 suppurative, 152 treatment of, 1 50 K. Keratitis, interstitial, 127 necrotic, 130 Keratitis, neuro-paralytic, 129 parenchymalous, 127 phlyctenular, 122 Knife, Graefe cataract, 196 iridectomy, 203 iridotomy, 204 paracentesis, 205 L. Lacrymal sac, abscess of, 119 blennorrhoea of, 119 fistule of, 1 20 syringe, 120 Lacrymation, 123 Lamina cribrosa, 10, 21 Lens, crystalline, 18, 31 absence of, 145 concave, 44, 47 convex, 44 dislocation of, 144 extractor, 200 Lenticular ganglion, 14 Leucoma, 130 Lids, 27 Lid speculum, 196 Ligament, suspensory, 1 8 Ligamentum pectinatum iridis, 14 Limbus corneie, 122 Lipoma, 105 Liquor Morgagni, 18 Lupus, III Lymph space of anterior chamber, 24 ciliary body, 25 conjunctiva, 25 cornea, 25 intervaginal, 21, 24 perichoroid, 24, 25 of sclera, 25 subdural, 21 suprachoroidea;, n of Tenon's capsule, 25 retina, 25 vitreous, 25 M. Macula lutea, 17 of cornea, 130 Massage, 118, 120 Melanoma, 132 Melano-sarcoma, 105 INDEX. 229 Membrane, arachnoid, 21 Bowman's, 10 Descemet's, 10 dura mater, 21 hyaloid, 1 8 Microphthalmus, 147 Milium, 112 Muscse volitantes, 163 Muscle, ciliary, action of, 31 external rectus, 25, 78 inferior " 25, 78 internal " 25, 78 superior " 25, 78 inferior oblique, 26, 78 superior " 25, 26, 78 levator palpebrse, 27, 29 orbicularis palpebrarum, 27, 29 tendo oculi, 31 tarsi, 31 Mydriasis, artificial, 152 emotional, 152 idiopathic, 152 symptomatic, 152 Mydriatics, 75 Myopia, 27, 57 accommodation in, 58 acquired, 58 congenital, 58 diagnosis by ophthalmoscope, 67 by retinoscopy, 7 1 high, 58 low, 58 moderate, 58 staphyloma in, 104 Myosis, artificial, 153 irritative, 153 paralytic, 153 reflex, 153 N. Nasal duct, stricture of, 119 Near point, 32, 57, 58 Nebula, 130 Nerve, optic, atrophy of, 189 ophthalmoscopic appearances of, 190 Nerves, 1st, 2d, 3d, 4th, 5th, 6th, 7th lacrymal, 21, 22 frontal infra-trochlear long ciliary, Nerves, nasal, short ciliary, sympa- thetic, 21, 22 Neuritis, optic, 185 retrobulbar, 188 Neuro-retinitis, 187 Nucleus of lens, 19 Nystagmus, 81 O. Ocular muscles, paralysis of, 78 physiology of, 78 scheme of action of, 79 strength of, 84 CEdema, no Onyx, 124, 128 Opacities, corneal, 130 Opaque nerve- fibres, 175 Ophthalmia, neonatorum, 100 sympathetic, 155 Ophthalmoplegia externa, 81 interna, 81 Ophthalmoscope, examination by, 50 by direct method, 51, 64 by indirect method, 52, 66 Optical centre, 47 Ora serrata, II, 14, 17 Orbit, abscess of, 193 tumors of, 193 Orthophoria, 83 Orthotropia, 83 P. Pagenstecher's ointment, 94 Pannus, 98, 124 Papilla, 66 Papillitis, 1 86 Paracentesis, cornese, 205 Paralysis of external rectus, 8 1 of inferior rectus, 81 of internal rectus, 8l of superior rectus, 8 1 of superior and inferior oblique, 81 Pediculus pubis, 113 Pericofneal ring, 122 Perimeter, 37 Periostitis, 193 Phlegmon, 108 Phthisis bulbi, 156 Phlyctenule, 122, 123 230 INI'l.X. Photophobia, 123 Pinguecula, 105 Pink-eye, 93 Placido'sdisc, 131 Plica semilunaris, 29 Polycoria, 147 Polypi, 105 Porus opticus, 17, 21, 24 Presbyopia, 72 in E, 72 in H. and comp. H. As., 73 in M. and comp. M. As., 73 in mixed astigmatism, 75 Prisms, 33, 43 Pterygium, 104, 212 Ptosis, acquired, 116 congenital, 106 operation for, 221 Puncta lacrymalia, 30 malposition of, 118 Pupil, 14 Argyll - Robertson ,153 dilatation of, 152 Pupillary membrane, persistent, 145, 147 Purkinje's sign, 145 R. Reflection, 42 Refracting media, 49 power, 47 Refraction, 42 determination of, by ophthalmo- scope, 67 index of, 42, 49 in heterophoria, 86 normal, 53 ophthalmoscope, 64 Retina, 15 anaemia of, 172 anaesthesia of, 183 detachment of, 181 exposure of, to light, 184 glioma of, 183 hemorrhage of, 174 hypenemia of, 172 hypenesthesia of, 183 normal sensibility of, 37 Retinitis, albuminuric, 176 central acute, 182 Retinitis, diffused chronic, 178 hemorrhagic, 175 pigmentosa, 179 Retinoscopy, 56, 70 S. Sac, lacrymal, 31 S;x'misch's incision, 1 29, 205 Sarcoma, 105, 132 Scissors, conjunct! val, 211 De Wecker's iritomy, 205 enucleation,2i4 iridectomy, 197 Sclera, 9 Scleritis, 132 Scotoma, 37 Skin grafting, 108 Spaces of Fontana, 1 1 , 24 Sphincter pupilbe, 14 Squint, alternating, 89 concomitant, 89 monolateral, 89 Staphyloma, 99, 1 24 ciliary, 133 of cornea, 131, 132, 206 of sclera, 133,206 posterior, 133 secondary, 135 Strabismus, 88 external, 91 internal, 90 hook, 210 Stricture of lacrymal duct, 221 Stye, 109 Style, 121 Sulcus sclera, 10 Sursumduction, 84 Symblepharon, 116, 214 Synchisis, 163 scintillans, 163 Synechioe, anterior, 126, 129 partial, 149 posterior, 148, 149 total, 149 T. Tarsorrhaphia, 217 Tarsus, 27, 29 Tenotomy, 91, 209 graded, 2 1 1 INDEX. Tension, description of, 169 Test card, astigmatic, 61 cards, 34 lenses, 34 cylinders, 36 lens-holder, 36 lenses, spherical, 45 Trichiasis, 112 Trachoma, 96 Tracts, optic, 19 U. Ulcer, deep, 124 resorption, 124 rodent, no serpiginous, 127 Uvea, 14 V. Veni, ophthalmic, 21 Venae vorticosse. 12 Vision, acuity of, 34 field of, 36, 37 Vitreous chamber, 18, 164 foreign bodies in, 164 W. Warty excrescences, 223 Wire loop, 200 Worsteds, Holmgren's, 60 X. Xanthelasma, 112 Z. Zone of Zinn, 14 CATALOGUE No. 7. FEBRUARY, 1895. BOOKS FOR STUDENTS, INCLUDING THE ? QUIZ-COMPENDS ? CONTENTS. PAGE PAG New Series of Manuals, 2,3,4,5 Obstetrics. . Pathology, Histology, Biology, Chemistry, . ii 6 Pharmacy, . Physical Diagnosis, Children's Diseas s 7 Physiology, . Dentistry, 8 Practice of Medicine, ii Dictionaries, 8 16 Prescription Books, Eye Diseases, Electricity, . 8 9 ? Quiz-Compends ? Skin Diseases, *4 Gynaecology, 10 Surgery and Bandaging, Hygiene, 9 Therapeutics, Materia Medica, 9 Urine and Urinary Organs, Medical Jurisprudence 10 Venereal Diseases, Nervous Diseases, 10 PUBLISHED BY P. BLAKISTON, SON & CO., Medical Booksellers, Importers and Publishers. 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" It is with pleasure that we notice what is probably the best chemistry for medical students for its size now in the market. Prof. Hartley has written the book because he had- something to say; and he has said it well." The Journal of the American Medical Association, Chicago, III. Price of each Book, Cloth, $3.00; Leather, $3.50. STUDENTS' TEXT-BOOKS AND MANUALS. ANATOMY. Morris' New Text-Book on Anatomy. Now Rtady. By ten leading Surgeons and Anatomists, and Edited by Henry Morris, F.R.C.S. 791 Specially Engraved Illustrations, 214 of which are printed in colors. Octavo. 1280 pages. Price in Cloth, 7.50; Sheep, 8.50; Half Russia, 9.50 ' Send for Descriptive Circular and Sample Pages. Macalister's Human Anatomy. 816 Illustrations. A new Text-book for Students and Practitioners, Systematic and Topo- graphical, including the Embryology, Histology, and Morphology of Man. With special reference to the requirements of Practical Surgery and Medicine. With 816 Illustrations, 400 of which are original. Octavo. Cloth, 7.50; Leather, 8.50 Ballou's Veterinary Anatomy and Physiology. Illustrated. By Wm. R. Ballon, M.D., Professor of Equine Anatomy at New York College of Veterinary Surgeons. 29 graphic Illustrations. I2mo. Cloth, i. oo ; Interleaved (or notes, 1.25 Holden's Dissector. A manual of Dissection of the Human Body. Sixth Edition. Edited by A. Hewson, M.D., Demonstra- tor of Anatomy at Jefferson Medical College. 311 Illustrations, many of which are new. Oil-cloth, 3.00; Sheep, 3.50 Holden's Human Osteology. Comprising a Description of the Bones, with Colored Delineations of the Attachments of the Muscles. The General and Microscopical Structure of Bone and its Development. With Lithographic Plates and Numerous Illus- trations. Seventh Edition. 8vo. Cloth, 6.00 Holden's Landmarks, Medical and Surgical. 4th Ed. Clo.,i.2S Potter's Compend of Anatomy. Fifth Edition. Enlarged. 16 Lithographic Plates. 117 Illustrations. Stt pagt 14. Cloth, i.oo; Interleaved for Notes, 1.25 CHEMISTRY. Hartley's Medical and Pharmaceutical Chemistry. Third Edition. Prepared specially for Medical, Pharmaceutical, and Dental Students. 60 Illustrations, Plate of Absorption Spectra, and Glossary. Revised and Enlarged. Cloth, 3.00 Trimble. Practical and Analytical Chemistry. A Course in Chemical Analysis, by Henry Trimble, Prof, of Analytical Chem- Utry in the Phila. College of Pharmacy. Illustrated. Fourth Edition, Enlarged. 8vo. Cloth, 1.50 Bloxam's Chemistry, Inorganic and Organic, with Experiments. Eighth Edition. a8i Illustrations. In Prets Iff Sft paget 2 to 3 for list of StuJentt' Maintalt . STUDENTS' TEXT-BOOKS AND MANUALS. 7 Chemistry : Continued. Richter's Inorganic Chemistry. Fourth American, from Sixth German Edition. Translated by Prof. Edgar F. Smith, PH.D. 89 Wood Engravings and Colored Plate of Spectra. Cloth, 3.00 Richter's Organic Chemistry, or Chemistry of the Carbon Compounds. Illustrated. Second Edition. Cloth, 4. 50 Sy monds. Manual of Chemistry, for the special use of Medi- cal Students. By BRANDRBTH SYMONDS, A.M., M.D., Asst. Physician Roosevelt Hospital, Out- Patient Department ; Attend- ing Physician Northwestern Dispensary, New York. Cloth, 2.00 Leffmann's Compend of Medical Chemistry. Including Urinary Analysis. Fourth Edition. Revised. See page 15. Cloth, i.oo; Interleaved for Notes, 1.23 Muter. Practical and Analytical Chemistry. Fourth Edi- tion. Revised, to meet the requirements of American Medical Colleges, by Prof. C. C. Hamilton. Illustrated. Cloth, 1.25 Holland. The Urine, Gastric Contents, Common Poisons, and Milk Analysis, Chemical and Microscopical. For La- boratory Use. Fifth Edition, Enlarged. Illustrated. Cloth, 1.25 Woody. Essentials of Chemistry for the Medical Student. Third Edition. Cloth, 1.25 CHILDREN. Goodhart and Starr. The Diseases of Children. Second Edition. By J. F. Goodhart, M.D., Physician to the Evelina Hospital for Children; Assistant Physician to Guy's Hospital, London. Revised and Edited by Louis Starr, M.D., Clinical Professor of Diseases of Children in the Hospital of the Univer- sity of Pennsylvania; Physician to the Children's Hospital, Philadelphia. Containing many Prescriptions and Formulae, conforming to the U. S. Pharmacopoeia, Directions for making Artificial Human Milk, for the Artificial Digestion of Milk, etc. Illustrated. . Cloth, 3.00; Leather, 3.50 Hatfield. Diseases of Children. By M. P. Hatfield, M.D., Professor of Diseases of Children, Chicago Medical College. Colored Plate, izmo. Cloth, i.oo; Interleaved, 1.25 Starr. Diseases of the Digestive Organs in Infancy and Childhood. With chapters on the Investigation of Disease, and on the General Management of Children. By Louis Starr, if.D., Clinical Professor of Diseases of Children in the Univer- sity of Pennsylvania. Illus. Second Edition. Cloth, 2.25 4^- Set pages 14 and 15 for list offQuiz-Compendtf 8 STUDENTS' TEXT-BOOKS AND MANUALS. DENTISTRY. Fillcbrown. Operative Dentistry. 330 Illus. Cloth, 2.50 Flagg's Plastics and Plastic Filling. 4th Ed. Cloth, 4.00 Gorgas. Dental Medicine. Fifth Edition. Cloth, 4.00 Harris. Principles and Practice of Dentistry. Including Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery and Mechanism. Twelfth Edition. Revised and enlarged by Professor Gorgas. 1028 Illustrations. Cloth, 7.00 ; Leather, 8.00 Richardson's Mechanical Dentistry. Sixth Edition. By Warren. 600 Illustrations. 8vo. Cloth, 4.50; Leather, 5.50 Sewill. Dental Surgery. 200 Illustrations. 3d Ed. Clo., 3.00 Taft's Operative Dentistry. 100 Illus. Cloth, 4. 25; Leather, 5.00 Talbot. Irregularities of the Teeth, and their Treatment. Illustrated. 8vo. Second Edition. Cloth, 3.00 Tomes' Dental Anatomy. Fourth Ed. 235 Illus. Cloth, 4.00 Tomes' Dental Surgery. 3d Edition. 292 Illus. Cloth, 5.00 Warren. Compend of Dental Pathology and Dental Medi- cine. Illustrated, ad Ed. Cloth, i.oo; Interleaved, 1.2$ Warren. Dental Prostheses and Metallurgy. 129 Illustra- tions. I2H10. I.5O DICTIONARIES. Gould's Student's Medical Dictionary. Containing the Defi- nition and Pronunciation of all words in Medicine, with many useful Tables, etc. J4 Dark Leather, 3.25 ; % MOT., Thumb Index, 4.23 Gould's Pocket Dictionary. 12,000 Medical Words Pro- nounced and Defined. Containing many Tables and an Elaborate Dose List. Thin 64010. Leather, gilt edges, i.oo; with Thumb Index, 1.25 Harris' Dictionary of Dentistry. Fifth Edition. Completely revised by Prof. Gorgas. Cloth, 5.00; Leather, 6.00 Cleaveland's Pronouncing Pocket Medical Lexicon. Small pocket size. Cloth, red edges .75 ; pocket-book style, i.oo Longley's Pocket Dictionary. The Student's Medical Lexicon, giving Definition and Pronunciation, with an Appendix giving Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 24010. Cloth, i.oo; pocket-book style, 1.95 EYE. Hartridge on Refraction. ?th Edition. Illus. Cloth, 1.75 Swanzy. Diseases of the Eye and their Treatment. 176 Illustrations. Fourth Edition. Cloth, 300; Leather, 3.50 Pox and Gould. Compend of Diseases of the Eye and Refraction. 2d Ed. Enlarged. 71 Illus. 39 Formulae. Cloth, i.oo; Interleaved for Notes, 1.25 *- .S> fiaget a to 5 for Hit of Studtnts' Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 9 ELECTRICITY. Bigelow. Plain Talks on Medical Electricity. Cloth, i.oo Mason's Compend of Medical Electricity. Cloth, i.oo Steavenson and Jones. Medical Electricity. A Practical Handbook. Illustrated. i2mo. Cloth, 2. 50 HYGIENE. Coplin and Bevan. Practical Hygiene. By W. M. L. Cop- lin, Adjunct Professor of Hygiene, Jefferson Medical College, Philadelphia, and Dr. D. Bevan. Illustrated. Cloth, 4.00 Parkes' (Ed. A.) Practical Hygiene. Seventh Edition, en- larged. Illustrated. 8vo. Cloth, 4.50 Parkes' (L. C.) Manual of Hygiene and Public Health. Second Edition. 121110. Cloth, 2.50 Wilson's Handbook of Hygiene and Sanitary Science. Seventh Edition. Revised and Illustrated. Cloth, 3.25 MATERIA MEDICA AND THERAPEUTICS. Potter's Compend of Materia Medica, Therapeutics, and Prescription 'Writing. Sixth Edition, revised and improved in accordance with U. S. P. 1890. See page If. Cloth, i.oo; Interleaved for Notes, 1.25 Davis. Essentials of Materia Medica and Prescription Writing. By J. Aubrey Davis, M.D., Demonstrator of Obstet- rics and Quiz-Master on Materia Medica, University of Penn- sylvania, tamo. Interleaved. Net, 1.50 Biddle's Materia Medica. Thirteenth Edition. By the late John B. Biddle, M.D. Revised by Clement Biddle, M.D. 8vo. Illustrated. Cloth, net, 4.00 ; Leather, net, 5.00 Potter. Handbook of Materia Medica, Pharmacy, and Therapeutics. Including Action of Medicines, Special Thera- peutics, Pharmacology, etc. By Saml. O. L. Potter, M.D., M.R.C.P. (Lond.), Professor of the Practice of Medicine in Cooper Medical College, San Francisco. Fifth Revised and Enlarged Edition. 800 pages. 8vo. Cloth, 4.50; Leather, 5.50 Sayre. Organic Materia Medica and Pharmacognosy. A Handbook for Students of Pharmacy and Medicine. By L. E. Sayre, PH.G., Professor of Pharmacy and Materia Medica, University of Kansas ; Member Committee of Revision of U. S. P. 543 Illustrations. 8vo. Cloth, 4.50 *S- See pages 14 and 15 /or list of t Quit-Contpendt f 10 STUDENTS' TEXT-BOOKS AND MANUALS. White and Wilcox. Materia Medica, Pharmacy. Phar- macology, and Therapeutics. Second American Edition. By Win. Hale White, M.U., F.R.C.P., etc.. Physician to and Lecturer on Materia Medica, Gay's Hospital. Revised by Reynold W. Wilcox, M.D..LI..D , Prof, of Clinical Medicine and Therapeutics at the New York Post Graduate Medical School. Visiting Physician St. Mark's Hospital, etc. Clo.,3.oo; Lea. ,3.50 MEDICAL JURISPRUDENCE. Reese. A Text-book of Medical Jurisprudence and Toxi- cology. By John J. Reese. M.D., Prof, of Medical Jurispru- dence and Toxicology in the Medical Depart., University of Pennsylvania. Fourth Edition. Revised by Henry Leffmann, M.D., Prof, of Chemistry, Pennsylvania College ot Dentistry; Hygienist and Food Inspector, State Board of Agriculture, etc. Cloth, 3.00 ; Leather, 3.50 NERVOUS DISEASES. Cowers. Manual of Diseases of the Nervous System. A Complete T_ext-book. By William R. Cowers, M.D., Prof. Clinical Medicine, University College, London. Physician to National Hospital for the Paralyzed and Epileptic. Second Edition. Revised, Enlarged, and in many parts Rewritten. With many new Illustrations. Octavo. VOL. I. Diseases of the Nerves and Spinal Cord. 616 pages. Cloth, 3.50 VOL. II. Diseases of the Brain and Cranial Nerves. General and Functional Diseases, 1069 pages. Cloth, 4.50 Ormerod. Diseases of Nervous System, Student's Guide to. By J. A. Ormerod, M.D., Oxon., F.R.C.P. (London), Mem. Path.. Clin., Ophthal., and Neurological Societies; Phys. to National Hospital for Paralyzed and Epileptic; Dem. of Morbid Anatomy, St. Bartholomew's Hospital, etc. 75 Illustrations. Cloth, 2.00 OBSTETRICS AND GYNAECOLOGY. Davis. A Manual of Obstetrics. By Edw. P. Davis, Clinical Lecturer on Obstetrics, Jefferson Medical College, Philadelphia. 16 Plates, and 134 Illustrations, izmo. id Edition. Cloth, 2.50 Byford. Diseases of Women. By W. H. Byford.M.o., Prof, of Gynaecology in Rush Medical College, and H. T. Byford, M.D., Surgeon to the Woman's Hospital, Chicago. Fourth Edi- tion. Enlarged. 306 1 11 us. Octavo. Cloth, a.oo ; Leather, 8.50 Lewers' Diseases of Women. A Practical Text-book. 139 Illustrations. Second Edition. Cloth, 2.50 Wells. Compend of Gynaecology. Illustrated. Cloth, i.oo Winckel's Obstetrics. A Text-book on Midwifery, includ- ing the Diseases of Childbed. By Dr. F. Winckel. Author- ized Translation, by J. Clifton Edgar, M.D., Lecturer on Ob- stetrics, University Medical College, New York. Nearly aoo handsome Illustrations. 8vo. Cloth, 6.00; Leather, 7.00 49- Sfe faff* a to y/or litt a/Nen< tfaMua.lt. STUDENTS' TEXT-BOOKS AND MANUALS. 11 Obstetrics and Gynaecology : Continued. Parvin's Winckel's Diseases of 'Women. Second Edition. Including a Section on Diseases of the Bladder and Urethra. 150 Illus. Revised. See page 3. Cloth, 3.00; Leather, 3.50 Landis' Compend of Obstetrics. Illustrated, sth Edition, Enlarged. By Wells. Cloth, i.oo ; Interleaved for Notes', 1.25 PATHOLOGY, HISTOLOGY, ETC. Stirling. Outlines of Practical Histology. A Manual for Students, zd Edition. 368 Illustrations. I2mo. Cloth, 3.00 Reeves. Medical Microscopy. Colored Illustrations. Cloth, net, 2.50 Wethered. Medical Microscopy. By Frank J. Wethered. M.D., M.R.C.P. 98 Illustrations. Cloth, 2.50 Hall. Compend of General Pathology and Morbid Anat- omy. 91 very fine Illustrations. Cloth, i.oo; Interleaved, 1.25 Gilliam's Essentials of Pathology. 47 Illus. Cloth, .75 Virchow's Post-Mortem Examinations. 3d Ed. Cloth, i.oo PHYSICAL DIAGNOSIS. Tyson's Student's Handbook of Physical Diagnosis. Illus- trated. Second Edition, Enlarged. i2mo. Cloth, 1.50 PHYSIOLOGY. Yeo's Physiology. Sixth Edition. The most Popular Stu- dents' Book. By Gerald F. Yeo, M.D., F.R.C.S., Professor of Physiology in King's College, London. Small Octavo. 234 carefully printed Illustrations. With a Full Glossary and Index. See page 3. Cloth, 3.00; Leather, 3.50 Brubaker's Compend of Physiology. Illustrated. Seventh Edition. Cloth, i.oo; Interleaved for Notes, 1.25 Kirke's Physiology. New 13* Ed. Thoroughly Revised and Enlarged. 502 Illustrations, some of which are printed in colors. (Blakiston's Authorized Edition.) Red Cl. , 4.00 ; Leather, 5.00 Landois' Human Physiology. Including Histology and Micro- scopical Anatomy, and with special reference to Practical Medi- cine. Fourth Edition. Translated and Edited by Prof. Stirling. 845 Illustrations. 2 vols. Cloth, net, 7.00 PRACTICE. Taylor. Practice of Medicine. A Manual. By Frederick Taylor, M.D., Physician to, and Lecturer on Medicine at, Guy's Hospital, London ; Physician to Evelina Hospital for Sick Chil- dren, and Examiner in Materia Medica and Pharmaceutical Chemistry, University of London. Cloth, 2.00; Leather, 2.50 Roberts' Practice. Revised Edition. A Handbook of the Theory and Practice of Medicine. By Frederick T. Roberts, M.D., M.R.C.P., Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Ninth Edition. Octavo. Cloth, 5.00 ; Sheep, 6.co et pages 14 and 15 for list of f Quiz- Commends f 12 STUDENTS' TEXT-BOOKS AND MANUALS. Practici : Continued. Hughes. Compend of the Practice of Medicine. 5th Edi- tion, Enlarged. Two parts, each, Cloth, i.oo; Interleaved for Notes, 1.25 PART i. Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. PART n. Diseases of the Respiratory System, Circulatory System, and Nervous System : Diseases of the Blood, etc. Physicians' Edition. Fifth Edition. Including a Section on Skin Diseases. With Index, i vol. Full Morocco, Gilt, 2. 50 from John A. Robinson, M.D., Assistant^ to Chair of Clinical Medicine, now Lecturer on Materia Mtdica, Rusk Medical Col- lege, Chicago. "Meets with my hearty approbation as a substitute for the ordinary note books almost universally used by medical students. It is concise, accurate, well arranged, and lucid, . . . just the thing for students to use while studying physical diagnosis and the more practical departments of medicine. Wythe's Dose and Symptom Book. Containing the Doses and Uses of all the principal Articles of the Materia Medica, etc. Seventeenth Edition. Completely Revised and Rewritten. 32010. Cloth, i.oo; Pocket-book style, 1.25 PHARMACY. Hartley. Medical and Pharmaceutical Chemistry. Third Edition. Cloth, 300: Leather, 3.50 Coblentz. Manual of Pharmacy. Illustrated. By Virgil Coblentz.PH D , Professor of Theory and Practice of Pharmacy, College of Pnarraacy of City of New York. Octavo. 500 pages. Cloth. 4.00 U. S. Pharmacopoeia, 1890, 7th Revision. Cloth, net, 2 50; Sheep, net, 3 oo. (Add 27 cents if to go by mail.) Sayre. Organic Materia Medica and Pharmacognosy. 543 Illustrations. See page Q. 8vo. Cloth, 4.50 Stewart's Compend of Pharmacy. Based upon Remington's Text-book of Pharmacy. Fifth Edition, Revised in accordance with new U.S P., 1890. Cloth, i.oo; Interleaved for Notes, 1.25 Robinson. Latin Grammar of Pharmacy and Medicine. By H. D. Robinson, PH.D., Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Intro- duction by L. E. Sayre, PH.G., Professor of Pharmacy in, and Dean of. the Dept. of Pharmacy, University of Kansas. 12010. Second Edition, Revised. Cloth, 2.00 SKIN DISEASES. Crocker. Diseases of the Skin, their Description, Pathology, Diagnosis, and Treatment, with Special Reference to the Skin Kniplions of Children. By H. Radcliffe Crocker, P.R.C p., Phy- sician for Diseases of the Skin in L'niversity College Hospital. Second Edition. Revised and Enlarged, with 92 Wood-cuts. Cloth, 5.00 Van Harlingen on Skin Diseases. Third Edition. Enlarged and Illustrated. 12010. In Preit. te faffs a to 5 for list of New KantuUt. STUDENTS' TEXT-BOOKS AND MANUALS. 13 SURGERY AND BANDAGING. Moullin's Surgery, by Hamilton. 600 Illustrations (some colored), 200 of which are original. Second Edition. Cloth, net, 7.00; Leather, net, 8.00; Half Russia, net, 9.00 *** Complete circulars, with sample pages and Illustrations, free upon application. Jacobson. Operations in Surgery. A Systematic Handbook for Physicians, Students, and Hospital Surgeons. By W. H. A. Jacobson, B.A. Oxon., F.R.C.S. Eng. ; Ass't Surgeon Guy's Hos- pital ; Surgeon at Royal Hospital for Children and Women, etc. 199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 Heath's Minor Surgery, and Bandaging. Tenth Edition. 158 Illustrations. 62 Formulae, and Diet Lists. Cloth, 2.00 Horwitz's Compend of Surgery, Minor Surgery and Bandaging, Amputations, Fractures, Dislocations, Surgical Diseases, and the Latest Antiseptic Rules, etc., with Differential Diagnosis and Treatment. By ORVILLB HORWITZ, B.S., M.D., Demonstrator of Surgery , Jefferson Medical College. $th Edition. Enlarged and Rearranged. Many new Illustrations and Formulae. i2mo. Cloth, i. oo ; Interleaved for the addition of Notes, 1.25 *** The new Section on Bandaging and Surgical Dressings con- sists of 32 Pages and 41 Illustrations. Every Bandage of any importance is figured. This, with the Section on Ligation of Arteries, forms an ample Text-book for the Surgical Laboratory. Walsham. Manual of Practical Surgery. Third Edition. Bv WM. J. WALSHAM, M.D., F.R.C.S., Asst. Surg. to, and Dem- of' Practical Surg. in, St. Bartholomew's Hospital; Surgeon to Metropolitan Free Hospital, London. With 318 Engravings. Seepages. Cloth, 3.00; Leather, 3.50 URINE, URINARY ORGANS, ETC. Holland. The Urine, Gastric Contents, Common Poisons, and The Milk. Chemical and Microscopical, for Laboratory Use. Illustrated. Fifth Edition. I2mo. Interleaved. Cloth, 1.25 Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- trations. I2mo. 572 pages. Cloth, 2.75 Marshall and Smith. On the Urine. The Chemical Analysis of the Urine. Colored Plates. I2mo. Cloth, i.oo Memminger. Diagnosis by the Urine. Illus. Cloth, i.oo Tyson. On the Urine. A Practical Guide to the Examination of Urine. With Colored Plates and Wood Engravings. Eighth Edition, Enlarged. i2mo. Cloth, 1.50 Van Niiys, Urine Analysis. Illus. Cloth, i.oo VENEREAL DISEASES. Hill and Cooper. Student's Manual of Venereal Diseases, with Formulae. Fourth Edition. I2mo. Cloth, i.oo ee pages 14 and 15 for list of f Quiz-Compends f PQUIZ-COMPENDS? The Best Compends for Students' Use in the Quiz Class, and when Pre- paring for Examinations. Compiled in accordance with the latest teachings of promi- nent Lecturers and the most popular Text-books. They form a most complete, practical, and exhaustive set of manuals, containing information nowhere else col- lected in such a condensed, practical shape. Thoroughly up to the times in every respect, containing many new prescriptions and formulae, and over six hundred illustra- tions, many of which have been drawn and engraved specially for this series. The authors have had large ex- perience as quiz-masters and attaches of colleges, with exceptional opportunities for noting the most recent ad- vances and methods. Cloth, each $1.00. Interleaved for Notes, $1.25. No. I. HUMAN ANATOMY, " Based upon Gray." Fifth Enlarged Edition, including Visceral Anatomy, formerly published separately. ID Lithograph Plates, New Tables, and 117 other Illustrations. By SAMUEL O. L. POTTER, M.A., M.D., M.R.C.P. (Lend.), late A. A. Surgeon U. S. Army, Professor of Practice, Cooper Medical College, San Fran- cisco. Nos. a and 3. PRACTICE OF MEDICINE. Fifth Edi- tion. By DANIBL E. HUGHES, M.D., Demonstrator of Clinical Medicine in Jefferson Medical College, Philadelphia. In two pans. PART I. Continued, Eruptive, and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc. (including Tests for Urine), General Diseases, etc. PART II. Diseases of the Respiratory System (including Phy- sical Diagnosis), Circulatory System, and Nervous System; Dis- eases of the Blood, etc. %* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and including a number of prescriptions hitherto unpub- lished. No. 4. PHYSIOLOGY, including Embryology. Seventh Edition. By ALBBRT P. BRUBAKBR, M.D., Prof, of Physiology, Penn'a College of Dental Surgery ; Demonstrator of Physiology in Jefferson Medical College, Philadelphia. Revised, Enlarged, with new Illustrations. No. 5. OBSTETRICS. Illustrated. Fifth Edition. By HENRY G. LANDIS, M.D. Edited by WILLIAM H. WELLS, M.D., Assistant Demonstrator of Clinical Obstetrics, Jefferson College, Philadelphia. New Illustrations. BLAKISTON'S ? QUIZ-COMPENDS ? No. 6. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Sixth Revised Edition, Based upon U. S. P. 1890. With especial Reference to the Physiological Action of Drugs, and a complete article on Pre- scription Writing, including many unofHcinal remedies. By SAMUEL O. L. POTTER, M.A., M.D., M.R.C.P. (Lond.).late A. A. Surg. U. S. Army; Prof, of Practice, Cooper Medical College, San Francisco. Improved and Enlarged, with Index. No. 7. GYN^COLOGY. A Compend of Diseases of Women. By WM. H. WELLS, M.D., Ass't Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. Illustrated. No. 8. DISEASES OF THE EYE AND REFRACTION, including Treatment and Surgery. By L. WEBSTER Fox, M.D., Chief Clinical Assistant Ophfhalmological Dept., Jefferson Med- ical College, etc., and GEO. M. GOULD, M.D. 71 Illustrations, 39 Formulae. Second Enlarged and improved Edition. Index. No. 9. SURGERY, Minor Surgery and Bandaging. Illus- trated. Fifth Edition. Including Fractures, Wounds, Dislocations, Sprains, Amputations, and other operations; Inflam- mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and other Surgical Diseases. By ORVILLE HORWITZ, A.M., M.D., Demonstrator of Surgery, Jefferson Medical College. Revised and Enlarged. 98 Formulae and 167 Illustrations. No. 10. CHEMISTRY. Fourth Edition. Inorganic and Organic. For Medical and Dental Students. Including Urinary Analysis and Medical Chemistry. By HENRY LKFFMANN, M.D., Prof, of Chemistry in Penn'a College of Dental Surgery, Phila. Fourth Edition, Revised and Rewritten, with Index. No. ii. PHARMACY. Based upon " Remington's Text-book of Pharmacy." By F. E. STEWART, M.D. , PH. G., Quiz-Master at Philadelphia College of Pharmacy. Fifth Edition, Revised. No. la. VETERINARY ANATOMY AND PHYSIOL- OGY. 29 Illustrations. By WM. R. BALLOU, M.D., Prof, of Equine Anatomy at N. Y. College of Veterinary Surgeons. No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- CINE. Containing all the most noteworthy points of interest to the Dental student. Second Edition. By GEO. W. WARREN, D.D.S., Clinical Chief, Penn'a College of Dental Surgery, Phila- delphia. Second Edition, Enlarged and Illustrated. No. 14. DISEASES OF CHILDREN. By DR. MARCUS P. HATFIELD, Prof, of Diseases of Children, Chicago Medical College. Colored Plate. No. 15. GENERAL PATHOLOGY AND MORBID ANATOMY. By H. NEWBBRY HALL, M. D., Professor of Pathology and Medical Chemistry Post-Gradnate School ; Sur- geon Emergency Hospital, Chicago, etc. 91 Illustrations. Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. fi@?" No series of books are so complete in detail, concise in language, or so well printed and bound. Each one forms a complete set of notes upon the subject under con- sideration, Illustrated Descriptive Circular Free. 3O.OOO COPIES Of These Books Have Already Been SoU. GOULD'S STUDENT'S MEDICAL DICTIONARY Based on Recent Medical Literature. Small 8vo, Half Morocco, as above, with Thumb Index, . . 4.?$ Plain Dark Leather, without Thumb Index, 3.25 A compact, concise Vocabulary, including all the Words and Phrases used in medicine, with their proper Pronunciation and Definitions. " One pleasing feature of the book is that the reader can almost invariably find the definition under the word he looks for, without being referred from one place to another, as is too commonly the case in medical dictionaries. The tables of the bacilli, nucrococci, leucomaiines and ptomaines are excellent, and contain a large amount of information in a limited space. The anatomical tables are also concise and clear. . . . We should unhesitatingly recommend this dictionary to our readers, feeling sure that it will prove of much value to them." American Journal of Medical Science. JUST PUBLISHED. GOULD'S POCKET DICTIONARY. 12,000 Medical Words Pronounced and Defined. Leather, gilt edges, JSi.oo; with Thumb Index, $1.25 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. JUN7 RB Form L9-Series 4939