THE LIBRARY

THE UNIVERSITY
OF CALIFORNIA

LOS ANGELES

MEDICAL BOOKS
1114 W HARRISON ST. CHICAGO

NORMAL FUNDUS,
grange Gofer.)

MANUAL

CLINICAL OPHTHALMOLOGY

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.

PTCM or WM. F. Fru. * Co.
1220-24 SANSOM ST.

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.

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

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.

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

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.

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

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-

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

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

15 LCBDT

10 EPGBU

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.

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).

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.

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-

5<D A MANUAL OF CLINICAL OPHTHALMOLOGY.

tion of rest, diverging rays will come to a focus, theoreti-
cally, at a point behind the retina, and converging rays will
come to a focus at a point in front of the retina. Therefore,
in a normal eye at rest, rays which proceed from the focus
upon the retina will emerge out of the cornea parallel, those
from behind the retina converging, and those from in front
of it diverging.

In examining the fundus of an eye by the ophthalmo-
scope, the foregoing optical principles are observed. For
instance, if the observer's eye is of normal refraction, and
at rest, not accommodating, the details of the fundus of the
eye under observation will be seen, provided the observed
eye is also suitably illuminated, at rest, and normal in its
refraction. Without the aid of artificial light the reflection
of light from the observed eye, which is projected along
the visual axis of the two eyes, is too feeble for illumi-
nation, and the pupil appears black. The pupil of observed
eye will still appear black when a light is interposed in
the line of vision between it and the observing eye, since
the two eyes are adapted to parallel rays only, and the
diverging rays from the interposed light would illuminate
both eyes, and the returning rays would focus at the
interposed light, as if proceeding from a point behind the
retina, and an inverted image of the interposed flame
would be focused upon the retinae of the two eyes. There-
fore, it is not only necessary, in order to see the fundus of
the eye under examination, that the observed and observ-
ing eyes shall be artificially luminous, but also that the
light shall be placed in such a position that its flame will
be effective as a source of illumination.

This necessary arrangement of the light was first accom-
plished by Helmholtz, who constructed an instrument by
which the light was suitably placed behind the observed

PHYSIOLOGICAL OPTICS. 51

eye. The invention of this instrument, the ophthalmoscope,
has placed ophthalmology among the fixed sciences, and
given to its study and practice an interest and effectiveness
surpassed by no other department of the medical sciences.
Prior to its discovery, the appearance in the living sub-
ject of the intra -ocular tissues was unknown. Indeed, our
knowledge of the subject was of a kind with the belief,
universally held and taught at that time, that there was
complete absorption of the light entering the eye.

FIG. 25.

DIRECT EXAMINATION BY OPHTHALMOSCOPE.

EXAMINATION BY THE OPHTHALMOSCOPE. There are two
methods of examining the eyes by the ophthalmoscope,
the direct and indirect.

By the former (Fig. 25), a real, erect, and four-fold
magnified image is seen by the observer. A is the observ-
ing, B the observed eye, 55 the plane mirror, and x the
source of illumination. The rays of light from x impinge

52 A MANUAL OF CLINICAL OPHTHALMOLOGY.

upon the mirror and are reflected along the dotted lines
cd c'd' into B, illuminating the fundus. A, looking
through opening in SS, along the line of the reflected
rays, sees /?'s retina around b. The dotted lines come
to a focus behind b at y. But b is now the source of
illumination, and rays emerging out of B pursue a
parallel course and are focused by the dioptric apparatus
of A at a.

FIG. 26.

INDIRECT EXAMINATION BY OPHTHALMOSCOPE.

By the indirect method, an inverted image is formed in
the air by the interposition of a strong convex lens
(i4 D -2O D ) (Fig. 26). M, observer's, K, observed eye ; S, the
mirror. Rays from the mirror S, pass through the lens C
(the refraction of these rays is not shown in figure), enter K,
and strike on the retina at A. On returning and being
refracted by the media of eye K, rays enter the lens C, and
are focused by it at B, forming an inverted aerial image,
of a portion of A"s retina.

PART III.
REFRACTION.

Normal refraction is dependent on three conditions:
(i) on the antero-posterior diameter of the globe, (2) the
transparency of the refracting media, and (3) the curve of
their surfaces. When an eye is of the right length antero-
posteriorly, the refracting media clear, and their surfaces
normal in curvature, parallel rays of light are brought to a
focus on the percipient layers of the retina, the rods and

FIG. 27.

CONDITION OF REFRACTION IN THE NORMAL PASSIVE EYE AND DURING
ACCOMMODATION.

cones, and the refraction is normal. The refraction is ab-
normal when parallel rays of light are not brought to a
focus on the retina in the absence of accommodation.

EMMETROPIA is the term used to denote normal refrac-
tion. In an emmetropic eye, parallel rays of light, rr, are
brought to a focus (Figs. 27, 28) on the retina, r lt without
accommodation, and diverging rays proceeding from a
point, p, nearer than infinity, are brought to a focus on

54 A MANUAL OF CLINICAL OPHTHALMOLOGY.

the retina, /t, by the exercise of a normal amount of
accommodation. Such an eye, to be exact, will recog-
nize any properly illuminated object whose height is equal
to the sine of an angle of 5'. An emmetropic eye of nor-
mal acuity of vision is an extremely rare condition, about
four per cent.

A normal refraction and a normal eye are distinct and
separate conditions, and should not be confounded. An
eye may be of normal refraction and yet be blind from
disease.

AMETROPIA is a generic term used to express variations

Fie. 28.

CONDITION OK REFRACTION IN THE NORMAL EYE DURING ACCOMMODA-

TION.

from the normal refraction, and has no reference to the
kind or degree of refractive error. An ametropic eye may
be hypermetropic, myopic, or astigmatic.

HYPERMETROPIA, HYPEROPIA (Fig. 29). is the most preva-
lent form of ametropia, and is that condition of refraction
in which parallel rays of light are never focused when the
eye is at rest, that is to say, when the eye is not accom-
modating. The curvature of the cornea and of the lens,
one or both, is so altered that parallel rays are intercepted
by the retina before they converge to a focus. In other
words, the antero-posterior diameter of the eye, the distance
between the apex of the cornea and the layer of rods and

REFRACTION. 55

cones, is too short. Such an eye is adapted to converging
rays. By contraction of the ciliary muscle, the curvature
of the anterior, and possibly the posterior, surface of the lens
is made more convex, and its antero-posterior diameter
is thus increased. In emmetropia this contraction of
the ciliary muscle, accommodation, is only necessary for
the perception of points of an object nearer the eye than
six metres. In hypermetropia, on the other hand, no point
can be seen at any distance without accommodation.
Hypermetropia is said to be latent when it is concealed
by constant contraction of the ciliary muscle ; and hyper-

FIG. 29.

HYPERMETROPIC EYE.

metropia which the contraction of the ciliary muscle, or
accommodation, cannot overcome is said to be manifest.
The sum of the two, latent and manifest, constitute the
total hypermetropia. The degrees of latent and manifest
hypermetropia depend on the power of accommodation,
the elasticity of the crystalline lens, and on the length of
the globe antero-posteriorly. The total hypermetropia
depends on the antero-posterior diameter of the eye alone.
The symptoms of latent hypermetropia will depend on
the age, sex, occupation, and on the acquired and heredi-
tary predisposition of the patient. A well-marked case
will complain of headache, either constant or following near

56 A MANUAL OF CLINICAL OPHTHALMOLOGY.

use of the eyes, pain in the eyes, blurring of letters in reading,
and lacrymation. No complaint will, be made of bad visi< >n.
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

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.

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.

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

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

PARALYSIS.

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,

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.

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,

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.

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.

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

Blepharitis, 109

angularis, 94

marginalis, 94, 109
Blepharospasm, 115
Blepharophimosis, 116
Blind spot, 37
Burns, 107

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

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

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

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

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

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,

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

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

Keratitis, interstitial, 127
necrotic, 130

Keratitis, neuro-paralytic, 129

parenchymalous, 127

phlyctenular, 122
Knife, Graefe cataract, 196

iridectomy, 203

iridotomy, 204

paracentesis, 205

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

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

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

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

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,

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

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

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

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

Ulcer, deep, 124
resorption, 124
rodent, no
serpiginous, 127

Uvea, 14

Veni, ophthalmic, 21
Venae vorticosse. 12
Vision, acuity of, 34
field of, 36, 37
Vitreous chamber, 18, 164

foreign bodies in, 164

Warty excrescences, 223
Wire loop, 200
Worsteds, Holmgren's, 60

Xanthelasma, 112

Zone of Zinn, 14

CATALOGUE No. 7.

FEBRUARY, 1895.

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No. 2. DISEASES OF WOMEN. 15O Illus.

SECOND EDITION.

The Diseases of Women. Including Diseases of the
Bladder and Urethra. By DR. F. WINCKEL, Professor
of Gynaecology and Director of the Royal University
Clinic for Women, in Munich. Second Edition. Re-
vised and Edited by Theophilus Parvin, M.D.,
Professor of Obstetrics and Diseases of Women and
Children in Jefferson Medical College. 150 Engrav-
ings, most of which are original.
" The book will be a valuable one to physicians, and a safe and

satisfactory one to put into the hands of students. It is issued in a

neat and attractive form, and at a very reasonable price." -Soften

Medical and Surgical Journal.

No. 3. ANATOMY. Sixth Edition.

311 ILLUSTRATIONS.

HOLDEN'S DISSECTOR. A Manual of the Dissections of
the Human Body. By JOHN LANGTON, F. R. c. s., Sur-
geon to, and Lecturer on Anatomy at, St. Bartholo-
mew's Hospital. Carefully Revised by A. HEWSON,
M.D., Demonstrator of Anatomy, Jefferson Medical
College; Chief of Surgical Clinic, Jefferson Hospital;
Mem. Assoc. Amer. Anatomists, etc. 311 Illustrations.
This book comes bound in oil-cloth price $3.00 as
well as in the regular cloth and leather styles.
" The work before us is a brilliant example of the new order of

text-books. * * * We would call special attention to the character

of the illustrations with which the volume is bountifully furnished."

American Journal o/" Medical Sciences.

No. 4. PHYSIOLOGY. Sixth Edition.

254 ILLUSTRATIONS AND A GLOSSARY.
A Manual of Physiology. By GERALD F. YEO, M.D.,
F.R.C.S., Professor of Physiology in King's College,
London. 254 Illustrations and a Glossary of Terms.
Sixth American from last English Edition, revised and
improved.

This volume was specially prepared to furnish students with a
new text-book of Physiology, elementary so far as to avoid theories
which have not borne the test of time and such details of methods
as are unnecessary for students in our medical colleges.

"The brief examination I have given it was so favorable that I
placed it in the list of text-books recommended in the circular of the
University Medical College." Prof. Levitt A. Stimson, M.D.,
37 East ssd Street, New York.

Price of each Book, Cloth, $3.00; Leather, $3.50.

4 THE NEW SERIES OF MANUALS.

No. 5. DISEASES OF CHILDREN.

SECOND EDITION.

A Manual. By J. F. GOODHART, M.D., Phys. to the
Evelina Hospital for Children ; Ass't Phys. to
Guy's Hospital, London. Second American Edition.
Edited and Rearranged by Louis STARR, M.D., Clinical
Prof, of Dis. of Children in the Hospital of the Univ.
of Pennsylvania, and Physician to the Children's Hos-
pital, Phila. Containing many new Prescriptions, a list
of over 50 Formulae, conforming to the U. S. Pharma-
copoeia, and Directions for making Artificial Human
Milk, for the Artificial Digestion of Milk, etc. Illus.

" A safe and reliable guide, and in many ways admirably adapted
to the wants of the student and practitioner." American Journal
of Medical Science.

No. 6. MATERIA MEDICA, PHARMACY,
PHARMACOLOGY, AND THERA-
PEUTICS. SECOND EDITION.

A Handbook for Students. By WM. HALE WIUTK,
M.D., F.R.C.P., etc., Physician to, and Lecturer on Ma-
teria Medica, Guy's Hospital ; Examiner in Materia
Medica, Royal College of Physicians, London, etc.

- Second American Edition. Revised and Enlarged by
REYNOLD W. WILCOX, M.D., LL.D., Prof, of Clinical
Medicine and Therapeutics, New York Post-Graduate
Medical School; Visiting Physician St. Mark's Hospital.
66 1 pages.

"This is a well-arranged, concise, and handy work on materia
medica, excellent as a reference manual or as a text-book for
students attending lectures on the subject." New Yark Medical
Record.

No. 7- MEDICAL JURISPRUDENCE AND

TOXICOLOGY. FOURTH EDITION.
By JOHN J. REESE, M.D., late Professor of Medical Juris-
prudence and Toxicology in the University of Penn-
sylvania. Revised by HENRY LEFFMANN, M.D., Prof,
of Chemistry, Pa.' College of Dentistry ; Hygienist and
Food Inspector, Pa. State Board of Agriculture.
" We lay this volume aside, after a careful perusal of its pages,
with the profound impression that it should be in the hands of every

doctor and lawyer. It fully meets the wants of all students

He has succeeded in admirably condensing into a handy volume all
the essential points." Cincinnati Lancet and Clinic.

Price of each Book, Cloth, $3.00 : Leather, $3.50.

THE NEW SERIES OF MANUALS. 6

No. 8. DISEASES OP THE EYE. 164Illus.

FOURTH EDITION.

Diseases of the Eye and their Treatment. A Handbook
for Physicians and Students. By HENRY R. SWANZY,
A.M., M.B., F.R.C.S.I., Surgeon to the National Eye and
Ear Infirmary ; Ophthalmic Surgeon to the Adelaide
Hospital, Dublin; Examiner in Ophthalmic Surgery
in the Royal University of Ireland. Fourth Edition,
Thoroughly Revised. 164 Illustrations and a Zephyr
Plate for Testing Color Blindness. 518 pages.

" Mr. Swanzy has succeeded in producing the most intellectually
conceived and thoroughly executed resume of the science within
the limits he has assigned himself. As a 'students' handbook/
small in size and moderate in price, it can hardly be equaled."
Medical News.

" A full, clear, and comprehensive statement of Eye Diseases
and their treatment, practical and thorough, and we feel fully jus-
tified in commending it to our readers. It is written in a clear and
forcible style, presenting in a condensed yet comprehensive form
current and modern information that will prove alike beneficial to
the student and general practitioner." Southern Practitioner.

No. 9. MENTAL DISEASES.

WITH ILLUSTRATIONS.

Lectures on Mental Diseases, designed for Medical Stu-
dents and General Practitioners. By HENRY PUTNAM
STEARNS, A.M., M.D., Physician Superintendent at the
Hartford Retreat, Lecturer on Mental Diseases in Yale
University, New Haven, Conn., Hon. Mem. British
Psycho. Asso'n, etc. With Illustrations and a Digest of
the Laws of the various States relating to the Commit-
ment and Care of the Insane. 636 pages.

No. 1O. MEDICAL CHEMISTRY.

THIRD EDITION. ILLUSTRATED.
A Text-Book of Medical and Pharmaceutical Chemistry.
By E. H. BARTLEY, M.D., Professor of Chemistry
and Toxicology at Long Island College Hospital,
Chief Chemist Board of Health, Brooklyn, N. Y., etc.
With Glossary and Illustrations. 684 pages.

" 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,
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Cloth, 1.25

Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus-
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Marshall and Smith. On the Urine. The Chemical Analysis of
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VENEREAL DISEASES.

Hill and Cooper. Student's Manual of Venereal Diseases,
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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-
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Compiled in accordance with the latest teachings of promi-
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They form a most complete, practical, and exhaustive
set of manuals, containing information nowhere else col-
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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
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exceptional opportunities for noting the most recent ad-
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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-
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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-
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%* These little books can be regarded as a full set of notes upon
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disease, and including a number of prescriptions hitherto unpub-
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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
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forms a complete set of notes upon the subject under con-
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Illustrated Descriptive Circular Free.

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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.

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